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Treatment of Peri-implantitis Lesions with
Laser-assisted Therapy and a Minimally in
Invasive Approach: A Case Report
Elvan Efeoglua, Gulin T. Eyyupoglub a Professor, Dr, Department of Periodontology, Faculty of Dentistry, Marmara University, Istanbul, b PhD Student, Department of Periodontology, Faculty of Dentistry, Marmara University, Istanbul, ABSTRACT: In addition to conventional treatment modalities, the use of lasers has been increasingly proposed
for the treatment of periodontal and peri-implant infections. A 56-year-old female patient had 5 implants with se-
vere and painful peri-implantitis lesions. Local and systemic anti-infective therapies were performed as an adjunct
to mechanical treatment but suppuration still persisted. This condition resolved after 3 treatments with diode
laser (810 nm) irradiation (1.0 W, CW). During the operation, 2 failed implants were removed, and Er,Cr:YSGG
(2780 nm) laser was used for decontamination of implant sockets (1.0 W, 20 Hz) and implant surfaces (0.5 W,
20 Hz), then the implant sockets were augmented. After ten months, radiographic findings showed bone fill in
the area of removed implants and no lesions around remaining implants. Laser decontamination provided us with
the opportunity to augment the sites without losing soft and hard tissues.
J Oral Laser Applications 2008; 8: 109-116. Peri-implantitis has been defined as an inflammatory pathogens, other local, systemic, and genetic factors process affecting the tissues around an osseointe- must coexist in order for prolonged, active infection to grated implant in function, resulting in loss of support- actually take place. The most remarkable of these fac- ing bone.1 It has been reported that the microbiota tors include smoking, non-parallel implant direction, associated with peri-implantitis corresponds to that ob- excessive mechanical stresses on the implant, systemic served at sites with advanced periodontitis, and it has conditions, long-term treatment with corticoids, and been suggested that periodontal pathogens present in radiation and chemotherapy.5 the periodontal pockets of teeth may colonize newly Diagnosis is based on changes of color on the peri- inserted implants and give rise to tissue breakdown.2 implant mucosa, bleeding on probing, increased prob- This is very common in the case of partially edentulous ing depth, suppuration, peri-implant radiotransparency patients with active periodontal disease and who also and gradual loss of bone height around the implant.6 bear implants. In this group of patients, colonization of Clinically unhealthy implants are classified as "ailing" the peri-implant sulcus is observed in one month fol- or "failing".7,8 It is necessary to distinguish between an lowing the connection of the implant to its prosthetic ailing vs a failing implant to determine the treatment abutment.3,4 This colonization does not necessarily steps necessary to salvage the unhealthy implant. Im- imply that peri-implantitis will develop with the subse- plants exhibiting soft tissue problems exclusively are quent rapid loss of bone height; hence, it is suggested classified as ailing and have a more favorable pro- that, in addition to the presence of these periodontal gnosis.7,9 Peri-implant mucositis involves inflammatory Vol 8, No 2, 2008 changes confined to the soft tissue surrounding an im- ria kill rates of up to 99.4% have been attained.18 The plant.10 Therefore, an implant exhibiting peri-implant semiconductor 809-nm, the CO2 and Er:YA tG lasers
mucositis is an ailing implant. In some instances, the ail- ecommended, since it appears that they do not ing implant may have exhibited early bone loss along exert a negative impact on the implant surface. The with soft tissue pocketing.7,9 enerates the least amount of heat in the Clinically, lack of osseointegration leads to implant bone tissue surrounding the im plant.1 r
f The deconta-
mobility and subsequent failure. Therefore, a mobile mination mechanism of the lasers is based on their implant is a failed implant. Non-functional, failed im- thermal effect, which denatures proteins and produces plants must be removed to prevent the associated cell necrosis.21 Another type of laser with a low ther- bone loss from continuing. The option of removing the mal effect on the bone and implant surface is the implant, allowing for healing, and then placing a new Er,Cr:YSGG, which represents an improvement over implant should not be ruled out.11 the technical properties of the Er:YAG.6 Treatment options for ailing and failing implants are Further regenerative treatment will depend on the varied. The clinician should start conservatively and amount of bone loss and the esthetic impact of the im- progress to more invasive therapy, based on a system plant in question. The main problem is augmentation of of comulative interceptive supportive therapy (CIST).12 the area in intrabony defects surrounding the implant The overall goal of therapy is to establish a functional and implant socket after removing the implant; if bone restoration and acceptable esthetics. Therefore, any loss is advanced, it will be necessary to surgically de- therapy provided should arrest further loss of bone bride the soft, peri-implant tissues affected by the support and re-establish a healthy peri-implant mucosal chronic infection, decontaminate the microimplant sur- face and, finally, apply bone regeneration techniques Various therapies have been advocated for the reso- aimed at recovering the lost bone.22 Bone substitutes lution of the peri-implant infection and in the restora- should not be placed in infected sites. The clinician tion of the peri-implant tissues. The most conservative should be confident that any active or recent infection approach to treatment involves nonsurgical therapy.
