journal club on Combined Surgical Resective and Regenerative Therapy forAdvanced Peri-implantitis with Concomitant Soft Tissue Volume Augmentation: A Case Report

COMBINED SURGICAL
RESECTIVE AND
REGENERATIVE THERAPY FOR
ADVANCED PERI-IMPLANTITIS
WITH CONCOMITANT SOFT
TISSUE VOLUME
AUGMENTATION: A CASE
REPORT
Frank Schwarz et al ; IJPRD
2014.
Shilpa Shivanand
III MDS

Introduction
Surgical regenerative treatment of peri-implantitis using
various bone substitutes and autografts with or without barrier
membrane has proven to be effective in controlling disease
progression for both short- and long-term periods
Roos-Jansaker et al
2011Despite clinical and radiographic improvements, it was
noted that flap elevation at these sites was commonly
associated with a significant increase in recession, which
may compromise the overall esthetic outcome.
Schwarz F et al
2006
These problems were notably pronounced when using a
combined surgical resective and regenerative treatment
procedure.
Becker J et al 2011

Introduction
To overcome the above limitations, a concomitant soft tissue
volume augmentation using SCTG has recently been
introduced and has proven to be effective in compensating
postoperative soft tissue remodeling and subsequent
shrinkage of the peri-implant mucosa.
Sahm N et al 2014
However, the commonly used trap-door technique for
harvesting a SCTG from the palate is technically
demanding and includes some potential intrasurgical risks
and postsurgical discomfort for the patient.
Roccuzzo M et al 2002
A recently introduced porcine-derived resorbable collagen
matrix was suggested to possess some physicochemical
properties needed to serve as a replacement graft for SCTG
and has proven to result in comparable volume gain when
compared with SCTG.
Thoma DS et al 2011, 2012

Aims
This study reports on a 3-year follow-up
after combined surgical
regenerative/resective therapy of advanced
peri-implantitis with concomitant soft
tissue volume augmentation using a
porcine-derived, resorbable collagen
matrix

Method and materials
 A 66-year-old partially edentulous woman who was a non-smoker and
who suffered from advanced periimplantitis at the mandibular right
second premolar implant was referred to the Department of Oral
Surgery, Heinrich Heine University, Düsseldorf, Germany, for treatment.
 Clinical examination by means of bone sounding, revealed a buccal
dehiscence as well as semicircular bone resorption to the middle of the
implant body with a probing depth of > 6 mm, an intrabony component of
3.7 mm, and a supracrestal component of approximately 1 mm at the
distal aspect as estimated radiologically.
Intrabony component = blue circles
circumferential component = arrows
m = mesial aspect; d = distal aspect
b = buccal aspect.
The red rectangle indicates the surface
area
undergoing an implantoplasty.
The orange rectangle indicates the

Inclusion criteria
No implant mobility
Presence of at least 2 mm of keratinized periimplant mucosa
to facilitate a repositioning of the mucoperiosteal flap at the
augmented areas
Treated chronic periodontitis and proper periodontal
maintenance care
Absence of any systemic disease that could influence the
outcome of the therapy (DM, osteoporosis, bisphosphonate
medication)
A good level of oral hygiene (Plaque Index< 1)

Treatment protocol
 To reduce clinical signs of inflammation (ie, pus
formation) before surgery, a single episode of
nonsurgical therapy using an Er:YAG laser device was
provided.

 At 2 weeks, the patient underwent the combined surgical
treatment procedure under local anesthesia.
 A full-thickness flap was elevated at the buccal aspect,
and the granulation tissue was meticulously removed
from the entire defect area and implant surface by
means of plastic curettes

 Subsequently, all buccally and supracrestally
exposed/threatened areas of the implant were completely
planed and smoothened using diamond burs under copious
irrigation with sterile saline.
 A debridement/decontamination of the remaining
unmodified implant surface areas facing the interproximal
alveolar bone was performed using plastic curettes and
cotton pellets soaked in sterile saline.

 These semi-circumferential, intrabony defect
components were homogeneously filled with NBM
(BioOss spongiosa granules, particle size 0.25 to 1 mm,
Geistlich).
 A slight overaugmentation resulted in an extension of
NBM to the buccal defect area.

 The CM was slightly oversized to cover 2 to 3 mm of the
defect borders and was applied in a double layer
(BioGide, Geistlich).

