Bone Loss and Purulence Around Implant: Correct Procedure?

Unfortunately there is no predictable treatment for periimplantitis. Rinsing the pocket is usually uneffective, access surgery may provide better results. A resective surgical approach may be the most effective for wide infrabony defects but may result in unacceptable aesthetic outcomes (lenghtening of the crown and abutment/implant exposure) and also in an extra loss of bone. Regenerative treatments on dental implants are unpredictable and laser treatment is a hope. For minor defects I would consider laser/mechanical treatment, a strict follow-up of the patient and a lot of chlorhexidine. In case this turns out to be uneffective I would try with open flap surgery (decontamination of implant surface and removal of granulation tissue). Keep the antibiotics in the closet and good luck.

furthermore, check the occlusion

Agree first check the occlusion, this can be a big issue , then raise flap ,remove soft tissue clean the implant surface with a prophy jet ( blast clean )then graft (we use synthetics that set hard ) and hopefully healing can commence . We used this protocol and shown it on numerous occsions not ideal ( maybe more acceptable to the patient than trephining the implant out) but worked every time ( clear of infection and areas improved on x-ray within 2 weeks). Treated first case like this 5 years ago and she has had no problem since. Good luck

Peri-implantitis is an enigmatic problem that continues to haunt implantologists. Often traced to excess cement left behind. This problem recurs because the crown abutment margin is often hidden in the peri-implant sulcus in the name of an aesthetic emergence profile. This practice however lends itself to inaccessibility of the critical margin in implantology i.e. the margin through which the implant emerges through the gums, critical because in many cases proves to be the Achilles' heel of oral implants. This is the margin that is most susceptible to infection as in the case of real teeth and very much more so in oral implants. However the incidence is surprisingly less than is expected, but when it occurs is very taxing. It remains a major drawback in oral implantology that awaits an effective solution. After exposure and debriding of infected tissue and prophy jetting the surface, try etching with hydrofluoric acid before grafting and closure. Cheers!

first, I have used laser disinfection with about 50/50 results, but at least 50% of the time it does heal! it usually then has some recession, but infection gone pretty much for good. I agree with the point about this being more likely the further subgingival the margin. also, this is the advantage of the platform switch. Remember, an implant is not a tooth! a perfectly fitting margin of an implant crown cemented out to the edge like we would a crown on a tooth will always be more inflammed and irritated than if the crown is submarginal, but sealed. (the net effect of the platform switch) Designs that make the abutment do the platform switch are even better as the crown margin is fully un-involved. fmn

There is a protocol published by the San Antonio group (Mellonig and Meffert) regarding treating the ailing implant. You should be able to Google it or any good and current Perio and/or implant textbook will reference it. essentially: 1. surgically access the area 2. degranulate 3. detoxify with implant surface with Citric acid or tetracycline (my preference). some are advocating detos with Laser. 4. treat as a bone defect and complete GBR procedure. hope this helps Dr Karateew DDS, Dip Perio, Dip Prosth

I agree but hydrofluoric acid its hard to control and very agressive , we use citric acid instead. best luck

Resection of the soft tissue will be the only cure, but the aesthetics will then be a problem. The surface of the implant can't be cleaned, much like a the surface of a tooth. Usually the anterior implants have the micro-gap subgingival, and this harbors the periodontal pathogens (JP; 2006) The system you are using has a micro-gap of 10-15 microns. Oral pathogens are .8-1.0 microns in size. Find another system

All the above will be are excellent suggestions,however I would not only check occlusion but I would also suspect some type of parafunction. Place the pt in a nightguard with soft liner in the implant area to help prevent the damaging effects of parafuction.

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I have used the LANAP protocol around failing implants with good results. Science is attempting to catch up to clinical practice. This months JOP Background: The bacterial endotoxin lipopolysaccharide (LPS) represents a prime pathogenic factor of peri-implantitis because of its ability to adhere tenaciously to dental titanium implants. Despite this, the current therapeutic approach to this disease remains based mainly on bacterial decontamination, paying little attention to the neutralization of bioactive bacterial products. The purpose of the present study was to evaluate whether irradiation with low-energy neodymiumdoped: yttrium, aluminum, and garnet (Nd:YAG) laser, in addition to the effects on bacterial implant decontamination, was capable of attenuating the LPS-induced inflammatory response. Methods: RAW 264.7 macrophages or human umbilical vein endothelial cells were cultured on titanium disks coated with Porphyromonas gingivalis LPS, subjected or not to irradiation with the Nd:YAG laser, and examined for the production of inflammatory cytokines and the expression of morphologic and molecular markers of cell activation. Results: Laser irradiation of LPS-coated titaniumdisks significantly reduced LPS-induced nitric oxide production and cell activation by the macrophages and strongly attenuated intercellular adhesion molecule-1 and vascular cell adhesion molecule expression, as well as interleukin-8 production by the endothelial cells. Conclusion: By blunting the LPS-induced inflammatory response, Nd:YAG laser irradiation may be viewed as a promising tool for the therapeutic management of peri-implantitis. J Periodontol 2009;80:977-984.

