Several recent studies suggest that short implants (i.e., implants < 8.0 mm in length) perform similarly to longer implants in terms of survival and stability of hard and soft tissues [
Resective surgery with implantoplasty [
Regenerative surgery is conditioned by two critical phases, the implant surface decontamination and the defect grafting and/or membrane coverage [
For this reason, in the literature, several chemical topical agents have been proposed in addition to open flap mechanical debridement, but it is hardly possible to compare their adjunctive effect since the grafting protocol differs between one research and another, and there are only few RCTs [
Recently, a new topical desiccant (HYBENX Oral Tissue Decontaminant, EPIEN Medical, Inc.) was introduced as an adjunct to ultrasonic and mechanical subgingival debridement in nonsurgical treatment of chronic periodontitis [
In this paper, we report the three-year results of a regenerative treatment protocol for peri-implantitis that combines the concomitant use of a desiccant agent and an abrasive air powder treatment to decontaminate the implant’s surface with the use of a composite graft without the use of membrane.
In this case series, the study sample was collected at the Clinic of Dental and Maxillofacial Surgery of the University of Verona. Inclusion criteria were as follows: at least one short or ultrashort single-crown plateau-design locking-taper implants presenting PD ≥ 5 mm with BoP+ and/or suppuration at least at one of the six probed sites, presence of semi-circumferential or circumferential peri-implant defects, marginal bone loss ≥2 mm in at least mesial or distal site on radiographic examination, at least one year of loading at the time of diagnosis, absence of implant mobility, and single-crown prosthesis. Exclusion criteria were as follows: cancer of the oral cavity, systemic diseases and/or conditions, radiotherapy of the head/neck in the last 6 months, bisphosphonates use, poor oral hygiene (i.e., FM-VPI > 25%); active periodontal disease (FM-BoP > 25%); and allergy to sulfonates and its derivatives. The retrospective protocol was reviewed and approved by the Ethics Committee for Clinical Sperimentation (CESC) of Verona and Rovigo, Italy (based in the University of Verona) (Prog. 1863CESC. Date of approval: 2018-07-04).
The surgical procedure is shown in Figures
Regenerative treatment of peri-implantitis in the upper posterior jaw in a male patient. (a) Clinical probing before treatment. (b) Application of desiccant. (c) Decontamination with low abrasive air powder. (d) Filling of the peri-implant bone defect. (e) Postoperative clinical aspect. (f) Clinical follow-up 5 years after surgical treatment. (g) Preoperative X-ray. (h) Postoperative X-ray. (i) 5-year follow-up.
Regenerative treatment of peri-implantitis around an implant placed in the posterior lower jaw of a male patient. (a) Clinical probing before treatment. (b) Intraoperative view of peri-implant bone defect. (c) Application of desiccant. (d) Decontamination with low abrasive air powder. (e) Filling of the peri-implant bone defect. (f) Postoperative clinical aspect. (g) Clinical follow-up 4 years after surgical treatment. (h) Preoperative X-ray. (i) 4-year follow-up.
The surface decontamination procedure consisted of the following 3-step protocol that was repeated twice: (1) application of a desiccant agent (HYBENX Oral Tissue Decontaminant, EPIEN Medical, MN, USA), to the defect and implant surface, with a 60-second incubation period; (2) thorough irrigation of the defect with saline solution to flush out the desiccant; and (3) administration of sodium bicarbonate–based abrasive air powder treatment (Airflow, EMS, Nyon, Switzerland) to all contaminated and exposed parts of the implant surface for 60 seconds.
Bone defects were filled with a composite graft composed of a mixture of 50% of inorganic bone (Bio-Oss, Geistlich Biomaterials) and 50% biphasic calcium sulfate (BondBone, MIS ImplantsTechnologies Ltd.), and Rifampicin was adjuncted (1 vial, Sanofi-Aventis) when considered appropriate.
No membranes were used to coverage the graft, and suture was performed with flap mobilization if needed. The original prosthesis or a temporary healing abutment of adequate dimension was reinserted, to obtain a nonsubmerged primary tension-free healing. Postoperative care included a 0.12% chlorhexidine + 0.05% cetylpyridinium chloride (CPC) rinse (GUM Paroex, Sunstar Suisse S.A.) twice daily for 2 weeks, 1 g of amoxicillin every 12 hours for 7 days, and 800 mg of ibuprofen as needed for pain. The patient was instructed to abstain from brushing for two weeks.
Sutures were removed after two weeks, and patients were placed on an 8- to 12-week recall schedule until the completion of treatment (2 years).