has been properly treated.
This kind of treatment modality includes three subcate-gories: pharmacological therapy, occlusal therapy, andmechanical debridement.8,10 Pharmacological therapies include subgingival irrigation with disinfecting agents,and topical and systemic antibiotics.9,10 Bacteria associ- In this case report, a 56-year-old female patient with ated with failing implants have been found to be sensi- severe and painful peri-implantitis lesions is presented tive to the following antibiotics: penicillin G, amoxicillin, combination of amoxicillin and metronidazole, and Her chief complaints were continuous and extensive pain in the mandibular anterior region, extraoral red- Mechanical debridement of tissues surrounding an ness, and swelling, which made it painful for the patient implant using either plastic hand instruments or ultra- to touch this area. However, there was no lymphoid in- sonic instruments with a plastic tip has been suggested.
volvement observed. Intraoral examination revealed an Plastic instruments are necessary to debride plaque edentulous maxilla and a complete denture. This exam- from titanium dental implants without damaging the ination further revealed five implants in the anterior soft titanium surface.15, 16 mandible, which were inserted five years ago, two of The clinician may use a surgical approach when non- which failed with pus discharge and inadequately at- surgical therapies are not indicated or are unsuccessful.
tached gingiva (Fig 2), one of the implants was dys- In an implant affected by "infectious failure," the functional, and the last two were observed to have assumption is implant surfaces exposed to periodon- moderate and severe peri-implantitis. In the first and topathogens have become contaminated with endotox- second molars of the posterior mandible, gingival in- ins that may interfere with the repair process.16 The flammation with deep pockets and Class III furcation first step in surgical therapy is exposing and treating defects were seen. Moreover, mobility on left second the bacterially contaminated implant and bone tissue premolar and molars were observed. The patient was prescribed combined antibiotic In the literature, efficacy studies of surgical lasers as therapy amoxicillin-clavulanate (1000 mg) and ornida- a method of decontamination on different implant sur- zole (500 mg) for five days and instructed to apply faces depending on power intensities show that bacte- home care. The mechanical periodontal therapy with The Journal of Oral Laser Applications

Fig 1a Clinical view at first visit.
Fig 1b Radiographic view at first visit.
Fig 2 Inadequate gingival attachment and diffuse inflammation of
Fig 3 Povidone-iodine irrigation.
peri-implant and lip mucosa.
an ultrasonic device, plastic curettes, and intrapocket Subsequently, the surgical phase was planned to im- povidone iodine (10%) irrigation was performed for prove the success of the augmentation of the implant several appointments (Fig 3). However, pus discharge sockets with the help of Er,Cr:YSGG laser (wavelength was persistent around the two failed implants; there- 2780 nm) decontamination. During the operation, two fore local metronidazole gel (25%) was applied as an failed implants were removed (Fig 5), intrabony granu- additional treatment. Slight improvement and gingival lation tissues were eliminated (Fig 6), and Er,Cr:YSGG recession was observed, but pus discharge was still pre- laser irradiation was used to decontaminate implant sockets and implant surfaces with a Z3 probe (320 As all of these conventional treatment approaches μm) in a noncontact mode (Fig 7). The energy settings failed to stop the suppuration, it was agreed upon to on the control panel were 1.0 W, 20 Hz, 11% air, 10% support the treatment with laser decontamination water for implant sockets and 0.5 W, 20 Hz, 11% air, therapy. The condition resolved after three exposures 10% water for implant surface, and energy densities of to subgingival diode laser (wavelength 810 nm) irradia- 37.5 and 25 J/cm2, respectively.
