Surgical therapy of peri-implantitis lesions by means of a bovine-derived xenograft: comparative results of a prospective study on two different implant surfaces

Impact of surface chemical treatment in surgical regenerative treatment of ligature-induced peri-implantitis: A canine study

BACKGROUND

Implant surface decontamination is a critical step in peri-implantitis treatment. The aim of this study was to assess the effect chemotherapeutic agents have on reosseointegration after treatment on ligature-inducted peri-implantitis.

METHODS

Six male canines had 36 implants placed and ligatures were placed around them for 28 weeks to establish peri-implantitis. The peri-implant defects were randomly treated by 1 of 3 methods: 0.12% chlorhexidine (CHX test group), 1.5% sodium hypochlorite (NaOCl test group), or saline (Control group). Sites treated with NaOCl and CHX were grafted with autogenous bone, and all sites then either received a collagen membrane or not. Histology sections were obtained at 6 months postsurgery to assess percentage of reosseointegration.

RESULTS

Thirty-five implants were analyzed (CHX: 13; NaOCl: 14; Control:8). NaOCl-treated sites demonstrated reosseointegration with direct bone-to-implant-contact on the previously contaminated surfaces (42% mean reosseointegration), which was significantly higher than Controls (p < 0.05). Correspondingly, clinical improvement was noted with a significant reduction in probing depth from 5.50 ± 1.24 mm at baseline to 4.46 ± 1.70 mm at 6-months postsurgery (p = 0.006). CHX-treated sites demonstrated a nonsignificant reosseointegration of 26% (p > 0.05); however, in the majority of cases, the new bone growth was at a distance from the implant surface without contact. Probing depths did not improve in the CHX group. The use of membrane did not influence reosseointegration or probing depths (all p > 0.05).

CONCLUSION

Titanium implants with peri-implantitis have the capacity to reosseointegrate following regenerative surgery. However, treatment response is contingent upon the chemotherapeutic agent selection. Additional chemical treatment with 1.5% NaOCl lead to the most favorable results in terms of changes in defect depth and percentage of reosseointegration as compared to CHX, which may hinder reosseointegration.

Surgical treatment of peri-implantitis

As utilisation of dental implants continues to rise, so does the incidence of biological complications. When peri-implantitis has already caused extensive bone resorption, the dentist faces the dilemma of which therapy is the most appropriate to maintain the implant. Since non-surgical approaches of peri-implantitis have shown limited effectiveness, the present paper describes different surgical treatment modalities, underlining their indications and limitations. The primary goal in the management of peri-implantitis is to decontaminate the surface of the infected implant and to eliminate deep peri-implant pockets. For this purpose, access flap debridement, with or without resective procedures, has shown to be effective in a large number of cases. These surgical treatments, however, may be linked to post-operative recession of the mucosal margin. In addition to disease resolution, reconstructive approaches also seek to regenerate the bone defect and to achieve re-osseointegration.

Etiology, pathogenesis and treatment of peri-implantitis: A European perspective

Peri-implantitis is a plaque-associated pathological condition occurring in tissues around dental implants. It is characterized by inflammation in the peri-implant mucosa and progressive loss of supporting bone. Over the last 30 years, peri-implantitis has become a major disease burden in dentistry. An understanding of the diagnosis, etiology and pathogenesis, epidemiology, and treatment of peri-implantitis must be a central component in undergraduate and postgraduate training programs in dentistry. In view of the strong role of European research in periodontology and implant dentistry, the focus of this review was to address peri-implantitis from a European perspective. One component of the work was to summarize new and reliable data on patients with dental implants to underpin the relevance of peri-implantitis from a population perspective. The nature of the peri-implantitis lesion was evaluated through results presented in preclinical models and evaluations of human biopsy material together with an appraisal of the microbiological characteristics. An overview of strategies and outcomes presented in clinical studies on nonsurgical and surgical treatment of peri-implantitis is discussed with a particular focus on end points of therapy and recommendations presented in the S3 level Clinical Practice Guideline for the prevention and treatment of peri-implant diseases.

A longitudinal analysis of the impact of nonsurgical and surgical treatment of peri-implantitis upon clinical parameters and implant stability quotient values. A 2-3-year follow-up

OBJECTIVES

In this study, the aim was to investigate the medium- to long-term impact of peri-implantitis treatment upon clinical parameters and implant stability quotient values and to ascertain if magnetic resonance frequency analysis can be used as a diagnostic tool to demonstrate postoperative healing following treatment of peri-implantitis.

MATERIALS AND METHODS

A total of n = 26 patients (n = 86 implants) diagnosed with peri-implantitis were recruited for this prospective cohort study and four different treatment modalities were used. Baseline measurements of a number of clinical parameters as well as implant stability measurements in the form of ISQ were recorded. These measurements were repeated at 6, 12, and 24-36 months following treatment. Analysis of variance was performed for all implants treated as well as separately for each treatment modality. A regression model was also used to determine factors affecting ISQ measurements over time.

RESULTS

Treatment of peri-implantitis resulted in significant improvements of both average PPDs and BOP (p < .0001 and p < .01). ISQ values marginally improved initially for all treatment modalities, but improvement was only maintained for 2-3 years in treatment modalities I (+1.28), III (+1.49), and IV (+2.92). There was a statistically significant negative linear correlation between average PPD and the ISQ values recorded both at baseline (r = -.618, p < 0.0001) and at 2/3 years (r = -.604, p < 0.0001).

CONCLUSION

Over the 2-3-year follow-up period, all four treatment modalities led to improved clinical and radiographic peri-implant parameters but implant stability posttreatment, as indicated by the fact that the recorded ISQ scores remained stable. As a result, use of MRFA as an adjunct to the traditionally used periodontal and radiographic tools for the evaluation of postoperative implant stability following the treatment of peri-implant disease cannot be recommended.

