COMBINED SURGICAL RESECTIVE AND REGENERATIVE THERAPY FORADVANCED PERI-IMPLANTITIS WITH CONCOMITANT SOFT TISSUE VOLUME AUGMENTATION: A CASE REPORTFrank Schwarz et al ; IJPRD 2014.

Shilpa ShivanandIII MDS

Introduction Surgical regenerative treatment of peri-implantitis using various bone substitutes and autografts with or without barrier membrane has proven to be effective in controlling disease progression for both short- and long-term periods

Roos-Jansaker et al 2011

Despite clinical and radiographic improvements, it was noted that flap elevation at these sites was commonly associated with a significant increase in recession, which may compromise the overall esthetic outcome.

Schwarz F et al 2006These problems were notably pronounced when using

a combined surgical resective and regenerative treatment procedure.

Becker J et al 2011

Introduction To overcome the above limitations, a concomitant soft tissue volume augmentation using SCTG has recently been introduced and has proven to be effective in compensating postoperative soft tissue remodeling and subsequent shrinkage of the peri-implant mucosa.

Sahm N et al 2014However, the commonly used trap-door technique for harvesting a SCTG from the palate is technically demanding and includes some potential intrasurgical risks and postsurgical discomfort for the patient.

Roccuzzo M et al 2002A recently introduced porcine-derived resorbable collagen matrix was suggested to possess some physicochemical properties needed to serve as a replacement graft for SCTG and has proven to result in comparable volume gain when compared with SCTG.

Thoma DS et al 2011, 2012

Aims

This study reports on a 3-year follow-up after combined surgical regenerative/resective therapy of advanced peri-implantitis with concomitant soft tissue volume augmentation using a porcine-derived, resorbable collagen matrix

Method and materials A 66-year-old partially edentulous woman who was a non-

smoker and who suffered from advanced periimplantitis at the mandibular right second premolar implant was referred to the Department of Oral Surgery, Heinrich Heine University, Düsseldorf, Germany, for treatment.

Clinical examination by means of bone sounding, revealed a buccal dehiscence as well as semicircular bone resorption to the middle of the implant body with a probing depth of > 6 mm, an intrabony component of 3.7 mm, and a supracrestal component of approximately 1 mm at the distal aspect as estimated radiologically.

Intrabony component = blue circles circumferential component = arrowsm = mesial aspect; d = distal aspectb = buccal aspect. The red rectangle indicates the surface areaundergoing an implantoplasty. The orange rectangle indicates the position of the collagen matrix.

Inclusion criteria

No implant mobility

Presence of at least 2 mm of keratinized periimplant mucosa to facilitate a repositioning of the mucoperiosteal flap at the augmented areasTreated chronic periodontitis and proper periodontal maintenance care

Absence of any systemic disease that could influence the outcome of the therapy (DM, osteoporosis, bisphosphonate medication)

A good level of oral hygiene (Plaque Index< 1)

Treatment protocol To reduce clinical signs of inflammation (ie, pus

formation) before surgery, a single episode of nonsurgical therapy using an Er:YAG laser device was provided.

At 2 weeks, the patient underwent the combined surgical treatment procedure under local anesthesia.

A full-thickness flap was elevated at the buccal aspect, and the granulation tissue was meticulously removed from the entire defect area and implant surface by means of plastic curettes

Subsequently, all buccally and supracrestally exposed/threatened areas of the implant were completely planed and smoothened using diamond burs under copious irrigation with sterile saline.

A debridement/decontamination of the remaining unmodified implant surface areas facing the interproximal alveolar bone was performed using plastic curettes and cotton pellets soaked in sterile saline.

These semi-circumferential, intrabony defect components were homogeneously filled with NBM (BioOss spongiosa granules, particle size 0.25 to 1 mm, Geistlich).

A slight overaugmentation resulted in an extension of NBM to the buccal defect area.

The CM was slightly oversized to cover 2 to 3 mm of the defect borders and was applied in a double layer (BioGide, Geistlich).

The native collagen matrix (Mucograft [MG] Geistlich) was trimmed and applied to the buccal aspect and adapted over the CM without any additional fixation.

Finally, the flap was repositioned and fixed with vertical/horizontal mattress as well as sling sutures (Resorba).

A systemic antibiotic medication (penicillin) was administered pre- (ie, 1 hour before) and postoperatively for 5 days to account for transmucosal healing.

Clinical measurements The following clinical parameters were assessed

immediately before surgery (baseline) and after 6, 12, 24, and 36 months using a periodontal probe: MR

BOP

PD

PI

KM

CAL from the

mucosalmargin to bottom of the probeablepocket

from IS to the bottomof the probeable pocket

from the implantshoulder (IS) to the mucosal margin

Results Postoperative wound healing (ie, no allergic

reactions, abscesses, or infections) was generally considered uneventful.

No flap dehiscences or premature exposures either of MG, CM, or NBM were noted.

PI, BOP, PD

MRMean MR values remainedalmost unchanged within the first6 months after surgery

However, a creeping attachment resulted in a decrease of mean MR values between12 and 24 months, even reaching a slight gain of 0.1 mm in tissue height after 36 months of healing

A marked decrease of mucosalheight by 0.6 mm was notedat 12 months.

CAL

Mean CAL values were markedly reduced at 6 months, slightly increased at 12 months, but improved at 24 months with stable conditions at 36 months.

