Failure ManagementIndication Sheet X3

Treatment concepts for Peri-Implantitis by PD Dr. Frank Schwarz, Dr. Narja Sahm and Prof. Dr. Juergen Becker, Duesseldorf, Germany> Therapeutic strategies for intraosseous and supracrestal defect components.

> The treatment steps: decontamination, implantoplasty, and augmentation / guided bone regeneration (GBR) can deliver good results.

> Geistlich Bio-Oss®, Geistlich Bio-Gide® and Geistlich Mucograft® are important components of treatment concepts for tissue regeneration.

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© Geistlich Pharma AG Business Unit Biomaterials CH-6110 Wolhusen phone +41 41 492 56 30 fax +41 41 492 56 39 www.geistlich-pharma.com

Literature references1 Schwarz et al. Journal of Clinical Periodontology. 2006;33:491-499.

Healing of intrabony peri-implantitis defects following application of a nanocrystalline hydroxyapatite (Ostim) or a bovine-derived xenograft (Bio-Oss) in combination with a collagen membrane (Bio-Gide). A case series.

2 Schwarz et al. Journal of Clinical Periodontology. 2006;33:584-595. Influence of different treatment approaches on non-submerged and submerged healing of ligature induced peri-implantitis lesions: an experimental study in dogs.

3 Schwarz et al. Clinical Oral Implants Research. 2007;18:161-170. Comparison of naturally occurring and ligature-induced peri-implantitis bone defects in humans and dogs.

4 Schwarz et al. Journal of Clinical Periodontology. 2008;35:80-87. Two-year clinical results following treatment of peri-implantitis lesions using a nanocrystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane.

5 Schwarz et al. Journal of Clinical Periodontology. 2009;36:807-814. Surgical regenerative treatment of peri-implantitis lesions using a nanocrystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane: a four-year clinical follow-up report.

6 Schwarz et al. Journal of Clinical Periodontology. 2010;37:449-455. Impact of defect configuration on the clinical outcome following surgical regenerative therapy of periimplantitis.

7 Schwarz & Becker. Quintessence Publishing Co. Ltd. London, 2010. Peri-implant Infection. Etiology, Diagnosis and Treatment.

Contact> PD Dr. Frank Schwarz, Heinrich Heine University, Westdeutsche Kieferklinik, Moorenstrasse 5, 40225 Duesseldorf, Germany telephone: +49 211 811 81 49, fax: +49 211 171 35 42, e-mail: Frank.Schwarz@med.uni-duesseldorf.de

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1. Synopsis: Regenerative TherapyCriteria

Intrabony Component

Supracrestal Component(< 1 mm)

Supracrestal Component(> 1 mm)Dehisced Areas

Thin Mucosa

Regenerative Measure

Geistlich Bio-Oss®

(0.25–1 mm)Gesitlich Bio-Gide®

Double Layer Technique

Geistlich Bio-Oss®

(1–2 mm)Contour Augmentation

Implantoplasty

Geistlich Mucograft®

Visualisation

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PD Dr. Frank Schwarz:„On the basis of our own clinical studies, peri-implant bone defects may be divided into definable categories (3). In principle, one can distinguish an intraosseous (class I) from a supraalveolar (class II) defect component (see Fig 6, s (a)). The appropriate choice of the treatment concept depends on the appearance (or alternate: occurrence) of each defect component combination. The various treatment concepts are presented below.“

Background information

2. Therapy: Clinical Procedure

DecontaminationIn addition to the mechanical removal of the biofilm, a decontamination or conditioning of the exposed implant surface is necessary to optimise the removal of bacteria and lipopolysac-charides from the microstructured implant surface. For this purpose, ste-rile saline-soaked cotton pellets may be used to clean the exposed implant surface. Clinical data support the ef-fectiveness of this procedure. 7

ImplantoplastyRemodelling of exposed implant parts by removal of the affected surface region using diamond abrasives. De-pending on the defect component, this procedure may lead to reduced bacterial plaque deposits and promo-te the formation of fibrous connective tissue.7 This procedure is indicated for supracrestal (class II), and vestibular-oral exposed implant regions without bony support (i.e. class Ia-Id).2, 6

Augmentation + GBRAn augmentation and GBR should only be carried out in connection with an intraosseous defect component. In analogy to systematic periodontal therapy, regenerative therapy should be only considered after successful pre-treatment and when symptoms associated with acute inflammation have subsided.

