|Year : 2019 | Volume
| Issue : 2 | Page : 49-53
Treatment of peri-implantitis with implantoplasty and diode laser
Anal Rutvik Trivedi, Vasumati G Patel, Shalini S Gupta, Bimal S Jathal
Department of Periodontology and Implantology, Faculty of Dental Sciences, DDU, Nadiad, Gujarat, India
|Date of Web Publication||18-Nov-2019|
Dr. Anal Rutvik Trivedi
3, Lakshya La Villa, Opp. Lambhavel Hanumanji Temple, Anand-Lambhavel Road, Anand - 388 001, Gujarat
Source of Support: None, Conflict of Interest: None
Dental implant surgery has developed to a widely used procedure for dental rehabilitation and is a secure and predictable procedure. But, some local and systemic risk factors can result in higher failure rates and affect implant survival. Peri-implant disease, namely peri-implantitis, have been extensively studied in present era as a major cause of implant failure. There are various treatment modalities to treat peri-implantitis, which give satisfactory results and improve survival rate of implant. Though it is difficult to determine what approach will improve implant survival, present case report is an attempt to treat peri-implantitis with implantoplasty and diode laser followed by regenerative periodontal therapy.
Keywords: Diode laser, implantoplasty, peri-implantitis, regenerative periodontal therapy
|How to cite this article:|
Trivedi AR, Patel VG, Gupta SS, Jathal BS. Treatment of peri-implantitis with implantoplasty and diode laser. Indian J Oral Health Res 2019;5:49-53
|How to cite this URL:|
Trivedi AR, Patel VG, Gupta SS, Jathal BS. Treatment of peri-implantitis with implantoplasty and diode laser. Indian J Oral Health Res [serial online] 2019 [cited 2022 May 19];5:49-53. Available from: https://www.ijohr.org/text.asp?2019/5/2/49/271145
| Introduction|| |
Nevertheless, despite the high success and survival rates of dental implants, there are several risk factors and complications that could lead to their ultimate failure. Peri-implantitis is a progressive and irreversible disease of implant-surrounding hard and soft tissues and is accompanied by bone resorption, decreased osseointegration, increased pocket formation, and purulence. The frequency of peri-implantitis has been reported in the range of 1%–19%.
When left untreated, peri-implantitis may cause progressive tissue destruction, bone loss, esthetic complications, and, eventually, implant loss. Based on numerous clinical trials and systematic reviews, several approaches for implant decontamination are available. In the context of this nonsurgical mechanical debridement, surgical debridement, disinfection with chemotherapeutic agents, and smoothening of implant surface, laser therapy along with regenerative periodontal therapy should be noted.,,,,, Mechanical debridement can be done with carbon, plastic or titanium curettes, ultrasonic scaling, or powder–air abrasion.
When a titanium implant surface has been exposed to the oral cavity and contaminated with bacteria, implantoplasty to completely flatten/smooth the exposed part of the implant using rotary instruments may be indicated. Initially recommended by Lang et al. and reported by Suh et al., this technique aims to reduce the roughness of the titanium surface to decrease plaque adherence because it has been demonstrated that rough surfaces accumulate more plaque than smooth or moderately rough surfaces.,, As implant decontamination is the key aspect to the resolution of peri-implantitis, different mechanical and chemical methods have been tested in that respect. Recently, a noticeable tendency has urged scientists toward the application of laser in order to decontaminate peri-implant inflamed area.,,In-vitro models have proven the efficacy of erbium-doped yttrium aluminum garnet, carbon dioxide laser, and diode lasers in high or even complete elimination of bacterial-loaded titanium discs., Diode lasers, in particular, have been shown to have potent bactericidal and photobiomodulatory effects promoting wound healing and tissue regeneration.,
Current evidence suggests that peri-implantitis does not respond to traditional nonsurgical therapy. In addition, surgical therapy has been demonstrated to result in significantly reduced probing depth and gains in clinical attachment levels around the affected implants. The aim of the present case report was to gain predictable results by detoxification of the implant body surfaces in a case with peri-implantitis.