MR & KM

However, at 24 months, the width of KM increased with mean MR values, even reaching baseline scores after 36 months of healing

It was noted that the decrease in mucosal height at 12 months was associated with an obvious decrease in mean KM values.

Radiographs Since clinical signs suggested a re-infection

(positive BOP scores), nonstandardized radiographs were taken at 6 and 12 months.

However, radiographic assessment pointed to an obvious decrease in translucency in the former defect area, which was also proven to be stable at 36 months.

Baseline

6 month 12 month 36 month

Discussion This case report presented a 3-year follow-up of

the clinical outcomes of a combined surgical resective and regenerative therapy for advanced peri-implantitis with concomitant soft tissue volume augmentation using MG.

After 36 months of transmucosal healing, it was observed that this surgical approach was associated with clinically important improvements in all investigated parameters.

Hence , it must be emphasized that the method of surface debridement and decontamination was clinically proven to be as effective as an Er:YAG laser device and supported the process of re-osseointegration at the intrabony defect component. Schwarz F et al 2008

While the current surgical procedure was associated with a marked increase in mean MR values at 12 months, a regain in mucosal height was noted between 12 and 24 months, even reaching the respective baseline value after 36 months of healing.

The observation that surgical regenerative treatment of moderate to advanced peri-implantitis may be associated with significant increases in mean MR is in accordance with previous studies employing either a nanocrystalline hydroxyapatite or an algae-derived xenograft with a resorbable synthetic membrane.

Roos-Jansaker AM et al 2007, Schwarz F et al 2006

Similar outcomes were also noted for the combined surgical regenerative and resective therapy of advanced periimplantitis without concomitant soft tissue volume augmentation, resulting in statistically significant increases in mean MR values after 6 months of healing.

Schwarz F et al 2011, 2012

Recent data of a prospective case series have indicated that a concomitant volume augmentation using SCTG may compensate for soft tissue changes and even result in a slight increase in mean mucosal height (0.07 ± 0.5 mm) at the buccal aspects in the short term (ie, 6 months).

Schwarz F et al 2014 However, the present case indicates that mucosal

soft tissue changes may be more pronounced between 6 and 12 months of healing and, therefore, the long term stability of these outcomes needs to be carefully considered.

Conclusion Within the limitations of a case report, it was

concluded that the presented combined surgical procedure was effective in controlling advanced peri-implantitis without compromising the overall esthetic outcome in the long term.

Cross references

I. Clinical efficacy of a xenogeneic collagen matrix in augmenting keratinized mucosa around implants: a randomized controlled prospective clinical trial. Lorenzo R et al. Clin Oral Implants Res. 2012Aim The aim of this controlled randomized clinical trial was to

evaluate the efficacy of a xenogeneic collagen matrix (CM) to augment the keratinized tissue around implants supporting prosthetic restorations at 6 months when compared with the standard treatment, the connective tissue autograft, CTG).

Method This randomized longitudinal parallel controlled clinical trial

studied 24 patients with at least one location with minimal keratinized tissue (≤1 mm).

Main outcome measures The 6 month width of keratinized tissue. As secondary

outcomes the esthetic outlook, the maintenance of periimplant mucosal health and the patient morbidity were assessed preoperatively and 1, 3, and 6 months postoperatively.

Results At 6 months, Group CTG attained a mean width of keratinized

tissue of 2.75 (1.5) mm, while the corresponding figure in Group CM was 2.8 (0.4) mm, the intergroup differences not being statistically significant. The surgical procedure in both group did not alter significantly the mucosal health in the affected abutments. There was a similar esthetic result and significant increase in the vestibular depth in both groups as a result of the surgery. In the CM group it changed from 2.2 (3.3) to 5.1 (2.5) mm at 6 months. The patients treated with the CM referred less pain, needed less pain medication, and the surgical time was shorter, although these differences were not statistically significant when compared with the CTG group.

Conclusion These results prove that this new CM was as effective and

predictable as the CTG for attaining a band of keratinized tissue.

II. Treatment of soft tissue recessions at titanium implants using a resorbable collagen matrix: a pilot study. Schwarz F et al. Clin Oral Implants Res. 2014

Objectives To histologically assess the effectiveness of a porcine

derived collagen matrix (CM) and a subepithelial connective tissue graft (CTG) for the coverage of single mucosal recessions at osseointegrated dental implants.

Method Chronic type mucosal Miller Class I like recessions (mean

clinical defect height: 0.67 ± 0.331.16 ± 0.19 mm) were established at the buccal aspect of titanium implants with platform switch in six beagle dogs. The defects were randomly allocated to either (1) coronally advanced flap surgery (CAF) + CM, (2) CAF + CTG or (3) CAF alone. At 12 weeks, histomorphometrical measurements were made (e.g.) between the implant shoulder (IS) and the mucosal margin (PM) and IS and the outer contour of the adjacent soft tissue (mucosal thickness [MT]).

Results All treatment procedures investigated were associated

with an almost complete soft tissue coverage of the defect area (i.e. coronal positioning of PM relative to IS). Mean IS - PM and MT values tended to be increased in both CAF + CM (1.04 ± 0.74 mm/0.71 ± 0.55 mm) and CAF + CTG (0.88 ± 1.23 mm/0.62 ± 0.66 mm) groups when compared with CAF (0.16 ± 0.28 mm/0.34 ± 0.23 mm) alone. These differences, however, did not reach statistical significance.

Conclusion Within the limits of this pilot study, it was concluded

that all treatment procedures investigated were effective in covering soft tissue recessions at titanium implants.