This case report describes the treatment of peri-implantitis lesions through a minimally invasive surgical procedure using a peri-implant excisional procedure and access surgery (PEAS). The prosthesis was disconnected, and the peri-implant granulation tissue removed after a peri-implant circular incision. Chemical debridement with hydrogen peroxide on a cotton ball and then mechanical debridement with a rotary round titanium brush and tufted brush with titanium bristles were conducted. The surgical intervention was effective in arresting the peri-implantitis. No further radiographic bone loss was observed over the 2-year follow-up period. This technique effectively cleans the contaminated implant surface, minimizes surgical morbidity, and allows for prosthesis delivery on the day of surgery. However, further studies with a larger sample size are needed to identify the reliability and validity of this novel technique.
Introduction
Having patients with peri-implantitis is now inevitable as implant therapy has become widespread. In a systematic review, the weighted mean prevalence of peri-implantitis was 21.7%, demonstrating a positive relationship between prevalence and time after loading at the patient level.1 Therefore, the necessity of active interventions to cope with peri-implantitis has increased.
Although implant restoration in the edentulous region has become a routine clinical procedure, the resolution of peri-implantitis has remained a challenging procedure even for experienced clinicians. After nonsurgical treatment of peri-implantitis, an attempt at a surgical approach is recommended if the pathology is not resolved.2 In many cases, a surgical approach is often required, and indeed, there have been reports about the limitations of nonsurgical treatment.3,4 In addition, in a case of peri-implantitis caused by residual cement, a surgical approach is straightforward to eliminate such local factors directly. Although the surgical protocol showed better clinical results, the outcomes of peri-implantitis treatment remain limited in the long term. In a previous study5 examining the results of surgical treatment of peri-implantitis, the 5-year implant survival rate was 88.9%, while the 5-year success rate was 53%, reflecting the difficulty of resolution of the lesion.
Accordingly, various techniques and surgical tools have been introduced and developed to increase the success rate of surgical treatment of peri-implantitis. In the conventional surgical approach of peri-implantitis, a full-thickness mucoperiosteal flap is raised after the intracrevicular incision and granulation tissue around the implant is removed with a curette. Decontamination of the exposed implant surface is applied with a chemical or mechanical method. Depending on the type of bone defect around the implant, a regenerative procedure can be performed.6
Recent periodontal surgery has focused on tissue preservation and reducing surgical morbidity. From this point of view, various flap designs, including a modified papilla preservation technique (MPPT),7 a simplified papilla preservation flap (SPPF),8 a minimally invasive surgical technique (MIST),9 and a modified MIST (M-MIST)10 have been proposed for tissue regeneration around the teeth with intrabony defects, demonstrating predictable outcomes. The advantage of the surgical approach is to improve postoperative wound stability and increase tissue intrinsic healing potential by minimizing the damage to the tissue and vascular systems while favoring the healing process of the tissue.
Unlike teeth, implants with a screw retained prosthesis can provide direct access to the pathology after removal of the prosthesis. Using these structural properties, the surgical procedure of a modified excisional new attachment procedure (ENAP) can be applied in peri-implantitis surgery. The inflammatory lesion can be excised, and the implant surface can be decontaminated, that is, the surgical protocol of peri-implantitis can be performed. Since this technique is a minimally invasive surgery, it also has the advantage of improving tissue healing.
The purpose of this clinical report is to describe a minimally invasive surgical procedure in peri-implantitis using a peri-implant excisional procedure and access surgery (PEAS) and to investigate the clinical outcomes of the surgical technique.
Clinical presentation
A female patient, 71 years of age, a nonsmoker, and with controlled diabetes mellitus (American Society of Anesthesiologists [ASA]-II following the classification of the American Society of Anesthesiologists),11 received single screw-retained metal-ceramic crowns supported by an external type dental implant in position #30 in another clinic 17 years ago. The patient has been enrolled in a recall maintenance program for 14 years. There has been a pathologic condition noted since April 2017, citing pain and bleeding on brushing in the right lower quadrant. During the first clinical examination, inflammatory signs including swelling, redness, and pus discharge was observed (Figure 1). In addition, probing depth (PPD) ≥5 mm and bleeding on probing (BOP) were observed and peri-implant bone loss was shown in the radiographic evaluation in position #30 (Figure 2). There was peri-implant marginal bone loss ≥2 mm mesially and distally to the aforementioned implant site. Based on these findings, the implant was diagnosed as peri-implantitis.