Changes in the marginal bone level were evaluated using a computerized measurement technique (Rasband, WS, ImageJ, US National Institutes of Health, Bethesda, Maryland, USA), comparing standardized periapical radiographs performed at the time of surgery (peri-implantitis) (T1) and at the follow-up (T2) (Figure
Radiographs were digitalized and used for measurements of bone-level changes between the baseline and last follow-up. mBD: mesial bone defect, dBD: distal bone defect, mCB: mesial crestal bone, dCB: distal crestal bone, IAI: implant-abutment interface.
The stability of the peri-implant tissues was evaluated by means of a millimeter-sized periodontal probe, applying a light intensity force (0.2 N). For each implant site, soft tissue variables examined included the following: probing depth (PD), with the deepest sites categorized as qualifying sites (Q-site); modified bleeding index (mBI); modified plaque index (mPI); recession of the vestibular and palatal/lingual side; and degree of keratinized issue (TK). Peri-implant measurements were performed on six sites. All of the foregoing parameters were recorded immediately before surgery (T1), and at the final follow-up examination (T2).
A database was created using Microsoft Excel, and statistical analysis was conducted using SPSS software (SPSS Inc, IBM). Nominal variables were expressed by frequency distributions, whereas continuous variables were expressed by mean and standard deviation. All variables were expressed in millimeters (mm), except for the FMPS and the FMBS, which were expressed in percentages. A
Patient demographics are shown in Table
Demographic variables.
Patients | Implants | |
---|---|---|
N | 15 | 17 |
Gender (M/F) | 10/5 | 11/6 |
ASA status (I/II) | 8/7 | 11/6 |
Length (8-mm length/≤6.0-mm length implants) | 9/8 | 8/9 |
Jaw (upper/lower) | 7/8 | 8/9 |
Periodontal history (Y/N) | 8/7 | 10/7 |
Smoking (Y/N) | 5/10 | 6/11 |
The clinical parameters evaluated in this study are summarized in Table
Clinical parameters of the implant population. PD: probing depth; REC: recession; m-BI: modified bleeding index; mPLI: modified plaque index; av-BD: average bone defect depth; m-BD: mesial bone defect depth; d-BD: distal bone defect depth; m-Angle: mesial angle of defect; d-Angle: distal angle of defect; KT: keratinized tissue; FM-BoP: full-mouth bleeding on probing; FM-VPI: full-mouth visible plaque index; Q-sites: deepest site; deep pockets: PD ≥ 6.0 mm.
Baseline | Follow-up | Variation |
|
|
---|---|---|---|---|
FM-BoP | — | 12.24% ± 11.6% | — | — |
FM-VPI | — | 8.41% ± 9.79% | — | — |
PD | 5.55 ± 0.84 | 3.01 ± 0.74 | −2.54 ± 1.14 | <0.0001 |
REC | 0.35 ± 0.61 | 0.58 ± 1.23 | −0.23 ± 0.83 | Ns |
Keratinized tissue (KT) | 1.00 ± 1.27 | 0.82 ± 1.18 | −0.18 ± 0.39 | Ns |
mBI | 1.27 ± 0.56 | 0.65 ± 0.70 | −0.63 ± 1.07 | <0.05 |
mPI | 0.18 ± 0.35 | 0.15 ± 0.34 | −0.03 ± 0.51 | Ns |
Number of deep pockets per implant | 2.41 ± 1.37 | 0.18 ± 0.39 | 2.23 ± 1.52 | <0.0001 |
PD-Q-sites | 8.12 ± 1.58 | 3.35 ± 1.17 | −4.76 ± 1.56 | <0.0001 |
mBI-Q-sites | 2.35 ± 0.79 | 0.88 ± 0.93 | −1.71 ± 1.05 | <0.01 |
mPI-Q-sites | 0.23 ± 0.66 | 0.18 ± 0.53 | −0.06 ± 0.24 | Ns |
m-angle | 22.42 ± 9.26 | — | — | — |
d-angle | 25.26 ± 11.38 | — | — | — |
m-BD | 2.57 ± 1.15 | 1.03 ± 0.82 | −1.54 ± 0.94 | <0.0001 |
d-BD | 2.97 ± 1.32 | 1.26 ± 0.98 | −1.70 ± 1.41 | <0.001 |
BD Q-sites | 3.04 ± 1.14 | 1.30 ± 0.93 | −1.74 ± 1.19 | <0.0001 |
The average bone filling rate was 57.4% ± 26.5% (60.0% ± 32.5% on mesial side and 53.7% ± 38.7% on distal side). Regions showing the most extensive bone loss at baseline displayed significant bone regeneration at the 3-year follow-up.
