Background information
Dr. Michael R. Norton:
«Periimplantitis is an inflammatory process that affects both the hard and soft tissues around an implant in function and results in marginal bone loss which may
eventually lead to loss of osseointegration. Bacterial infections play a major role in
the aetiology1,2,3. Therefore control of the infection is a major factor when treating
periimplantitis. In the literature different criteria for implant success have been
used. Therefore it is difficult to estimate the prelevance of peri-implantitis. However, Schwarz et al conclude from various studies4,5,6,7 that the prelevance of periimplantitis may vary between 10 and 29 %8. I have seen no more than 6 patients presenting with periimplantitis in my own practice over the last 16 years. This may be
related to the fact that I use implants without a porous coating such as TPS or HA.
The use of Geistlich Bio-Oss® and Geistlich Bio-Gide® has been described
to be an adequate means to aid restoration of the osseointegration of the implant8
and certainly has a role to play in the reconstruction of periimplantitis-induced defects. However, before embarking on surgery it is appropriate to use a non-interventional antimicrobial therapy. I routinely use systemic antibiotics along with
sub-mucosal irrigation of 10mL 0.12% chlorhexidine followed by sub-mucosal
topical application of 2% w/w Minocycline HCL (Dentomycin™). However, when
there are radiographic changes to the extent seen in the case presented, I plan for
immediate surgical intervention.
After raising a full thickness flap on a wide base, local degranulation and
thorough curettage are undertaken as a fundamental principle of debridement. The
use of chlorhexidine arose as a result of my early concerns for using citric acid
which has been previously recommended but which demineralizes the surrounding
bone. Also the fact that at a concentration of 0.12% with an exposure time of 5 minutes, chlorhexidine is a very effective antibacterial agent. In addition Tetracycline
which is quite often used in oral surgery is used as a solution to rehydrate the Geistlich Bio-Oss®. This is an anecdotal concept, based on the knowledge that tetracycline
binds to hydroxapatite.
Sometimes we take smears for bacterial culturing but we always use a combination of Amoxicillin / Metronidazole as a cover even if we are to take swabs for
culturing and antibiotic sensitivity testing. If a further course of antibiotics is indicated I typically use Clindamycin or Azithromycin.»
2. Aims of the therapy
> Therapy of the bacterial infection
> Regeneration of the bone lost around the implant by using Geistlich Bio-Oss® and
Geistlich Bio-Gide®
3. Surgical procedure
Fig. 2 Occlusal view of the infected site.
Fig. 1 Clinical situation: At the 5-year review the patient (65 years, male) complains
of recent soreness at position 13. On examination tissues are pink and healthy in
appearance but on palpation a purulent
exudate is apparent from around the periimplant sulci of 2 out of 3 implants in the
right quadrant. The patient is prescribed a
combined course of Amoxicillin 500mg TDS
and Metronidazole 200mg TDS for 5 days.
Prosthesis type: Non-resilient milled bar,
precision attachment-retained overdenture.
2
Fig. 3 On completion of the course of antibiotics, flap reflection reveals large craterlike infrabony defects and plaques of calculus-like material visible on the surface of
the implants. All soft tissues are thoroughly
degranulated.