tion with energy outputs of 1.0 W, continuous wave, Decontaminated implant sockets were augmented and 600-μm flexible fiber delivery system (Fig 4). with bone substitutes and collagen membrane (Bio-Oss®, Bio-Gide®) (Fig 8). Vol 8, No 2, 2008 Fig 4 Diode laser irradiation.
Fig 5a Removal of the bridge and spontaneous extraction of
2 implants.
Fig 5b The axes of the implants were not parallel.
Fig 6 Infected implant sockets and peri-implant bone defect.
Fig 7a Implant surface decontamination with Er,Cr:YSGG irradia-
Fig 7b Socket decontamination with Er,Cr:YSGG irradiation.
The Journal of Oral Laser Applications Fig 8a Alveolar augmentation with bone substitutes.
Fig 8b Placement of collagen membrane.
Fig 9 Placement of the e-PTFE membrane over the collagen
Fig 10 Appearance of the augmented area after six weeks.
Due to inadequately attached gingiva, a second layer satisfactory for the patient in terms of function and es- consisting of e-PTFE membrane was placed for protec- thetics (Fig 14). Follow-up is planned after the first tion of the augmented area (Fig 9). The healing period phase of treatment, with intervals of three months.
was uneventful (Fig 10). After ten months, radiographic findings showed bone fill in the area of the removed implants and therewere no lesions around the remaining implants (Fig This case presents the possible clinical consequence of 11). Consequently, the first phase of the main therapy incorrect treatment planning, including keeping peri- was completed. The patient preferred to postpone the odontally affected teeth, improper prosthetic restora- complete treatment. tions, and non-parallel implant direction on the long- The mobile premolars and molars on the left side of term stability of dental implants. Fardal et al4 also pre- the mandible were splinted with fiber-supported com- sented a case with severe peri-implantitis in a patient posite restorations (Fig 12). The patient's current fixed with refractory periodontitis. They suggested that the partial denture with implant abutment was not re- remaining teeth had acted as a reservoir for periodon- placed, but was cemented again temporarily. tal pathogens involved in the peri-implantitis lesions. Occlusal adjustment was performed (Fig 13), due to There is considerable evidence to support a cause combination syndrome. This part of the therapy was and effect relationship between microbial colonization Vol 8, No 2, 2008

Fig 11 Bone fill and preservation of bone level at tenth months.
Fig 12a Fiber splint material.
Fig 12b Fiber-supported
uni-composite restoration to
stabilize mandibular left pre-
molar and molar.
Fig 13 Occlusal adjustment to eliminate primary contacts.
Fig 14 Esthetic appearance.
and the pathogenesis of implant failures.23-25 Deconta- done iodine (10%) was also used as an adjunct to sys- mination of structured implant surfaces is difficult to temic antibiotics, and although subsequent local achieve, since conventional mechanical treatment ap- metronidazole gel failed to stop the suppuration, it did proaches, such as plastic curettes, sonic/ultrasonic somewhat decrease it. At the same time, mechanical scalers, and air-powder flow, have been proven to be debridement was performed at every appointment.
insufficient for obtaining a complete removal and elimi- During the nonsurgical phase of therapy, ceasing the nation of both plaque biofilms and bacteria on rough- disease activity and elimination of infection was thus ened implant surfaces.26,27 The use of topical antiseptic achieved by diode laser (810 nm) irradiation.
