Use of the Erbium laser in treatment of peri-implantitis

LivingWell Dental Hospital

LivingWell Institute of Dental Research

Ho-yeol Jang , Jang-yeol Lee , Young-kyun Chung , Hwa-su Koong ,

Hyoun-chull Kim , Il-hae Park , Sang-chull Lee

Ⅰ. Introduction

At the First European Workshop on Periodon

tology, peri-implantitis was defined as an infla

mmatory process affecting the tissues around an

osseointegrated implant in function, resulting in

loss of supporting bone. Peri-implant mucositis

was defined as reversible inflammatory changes of

the peri-implant soft tissues without any bone

loss1). The infectious etiology of peri-implantitis is

evident2). High levels of periodontal pathogens

including Actinobacillus actinomycetemcomitans,

Porphyromonas gingivalis, Porphyromonas

intermedia, Tannerella forsythia and Treponema

denticola, have been associated with peri-

implantitis3,4).

The retrograde peri-implantitis is defined as a

clinically symptomatic periapical lesion (diagnosed

as aradiolucency) that develops shortly after

implant insertion while the coronal portion of the

implant achieves a normal bone to implant

interface. The term retrograde peri-implantitis

has just recently been introduced through several

case reports5~9). The retrograde peri-implantitis is

often accompanied by symptoms of pain,

tenderness, swelling, and/or the presence of a

fistulous tract. It should be distinguished from a

clinically asymptomatic, peri-apical radiolucency,

which is usually caused by placing implants that

are shorter than the drilled cavity or by a heat-

induced aseptic bone necrosis6,10,11). Retrograde

peri-implantitis can result from bacterial

contamination during insertion, premature loading

leading to bone micro-fractures, or the presence

of a pre-existing inflammation (bacteria, inflam

matory cells, and/or remaining cells from a cyst,

granuloma). Such lesions start at the implant apex

but exhibit the capacity of spreading coronally,

proximally, and facially.

The presence of bacteria on implant surfaces may

result in an inflammation of the peri-implant

mucosa, and, if left untreated, it may lead to a

progressive destruction of the alveolar bone

supporting the implant and implant failure12,13).

Therefore, the principal objective of treatment is

the complete removal of all bacterial plaque

biofilms and calcified calculus from the implant

surfaces in order to stop disease progression.

Ideally, the bone-to-implant contacts should

increase and the implant undergoes re-

osseointegration.

Recently, in addition to conventional tools, the

Erbium laser has been proposed for treatment of

peri-implant infections. As the Erbium laser can

perform excellent tissue ablation with high

bactericidal effect, detoxification, and removing

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plaque and calculus, they are expected to be one of

the most promising new technical modalities for

treatment of failing implants.

Ⅱ. Materials & Methods

A. CASE 1(Peri-implantitis)

A 56-years old male patient had been performed

implantation on left maxillary central incisor with

Tapered Screw-Vent implant(Zimmer, U.S.A) and

immediate loading. After 3 months, it was

observed an inflammatory process around the

implant. At first time, non-surgical treatments was

performed with the Er:YAG laser (Key3, Kavo,

Germany)(Fig. 1) during 2 months, but it was

continued inflammatory changes of the peri-

implant soft tissues and loss of supporting bone on

measurement of a probing depth and the

radiograph(Fig.2,3). So peri-implantitis was

diagnosed and surgical treatment was planned with

the autogenous bone graft. Probing depth was

measured from the mucosal margin to the bottom

of the probeable sulcus before treatment using a

periodontal probe. When a full-thickness flap was

raised, the implant was surrounded by granulation

tissue(Fig. 4). The Er:YAG laser(Anybeam E,

B&B, Korea)(Fig. 5) with the chisel tip was

performed removal of granulation tissue and

irradiation on the implant surface(Fig. 6). The left

maxillary tuberosity bone was harvested with bone

rongeur. The autogenous bone grafts were then

placed into the peri-implant bone defect(Fig. 7).

The flap was closed with interrupted sutures(Fig.

8).

Fig. 1. Er:YAG laser (Key3, Kavo, Germany).

Fig. 2. Deep probing depth.

Fig. 3. Pre-operative radiograph.

Fig. 4. Full thickness flap elevation.