In Vitro Handling Characteristics of a Particulate Bone Substitute for Ridge Preservation Procedures

While particulate bone substitute materials are applied in a variety of augmentation procedures, standardized defects are being used for preclinical testing. This in vitro study evaluated the density and homogeneity of a particulate bone substitute in ridge preservation procedures. Premolars and molars were extracted in ten semimandibles of minipig cadavers. Light body impression material was used for determining the volume of the extraction sites followed by augmentation with particulate material, thereby weighing the graft material needed. Microradiographs and histologic sections were obtained for evaluating the homogeneity and density of the augmentation material. Statistical analyses were based on Shapiro-Wilk tests, Spearman's rho and one sample Wilcoxon test followed by Bonferroni-Holm correction for multiple testing (α = 0.05). Based on 103 single alveoli evaluated, the mean volume determined was 0.120 cm3 requiring a mean amount of graft material of 0.155 g. With only three exceptions, all parameters (volume, mass of augmentation material, density and homogeneity) correlated significantly (p < 0.020). The apical parts of the alveoli showed reduced density as compared to the middle parts (p < 0.001) and the homogeneity of the augmentation material was also lower as compared to the middle (p < 0.001) and cervical parts (p Collapse

Key Words

• alveolar ridge augmentation
• bone substitute materials
• ridge preservation

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Affiliation(s)

Samira Dahl
Virgilia Klär-Quarz
Annika Schulz
Matthias Karl
Tanja Grobecker-Karl Department of Prosthodontics, Saarland University, 66421 Homburg, Saar, Germany; (S.D.); (V.K.-Q.); (A.S.); (M.K.)

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Supportive care for the prevention of disease recurrence/progression following peri-implantitis treatment: A systematic review

OBJECTIVES

This systematic review aimed to evaluate the efficacy of supportive care provision, frequency and protocol in patients treated for peri-implantitis, as reported in prospective and retrospective studies of at least 3-years duration.

MATERIALS AND METHODS

A systematic search of three electronic databases was undertaken up to 21 July 2022 and supplemented by hand-search to identify studies that included participants treated for peri-implantitis and followed for at least 3 years. Owing to high heterogeneity, a meta-analysis was not appropriate, and therefore, data and risk of bias were explored qualitatively. PRISMA guidelines for reporting were followed.

RESULTS

The search identified 2596 studies. Of 270 records selected during screening, 255 were excluded through independent review and 15 studies (10 prospective and 5 retrospective, with at least 20 patients) were retained for qualitative assessments. Study designs, population characteristics, supportive care protocols and reported outcomes varied markedly. Thirteen of the 15 studies had low risk of bias. Supportive peri-implant care (SPIC) following different surgical peri-implantitis treatment protocols and with recall intervals varying between 2 months and annually resulted in peri-implant tissue stability (no disease recurrence or progression) ranging from 24.4% to 100% at patient level and from 28.3% to 100% at implant level. Sevenhundred and eighty-five patients with 790 implants were included in this review.

CONCLUSIONS

Provision of SPIC following peri-implantitis therapy may prevent disease recurrence or progression. Insufficient evidence is available to identify (i) a specific supportive care protocol for secondary prevention of peri-implantitis, (ii) the effect of adjunctive local antiseptic agents in the secondary prevention of peri-implantitis and (iii) the impact of frequency of supportive care measures. Prospective, randomised, controlled studies designed to evaluate supportive care protocols are needed in future.

Reconstructive Peri-Implantitis Therapy by Using Bovine Bone Substitute with or without Hyaluronic Acid: A Randomized Clinical Controlled Pilot Study

BACKGROUND

The present pilot study aimed to assess clinical and radiographic efficiencies of bovine bone substitute (BBS) merged with hyaluronic acid (HA) in peri-implantits reconstructive surgery.

METHODS

Peri-implantitis (diagnosed 6.03 ± 1.61 years of implant loading) bone defects were randomly treated either with BBS plus HA (test group) or BBS alone (control group). Clinical parameters including peri-implant probing depth (PPD), bleeding on probing (BOP), implant stability (ISQ), and radiographic changes in vertical and horizontal marginal bone (MB) levels were assessed at six months postoperatively. New temporary and permanent screw-retained crowns were made at two weeks and three months postoperatively. Data were analyzed using parametric and non-parametric tests.

RESULTS

In both groups, 75% of patients and 83% of implants achieved treatment success after six months (no BOP, PPD <5 mm, and no further MB loss). Clinical outcomes improved over time within groups; however, without significant difference between them. ISQ value obtained significant increases in the test compared to the control group at six months postoperatively (p < 0.05). The vertical MB gain was significantly greater in the test group compared to the control (p < 0.05).

CONCLUSIONS

Short-term outcomes suggested that BBS merged with HA could improve clinical and radiographic outcomes in peri-implantitis reconstructive therapy.

The efficacy of bone reconstructive therapies in the management of peri-implantitis. A systematic review and meta-analysis

AIM

To evaluate the efficacy of bone reconstructive procedures for the reduction of probing pocket depth (PPD), bleeding on probing (BOP), and suppuration in peri-implantitis-related bone defects at ≥12-month follow-up.

MATERIALS AND METHODS

Three databases were searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared bone reconstructive therapies to access flap surgery (AFS) (Focused Question-FQ 1), and RCTs, CCTs, and prospective case series that assessed the efficacy of reconstructive therapies (FQ 2). Meta-analysis was performed for FQ1 when more than three studies were identified, while for FQ2 a network was drawn based on RCTs with common treatment arms.