At the deepest sites for each implant (Q-sites), the mean PD was significantly reduced by 4.76 ± 1.56 mm, from 8.12 ± 1.58 mm to 3.35 ± 1.17 mm (
Table
Clinical parameters of the implants population stratified by maxilla or mandible placement. Parameters evaluated include probing depth (PD); bleeding index (mPLI); plaque index (mBI); mesial bone defect (m-Bone defect); mesial angle of defect (m-Angle); distal angle of defect (d-Angle); keratinized tissue (KT); full-mouth BoP (FM-BoP); full-mouth visible plaque index (FM-VPI).
Baseline |
|
Follow-up |
|
Variation |
|
||||
---|---|---|---|---|---|---|---|---|---|
Lower | Upper | Lower | Upper | Lower | Upper | ||||
PD | 5.88 ± 0.45 | 5.16 ± 1.03 | 0.07 | 2.92 ± 0.74 | 3.10 ± 0.78 | 0.67 | 2.96 ± 0.93 | 2.06 ± 1.23 | 0.09 |
mBI | 1.39 ± 0.60 | 1.15 ± 0.53 | 0.37 | 0.68 ± 0.74 | 0.60 ± 0.69 | 0.81 | 0.70 ± 1.25 | 0.54 ± 0.90 | 0.54 |
PI | 0.17 ± 0.35 | 0.19 ± 0.37 | 1 | 0.17 ± 0.35 | 0.13 ± 0.35 | 0.81 | 0.00 ± 0.50 | 0.06 ± 0.56 | 0.74 |
Rec | 0.11 ± 0.33 | 0.62 ± 0.74 | 0.17 | 0.22 ± 0.44 | 1.00 ± 1.69 | 0.32 | −0.11 ± 0.60 | −0.37 ± 1.06 | 0.96 |
KT | 0.44 ± 1.01 | 1.62 ± 1.30 | 0.06 | 0.33 ± 0.70 | 1.37 ± 1.40 | 0.11 | 0.11 ± 0.33 | 0.25 ± 0.46 | 0.67 |
FM-BoP | — | — | — | 14 ± 15% | 10.2 ± 6.5% | 0.96 | — | — | — |
FM-VPI | — | — | — | 5.1 ± 5.9% | 12.1 ± 12.2% | 0.24 | — | — | — |
PD ≥ 6.0 mm | 2.67 ± 1.50 | 2.12 ± 1.25 | 0.64 | 0.00 ± 0.00 | 0.37 ± 0.52 | 0.08 | 2.67 ± 1.50 | 1.75 ± 1.49 | 0.64 |
PD Q-sites | 8.89 ± 1.36 | 7.25 ± 1.39 | 0.04 |
3.44 ± 1.23 | 3.25 ± 1.16 | 0.81 | 5.44 ± 1.24 | 4.00 ± 1.60 | 0.09 |
mBI Q-sites | 2.44 ± 0.88 | 2.25 ± 0.71 | 0.54 | 0.67 ± 0.87 | 1.12 ± 0.99 | 0.37 | 2.00 ± 1.11 | 1.37 ± 0.92 | 0.24 |
mPI Q-sites | 0.22 ± 0.67 | 0.25 ± 0.71 | 1 | 0.11 ± 0.33 | 0.25 ± 0.71 | 1 | 0.11 ± 0.33 | 0.00 ± 0.00 | 0.74 |
Mesial angle | 22.29 ± 8.23 | 22.58 ± 10.90 | 1 | — | — | — | — | — | — |
Distal angle | 28.06 ± 11.9 | 22.08 ± 10.60 | 0.28 | — | — | — | — | — | — |
m-BD | 2.91 ± 1.33 | 2.18 ± 0.82 | 0.20 | 1.37 ± 0.81 | 0.64 ± 0.66 | 0.06 | 1.54 ± 1.02 | 1.54 ± 0.89 | 0.74 |
d-BD | 3.06 ± 1.49 | 2.86 ± 1.21 | 0.67 | 1.22 ± 0.90 | 1.31 ± 1.12 | 0.89 | 1.84 ± 1.39 | 1.55 ± 1.52 | 0.61 |
BD Q-sites | 3.17 ± 1.13 | 2.89 ± 1.21 | 0.54 | 1.41 ± 0.94 | 1.17 ± 0.99 | 0.48 | 1.76 ± 1.13 | 1.33 ± 0.47 | 1 |
The use of desiccants in concert with air powder abrasion, followed by composite bone grafting, has been effective in the cases included in this study.
