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Management of complications Periimplantitis lesions

Indication sheet X4

Therapy concept of Jean-Louis Giovannoli, Paris, France

> Mucosal plastic surgery in the restorative treatment of a complex case of periimplantitis

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© Geistlich Pharma AGBusiness Unit BiomaterialsCH-6110 Wolhusenphone +41 41 492 56 30 fax +41 41 492 56 39www.geistlich-pharma.com

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Zone

Bone assessment

Soft tissue assessment

n Aesthetic zone nOutside of the aesthetic zonen Single tooth missing nMultiple teeth missingn Anterior section of mandible

n Bone lesions present nNo bone lesions present

n Recession nNo recession

n Inflammation nInfection

n Thick biotype nThin biotype

n Primary closure possible nPrimary closure not possible

n Papilla intact nPapilla affected or absentn Mucosa adequately keratinised nMucosa not adequately keratinised

1. Indication profile

Literature references1 Roos-Jansaker A.M., Renvert S., Egelberg J.: Treatment of peri-implant infections: A literature review. J. Clin. Periodont. 2003;30:467-485.2 Leonhardt A., Dahlen G. & Renvert S.: Five-year clinical, microbiological and radiological outcome following treatment of peri-implantitis in man. J. Periodontol.

2003;74:1415-1422.3 Schwarz F., Bieling K., Latz T., Nuesry E. & Becker J. : Healing of intrabony peri-implantitis defects following application of a nanocrystalline hydroxyapatite (Ostim®) or a

bovine-derived xenograft (Bio-Oss®) in combination with a collagen membrane (Bio-Gide®): a case series. J. Clin. Periodontol. 2006;33:491-499.4 Roos-Jansaker A-M., Renvert H., Lindahl C., Renvert S. : Surgical treatment of peri-implantitis using a bone substitute with and without a resorbable membrane. A prospective

cohort study. J. Clin Periodont. 2007;34:625-632.5 Esposito M., Grusovin M.G., Coulthard P., Worthington H.V. : The efficacy of interventions to treat peri-implantitis: a Cochrane systematic review of RCTs. Eur J Oral

Implantol 2008;1(2):111-125.6 Giovannoli J.L. : Mucosal plastic surgery in the restorative treatment of a case of periimplantitis. Titane 2010;7(1):45-47.

Contact> Dr. Jean-Louis Giovannoli, 26 avenue Kléber, 75116 Paris. E-mail : giokleber@aol.com

Suppliers> Hydrogen peroxide : Cooper ; 10 volume percent ; 125 mL vial

> Air polisher, abrasive powder and plastic curettes : Satelec ; 24 avenue du Général-de-Gaulle ; 91178 Viry-Châtillon ; Tel. : +33 (0)1 69 56 56 56

> Mini-nails : Dentsply Friadent France ; ROUTE DE MONTEREAU 77140 Darvault. Tel. : +33 (0)1 60 55 55 45

> Sutures : 4-0 Ti-Cron cardiopoint 3/8/18 mm non-resorbable ; polyester, plaited and treated

> Local anaesthetic : articaine

> Antibiotic : amoxicilin, 2g/day for 6 days

Other indication sheets> To receive indication sheets free of charge, please visit our website: www.geistlich.com/indicationsheets> If you do not wish to receive our indication sheets any longer, please unsubscribe at your local distributor.

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Dr Jean-Louis Giovannoli :“In the scope of conservative treatment of periimplantitis, surgical intervention can be indicated, combining the use of a bone substitute and a resorbable membrane, based on the concept of Guided Bone Regeneration (GBR).For this, it is necessary in a first session to bring the infection under control by applying all the standard anti-infectious means used for periodontal decontamination. When the inflammatory state of the superficial soft tissues is satisfactory, surgical intervention is possible, provided that the morphology of the bone defect is favourable, and above all, that the mucosal situation allows the membrane to be completely concealed during the entire tissue maturing phase. To achieve this, it is absolutely necessary that a substantial height of keratinised mucosa is available.In the following clinical case presented, two mandibular implants that had been in place for almost ten years showed clinical and radiological signs characteristic for periimplantitis complicated by mucosal recession.This case illustrates the possibility of adapting the mucosal conditions by applying a free gingival graft in a first surgical session and then treating the lesion in a second surgical session, observing the technical principles of Guided Bone Regeneration.”