RESULTS

Seven RCTs were identified for FQ1 while five RCTs and six prospective case series for FQ2. There was no significant difference in PPD change between AFS and reconstructive surgery (-0.387; p = .325) at 12 months. Furthermore, no clear differences in terms of PPD and BOP changes resulted from the different reconstructive therapies included in the network. Only a small percentage of treated cases with any modality achieved peri-implantitis resolution, as defined by different composite outcomes.

CONCLUSIONS

Reconstructive surgery does not offer significant improvements in peri-implant clinical parameters as compared to AFS at 12 months. It was not possible to establish a hierarchy of efficacy among the different biomaterials employed for reconstructive surgery.

Peri-Implantitis Regenerative Therapy: A Review

Simple Summary

Regenerative therapies are one of the options to treat peri-implantitis diseases that cause peri-implant bone loss. This review reports classic and current literature to describe the available knowledge on regenerative peri-implant techniques.

Abstract

The surgical techniques available to clinicians to treat peri-implant diseases can be divided into resective and regenerative. Peri-implant diseases are inflammatory conditions affecting the soft and hard tissues around dental implants. Despite the large number of investigations aimed at identifying the best approach to treat these conditions, there is still no universally recognized protocol to solve these complications successfully and predictably. This review will focus on the regenerative treatment of peri-implant osseous defects in order to provide some evidence that can aid clinicians in the approach to peri-implant disease treatment.

Reconstructive treatment of peri-implantitis infrabony defects of various configurations: 5-year survival and success

Aim

To present the 5 years outcomes of a reconstructive surgical protocol for peri‐implantitis defects with different morphologies, by means of deproteinized bovine bone mineral with 10% collagen (DBBMC).

Material and Methods

The original population of this case series consisted of 75 patients with one crater‐like defect and probing depth (PD) ≥6 mm. After flap elevation, defects were assigned to one characteristic class and treated by means of DBBMC. Following healing, patients were enrolled in an individualized supportive periodontal/peri‐implant (SPT) program.

Results

Fifty‐one patients reached the 5 years examination, as 11 patients were lost to follow‐up and 13 implants were removed. Overall treatment success was registered in 29 patients (45.3%). Mean PD and BOP significantly decreased at one year and remained stable for the rest of observation period. No correlation was found between implant survival rate and defect configuration (p = 0.213). Patients, who did not fully adhere to the SPT, experienced more complications and implant loss than those who regularly attended recall appointments (p = 0.009).

Conclusions

The proposed reconstructive treatment resulted in a high 5 years implant survival rate in patients who fully adhered to SPT. The resolution of the peri‐implantitis defect does not seem significantly associated with the defect configuration at the time of treatment.

Resolution of peri-implantitis by means of implantoplasty as adjunct to surgical therapy: A retrospective study

BACKGROUND

There is a paucity of data on the effectiveness of implantoplasty as adjunct to the surgical management of peri-implantitis.

PURPOSE

To evaluate the resolution of peri-implantitis by means of implantoplasty as adjunct to surgical resective (RES) and reconstructive (REC) therapies and supportive maintenance.

METHODS

Patients that underwent surgical therapy to manage peri-implantitis with a follow-up of ≥12 months and enrolled in a regular peri-implant supportive care were recruited. RES group consisted of two interventions that included osseous recontouring and apically position flap (APF) and soft tissue conditioning (STC). REC was performed in the infra-osseous compartment of combined defects. Implant survival rate was recorded. Clinical and radiographic parameters were evaluated to define a "dogmatic" (case definition #1) and a "flexible" (case definition #2) therapeutic success. Univariate and multivariate multilevel backward logistic regression were applied for statistical analysis.

RESULTS

Overall, 43 patients (n_implants  = 135) were retrospectively assessed. Mean observational period was ∼24 months. Implant survival rate was 97.8%, being significantly higher for APF, STC, and APF + STC (RES) when compared with REC (P = 0.01) therapy, in particular for advanced lesions (>50% of bone loss). The overall therapeutic success rate at implant-level was 66% and 79.5% for case definition #1 and #2, respectively. APF group displayed more efficient disease resolution when considered success definition #1 (72%). Contrarily, when the data were adhered to success definition #2, STC group showed a slightly higher disease resolution rate (87%). For RES group, location, favoring anterior (P = 0.04) and defect type, favoring class II (P = 0.02) displayed statistical significance for therapeutic success. For REC group, implants exhibiting a wider band of keratinized mucosa (KM) demonstrated higher therapeutic success (P = 0.008).

CONCLUSION

Implantoplasty as an adjunct to surgical therapy proved effective in terms of disease resolution and implant survival rate. Implant location, defect morphology as well as the buccal width of KM are indicators of therapeutic success.

Peri-Implantitis: A Clinical Update on Prevalence and Surgical Treatment Outcomes

Dental implants may be considered a reliable routine procedure in clinical practice for the replacement of missing teeth. Results from long-term studies indicate that implant-supported dental prostheses constitute a predictable treatment method for the management of fully and partially edentulous patients. Implants and their restorations, however, are not free from biological complications. In fact, peri-implantitis, defined as progressive bone loss associated to clinical inflammation, is not a rare finding nowadays. This constitutes a concern for clinicians and patients given the negative impact on the quality of life and the sequelae originated by peri-implantitis lesions. The purpose of this narrative review is to report on the prevalence of peri-implantitis and to overview the indications, contraindications, complexity, predictability and effectiveness of the different surgical therapeutic modalities to manage this disorder.