Dear Frank Nelson, There are actually 2 critical margins to think about. The first one is the abutment-fixture margin that used to cause bone resorption up to 2mm away from it. Platform switching has solved this problem. The second one is the crown-abutment margin which is often hidden in the sulcus. This is the enigmatic problem that has yet to be resolved. In the natural tooth, the margin is hidden half a mm into the sulcus that makes it accessible and easy to maintain. In the implant especially with the emphasis on a good emergence profile, we have created an iatrogenic deep pocket in the name of aesthetics and on top of it hidden the crown-abutment margin deep into it. This has potential longterm consequences because of the possibility of excess cement left behind and in the case of screw retained, the microgap being colonised with microorganisms. Cheers to a successful resolution!

Unless you are going to get very agressive in the treatment of this lesion, the best bet is to extract the implant, graft, and replace it. The reason for this is that, in the presence of an inflammatory lesion, you will never get bone to grow back. You will start to see loss of both the facial and palatal plates as well as a zipping effect of bone on the adjacent teeth. Inflammatory cytokines are osteopromoters of osteoclastic activity. You can throw all of the chemotherapeutic agents you want to in this case, but it will not resolve. One of the things you did not state is the relative 3D positioning of the implant. Is the implant facially inclined? If so, there is no way to regrow the facial plate. Assuming that the implant is correctly placed within the alveolus, only definitive debridement of inflammatory tissue, bacterial endotoxins, and any other contaminants - COMBINED with a graft and membrane (preferably unloaded)- has any chance of resolving this problem. My instrument of choice is an ablative hard tissue laser. Our published SEM studies (Implant Dentistry 2004) prove the efficacy of this paradigm over the old Meffert protocol of citric acid. But you MUST use a completely resorbable graft (i.e. bTCP and NOT Bio-Oss) or the implant will not re-integrate. RJM

People have talked alot about surface detoxification with citric acid, could someone please outline the steps involved (detail please) and where you can get 40% citric acid? thanks

Like the other have said regarding the dental implant, check the occlusion and check for bruxism.

We've used the Citric acid protocol a couple of times with moderate success. We mixed it from powder form in sterile water. Saline might have been better? I've noticed some recommendations of debridement with the Cavitron in addition to the Citric acid & . Is your patient a smoker? (could we call smoking a form of parafunction? lol) It looks like the research is recommending Yd:YAG though. Maybe refer this patient to an OMFS as a 'possible method to preserve the implant'. Maybe your OMFS won't hate you after this! Good luck, it seems 50:50 no matter what you do.

Dr. Chow, Dr. Miller,et al, have you heard of casting the abutment as part of the crown, then retaining the whole thing with one screw? That would eliminate one set of problems... (creating a whole new set of problems and a huge lab bill...)

When we were using primarily screw retained restorations, most of the crowns we fabricated were cast with the abutments. It certainly simplified the restorative protocol. But it also created a new problem that we became sensitive to in later years. Assuming that the placement of the implant was close to ideal, the screw access was in the center of the central fossa. After torqing the screw, the access opening was then filled with a material that was relatively easy to remove if the screw ever needed to be tightened. Since these materials were relatively soft in comparison to porcelain, the central holding cusps of the opposing teeth would quickly wear the occlusal stop and the occlusion would change, often with an eccentric occlusal contact. This tended to loosen screws or, worse, resulted in porcelain fracture. Not to mention the constant negative comments from the patient about the opening that kept developing in the crown. This was the impetus towards moving to cement-on restorations. I will occasionally use screw retained restorations if they are fixed-detachable but in a single crown only if the intermaxillary space is less than 5mm. RJM

Dr. Miller, thanks. Your contributions are always informative. I didn't think about the occlusal change problems. That would tend to be a bigger problem than cement removal and subgingival plaque control. WaterPik rocks for gum health...

Expose the implant,make a good examination to decide if any grafting material can be put around( As in natural tooth 3 walls pocket),laser treat these areas,determine parts of the implant that should be left out of the bone and smooth it with burs(Implantoplasty),Clean the implant very good with normal saline jet,put your graft,and close the flap,you ll end with a longer exposed implant,not recommended in highly esthetic regions.