All of the 17 implants treated using the proposed surgical treatment remained in function for the duration of the study. Of the 42 deep pockets (PD ≥ 6 mm) initially discovered at baseline, only 3 remained at follow-up, and average probing pocket depth and bone defect depth were significantly reduced, especially at the level of the deepest sites.
The rationale for the use of the desiccant solution was that it quickly and completely denatures organic molecular biofilm components. This disrupts the molecular attachment mechanisms of the biofilm and enables easier and more effective mechanical debridement procedure [
The use of sulphonic/sulphuric acids was also based on reports demonstrating the clinical effectiveness both on periodontal and peri-implant biofilms. In a split-mouth RCT on patients with chronic periodontitis, nonsurgical therapy with the adjunctive application of desiccant brought to significative greater reduction of BoP than ultrasonic debridement alone after three months [
Despite these findings, there is no evidence about the application of this product on the contaminated implant surface during an open flap decontamination procedure, with the exception of a case report involving two implant in a single patient treated with clinical success [
Sandblasting systems using different abrasive particles have been used for the surgical treatment of peri-implantitis in animals and humans [
Current regenerative surgical strategies for the treatment of peri-implantitis could involve the use of barrier membranes to cover the grafted defect [
In a study involving the use of membranes, the prevalence of complications during healing has been shown to be absent in patients treated with bone graft alone, compared with a rate of between 55% and 60% in patients treated with a membrane [
Several controlled clinical trials compared the results of procedures performed in the presence or absence of barrier membranes [
Because of extensive heterogeneity of variables like decontamination protocol, grafting material, and systemic/local antimicrobics, it is difficult to compare the results of different studies. Moreover, only histology can confirm whether the graft has made direct contact with the implant surface or if it is acting as a filler only. In lack of histological analysis, the treatment’s efficacy can only be supported by similar protocols reported in the literature. For example, Benheke et al. [
Roccuzzo et al. examined the use of deproteinized bovine bone mineral with 10% collagen and without membrane coverage or submerged healing in patients suffering from peri-implantitis [
Short and ultrashort locking-taper implants are mainly positioned 2-mm subcrestally and in posterior atrophic areas, where the alveolar ridges are usually wide and the defects circumferential and contentive.
In the present study, all the patients enrolled presented with circumferential contentive defects (Class Ie) or with semicircular bone resorption associated with loss of the vestibular/palatal bone (Class Ib) [
On this basis, although in some other circumstances the use of membranes may be considered beneficial (e.g., specific noncontentive bone defects) [
The importance of optimal plaque control, both before and after surgical therapy, has been extensively described [
This is particularly true for patients with a history of periodontitis. In this study, patients underwent a personalized supportive periodontal treatment protocol (SPT), the content of which was influenced by the presence of periodontitis. In fact, patients with an history of periodontitis had a frequency of recall for SPT that was on average 4.5 months, whereas healthy patients had an average frequency of oral hygiene recalls of 6.9 months. Nevertheless, periodontal patients were found to have a higher percentage of bleeding (17%) than nonperiodontal patients (5%), and this justifies the fact that such patients should follow a SPT closer in time to have a long-term success of the therapy.
With the limitations of this retrospective case series, the protocol proposed in this study for regenerative treatment of peri-implantitis kept in function all the implants of the sample. The grafting technique proved to be effective from a radiographic point of view. The kind of bone defect treated, mainly circumferential, allowed to avoid the use of barrier membranes in order to reduce patient morbidity. The sample consisted of short and ultrashort implants, and a possible deduction, which requires further clinical confirmations from randomized prospective studies, is that the length of the implant does not affect treatment possibilities if the implant stability is preserved. Reduction of inflammation and clinical and radiographic improvements encourage further and more accurate research on the proposed decontamination method.
The data used to support the findings of this study are available from the corresponding author upon request.
The present research was presented as a poster at the EuroPerio 9 Congress (June 2019, Amsterdam, Netherlands).
The authors declare that there are no conflicts of interest.
Giorgio Lombardo was involved in investigation, project administration, resource collection, and review and editing of the manuscript. Mauro Marincola was involved in investigation and conceptualization. Andrea Cicconetti was involved in investigation. Jacopo Pighi was involved in investigation, data curation, and original draft preparation. Giovanni Corrocher was involved in investigation. Xiomara Serpa-Romero and Luis Armando Vila Sierra were involved in conceptualization. Miguel Angel Simancas-Pallares and Annarita Signoriello were involved in formal analysis. Miguel Angel Simancas-Pallares was involved in validation. Jacopo Pighi and Annarita Signoriello were involved in data curation. Jeffrey Lehrberg verified the methodology. Luisa Arevalo-Tovar and Pier Francesco Nocini were involved in supervision.