2. Synopsis: Surgical Treatment of Peri-implantitis3, 7

Fig. 1 Vestibular dehiscence Fig. 2 Vestibular dehiscence + semi-circumferential bone resorption

Fig. 3 Vestibular dehiscence + circumferential bone resorption

Fig. 4 Vestibular and oral dehiscence + circumferen-tial bone resorption

Fig. 5 Circumferential bone resorption Fig. 6 Supracrestal exposure of structured implant parts

Fig. 1 Baseline (implant regio 045): Thin mucosal biotype suppuration / BOP +.

Fig. 2 Combined Class Ib + II defect con-figuration.

Fig. 4 Intrabony defect component (i.e. class Ib) using Geistlich Bio-Oss® (0.25–1 mm).

Fig. 5 Geistlich Bio-Gide® application ac-cording to the „double-layer“ technique.

Fig. 6 Collagen matrix Geistlich Muco-graft® – to compensate for the thin mu-cosal biotype.

Fig. 7 The collagen matrix Geistlich Mucograft® is placed on top of the colla-gen membrane Geistlich Bio-Gide®.

Fig. 8 Transmucosal wound healing (peri- and post-op administration of amoxicil-lin).

Fig. 9 Undisturbed wound healing at su-ture removal (10 days).

Fig. 10 Clinical Situation at 4 weeks. Fig. 11 Clinical Situation at 4 months:PD: 2mm suppuration / BOP–.

Fig. 12 Clinical Situation at 8 months clearly indicating a clinically relevant gain in mucosal thickness.

Fig. 1 Patelliform + supracrestal bone loss at implants regio 024 and 025.

Fig. 2 Fistula 025. Fig. 3 Both implants revealed clinical signs of suppuration.

Fig. 4 Combined Class Ie and Class II de-fect configurations.

Fig. 9 Implant 024 – Clinical Situation at 12 months: PD: 2 mm suppuration / BOP–.

Fig. 10 Implant 025 – Clinical Situation at 12 months: PD: 3 mm suppuration / BOP–.

Fig. 11 Radiographic bone gain at 12 months.

Fig. 1 Funnel-form bone loss at im-plant regio 022.

Fig. 1 Patelliform bone loss at im-plant regio 013.

Fig. 5 Implantoplasty to smoothen exposed implant parts.

Fig. 9 Situation at suture removal indicating a slight exposure of the collagen membrane (should be ma-naged by local antiseptic therapy, i.e. chlorhexidine gel for 10 days).

Fig. 2 Clinical Situation at Baseline:PD: 6 mm suppuration / BOP +.

Fig. 6 Class Ic defect component using Geistlich Bio-Oss® (0.25–1 mm).

Fig. 10 Clinical Situation at 12 months: PD: 2 mm suppuration / BOP –.

Fig. 3 Class Ic defect configuration.

Fig. 11 Radiographic bone gain at 6 months.

Fig. 4 A minor class Ia defect plus class Ic component.

Fig. 12 Radiographic bone gain at 12 months.

Fig. 5 Augmentation of the defect component (Class Ib) using Geist-lich Bio-Oss® (0.25–1 mm).

Fig. 2 Clinical Situation at Baseline:Probing depth (PD): 6 mm suppura-tion / bleeding on probing (BOP) +.

Fig. 6 Geistlich Bio-Gide® applica-tion (collagen membrane).

Fig. 3 Modified papilla preservation flap technique to access Class Ib de-fect configuration.

Fig. 7 Clinical Situation at 12 months: PD: 2 mm suppuration / BOP –.

Fig. 4 Implantoplasty to smoothen exposed (i.e. vestibular aspect) im-plant parts.

Fig. 8 Radiographic bone gain at 12 months.

Surgical Procedure: Implantoplasty + Regenerative Treatment (Class Ib)1, 4, 5, 6

Surgical Procedure: Implantoplasty + Regenerative Treatment (Class Ic)1, 4, 5, 6

Soft Tissue Management: Collagen Matrix (Class Ib + II)1, 4, 5

Surgical Procedure: Implantoplasty + Regenerative Treatment (Control) (Class Ie + II) 1, 4, 5

Fig. 7 „Double-layer“ membrane technique at both vestibular and lin-gual aspects.

Fig. 8 Transmucosal wound healing.

Fig. 3 Implantoplasty at the supracrestal component.

Fig. 5 Implantoplasty to smoothen expo-sed supracrestal implant parts.

Fig. 6 Augmentation of the intrabony defect component plus contour augmen-tation.

Fig. 7 „Double-layer“ membrane tech-nique at both vestibular and lingual as-pects.

Fig. 8 Transmucosal wound healing (peri- and post-op administration of amoxicil-lin).

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Ib

Ie

Ic

II