General information

2. Treatment objectives> Substitution of the periimplant bone lesion by GBR combining the use of a bone substitute

( Geistlich Bio-Oss®) and a resorbable membrane (Geistlich Bio-Gide®).

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Fig. 7 Healing of the wound 2 months later. No inflammation.

Fig. 8 The volume of the soft tissues is now adequate for periimplant GBR.

Fig. 9 Occlusal view of the reconstituted volume of soft tissue.

Fig. 4 Initial radiograph showing a crater-shaped lesion at the implant in region 41. The miniature screw is from a previous orthognatic surgery, 10 years prior.

Fig. 5 Free gingival graft taken from the palate. View of the receiving site. The split-thickness flap relieves tension and adhesions.

Fig. 6 The graft is placed and sutured to the site (6.0 resorbable thread) distally and mesially.

Fig. 10 The lingual view shows a tissue volume that was sufficient prior to GBR.

Fig. 11 The lesion is curetted thoroughly using plastic curettes specially designed for use in implantology in order to eliminate all granulation tissue (Satelec).

Fig. 13 An air polisher emitting bicarbonate was subsequently used for decontamination, followed by application of 5 volume percent hydrogen peroxide.

Fig. 15 The implant surface is decontaminated by applying a swab soaked with 10  volume percent hydrogen peroxide solution.

Fig. 16 The peroxide solution is left in place for several minutes.

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Fig. 17 Placement of Geistlich Bio-Oss® which was first impregnated with physiological serum, avoiding excessive compaction.

Fig. 18a Perforation of the Geistlich Bio-Gide® membrane using a rubber dam punch.

Fig. 22 The prostheses are put back in place for wound healing.

Fig. 26 4 years after surgery, the radiograph shows a high level of dense bone around the implants.

Fig. 18b Preparation of the mini-nails for fixation and use of the nail holder.

Fig. 20 The resorbable collagen membrane used has low rigidity. In this case, its primary purpose is to keep the bone substitute material in place.

Fig. 21 Discontinuous sutures for stabilising the flap and the bone volume reconstruction.

Fig. 12 In a first session, granulation tissue is elimi-nated mechanically.

Fig. 14 The probe reveals a circumferential peri-implant lesion of approx. 10 mm at the implant in region 41.

Fig. 2 Clinical situation 2 weeks after supra gingival decontamination (removal of dental calculus, plaque control).

Fig. 1 Visualisation of the periimplant lesion accompanied by mucosal recession. When probed, the distal part of the lesion bleeds.

Fig. 3 Removal of the prostheses reveals a substan-tial loss of periimplant supportive tissue.

3. Surgical technique

Fig. 19 The Geistlich Bio-Gide® membrane is placed in form of a “poncho” across the implants and is stabilised using 2 mini-nails.

Fig. 28 The profile of the augmented ridge is well developed around the implants. The root recession and the periodontal status have remained stable thanks to the bone support.

Fig. 27 Re-entry confirmed radiographic findings and shows a stable bone augmentation (intervention condu cted for pin removal and ridge contour refine-ment).

Fig. 29 The flap is repositioned and stabilised by means of discontinuous sutures.

Fig. 23 Control radiograph 3 months later. The hard tissues are in the mineralisation phase.

Fig. 24 Control radiograph 9 months after surgery. Notice the stabilisation of the bone level and the increase in density of the site.

Fig. 25 Clinical situation 9 months after surgery. Thanks to the amount of keratinised mucosa, all risk of expo sing the membrane could be avoided, includ-ing in the interproximal zone, thereby preserving the whole volume of repaired tissue. Note the stability of the interproximal reconstruction.