Surface Topography of Titanium Affects Their Osteogenic Potential through DNA Methylation

It is widely accepted that sandblasted/large-grit/acid-etched (SLA) surfaces of titanium (Ti) have a higher osteogenic potential than machined ones. However, most studies focused on differential gene expression without elucidating the underlying mechanism for this difference. The aim of this study was to evaluate how the surface roughness of dental Ti implants affects their osteogenic potential. Mouse preosteoblast MC3T3-E1 cells were seeded on machined and SLA Ti discs. The cellular activities of the discs were analyzed using confocal laser scanning microscopy, proliferation assays, and real-time polymerase chain reaction (PCR). DNA methylation was evaluated using a methylation-specific PCR. The cell morphology was slightly different between the two types of surfaces. While cellular proliferation was slightly greater on the machined surfaces, the osteogenic response of the SLA surfaces was superior, and they showed increased alkaline phosphatase (Alp) activity and higher bone marker gene expression levels (Type I collagen, Alp, and osteocalcin). The degree of DNA methylation on the Alp gene was lower on the SLA surfaces than on the machined surfaces. DNA methyltransferase inhibitor stimulated the Alp gene expression on the machined surfaces, similar to the SLA surfaces. The superior osteogenic potential of the SLA surfaces can be attributed to a different epigenetic landscape, specifically, the DNA methylation of Alp genes. This finding offers novel insights into epigenetics to supplement genetics and raises the possibility of using epidrugs as potential therapeutic targets to enhance osteogenesis on implant surfaces.

Changes in the surface topography and element proportion of clinically failed SLA implants after in vitro debridement by different methods

OBJECTIVE

To evaluate the surface topography and element proportion changes in clinically failed implants after different modalities in vitro debridement and to compare the cleaning effect of different method combinations.

MATERIAL AND METHODS

Thirty clinical failed implants were treated by different debridement methods in vitro as follows: Group 1: physiologic saline irrigation; Group 2: glycine powder air polishing; Group 3: glycine powder air polishing + ethylenediaminetetraacetic acid (EDTA); Group 4: polyetheretherketone (PEEK) tip ultrasonic scaling; and Group 5: PEEK tip ultrasonic scaling + EDTA. The relative contaminated area reduction (RCAR), visual analogue scale (VAS, the higher value means, the better cleaning effect) and surface roughness were assessed using scanning electron microscopy (SEM), stereoscopic microscopy (SM) and white light interferometry (WLI). Surface chemistry was determined by energy dispersive spectroscopy (EDS).

RESULTS

Group 4 and Group 5 showed higher RCARs (82.90%, 82.89%), VAS scores (2.61, 2.33) and roughness reductions (-0.85 μm, -1.80 μm). Group 3 attained the highest decrease of C% (carbon, -26.67%), O% (oxygen, -13.71%) and N% (nitrogen, -5.66%), and the highest increase of Ti% (titanium, 49.67%). PEEK remnants were detected on the implant surface of Groups 4 and 5.

CONCLUSION

Within the limitation of the present in vitro design, PEEK tip ultrasonic scaling was more effective in eliminating visible contamination, while glycine powder air polishing combined with EDTA treatment was more conducive to expose the original surface element distribution. Both methods have their own advantages in decontamination, but none of them could reconstruct the surface as the pristine implant.

Sub-Periosteal Peri-Implant Augmented Layer Technique to Treat Peri-Implantitis Lesions

INTRODUCTION

The efficacy of surgical regenerative procedures to treat peri-implantitis lesions has been extensively reviewed. Regenerative treatment showed a variable rate of success, in terms of pocket reduction, gain in bone support, and elimination of signs of infection/inflammation. The aim of the present case report is to illustrate the use of the sub-periosteal peri-implant augmented layer (SPAL) technique to correct peri-implantitis defects CASE PRESENTATION: Surgical treatment of three class Ib and one class Ic peri-implantitis lesions in three patients was performed by means of the SPAL technique. A partial-thickness flap was elevated, leaving the periosteal layer on the buccal cortical bone plate. The periosteal layer was in turn elevated to create a pouch, which was used to stabilize a bovine-derived xenograft (deproteinized bovine bone mineral) at the peri-implant buccal bone defect. No barrier membrane was used. In case of insufficient dimensions of peri-implant mucosa, a connective tissue graft (CTG) was buccally positioned at the most coronal portion of the implant. Treatment resulted in substantial reconstruction of peri-implant support associated with reduced probing depth and absence of inflammation.

CONCLUSIONS

SPAL technique with or without additional CTG may be a suitable option to obtain clinical remission of peri-implantitis defects associated with buccal bone dehiscence.

Peri-Implant Diseases: Diagnosis, Clinical, Histological, Microbiological Characteristics and Treatment Strategies. A Narrative Review

Since the use of dental implants is continuously increasing, it is imperative for dental practitioners to understand the nature and treatment of peri-implant diseases. The purpose of this manuscript is to comprehensively review peri-implant diseases, their characteristics, as well as their non-surgical and surgical treatment. To that end, the current literature was searched and a narrative review was conducted. It is essential that the case definitions described in the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions are used to diagnose and classify peri-implant health, peri-implant mucositis and peri-implantitis. While recent epidemiologic studies on peri-implant diseases exist, there is great heterogeneity in the definition of these conditions. Several risk factors and indicators are reported in the literature, with smoking and diabetes being the most universally accepted. In peri-implant mucositis, non-surgical treatment seems to be sufficient. However, for the treatment of peri-implantitis, a surgical approach, which includes open-flap debridement, apically positioned flap and guided bone regeneration, is considered more appropriate. A great variety of adjuncts to mechanical treatment have been reported with controversial results. Finally, studies comparing results from different peri-implantitis treatments are warranted in randomized controlled clinical trials in order to provide stronger evidence-based approaches.

The influence of implant surface roughness on decontamination by antimicrobial photodynamic therapy and chemical agents: A preliminary study in vitro

BACKGROUND

The aim of this preliminary study was to analyze the effectiveness of three different protocols of decontamination on five commercial moderate rough implants.