| Case Report|| |
A 38-year-old male patient reported to the department of prosthodontics and oral implantology with the chief complaint of persistent pus discharge from the sinus opening near to an implant placed in the lower left first molar region. The implant (Nobel Biocare RP, 4.3 × 10, Nobelpharma Canada Inc.) had been placed before 2 years in the same department. Treatment was started with antibiotics, namely tablet amoxicillin 500 mg t.i.d. and tablet metronidazole 400 mg b.i.d., for 7 days. The sinus tract was resolved, but, still the patient was complaining about sour taste and pus discharge from the same site in the morning. Hence, the patient was referred to the department of periodontology and oral implantology for the same. Pus discharge and sinus opening were absent at the time of presentation. On examination, peri-implant probing depth (Implacare Hu Friedy® PH 6 COLORVUE PROBE, Mfg. Co., LLC, Europe), 6 mm mesio-buccal, 5 mm disto-buccal, and 5 mm on the lingual aspect in relation to the implant placed in 36 region, was found [Figure 1] and [Figure 2]. Bleeding on probing (BOP) was present. A diagnosis of peri-implantitis was confirmed, with the patient's intraoral periapical (IOPA) of 36 region showing arc-shaped bone loss with three implant threads exposed [Figure 3]. Open flap debridement with implantoplasty, treatment with diode laser, and regenerative periodontal procedure were planned following patient consent for the treatment.
|Figure 3: Intraoral periapical of 36 region showing arc-shaped bone loss with three implant threads exposed|
Click here to view
Implant prosthesis was replaced with healing abutment. After achieving adequate local anesthesia (1:100,000 epinephrine), full-thickness mucoperiosteal flap was reflected following crevicular incisions in the adjacent interdental papillary region and the crestal incisions around the implant. Then, tissue debridement was done with metal curettes (Hu Friedy, Mfg. Co., LLC, Europe) [Figure 4] and [Figure 5]. Implantoplasty procedure was carried out with a diamond grit polishing bur [Figure 6] The peri-implant bony defect was thoroughly washed with normal saline [Figure 7]. Further, tissue laden with metal particles was cleaned with plastic curettes (Implacare, Hu Friedy) [Figure 8]. 808 ± 5 nm diode laser (DenMat Sapphire® Portable Diode laser, DenMat Holdings, LLC Lompoc, CA) aiming beam was moved in an apico-coronal and mesio-distal direction for 10 s at each site of the inflamed peri-implant bony crater-shaped defect (mesio-buccal, buccal, disto-buccal, and lingual) to implant. It was used at a power of 0.1 W, noncontact in a continuous wave mode on each site, for a total time of 30 s [Figure 9]. After presuturing bone graft (Perioglass®, NOVABONE products LLC, USA), placement was done [Figure 10]. Sutures were taken followed by periodontal dressing. Postoperative antibiotics, analgesics, and mouth rinse were prescribed. The patient was called for follow-up and suture removal after 10 days.
|Figure 7: Peri-implant bony defect was thoroughly washed with normal saline after implantoplasty|
Click here to view
|Figure 8: Peri-implant tissue laden with metal particles was cleaned with plastic curettes|
Click here to view
|Figure 9: Irradiated peri-implant bone with diode laser low-level laser therapy|
Click here to view
After 3 months during re-evaluation, BOP was absent and peri-implant probing depths were measured 1 mm mesio-buccal, 1 mm disto-buccal, and 2 mm on the lingual aspect [Figure 11] and [Figure 12].
|Figure 11: Postoperative peri-implant probing depth, mesio-buccal, after 3 months|
Click here to view
|Figure 12: Postoperative peri-implant probing depth, lingual, after 3 months|
Click here to view
| Discussion|| |
Human studies have shown that combining implant surface cleaning with mechanical methods such as curettes and saline-soaked cotton pellets contributes to obtaining clinically stable results up to 24 months. An in-vitro study using a surface profilometer showed that metal curettes reduce the roughness of rough-surfaced implants and decrease the attachment of Streptococcus sanguinis which is an important early colonizer in the oral cavity. Metallic curettes after 20 s of use can remove superficial material from the rough surface on an average of 0.83 μm compared to 0.19 μm removed by titanium curettes and ultrasonic tips covered with plastic inserts. In the present case report, metal curettes had been used in open flap debridement around the implant.
The aim of implantoplasty is to produce a smooth and polished implant surface, thereby reducing the amount of dental plaque that attaches to it as well as removing the implant threads, providing a less attractive environment to bacteria.,In-vitro studies have shown that the use of diamond polishing devices can remove the coating of the implant surface entirely, thus exposing the body of the fixture. There is no consensus about the type of bur to use for implantoplasty. An in-vivo study showed that diamond grit and carborundum polishing or just the carborundum gives similarly polished surfaces., The release of titanium particles from implant fixtures placed onto the peri-implant bone during preparation of the implant bed has been reported. In the present case report, the peri-implant region was thoroughly rinsed with saline during and after implantoplasty. To clean all the released titanium particle debris from the peri-implant bone surfaces, saline-soaked cotton pellets and plastic curettes were used to prevent scratching over the polished implant surface. Previous studies have shown that the released titanium particle debris is mainly concentrated at the crestal parts of the bone in contrast to the apical areas. Debris amounts reaching 0.2–3.0 mg may induce peri-implant osteolysis, which manifests as early marginal bone loss around the implant.,
Diode lasers have a bactericidal effect due to a localized increase in temperature, which stimulates fibroblasts and osteoblasts, which, in turn, causes increased production of RNA messengers, leading to significant collagen production during periodontal tissue healing.