Figure 1. Clinical photograph before nonsurgical treatment. Inflammation signs including swelling, pus, and redness were observed. Figure 2. Radiographic photograph showing a crater-like peri-implant bone loss.
Figure 1. Clinical photograph before nonsurgical treatment. Inflammation signs including swelling, pus, and redness were observed. Figure 2. Radiographic photograph showing a crater-like peri-implant bone loss.
At baseline, nonsurgical treatment under local anesthesia with lidocaine containing 1:100 000 epinephrine was performed. The patient was informed about the clinical condition of the implants and oral hygiene instruction with an interdental brush was given. Four weeks later, re-evaluation was performed to decide whether to conduct surgical treatment (Figure 3). The implant showed bleeding on probing and pus discharge was observed (Figure 4). Therefore, it was decided to proceed to surgical treatment.
Figure 3. Clinical photograph before surgery. Figure 4. Pus discharge after local anesthesia. Figure 5. Prosthesis removal. Note the plaque accumulation around the prosthesis. Figure 6. Occlusal view after prosthesis removal. Figure 7. Peri-implant excisional procedure and access surgery (PEAS) was performed. Figure 8. The prosthesis was reconnected after the surgery.
Figure 3. Clinical photograph before surgery. Figure 4. Pus discharge after local anesthesia. Figure 5. Prosthesis removal. Note the plaque accumulation around the prosthesis. Figure 6. Occlusal view after prosthesis removal. Figure 7. Peri-implant excisional procedure and access surgery (PEAS) was performed. Figure 8. The prosthesis was reconnected after the surgery.
Local anesthesia was induced with lidocaine containing 1:100 000 epinephrine. The implant prosthesis was removed (Figures 5 and 6) and then a peri-implant circular incision was made (Figure 7). Subsequently, granulation tissue around the implant was completely removed using a curette. Chemical debridement using hydrogen peroxide on a cotton ball was performed for 1 minute. After mechanical debridement, thorough debridement of the implant surface was made with two types of rotary brush connected to a surgical handpiece under saline irrigation. A round rotary brush (R-brush, Neobiotech, Seoul, Korea) was applied at the suprabony defect and a tufted brush with titanium bristles (TN-brush, Dentium, Seoul, Korea) was applied at the intrabony defect to remove locally contaminated factors. Subsequently, ample irrigation with sterile saline was conducted to purge the surgical site. The implant prosthesis was delivered after thorough debridement and sterilization with chlorhexidine and the screw access hole was filled with Teflon and resin (Figure 8). Sutures were not made around the surgical site. Finally, minocycline hydrochloride ointment (Dongkook Pharmaceutical, Seoul, Korea) was applied to the surgical site. Antibiotic therapy was prescribed using 100 mg of cefdinir and analgesic therapy with 650 mg of acetaminophen 3 times daily from the surgery day for 7 days. Use of a mouth rinse twice a day with 0.2% chlorhexidine solution for 1 minute was also prescribed after the surgery.
The patient was placed on a tailored professional maintenance program with 3-month periodic care. The implant showed clinical stability, with no pus discharge or spontaneous bleeding. Probing pocket depth (PPD) was decreased from baseline to 24 months follow-up. Marginal mucosal recession (REC) of 1 mm was observed at the mid-lingual site at the 12-month follow-up and 1 mm of REC at the mid-buccal site and 2 mm of REC at the mid-lingual site at the 24-month follow-up (Table 1, Figure 9). Her modified sulcus bleeding index (mSBI)12 score was 3 from baseline to the 6-month follow-up; however, the parameter was decreased to 0 or 1 at the 12- or 24-month follow-up. Her full mouth plaque index (FMPI) was 32% at baseline; however, the percentage was decreased to approximately 20% at the next follow-ups. A radiographic examination was obtained 2 year after the surgery, showing peri-implant bone fill at the mesial or distal site. The crater-like shape of the bone loss had changed to a horizontal bone loss pattern and the bottom of the defect was shifted a little upwards (Figures 2 and 10).