MATERIAL AND METHODS

The types of implants investigated were: Neoporos Drive CM (CM; Neodent®), Drive CM Acqua (ACQ; Neodent®), SLActive (SLA; Straumann®), Osseotite (OT; Biomet 3i®) and Nanotite (NT; Biomet 3i®). Implant surface properties (n = 2/type of implant; control groups) were analyzed by scanning electron microscopy (SEM) images to determine surface roughness parameters (SRP) and energy disperse X-ray spectrometry to determine the chemical composition. Implants were then inoculated with Aggregatibacter actinomycetencomitans in vitro (n = 6/type of implant;experimental groups) and the contaminated areas were determined in SEM images (500x magnifications). Decontamination of implants was performed in duplicate by three protocols: antimicrobial photodynamic therapy (aPDT), EDTA associated with citric acid (EDTA + CA) and 0.12 % chlorhexidine (CHX). The remaining contaminated area (rCtA) was determined in SEM images (500x magnifications). All quantitative analysis through SEM images were analyzed in ImageJ® software for two-dimensional parameters.

RESULTS

No significant differences were found in SRP among implants (control group), except for Rv (lowest valley) between SLA vs. OT (p=0.0031; Kruskal Wallis post hoc Dunn). NT implants showed highest contaminated area vs. ACQ implants (68.19 % ± 8.63 % and 57.32 % ± 5.38 %, respectively; p = 0.0016, Tukey's test). SRP after decontamination showed statistical difference for Ra (arithmetical mean deviation) for all decontamination groups when compared to control (p < 0.05; ANOVA with post-hoc Tukey's multiple comparisons test), only CM implants showed statistical difference when compared decontamination protocols to control with highest modification of SRP for EDTA + AC group. For decontamination analysis, for applicability of different protocols in the same type of implant, only SLA showed statistical significant difference for aPDT vs. EDTA + CA (p = 0.0114; ANOVA with post-hoc Tukey's multiple comparisons test) with lowest rCTA for aPDT, however for ACQ implants the aPDT showed lowest rCTA with no statistical difference (p > 0.05; ANOVA with post-hoc Tukey's multiple comparisons test). No statistical difference was observed between the decontamination protocols at other implant types.

CONCLUSION

It can be suggested that the chemical-physical characteristics of dental implants can be effected by the process of contamination and decontamination by aPDT and chemical agents.

Surgical treatment of peri-implantitis defects with two different xenograft granules: A randomized clinical pilot study

Objectives

To investigate whether xenograft EB (EndoBon) is non‐inferior to xenograft BO (Bio‐Oss) when used in reconstructive surgery of peri‐implant osseous defects.

Materials and methods

Dental patients with one implant each demonstrating peri‐implantitis were randomized to receive surgical debridement and defect fill with either BO or EB. Changes in bone level (BL) and intrabony defect depth (IDD) evaluated radiographically were the primary outcomes. The secondary outcomes included changes in probing pocket depth (PPD), bleeding on probing (BoP), and suppuration on probing (SoP). All outcomes were recorded before treatment and at 6 and 12 months post‐treatment.

Results

Twenty‐four patients (n = 11 BO, n = 13 EB) completed the study. Both groups demonstrated significant within‐group improvements in all clinical and radiographic parameters at 6 and 12 months (p ≤ .001). At 12 months, both groups presented with IDD reductions of 2.5–3.0 mm on average. The inter‐group differences were not statistically significant at all time points and for all the examined parameters (p > .05). While the radiographic defect fill in both groups exceeded > 1 mm and can be considered treatment success, successful treatment outcomes as defined by Consensus Reporting (no further bone loss, PPD ≤ 5 mm, no BOP, and no SoP) were identified in 2/11 (18%) BO and 0/13 (0%) EB individuals (Fisher's exact test, p = .199).

Conclusions

Within the limitations of this pilot study, the application of xenograft EB showed to be non‐inferior to xenograft BO when used in reconstructive surgery of peri‐implant osseous defects.

Successful Management of Peri-Implantitis around Short and Ultrashort Single-Crown Implants: A Case Series with a 3-Year Follow-Up

Introduction and Aim

In case of peri-implantitis, resective surgery is contraindicated for short and ultrashort implants, limiting the treatment options to regenerative surgery or to implant removal. This retrospective case series presents the clinical and radiographic outcomes of a surgical regenerative procedure to treat peri-implantitis around short and ultrashort implants.

Materials and Methods

The study is a retrospective evaluation of patients suffering from peri-implantitis and those who underwent access flap surgery, concomitant chemical and mechanical decontamination of implant surface, and bone grafting using a self-hardening mixture of bone substitutes and biphasic calcium sulfate. No membranes were applied to cover the grafting material, and primary tension-free closure was achieved. The retrospective protocol was reviewed and approved by the Ethics Committee for Clinical Sperimentation (CESC) of Verona and Rovigo, Italy (based in the University of Verona) (Prog. 1863CESC. Date of approval: 2018-07-04).

Results

15 patients (17 implants) have been diagnosed with peri-implantitis after a mean follow-up of 24 months after loading. Implant length was between 5 and 8 mm. 8 patients (10 implants) had a history of periodontitis. At baseline, the mean PD (probing pocket dept) at the deepest site was 8.12 mm, with an average mBI (modified bleeding index) of 2.35 and a mean BD (bone defect depth) of 3.04 mm. At the 3-year follow-up, the CSR was 100%, the mean mBI was 0.88 (average reduction: −1.47), the mean PD was 3.35 mm (mean PD reduction: 4.77 mm), and the mean bone defect was reduced by 1.74 mm, with a mean bone fill of 55%.