Shortly after laser was invented in 1960, Mester et al. noticed photobiomodulatory effect of laser over mice. Low-level laser therapy with diode laser has an effect on fibroblasts by promoting proliferation and increasing cell numbers, secretion of growth factors, and differentiation of fibroblasts into myofibroblasts. Various in-vitro studies have shown that laser irradiation increases basic fibroblast growth factor release from gingival fibroblasts., This collectively results in improved wound contraction and accelerated wound healing., However, a precisely determined dose has not been proved for each indication. Biostimulation has been reported in literature with doses between 0.001 J/cm2 and 10 J/cm2 as a therapeutic window. Even though the applied dose is in the therapeutic window range, it might be too low or too high for the desired effect. Mester et al. suggested in 1971 that doses of ≈1–2 J/cm2 are necessary to obtain an effect on wound healing. One randomized, split-mouth clinical trial showed the additional photobiomodulatory effect of 810-nm diode laser over modified Widman flap surgery in cases with chronic periodontitis; bone and root surfaces were irradiated at 0.1 W in continuous mode.
| Conclusion|| |
It can be stated with some assurance that physical alteration (smoothing) of the implant surface using metallic instruments has been demonstrated to slow or halt the progression of bone loss in humans as well as in animals. While this application is certainly useful, the drawbacks include soft-tissue retraction and esthetic compromises. At present, a combination of physical and chemical approaches possibly with appropriate laser therapy may prove to provide more predictable results. From this case report, it can be argued that further investigation of optimal ways to treat implants affected by peri-implantitis as well as the prevention of these problems is warranted.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: Factors associated with peri-implant lesions. J Clin Periodontol 2006;33:296-301.
Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM, et al.
Definition, etiology, prevention and treatment of peri-implantitis – Areview. Head Face Med 2014;10:34.
Atieh MA, Alsabeeha NH, Faggion CM Jr., Duncan WJ. The frequency of peri-implant diseases: A systematic review and meta-analysis. J Periodontol 2013;84:1586-98.
Ntrouka VI, Slot DE, Louropoulou A, Van der Weijden F. The effect of chemotherapeutic agents on contaminated titanium surfaces: A systematic review. Clin Oral Implants Res 2011;22:681-90.
Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri-implantitis: A systematic review. J Clin Periodontol 2008;35:621-9.
Schwarz F, Jepsen S, Herten M, Sager M, Rothamel D, Becker J. Influence of different treatment approaches on non-submerged and submerged healing of ligature induced peri-implantitis lesions: An experimental study in dogs. J Clin Periodontol 2006;33:584-95.
Persson LG, Mouhyi J, Berglundh T, Sennerby L, Lindhe J. Carbon dioxide laser and hydrogen peroxide conditioning in the treatment of periimplantitis: An experimental study in the dog. Clin Implant Dent Relat Res 2004;6:230-8.
Schwarz F, Sculean A, Berakdar M, Georg T, Reich E, Becker J. Clinical evaluation of an er:YAG laser combined with scaling and root planing for non-surgical periodontal treatment. A controlled, prospective clinical study. J Clin Periodontol 2003;30:26-34.
Ashnagar S, Nowzari H, Nokhbatolfoghahaei H, Yaghoub Zadeh B, Chiniforush N, Choukhachi Zadeh N. Laser treatment of peri-implantitis: A literature review. J Lasers Med Sci 2014;5:153-62.
Louropoulou A, Slot DE, Van der Weijden FA. Titanium surface alterations following the use of different mechanical instruments: A systematic review. Clin Oral Implants Res 2012;23:643-58.
Lang NP, Wilson TG, Corbet EF. Biological complications with dental implants: Their prevention, diagnosis and treatment. Clin Oral Implants Res 2000;11 Suppl 1:146-55.
Suh JJ, Simon Z, Jeon YS, Choi BG, Kim CK. The use of implantoplasty and guided bone regeneration in the treatment of peri-implantitis: Two case reports. Implant Dent 2003;12:277-82.
Valderrama P, Wilson TG Jr. Detoxification of implant surfaces affected by peri-implant disease: An overview of surgical methods. Int J Dent 2013;2013:740680.
Quirynen M, van der Mei HC, Bollen CM, Schotte A, Marechal M, Doornbusch GI, et al.
study of the influence of the surface roughness of implants on the microbiology of supra- and subgingival plaque. J Dent Res 1993;72:1304-9.
Subramani K, Jung RE, Molenberg A, Hammerle CH. Biofilm on dental implants: A review of the literature. Int J Oral Maxillofac Implants 2009;24:616-26.
