Advanced peri-implantitis cases with radical surgical treatment
A 44-year-old Caucasian man was referred to our office to replace implants that were expected to be imminently lost. Over the past five years, the patient reported receiving multiple implant therapies where many of the implants were removed and replaced. There were sites where the implants had been replaced on three occasions during that period. The patient did not understand the aetiology of the loss, had never received oral hygiene instruction or other forms of long-term supportive periodontal therapy and had no concept of peri-implantitis. The initial diagnosis was uncontrolled chronic adult periodontitis with horizontal bone loss affecting both the upper and lower dental arches. Additionally, peri-implantitis was present in varying degrees of aggression at all implant positions. Multiple photographs and radiographs were included in the initial diagnosis. The aetiology of the problem was described to the patient. Supportive periodontal therapy was initiated, and various surgical designs for implantotomywere applied with great success. Because of the degree of bone loss associated with the implant in position 42 (), the corrective surgical therapy was complicated and divided into two stages as follows:\nThe removal of implant 42 followed by GBR to re-establish the width and height of the hard tissue Placement of a 'remedial' implant into position 42 accompanied by a subepithelial connective tissue graft to replace the missing width of KGT at the site and further GBR (if necessary)\nThe same surgical protocol as in the preceding case was followed.\nA mucoperiosteal flap was raised to allow full visualization of the affected site (). The site was partially debrided and implant 42 was removed by luxation, which minimizes trauma to the socket walls (). The socket was debrided of all inflammatory and granulation tissue, but any remaining sulcular epithelium was kept intact in the soft tissue margin (). The lingual soft tissue was then reflected to allow the submucosal placement of the Bio-Gide membrane (Geistlich Pharma, Wolhusen, Switzerland). The vacant void was then packed with xenograft Bio-Oss (Geistlich Pharma) with a particle size of 0.25-1.0 mm and covered with Bio-Gide. These efforts attempted to re-establish a crestal hard tissue of a normal height. Last, 5.0 Prolene sutures were used to close the wound ().\nFive months postoperatively, a periapical radiograph was taken to display the newly augmented crestal bone (). After that, the implants (MIS, SEVEN) were placed by centralizing them to the 'bony ridge' and following the same surgical protocol (). The primary stability of both inserted implants was high; both implants had an initial seating torque of 50 Ncm as calibrated on the seating apparatus (Implantmed). Final seating of the implants (torque value>50 Ncm) was carried out using a hand wrench (). The crestal bone was further augmented with the xenograft and covered with Bio-Gide. Connective tissue was harvested from the right palatal vault and sutured to the underside of the extended, reflected labial mucosal flap ().\nFive months later, the implants were exposed via a crestal incision displaced to the lingual side, and healing abutments were fitted. The final fixed bridge was fitted four weeks later (). All of the treatments proceeded uneventfully, and the results showed a marked improvement in marginal gingival tissue levels and bone levels (). To date, the patient has received periodic examinations and radiographs over two years. After two years, observational radiographs will be taken every 12 months. The patient remains in supportive periodontal therapy.