Diagnosing between ailing and failing implants: The haste to remove salvageable implants
The replacement of hopeless or missing teeth can be predictably achieved with endosseous dental implants and has demonstrated high survival rates in the literature when restoring single teeth, multiple teeth, and/or completely edentulous cases. Failures, however, do occur and have been on the rise now that the term “implant success” has replaced the term “implant survival.” Periodontist Dr. Scott Froum presents a case report describing the use of the Er:YAG laser for implant surface decontamination and concomitant regenerative therapy to treat an implant with advanced peri-implantitis.
The replacement of hopeless or missing teeth can be predictably achieved with endosseous dental implants (1) and has demonstrated high survival rates in the literature when restoring single teeth, multiple teeth, and/or completely edentulous cases. (2,3) Failures, however, do occur (4) and have been on the rise now that the term “implant success” has replaced the term “implant survival.” (5) Clinicians began to realize that an implant can still integrate or remain integrated showing no signs of mobility; however, a variety of other complications affecting the implant could still occur. Malpositioned implants, fractured implants or prostheses, and implants ailing with peri-implant mucositis or peri-implantitis are some of those complications that are seen in increasing numbers. (6) In addition, recent investigations now include the esthetic outcome of implant restorations, (7) and patient-based outcomes related to satisfaction (8) as inclusion criteria in their studies raise the bar on what is now considered implant success.
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The term “ailing” implant has been described in the literature as an implant that has not failed, requiring explantation, but needs some form of therapy in order to preclude failure. (9) A biological complication of implant therapy characterized by inflammation in the soft tissues and progressive bone loss of supporting bone surrounding an osseointegrated implant is peri-implantitis, (10) and can be the cause of an implant status changing from healthy to ailing. Although the diagnosis of peri-implantitis has been defined and reviewed, proposed treatment has varied considerably. In fact, to date, there have been six systemic reviews regarding the treatment of peri-implantitis, (11) all using various treatment methods with different rationales for treating ailing implants vs. explantation. When deciding whether to treat an ailing implant as opposed to explanation, a similar decision matrix can be established as when deciding upon whether to save or extract a natural tooth. (12) For example, is the implant strategic in the alveolar arch; in other words, does it support a single-tooth restoration or a full prosthesis? If explanted, can the implant be replaced, or do anatomical and/or financial limitations exist? In addition, the age, medical history, smoking status, oral hygiene status, and — most importantly — desires of the patient all have to be taken into consideration.
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One of the most important considerations when treating implants affected by peri-implantitis is the ability of the clinician to fully detoxify the implant surface during surgery. Surface decontamination using various techniques has been described in the literature (13) and is, in this author’s opinion, one of the most important considerations and keys to regenerative success around implants ailing from peri-implantitis. A more recent paper describing the use of a regenerative approach used to treat 51 peri-implantitis-affected implants with three- to seven-and-a-half-year follow-up reported encouraging results using a reproducible method, including a unique and meticulous method of thorough surface decontamination. (14) If the clinician is unable to thoroughly detoxify an implant surface, either a referral should be made or explantation of the implant is warranted since regenerative methods will have a much lower success rate. (15)
A recent review looked at the Er:YAG laser as a method of detoxifying implant surfaces. (16) This laser has the ability to effectively remove calculus and bacterial colonies from the impregnated implant surface without causing thermal damage to the implant and surrounding tissues. In addition, the ease of use and the focused beam allows access to often unattainable areas on the diseased implant, making a once recommended explanation into a regenerative possibility. The following case report describes the use of the Er:YAG laser for implant surface decontamination and concomitant regenerative therapy to treat an implant with advanced peri-implantitis.
A 52-year-old woman with a noncontributory medical history, taking no medications with no reported food or drug allergies, was referred to my office from a general dentist in order to obtain a second opinion. She had a lower right premolar implant placed in an oral surgery office five years ago that was suffering from severe peri-implantitis. (Fig. 1) Her first dentist told her that the implant had to be removed and that her treatment options were a fixed partial denture in the form of a three-unit bridge or a partial denture because re-implantation was not feasible. In addition, he sent her to a periodontal office that verified his statement, telling the patient that because of nerve proximity and the poor chance of ridge augmentation, re-implantation was unlikely. When she asked if saving the implant was possible, both the dentist and the periodontist told the patient that because of the level of bone loss, regenerative treatment would not work.
The patient did not accept either treatment option; instead, she decided to get another opinion. Considerations to engage in regenerative therapy included her poor chance of re-implantation, not accepting other restorative options, good oral hygiene practice, and compliance with regular maintenance intervals. In addition, the patient accepted that if, during surgery, it was not possible to detoxify all aspects of the implant surface, explantation would be necessary. Sulcular incisions were performed and a full-thickness mucoperiosteal flap was elevated. The implant surface was then hand-scaled with titanium scalers to remove degranulation tissue. An Er:YAG laser was then used to thoroughly detoxify the implant surface. (Fig. 2)
After debridement, a probe was placed measuring 10 mm of bone loss around the implant. (Fig. 3) The implant was then irrigated with copious amounts of sterile saline and etched with 24% EDTA. A combination regenerative approach was taken with a mixture of enamel matrix derivative, (Fig. 4) bone allograft, bone autograft, and a collagen membrane. The flap was then coronally advanced, and primary closure was attained. The patient was followed closely for the next year and hygiene was reinforced at her eight-week maintenance intervals. Her 12-month postop radiograph revealed strong evidence of linear bone growth. (Fig. 5) Her clinical analysis demonstrated a remarkable reduction in pocket depth as well as no evidence of bleeding upon probing and suppuration. (Fig. 6) At this point, the regenerative procedure can be considered a success; however, the patient will be closely followed to preclude relapse.
Scott Froum, DDS, is a periodontist and co-editor of Surgical-Restorative Resource e-newsletter, as well as a contributing author for DentistryIQ and Dental Economics. He is a clinical associate professor at the New York University Dental School in the Department of Periodontology and Implantology. Dr. Froum is in private practice in New York City. You may contact him through his website at www.drscottfroum.com.
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