Conclusions

The results of the present case series suggest that if accurate surface decontamination is achieved, high survival rate and good clinical and radiographic results can be obtained after 3 years. However, only the histological examination could confirm the growth of new bone in direct contact with the implant surface or if the grafted material only fills the space left by the peri-implant defect.

Management of peri-implantitis - A contemporary synopsis

Prevalence of peri-implant complication is expected to be on the rise with the increased number of implants being placed. Depending on the degree of osseous involvement, the clinician needs to decide if the treatment goal is to arrest the disease progression, regeneration or explantation and replacement. Host's medical status, defect configuration, aesthetic outcome, ability to access for plaque control post-treatment, and the patient's wishes are key factors to consider. The purpose of this review is to provide a contemporary synopsis on the management of peri-implantitis with emphasis on explantation. Guidance on the identification of factors/situations where salvaging an implant may be less favourable is discussed and the various techniques to remove a fractured, or peri-implantitis-affected non-mobile implant are described.

Is Peri-Implantitis Curable?

Peri-implant mucositis and peri-implantitis are clinically associated with inflammation of soft tissue around implants; however, peri-implantitis is associated with radiographic bone loss. Recently a new classification scheme-peri-implant health, peri-implant mucositis, peri-implantitis, and peri-implant soft-tissue and hard-tissue deficiencies-was introduced. Although various clinical interventions to treat peri-implant diseases have been suggested, early diagnosis and treatment is the key to successful outcomes. Clinicians can select nonsurgical or surgical techniques according to the clinical parameters present, although surgical intervention seems to be more effective in treating peri-implantitis. The best approach to treat peri-implantitis remains controversial.

Clinical outcomes following surgical treatment of peri-implantitis at grafted and non-grafted implant sites: a retrospective analysis

Background

This retrospective analysis aimed at comparing the clinical outcomes following combined surgical therapy of peri-implantitis at initially grafted and non-grafted (i.e., pristine) implant sites.

Methods

A total of 39 patients exhibiting 57 implants diagnosed with peri-implantitis (i.e., 16 implants at grafted and 41 implants at non-grafted sites) were included. Each subject had received a combined (i.e., implantoplasty and augmentative therapy) surgical treatment procedures at respective implants (grafted sites: 10 patients, 16 implants, non-grafted sites: 29 patients, 41 implants). A chi-squared test (χ²) was used to assess whether the initial grafting procedure did affect the treatment outcomes (i.e., disease resolution, bleeding on probing (BOP), probing pocket depths (PD)). The mean follow-up period was 41.9 ± 34.75 months.

Results

At the patient level, disease resolution (i.e., absence of BOP and PD ≥ 6 mm) was obtained in 4/10 (40%) at grafted and in 7/27 (24.1%) at non-grafted implant sites (p = 0.579). BOP reductions was found to be 60.64 ± 40.81% at non-grafted and 77.45 ± 30.92% at grafted sites (p = 0.778). PD reductions amounted to 2.20 ± 2.22 mm at non-grafted and 1.57 ± 1.54 mm at grafted sites (p = 0.969).

Conclusions

The initial bone-grafting procedures at the implant sites did not influence the effectiveness of combined surgical therapy of peri-implantitis.

Vancomycin and tobramycin impregnated mineralized allograft for the surgical regenerative treatment of peri-implantitis: a 1-year follow-up case series

OBJECTIVES

To assess the clinical and radiographic outcomes of the regenerative treatment of peri-implantitis using a vancomycin and tobramycin impregnated allograft (VTA) after a 12-month period.

MATERIAL AND METHODS

Thirteen consecutive patients who required a regenerative treatment of peri-implantitis were recruited. For the 17 implant sites, a flap was raised, and after mechanical and chemical implant decontamination, a vancomycin and tobramycin impregnated allograft was placed in the defect and then covered with a collagen membrane. Soft tissues were sutured allowing a non-submerged healing. Clinical and radiographic variables were evaluated at baseline and at 12 months after treatment.

RESULTS

No signs of continuous bone loss were observed and no implant was lost, yielding a 100% survival rate. All patient's clinical examination at 12 months revealed peri-implant health showing absence of suppuration and a statistically significant reduction in terms of bleeding on probing scores (70.6%, P = 0.001). Initial probing pocket depth (7.88 ± 1.22 mm) was significantly reduced at 12 months healing, a mean reduction of 4.23 ± 1.47 mm (P = 0.001) was achieved. The mean radiological infrabony defect at baseline reached 4.33 ± 1.62 mm, and was significantly reduced up to 0.56 ± 0.88 mm, which represents an 86.99 ± 18.2% bone fill from the original infrabony defect.

CONCLUSIONS

Within the limits of the study, the application of VTA with a collagen membrane yielded positive outcomes in terms of radiographic bone fill, pocket depth reduction, and attachment gain after a 12-month period. Thus, VTA plus a collagen membrane seem to be suitable for the regenerative treatment of peri-implantitis.

CLINICAL RELEVANCE

The use of locally delivered antibiotic together with the bone graft may reduce the undesirable effects related to the systemic administration and the risk of resistances. In the light of the results obtained, these grafting materials might offer new treatment strategies in the surgical regenerative treatment of peri-implantitis.

Porous titanium granules in the treatment of peri-implant osseous defects-a 7-year follow-up study

Background

A great number of different treatment protocols for peri-implantitis have been suggested but there is no consensus regarding the most effective intervention. The aim of the present study was to evaluate the long-term clinical and radiographic results from a study on peri-implant osseous defect reconstruction.

Patients having participated in a randomized clinical study 7 years earlier were invited for a re-examination. The treatment procedures included open flap debridement (OFD) with or without defect reconstruction with porous titanium granules (PTGs). Clinical parameters (probing pocket depth and bleeding on probing) and radiographic measurements were registered.