agents and locally applied antibiotics is recommended During surgical-phase planning, it is essential for the for implant detoxification. Povidone iodine is widely clinician to recognize unhealthy implants and to deter- used as a topical antiseptic in medicine and potentially mine whether they are ailing, failing, or failed. Ailing beneficial in the management of some periodontal dis- and failing implants are amenable to therapy. Implants eases.28,29 Controlled release devices that contain diagnosed as failed should be removed. Extraction of metronidazole (25%) are also beneficial agents in an- implants may result in a severely deformed alveolar timicrobial periodontal therapy.30 In this case, povi- ridge, and restoration of these cases is usually difficult, The Journal of Oral Laser Applications because of oral hygiene, esthetic, and prosthetic prob- lems. The most important measure to this end is to de- 1. Albrektsson T, Zarb G, Worthington P f
contaminate implant and tissue surfaces beforehand, in , Eriksson AR. The long- term efficacy of currently used dent plants: a review and pro- order to enable bone regeneration to take place. With posed criteria of success. Int J Oral Maxillofac Im the help of Er,Cr:YSGG laser, decontamination was provided without producing any increase of tempera- 2. Leonhardt A, Adolfsson B, Lekholm U, We
om M, Dahlen G.
ture on the irradiated area.
A longitudinal microbiological study on osseointegrated titanium The combination of bone substitutes and a collagen implants in partially edentulous patients. Clin Oral Impl Res 1993;4:113-120.
membrane seems to be preferable in the surgical treat- 3. Danser MM, Van Winkelhoff AJ, Graaff J, Loos BG, Van der ment of peri-implantitis defects and socket augmenta- Velden U. Short-term effect of full-mouth extraction on peri- tion. In this context, it must also be emphasized that odontal pathogens colonizing the oral mucous membranes. J Clin membrane exposure has been reported to be a fre- quent complication.31 In the present case, successful 4. Fardal Ø, Johannessen AC, Olson I. Severe, rapidly progressing peri-implantitis. J Clin Periodontol 1999;26:313-317.
decontamination was achieved by laser. Subsequently, 5. Quirynen M, Listgarten MA. Distribution of bacterial morpho- augmentation of peri-implantitis defects was performed types around natural teeth and titanium implants ad modum with bone substitutes and double-layer membrane, Branemark. Clin Oral Impl Res 1990;1:8-12.
which resulted in decreased radiolucency within the im- 6. Sanchez-Garces MA, Gay-Escoda C. Periimplantitis. Med Oral plant sockets and gain in the alveolar bone height.
Patol Oral C›r Bucal 2004;9(supplement):63-74.
7. Meffert RM. Treatment of the ailing, failing implant. J Calif Dent Assoc 1992;20:42-45. 8. Meffert RM, Langer B, Fritz ME. Dental implants: a review. J Peri- 9. Meffert RM. Maintenance and treatment of the ailing and failing The development of laser assisted techniques in peri- implant. J Indiana Dent Assoc 1994;73:22-24.
odontology and implantology is directed towards mini- 10. Jovanovic SA. The management of peri-implant breakdown mally invasive procedures, with high success rates, around functioning osseointegrated dental implants. J Periodontol1993:64(supplement):1176-1183. which result in shorter healing periods, high patient 11. Torosian J, Rosenberg ES. The failing and failed implant: a clinical, comfort, and predictability of the final result. In the microbiologic, and treatment review. J Esthet Dent 1993;5:97- presented case, both diode and Er,Cr:YSGG lasers in the nonsurgical and surgical steps of the treatment 12. Branemark PI, Hansson B, Adell R, et al. Osseointegrated im- were used. The highest risk factor in the augmentation plants in the treatment of the edentulous jaw. Experience from a10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1- procedure and in regenerative periodontal surgery is infected implantation defects/sockets. Placement of the 13. Danesh-Meyer MJ. Dental Implants. Part I: Biological basis, im- bone substitutes and membranes into infected alveolar plant types, and the peri-implant sulcus. J N Z Soc Periodontol sockets would result in an unsuccessful treatment. In this case, laser decontamination was the only option 14. Matarasso S, Quaremba G, Coraggio F, et al. Maintenance of im- plants: an in vitro study of titanium implant surface modifications for a minimum-risk treatment, without losing soft and subsequent to the application of different prophylaxis proce- hard tissues and without the need for a second surgical dures. Clin Oral Impl Res 1996;7:64-72.