B. CASE 2(Retrograde peri-implantitis)

A 52-years old male patient had been performed

implantation on right and left mandibular lateral

incisors with Tapered Screw-Vent implant

(Zimmer, U.S.A) and immediate loading. After 4

months, a fistula was presented on buccal gingiva

and the radiograph was showed a clear

radiolucency around the apical part of right

mandibular lateral incisor implant, while the bone

apposition at the coronal part seemed intact(Fig.

9,10). At first time, non-surgical treatments was

performed with the Er,Cr:YSGG laser(waterlase,

Biolase, U.S.A)(Fig. 11) during 2 months, but a

fistula was not disappeared. So retrograde peri-

implantitis was diagnosed and surgical treatment

was planned with the DFDB allograft. When a full-

thickness flap was raised, a perforation of the

buccal bone plate was present(Fig. 12). It was

performed a trepanation of the defect with the

piezoelectric device(PIEZOSurgery, Mectron

Medical Technology, Italy)(Fig. 13). It was

removed granulation tissue of the bony cavity

walls except the implant surface with hand

instruments(Fig. 14). The Er,Cr:YSGG laser

(Waterlase, Biolase, USA) was performed removal

of granulation tissue and irradiation on the implant

surface(Fig. 15,16). PRP(platelet-riched plasma)

gel was sprayed on implant surface(Fig. 17) and

all defects were filled with DFDB allograft(Puros,

Tutogen, USA) mixed in PRP gel after making

multiple perforations of the bone surface(Fig.

18,19). PRP gel membrane was covered the

graft(Fig. 20). Primary wound closure was

achieved with mattress and interrupted

sutures(Fig. 21). Post-operative radiograph was

taken immediately thereafter(Fig. 22).

Fig. 5. Er:YAG laser(Anybeam E, B&B, Korea).

Fig. 6. Remove of granulation tissue and implant

surface detoxification with Er:YAG laser

(Anybeam, B&B, Korea).

Fig. 7. Autogenous bone graft (harvested from left

maxillary. tuberosity).

Fig. 8. Suture .

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Fig. 9. Fistula on buccal gingival of #42.

Fig. 10. Pre-operative radiograph.

Fig. 11. Er,Cr:YSGG laser(waterlase, Biolase,

U.S.A).

Fig. 12. Full thickness flap elevation.

Fig. 13. Trepination of the defect with piezo

electric device.

Fig. 14. Mechanical curettage on bony wall.

Fig. 15. Removal of granulation tissue and implant

surface detoxification with Er,Cr:YSGG laser.

Fig. 16. Complete elimination of granulation tissue.

Fig. 17. PRP spray on implant surface.

Fig. 18. Cavity filling with DFDB allograft (Puros,

Tutogen, USA) mixed in PRP gel.

Fig. 22. Immediate post-operative radiograph.

Fig. 23. 11 days after surgery.

Fig. 24. 50 days after surgery.

Fig. 19. After bone graft

Fig. 20. PRP gel placement on graft.

Fig. 21. Suture.

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Ⅲ. Result

In these cases, no complications such as

abscesses, or infections were observed, and

implants and grafts were stable. In case 1, there

are a significant reduction of pocket depth and gain

of clinical attachment level(Fig. 23,24,25). In case

2, a fistula was disappeared and implants

osseointegrated as confirmed by post-operative

radiograph(Fig. 26).

Ⅳ. Discussion

Most titanium implants feature a rough surface to

increase areas of implant-bone contact and

anchorage force in alveolar bone. However surface

roughness makes elimination of bacteria from

implants difficult. Several treatment regimens have

been proposed for cleaning and decontamination of

implant surfaces in order to treat peri-implantitis.

However, some of the recommended cleaning

methods have been reported to change or damage

the surface properties of implants14~17).

Mechanical debridement is usually performed

using specific instruments made out of materials

less hard than titanium (i.e. plastic curettes,

polishing with rubber cups) in order to avoid a

roughening of the metallic surface which in turn

may favour bacterial colonization18~21). Since

mechanical methods alone are insufficient in the

elimination of bacteria on roughened implant

surfaces, adjunctive chemical agents (i.e. irrigation

with local disinfectants, local or systemic antibiotic

therapy) were examined clinically and proven to

enhance healing following treatment12,22).

Bactericidal chemicals such as chlorhexidine

digluconate or iodine solutions are useful adjuncts

in the treatment of peri-implantitis. And therapy of

peri-implantitis by local delivery of tetracycline

had a positive effect on clinical and microbiological

parameters. Fiber therapy seems particularly

suited for the therapy of not too advanced peri-

implantitis lesions assuming the typical defect

morphology of a circumferential saucer.