Figure 9. Clinical photograph 2 year after the surgery. Note the marginal mucosal recession at the buccal site. Figure 10. Radiographic photograph 2 year after the surgery. Note that the crater-like shape bone loss has changed to a horizontal bone loss pattern and the bottom of the defect has shifted a little upwards.
Figure 9. Clinical photograph 2 year after the surgery. Note the marginal mucosal recession at the buccal site. Figure 10. Radiographic photograph 2 year after the surgery. Note that the crater-like shape bone loss has changed to a horizontal bone loss pattern and the bottom of the defect has shifted a little upwards.
Discussion
Peri-implantitis is defined as a pathologic condition associated with a clinical manifestation of inflammation in peri-implant tissue along with progressive bone loss.13–15 Nonsurgical treatments including scaling, topical antibiotics, or systemic antibiotics may not be effective in resolving or reversing the progression of bone loss, and persistent bone loss can lead to loss of the implant. In this case report, minimally invasive surgical treatment was performed since the pathology of the peri-implant was not resolved after nonsurgical treatment.
Numerous methods have been suggested for implant surface decontamination, including mechanical methods, chemical methods, lasers, and photodynamic therapy. 16 However, as of yet, clearly neither method have been shown superior clinical results.17 To improve the clinical outcome, combination with chemical and mechanical debridement was performed to reduce local factors in this case report.
Decontamination of the implant surface can be challenging for the clinicians due to the differences of topography and surface structure of dental implants from that of the natural tooth. It has been demonstrated that it would be difficult to access an implant with a deep probing depth and decontaminate it unlike for natural teeth.5 In addition, the suprastructure of a dental implant can affect its accessibility to decontaminate the implant surface. A recent review recommended removal of the suprastructure when performing the surgical treatment for increased accessibility and cleansability.18 In this case report, the prosthesis was removed to improve surface decontamination of the implant fixture and to cleanse the local factors attached to the suprastructure. However, restorations with new and polished surfaces might be better for long-term survival of the restorations. A comparative study to evaluate the effect of the new prosthesis to the peri-implantitis treatment outcomes should be performed in the future.
The flap design can be modified to a less invasive method compared to previous studies by removing the suprastructure.19–21 Unlike natural teeth, the removal of the suprastructure of the implant restoration allows access to the implant fixture surface without horizontally or vertically extending the incision. In addition, the PEAS technique enabled a suprastructure connection on the day of peri-implantitis surgery, minimizing any change of the position of the opposite teeth.
Titanium ions generated by the process of biocorrosion in the peri-implantitis site may be present in the peri-implant soft tissue. It has been demonstrated that a high concentration of titanium ions can reduce the viability of gingival epithelial cells and induce necrosis.22 As the soft tissue is considered to be the primary physical barrier, when performing surgical treatment of peri-implantitis, the metal ions should be eliminated. Following this biologic rationale, the peri-implant soft tissue was removed followed by a peri-implant circular incision.
The PEAS technique has limitations in that it can only be applied to the implant from which the suprastructure can be removed. If it is difficult to remove the suprastructure because it is the cementation type, it would be necessary to perform conventional peri-implantitis surgery. In addition, the inherent limitation of a case report, it cannot be concluded that it is applicable to all clinical situations. Therefore, further studies with larger sample sizes and prospective design are needed to identify the reliability and validity of this novel technique related with defect size or morphology.
Conclusion
The PEAS technique presents a favorable resolution of peri-implantitis in the mandibular posterior area without progressive bone loss. A minimally invasive surgical procedure with thorough debridement with a rotary round brush and a tufted brush with titanium bristles produced good clinical results and reduced patient morbidity. In addition, good oral hygiene and a maintenance program should be conducted to guarantee the clinical outcomes of peri-implantitis treatment.
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References
Acknowledgments The authors declare no conflicts of interest.