operation. Finally, proper attention to personal and 15. Rams TE, Link CC jr. Microbiology of failing dental implants in hu- professional plaque removal will allow the maintenance mans: electron microscopic observations. J Oral Implantol 1983;11:93-100. of a successful treatment outcome. Within the limits of 16. Rapley JW, Swan RH, Hollman WW et al. The surface character- the present case, it can be concluded that laser decon- istics produced by various oral hygiene instruments and materials tamination may be a favorable choice for elimination of on titanium implant abutments. Int J Oral Maxillofac Implants 17. Meffert RM. How to treat ailing and failing implants. Implant Dent 1992;1: 25-33.
18. Kreisler M, Kohnen W, Marinello C, Schoof J, Langnau E, Jansen B et al. Antimicrobial efficacy of semiconductor laser irradiationon implant surfaces. Int J Oral Maxillofac Implants 2003;18:706- The authors would like to thank Enver Atali, Electronic Engi., for his kindest technical support.
19. Walsh LJ. The use of laser in implantology: an overview. J Oral 20. Kreisler M, Al Haj H, d´Hoedt B. Temperature changes at im- plant bone interface during simulated surface decontaminationwith an Er:YAG laser. Int J Prosthodont 2002;15:582-587.
Vol 8, No 2, 2008 21. Goldman MJ. Bone regeneration around an ailing implant using 27. Greenstein G. Povidone-iodine's effects and role in the manage- guided bone regeneration. A case report. J Periodontol 1992; ment of periodont al diseases: a review C
eriodontol 1999;70: 22. Alcoforado GA, Rams TE, Feik D, Slots J. Microbial aspects of 28. Rosling B, Hellström MK, Ramberg P , Socransky SS, Lindhe J. The failing osseointegrated dental implants in humans. J Parodontol -iodine as an adjunct to non-surgical treatment of chronic periodontitis. J Clin P 23. Becker W, Becker BE, Newman MG, Nyman S. Clinical and mi- 29. Stelzel M, Flores-de-Jacoby L. T opical metr r
onidazole application crobiologic findings that may contribute to dental implant failure.
compared with subgingiv al scaling. J Clin P nce
Int J Oral Maxillofac Implants 1990;5:31-38.
24. Mombelli A, Buser D, Lang NP. Colonization of osseointegrated 30. Nociti FH Jr, Machado MAN, Stefani CM, Sallum EA, Sallum AW.
titanium implants in edentulous patients. Early results. Oral Mi- Absorbable versus nonabsorbable membranes and bone grafts in crobiol Immunol 1988;3:113-120.
the treatment of ligature-induced peri-implantitis defects in dogs.
25. Schwarz F, Sculean A , Romanos G, Her ten M, Horn N, Part I. A. clinical investigation. Clin Oral Impl Res 2001;12:115- Scherbaum W, Becker J. Influence of different treatment ap- proaches on the removal of early plaque biofilms and the viabilityof SAOS2 osteoblasts grown on titanium implants. Clin Oral In-vestig 2005;9:111-117.
Contact address: Professor E. Efeoglu, Buyukciftlik Sok.
26. Kreisler M, Kohnen W, Christoffers AB, Gotz H, Jansen B, No.6 Nisantasi/ Istanbul 34365, Turkey. Tel: +90-532-334- Duschner H, d'Hoedt B. In vitro evaluation of the biocompatibil- 03-58, Fax: +90-212-291-74-15. e-mail: e.efeoglu@superon- ity of contaminated implant surfaces treated with an Er: YAG line.com or [email protected] laser and an air powder system. Clin Oral Implants Res 2005;16:36-43.
The Journal of Oral Laser Applications

Source: http://jola.quintessenz.de/jola_2008_02_s0109.pdf