Perio Contest 2018/ 30 April 2018/

Case 81 | Perio Contest 2018 | Israel

Dr Navit Shamai Clemer

Peri-implantitis case report.

68 years old woman, complained about swelling and suppuration around the implants.

The patient suffers from Hypercholesterolemia, controlled with statins.

She is a former smoker, she had been smoking 20 cigarettes a day for 35 years.

10 years before her admission, she underwent comprehensive dental treatment. All of her teeth in the upper jaw were extracted. A fixed dental bridge on 7 implants was done in the upper jaw and a partial denture was performed in the lower jaw. The following pictures and explanations presenting the case from the initial examination, anti-infective treatment, surgical treatment and 3 years follow up.

Fig1. Initial examination.
Multiple recessions around teeth and implants, signs of inflammation around the implants – including redness, swollenness and suppuration. Fistula apical to the implant in position of tooth 13.

Fig2. Frontal and laterals view with the lower partial dentures.

Fig3. Implants at the position of teeth number 15,14,13,12,22,23,25.
The peri-apical radiographs from her initial examinations revealed bone loss around all the implants, except for the implant in position of tooth 25. The implant bone loss was between 2 threads in some of the implants to 7 threads like at implant positioned at tooth 22.
At the lower jaw, Evidence of horizontal bone loss. Compared to her periapical radiographs 10 years before her examination, there is no further bone loss and no further clinical attachment loss at the lower jaw.

Fig4. Although the x –rays weren’t taken at the same angle, Comparing those periapical radiographs, taken 8 years apart, we can see at least few sites where the Bone loss around the implants progressed and more threads are exposed.

Fig5. Clinical photographs demonstrating plaque, exposure of the implants shoulders, swelling, redness and suppuration around the implants.
Probing pocket depth was deep around most of the sites. Most of the sites with bleeding on probing, recessions up to 2 mm.

Fig6. Lower jaw, lost of posterior teeth. Rehabelated by partial denture.
On periodontal examination, probing pocked depth didn’t exceed 4 mm, bleeding on probing was positive in multiple sites. recessions up to 5 mm. clinical attachment loss up to 7 mm, Mobility up to degree 2.

Fig8. Diagnosis

Fig9. The treatment goal was to stop disease progression and to maintain the existing implants as much as possible. The problems we had to address first, was her lack of awareness to the disease and it severity. second problem was her bad oral hygiene and no regular SPT in the past, which are known risk indicators for peri-implant disease.
A major advantage in the treatment plan is her low smile line which made the treatment plan possible.

Fig10. The photodynamic therapy.

Fig11. Clinical frontal and lateral photos at re-evaluation after the anti-infective phase.
There is significant improvement in the mucosa appearance, with reduction in redness, swollenness and deepening of the recessions. Opening of black triangles. Significant improvement in plaque score, which is now 1%. FMBS around teeth reduced to 8%, but 61% remained around the implants.

Fig12. Clinical photos of all the sextants of the upper jaw at re-evaluation. The improvement and the reduction of the inflammation is evident.
In the periodontal charting, the recessions are deeper, up to 3 mm and pocket depth reduced.
In spite of the intensive anti-infective phase and as anticipated, still 5 implants have probing depth above 6 mm.

Fig13. Second microbiological examination reveals reduction of bacterial load

Fig14. The additional therapy requires surgical access to the implants surface for debridement and decontamination .
The surgical plan was to reduce pockets around the implants and change the morphology of the tissue so it would be accessible for self and professional maintenance.
In order to arrest the progression of the disease, I also decided to thicken the mucosa with a free graft, A procedure that might be beneficial according to series of articles that were published recently. The two articles cited here are examples to articles that provide evidence that thick tissue or augmentation of thin tissues will result in less crestal bone loss and improvement of gingival index, volume of peri-implant sulcular fluid and so on.

Fig15.
The first surgical procedure was to treat implants in position 12,13,14,15.
Probing to bone gave me the impression that the bone loss around the implants was horizontal
And the incisions were planned according to the extent of pocket reduction needed and according to the width of keratinized mucosa.

Fig16. At the buccal, intrsulcular incisions were made with a small submarginal incision next to implant 14 with excessive tissue.

Fig17.At the palate, wide submarginal incision according to the sounding.

Fig18. The picture shows the deep double flap that was made in order to get massive reduction of the pockets and to use the secondary flap as a free graft.

Fig19. after flap elevation , the implants surface were accessible for mechanical debridement,
The implants surface looks bright after the meticulous cleaning with ultrasonic device.
Chemical decontamination was preformed using tetrecyclin.

Fig20. The buccal area after flap elevation. Implant at 14 position showed intra-bony defect 7 mm deep. Above the defect there is a thick, non Supporting bone that wouldn’t allow for optimal coverage of the bone post surgical. osteoplasty was done.

Fig21. After the osteoplasty.

Fig22. Chemical disinfection with tetracyclin.

Fig23. The autogenic bone that was removed during the osteoplaty was used to fill the infra-bony defect around implant 14.

Fig24. The tissue from the secondary flap was used to make the keratinized gingiva thicker.
It was sutured with vicril and tighten to the implants with SLING and CRISS CROSS

Fig25. Flap closure.

Fig27. I continued to pocket reduction and keratinized gingiva thickening around implants 22,23,25
From new x ray and probing to bone, I evaluated the extent of bone loss and planned the extent of pocket reduction.

Fig28. The intra sulcular incisions that were made bucally.

Fig29. The palatal submarginal incisions and double flap.

Fig30. After elevation of the buccal flap, horizontal bone loss with buccal vertical defect along the implant. As before, meticulous mechanical debridement and chemical decontamination were performed. The implants surface is bright after the ultra-sonic cleaning.

Fig31. Palatal photo after flap elevation.

Fig32. subepithelial connective tissue graft was harvested from the tuberosity.

Fig33. The subepithelial connective tissue graft from the tuberosity and the free graft from the secondary flap.

Fig34. the subepitheliai connective tissue graft tightened to the implants with sling and criss cross vicril sutures.

Fig35. the secondary flap thickening the keratinized gingiva by fixation to the inner aspect of the flap.

Fig36. Closure of the flaps with external vertical matress.

Fig38. 6 month after the surgeries. Bop reduced to 46% around implants.
Notice the healthy appearance of the mucosa, deeper recessions, black triangles between the implants. And the ability of the patient to maintain, good oral hygiene in spite of the exposure of threads and surface of the implant.

Fig39. Periodontal examination after surgeries showing significant reduction in probing depth, most of the pockets are 3 mm, Beside 3 sites with 4 mm. Recessions up to 6 mm.

Fig40. Clinical photos of buccal and palatal. Shows healthy mucosa, deeper recessions and current morphology that supports self oral hygiene.

Fig41. Peri-apicals taken 2 years from initial examination, showing stability and no progression of bone loss.

Fig42. Periodontal examination 3 years after the treatment, pockets around implants are stable and there is no progression of attachment loss.

Fig43. Upper jaw as it looks today. 3 years after the treatment. We can see that the disease has not progressed, which was my main goal all through the treatment.