Peters N, Tawse-Smith A, Leichter J, Tompkins G. Laser therapy: The future of peri-implantitis management. Braz J Periodontol 2012;22:23-9.
Schwarz F, Nuesry E, Bieling K, Herten M, Becker J. Influence of an erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er, Cr:YSGG) laser on the reestablishment of the biocompatibility of contaminated titanium implant surfaces. J Periodontol 2006;77:1820-7.
Tosun E, Tasar F, Strauss R, Kıvanc DG, Ungor C. Comparative evaluation of antimicrobial effects of er:YAG, diode, and CO2
lasers on titanium discs: An experimental study. J Oral Maxillofac Surg 2012;70:1064-9.
Stubinger S, Etter C, Miskiewicz M, Homann F, Saldamli B, Wieland M, et al.
Surface alterations of polished and sandblasted and acid-etched titanium implants after er:YAG, carbon dioxide, and diode laser irradiation. Int J Oral Maxillofac Implants 2010;25:104-11.
Kurtzman GM, Weitz M, Kaminer R, Gober DD. Treatment of peri-implantitis with a diode laser. Inside Dent 2016;12:1-7.
Roncati M, Lucchese A, Carinci F. Non-surgical treatment of peri-implantitis with the adjunctive use of an 810-nm diode laser. J Indian Soc Periodontol 2013;17:812-5.
] [Full text]
Romanos GE, Weitz D. Therapy of peri-implant diseases. Where is the evidence? J Evid Based Dent Pract 2012;12:204-8.
Faggion CM Jr., Chambrone L, Listl S, Tu YK. Network meta-analysis for evaluating interventions in implant dentistry: The case of peri-implantitis treatment. Clin Implant Dent Relat Res 2013;15:576-88.
Schwarz F, John G, Mainusch S, Sahm N, Becker J. Combined surgical therapy of peri-implantitis evaluating two methods of surface debridement and decontamination. A two-year clinical follow up report. J Clin Periodontol 2012;39:789-97.
Duarte PM, Reis AF, de Freitas PM, Ota-Tsuzuki C. Bacterial adhesion on smooth and rough titanium surfaces after treatment with different instruments. J Periodontol 2009;80:1824-32.
Mengel R, Buns CE, Mengel C, Flores-de-Jacoby L. Anin vitro
study of the treatment of implant surfaces with different instruments. Int J Oral Maxillofac Implants 1998;13:91-6.
Alani A, Bishop K. Peri-implantitis. Part 3: Current modes of management. Br Dent J 2014;217:345-9.
An YZ, Lee JH, Heo YK, Lee JS, Jung UW, Choi SH. Surgical treatment of severe peri-implantitis using a round titanium brush for implant surface decontamination: A Case report with clinical reentry. J Oral Implantol 2017;43:218-25.
Augthun M, Tinschert J, Huber A.In vitro
studies on the effect of cleaning methods on different implant surfaces. J Periodontol 1998;69:857-64.
Meyer U, Bühner M, Büchter A, Kruse-Lösler B, Stamm T, Wiesmann HP. Fast element mapping of titanium wear around implants of different surface structures. Clin Oral Implants Res 2006;17:206-11.
Cobb CM. Lasers in periodontics: A review of the literature. J Periodontol 2006;77:545-64.
Kreisler M, Christoffers AB, Al-Haj H, Willershausen B, d'Hoedt B. Low level 809-nm diode laser-inducedin vitro
stimulation of the proliferation of human gingival fibroblasts. Lasers Surg Med 2002;30:365-9.
Pereira AN, Eduardo Cde P, Matson E, Marques MM. Effect of low-power laser irradiation on cell growth and procollagen synthesis of cultured fibroblasts. Lasers Surg Med 2002;31:263-7.
Aukhil I. Biology of wound healing. Periodontol 2000 2000;22:44-50.
Roberts AB, Sporn MB. The Molecular and Cellular Biology of Wound Repair. 2nd
ed. New York: Plenum Publishers; 1996. p. 275-308.
Cochran DL, Wozney JM. Biological mediators for periodontal regeneration. Periodontol 2000 1999;19:40-58.
Tuner J, Hode L. Some Basic Laser Physics. 2nd
ed. Grangesberg (Sweden): Prima Books; 2007. p. 317-38.
Mester E, Spiry T, Szende B, Tota JG. Effect of laser rays on wound healing. Am J Surg 1971;122:532-5.
Aena PJ, Parul A, Siddharth P, Pravesh G, Vikas D, Vandita A. The clinical efficacy of laser assisted modified Widman flap: A randomized split mouth clinical trial. Indian J Dent Res 2015;26:384-9.
] [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]