Findings

Of the original 32 patients, 12 patients with 12 implants were finally examined after 7 years (7.3 years [6.7–8]). Patients had been maintained one to two times yearly. The PTG group showed a mean probing pocket depth of 4.3 mm ± 2.4 compared with 3.5 mm ± 1.2 in the OFD group, at the deepest site. The change between the 12 months and the 7-year examination was similar in both groups.

Five of the test implants and five of the control implants had at least one site with positive bleeding on probing score.

The mean radiographic defect depth change as compared to 12 months was an increase of 1.9 mm ± 2.0 in the PTG group and a mean radiographic defect depth increase of 1.3 mm ± 1.4 in the OFD group.

Due to the small number of patients, a statistical analysis was not performed, but the results indicated a minimal difference in osseous defect depth as compared with baseline and between groups.

No PTG exposed to the oral cavity was observed, but the graft particles were seemingly scattered in the peri-implant soft tissue.

Conclusions

This long-term follow-up of surgical treatment of peri-implant osseous defects showed unpredictable results.

Guided Bone Regeneration Using Collagen Scaffolds, Growth Factors, and Periodontal Ligament Stem Cells for Treatment of Peri-Implant Bone Defects In Vivo

Introduction

The aim of the study was an evaluation of different approaches for guided bone regeneration (GBR) of peri-implant defects in an in vivo animal model.

Materials and Methods

In minipigs (n = 15), peri-implant defects around calcium phosphate- (CaP-; n = 46) coated implants were created and randomly filled with (1) blank, (2) collagen/hydroxylapatite/β-tricalcium phosphate scaffold (CHT), (3) CHT + growth factor cocktail (GFC), (4) jellyfish collagen matrix, (5) jellyfish collagen matrix + GFC, (6) collagen powder, and (7) collagen powder + periodontal ligament stem cells (PDLSC). Additional collagen membranes were used for coverage of the defects. After 120 days of healing, bone growth was evaluated histologically (bone to implant contact (BIC;%)), vertical bone apposition (VBA; mm), and new bone height (NBH; %).

Results

In all groups, new bone formation was seen. Though, when compared to the blank group, no significant differences were detected for all parameters. BIC and NBH in the group with collagen matrix as well as the group with the collagen matrix + GFC were significantly less when compared to the collagen powder group (all: p < 0.003).

Conclusion

GBR procedures, in combination with CaP-coated implants, will lead to an enhancement of peri-implant bone growth. There was no additional significant enhancement of osseous regeneration when using GFC or PDLSC.

Surgical Regenerative Treatments for Peri-Implantitis: Meta-analysis of Recent Findings in a Systematic Literature Review

OBJECTIVES

The purpose of the present study was to systematically review the literature on the surgical regenerative treatment of the peri-implantitis and to determine an effective therapeutic predictable option for their clinical management.

MATERIAL AND METHODS

The study searched MEDLINE and EMBASE databases from 2006 to 2016. Clinical human studies that had reported changes in probing depth (PD) and/or bleeding on probing (BOP) and/or radiologic marginal bone level (RBL) changes after peri-implantitis surgical treatment at 12-month follow-up or longer were included accordingly to PRISMA guidelines.

RESULTS

The initial search obtained 883 citations. After screening and determination of eligibility, 18 articles were included in the review. The meta-analysis of selected studies revealed that the weighted mean RBL fill was 1.97 mm (95% confidence interval [CI] = 1.58 to 2.35 mm), PD reduction was 2.78 mm (95% CI = 2.31 to 3.25 mm), and BOP reduced by 52.5% (95% CI = 41.6 to 63.1%). Defect fill in studies using and not using barrier membranes for graft coverage was 1.86 mm (95% CI = 1.36 to 2.36 mm) and 2.12 mm (95% CI = 1.46 to 2.78 mm) correspondingly. High heterogeneity among the studies regarding defects morphology, surgical protocols, and selection of biomaterials were found.

CONCLUSIONS

All included studies underlined an improvement of clinical conditions after the surgical regenerative treatment of peri-implantitis, however, there is a lack of scientific evidence in the literature regarding the superiority of the regenerative versus non-regenerative surgical treatment. The presence of a barrier membrane or submergence in the regenerative procedure does not seem to be fundamental in order to obtain clinical success of the surgery.

Efficacy of alternative or adjunctive measures to conventional treatment of peri-implant mucositis and peri-implantitis: a systematic review and meta-analysis

In patients with peri-implant mucositis and peri-implantitis, what is the efficacy of nonsurgical (i.e. referring to peri-implant mucositis and peri-implantitis) and surgical (i.e. referring to peri-implantitis) treatments with alternative or adjunctive measures on changing signs of inflammation compared with conventional nonsurgical (i.e. mechanical/ultrasonic debridement) and surgical (i.e. open flap debridement) treatments alone? After electronic database and hand search, a total of 40 publications (reporting on 32 studies) were finally considered for the qualitative and quantitative assessment. The weighted mean changes (WM)/ and WM differences (WMD) were estimated for bleeding on probing scores (BOP) and probing pocket depths (PD) (random effect model). Peri-implant mucositis: WMD in BOP and PD reductions amounted to -8.16 % [SE = 4.61] and -0.15 mm [SE = 0.13], not favouring adjunctive antiseptics/antibiotics (local and systemic) over control measures (p > 0.05). Peri-implantitis (nonsurgical): WMD in BOP scores amounted to -23.12 % [SE = 4.81] and -16.53 % [SE = 4.41], favouring alternative measures (glycine powder air polishing, Er:YAG laser) for plaque removal and adjunctive local antibiotics over control measures (p < 0.001), respectively. Peri-implantitis (surgical): WMD in BOP and PD reductions did not favour alternative over control measures for surface decontamination. WM reductions following open flap surgery (±resective therapy) and adjunctive augmentative therapy amounted to 34.81 and 50.73 % for BOP and 1.75 and 2.20 mm for PD, respectively. While mechanical debridement alone was found to be effective for the management of peri-implant mucositis, alternative/adjunctive measures may improve the efficacy over/of conventional nonsurgical treatments at peri-implantitis sites. Adjunctive resective and/or augmentative measures are promising; however, their beneficial effect on the clinical outcome of surgical treatments needs to be further investigated.