Furthermore, surgical therapy in combination with

systemic antibiotics resulted in a resolution of the

peri-implantitis lesion23). Air-powder flow may be

Fig. 25. 150 days after surgery.

Fig. 26. Post-operative radiograph after 4 months.

used for implant surface decontamination24).

However, there are limitations in its application

because they can be associated with an increased

risk of emphysema25).

In addition to these conventional tools, the use of

lasers has been proposed for cleaning and for the

detoxification of implant surfaces. The interaction

between laser light and metal surfaces is mainly

determined by the degree of absorption and

reflection. Each metal features a certain spectral

reflection capacity, which is dependent on the

specific wavelenght of the laser. The reflection

capacity of titanium for the Er:YAG laser with its

wavelenght of 2940 nm in the near infrared

spectrum is 71% and rises up to 96% for the CO2

laser at 10,000nm26). In this situation, the implant

surface does not absorb the irradiation and

subsequently there is no temperature increase,

which would damage the implant surface. The

results from recently published studies have

indicated that among all lasers used in the field of

dentistry, only the carbon dioxide(CO2), the diode

and the Er:YAG laser may be useful for the

instrumentation of implant surfaces because the

implant body temperature does not increase

significantly after laser irradiation27~32). In contrast,

the use of an Nd:YAG laser resulted in extensive

melting and damage of the porous titanium surface

and coating27,28,32).Therefore the carbon

dioxide(CO2), the Diode and the Er:YAG lasers are

recommended, since it appears that they do not

exert a negative impact on the implant surface.

Since, neither CO2 nor diode lasers were effective

in removing plaque biofilms from implant surface,

both types of lasers were only used adjunctive to

mechanical treatment procedures33~35). In contrast,

as described above, several investigations have

reported on the promising ability of the Er:YAG

laser for calculus removal from implant surface

without producing major thermal side-effects to

adjacent tissue36,37).

Ⅴ. Conclusion

In recent years, the use of the Erbium laser has

beenexpected to serve as an alternative or

adjunctive treatment to conventional, mechanical

periodontal therapy. Among all lasers used in the

field of dentistry, the Erbium laser seems to

possess characteristics most suitable for peri-

implantitis, due to its ability to ablate both soft and

hard tissues as well as bacterial biofilms and

calculus without causing major thermal damage to

the adjacent tissue and implant surface. This study

demonstrates that surgical treatment involving the

combined use of the mechanical instruments and

the Erbium laser might to have more bactericidal,

detoxification, and removing calculus and plaque

effects in the peri-implantitis treatment. And it is

suitable to promote re-osseointegration at

contaminated implant surfaces. However it needs a

careful and controlled using, because laser

irradiation can result in morphological alterations of

implant surfaces when defined energy settings are

exceeded.

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Abstract

임프란트 주위염 치료에서 Erbium laser의 활용

장호열, 이장렬, 정 균, 궁화수, 김현철, 박일해, 이상철

리빙웰치과병원

리빙웰 치의학 연구소

치근 심미적이고 기능적인 장점 때문에 임프란트 치료는 보편화 되었고 환자들의 요구도 또한 높아지고

있다. 하지만 시술의 증가와 더불어 술후 관리의 소흘로 인한 실패의 증례도 많이 보고되고 있다. peri-

implantitis는 급격한 골 소실을 동반한 임프란트 주위 연조직의 염증 상태를 나타낸다. 그 중 치관 부위의

골유착은 정상이지만 임프란트 치근단 부위의 방사선 투과성 병소를 보이는 경우는 retrograde peri-

implantitis라고 분류한다. 일반적으로 peri-implantitis의 치료를 위해 기계적, 화학적 요법 및 항생제 요

법이 병용되어 사용되고 있다. 부가적으로 조직에 한 흡수성이 뛰어난 Er:YAG laser의 높은 살균 및

detoxification효과, 그리고 치태 및 치석 제거 효과는 임프란트 주위염의 치료에 활용할 수 있다. 하지만

높은 에너지를 사용할 경우 임프란트 표면에 변성을 초래할 수 있으므로 주의가 필요하가. 본 증례들을 통

해 임프란트 주위염 치료시 Er:YAG laser를 활용할 때의 장점과 잠재성에 해 고찰하고자 한다.

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