Regenerative Medicine for Periodontal and Peri-implant Diseases

The balance between bone resorption and bone formation is vital for maintenance and regeneration of alveolar bone and supporting structures around teeth and dental implants. Tissue regeneration in the oral cavity is regulated by multiple cell types, signaling mechanisms, and matrix interactions. A goal for periodontal tissue engineering/regenerative medicine is to restore oral soft and hard tissues through cell, scaffold, and/or signaling approaches to functional and aesthetic oral tissues. Bony defects in the oral cavity can vary significantly, ranging from smaller intrabony lesions resulting from periodontal or peri-implant diseases to large osseous defects that extend through the jaws as a result of trauma, tumor resection, or congenital defects. The disparity in size and location of these alveolar defects is compounded further by patient-specific and environmental factors that contribute to the challenges in periodontal regeneration, peri-implant tissue regeneration, and alveolar ridge reconstruction. Efforts have been made over the last few decades to produce reliable and predictable methods to stimulate bone regeneration in alveolar bone defects. Tissue engineering/regenerative medicine provide new avenues to enhance tissue regeneration by introducing bioactive models or constructing patient-specific substitutes. This review presents an overview of therapies (e.g., protein, gene, and cell based) and biomaterials (e.g., resorbable, nonresorbable, and 3-dimensionally printed) used for alveolar bone engineering around teeth and implants and for implant site development, with emphasis on most recent findings and future directions.

Adjunctive Systemic and Local Antimicrobial Therapy in the Surgical Treatment of Peri-implantitis

The aim of the present randomized controlled clinical trial was to investigate the adjunctive effect of systemic antibiotics and the local use of chlorhexidine for implant surface decontamination in the surgical treatment of peri-implantitis. One hundred patients with severe peri-implantitis were recruited. Surgical therapy was performed with or without adjunctive systemic antibiotics or the local use of chlorhexidine for implant surface decontamination. Treatment outcomes were evaluated at 1 y. A binary logistic regression analysis was used to identify factors influencing the probability of treatment success, that is, probing pocket depth ≤5 mm, absence of bleeding/suppuration on probing, and no additional bone loss. Treatment success was obtained in 45% of all implants but was higher in implants with a nonmodified surface (79%) than those with a modified surface (34%). The local use of chlorhexidine had no overall effect on treatment outcomes. While adjunctive systemic antibiotics had no impact on treatment success at implants with a nonmodified surface, a positive effect on treatment success was observed at implants with a modified surface. The likelihood for treatment success using adjunctive systemic antibiotics in patients with implants with a modified surface, however, was low. As the effect of adjunctive systemic antibiotics depended on implant surface characteristics, recommendations for their use in the surgical treatment of peri-implantitis should be based on careful assessments of the targeted implant ( ClinicalTrials.gov NCT01857804).

Pathological mandibular fracture: A severe complication of periimplantitis

Nowadays, dental implant treatment is a very common option for patients even in medical compromised conditons. Some complications related to them have been described. Periimplantitis (PI) is one of the biggest concerns complications of these kind of treatments, probably has a multifactorial aethiology. Usually the consequences of PI are the loss of the implants and prostheses, expenses of money and time for dentists and patients. Very often PI implies the necesity of repeating the treatment . Pathological mandibular fracture due to PI is a severe but infrequent complication after dental implant treatment, especially after PI. In this study we present three cases of mandibular pathologic fractures among patients with different medical and dental records but similar management: two of them had been treated years ago of oral squamous cell carcinoma with surgery and radiotherapy, the other patient received oral bisphosphonates for osteoporosis some years after implantation. We analized the causes, consequences and posible prevention of these fractures as well as the special features of this kind of mandibular fractures and the different existing treatments. Key words:Periimplantitis, pathological mandibular fracture, mandibular atrophy, bicortical implants.

Erythritol-Enriched Air-Polishing Powder for the Surgical Treatment of Peri-Implantitis

Peri-implantitis represents a major complication that can compromise the success and survival of implant-supported rehabilitations. Both surgical and nonsurgical treatment protocols were proposed to improve clinical parameters and to treat implants affected by peri-implantitis. A systematic review of the literature was performed on electronic databases. The use of air-polishing powder in surgical treatment of peri-implantitis was investigated. A total of five articles, of different study designs, were included in the review. A meta-analysis could not be performed. The data from included studies reported a substantial benefit of the use of air-polishing powders for the decontamination of implant surface in surgical protocols. A case report of guided bone regeneration in sites with implants affected by peri-implantitis was presented. Surgical treatment of peri-implantitis, though demanding and not supported by a wide scientific literature, could be considered a viable treatment option if an adequate decontamination of infected surfaces could be obtained.

Treatment of peri-implantitis and the failing implant

Appropriate treatment of implants is becoming increasingly important for the general dentist as the number of implants placed per year continues to increase. Early diagnosis of peri-implantitis is imperative; initiating the correct treatment protocol depends on a proper diagnosis. Several risk factors exist for the development of peri-implantitis, which can guide patient selection and treatment planning. Treatment of peri-implantitis should be tailored to the severity of the lesion (as outlined by the cumulative interceptive supportive treatment protocol), ranging from mechanical debridement to explantation. Several surgical and nonsurgical treatment alternatives exist. There is little consensus on superior treatment methods.