 The native collagen matrix (Mucograft [MG] Geistlich)
was trimmed and applied to the buccal aspect and
adapted over the CM without any additional fixation.

 Finally, the flap was repositioned and fixed with
vertical/horizontal mattress as well as sling sutures
(Resorba).
 A systemic antibiotic medication (penicillin) was
administered pre- (ie, 1 hour before) and postoperatively
for 5 days to account for transmucosal healing.

Clinical measurements
 The following clinical parameters were assessed
immediately before surgery (baseline) and after 6, 12,
24, and 36 months using a periodontal probe:
MR
BOP
PD
PI
KM
CAL
from the
mucosal
margin to
bottom of the
probeable
pocket
from IS to the
bottom
of the probeable
pocket
from the implant
shoulder (IS) to
the mucosal
margin

Results
 Postoperative wound healing (ie, no allergic reactions,
abscesses, or infections) was generally considered
uneventful.
 No flap dehiscences or premature exposures either of
MG, CM, or NBM were noted.

MR
Mean MR values remained
almost unchanged within the first
6 months after surgery
However, a creeping
attachment resulted in a
decrease of mean MR values
between
12 and 24 months,
even reaching a slight gain of
0.1 mm in tissue height after
36 months of healing
A marked decrease of mucosal
height by 0.6 mm was noted
at 12 months.

CAL
Mean CAL values were markedly reduced at 6
months, slightly increased at 12 months, but
improved at 24 months with stable conditions at 36
months.

MR & KM
However, at 24 months, the width of KM increased with
mean MR values, even reaching baseline scores after 36
months of healing
It was noted that the
decrease in mucosal
height at 12 months
was associated with
an obvious
decrease in mean
KM values.

Radiographs
 Since clinical signs suggested a re-infection (positive
BOP scores), nonstandardized radiographs were taken
at 6 and 12 months.
 However, radiographic assessment pointed to an
obvious decrease in translucency in the former defect
area, which was also proven to be stable at 36 months.
Baselin
e
6 month 12 month 36 month

Discussion
 This case report presented a 3-year follow-up of the
clinical outcomes of a combined surgical resective and
regenerative therapy for advanced peri-implantitis with
concomitant soft tissue volume augmentation using MG.
 After 36 months of transmucosal healing, it was
observed that this surgical approach was associated
with clinically important improvements in all investigated
parameters.
 Hence , it must be emphasized that the method of
surface debridement and decontamination was clinically
proven to be as effective as an Er:YAG laser device and
supported the process of re-osseointegration at the
intrabony defect component.

 While the current surgical procedure was associated
with a marked increase in mean MR values at 12
months, a regain in mucosal height was noted between
12 and 24 months, even reaching the respective
baseline value after 36 months of healing.

 The observation that surgical regenerative treatment of
moderate to advanced peri-implantitis may be
associated with significant increases in mean MR is in
accordance with previous studies employing either a
nanocrystalline hydroxyapatite or an algae-derived
xenograft with a resorbable synthetic membrane.
Roos-Jansaker AM et al 2007, Schwarz F et al
2006

 Similar outcomes were also noted for the combined
surgical regenerative and resective therapy of advanced
periimplantitis without concomitant soft tissue volume
augmentation, resulting in statistically significant
increases in mean MR values after 6 months of healing.
Schwarz F et al 2011, 2012

 Recent data of a prospective case series have indicated
that a concomitant volume augmentation using SCTG
may compensate for soft tissue changes and even result
in a slight increase in mean mucosal height (0.07 ± 0.5
mm) at the buccal aspects in the short term (ie, 6
months).
Schwarz F et al 2014
 However, the present case indicates that mucosal soft
tissue changes may be more pronounced between 6
and 12 months of healing and, therefore, the long term
stability of these outcomes needs to be carefully
considered.

Conclusion
 Within the limitations of a case report, it was concluded
that the presented combined surgical procedure was
effective in controlling advanced peri-implantitis without
compromising the overall esthetic outcome in the long
term.

I. Clinical efficacy of a xenogeneic collagen matrix in
augmenting keratinized mucosa around implants: a
randomized controlled prospective clinical trial. Lorenzo R et
al. Clin Oral Implants Res. 2012
Aim
 The aim of this controlled randomized clinical trial was to
evaluate the efficacy of a xenogeneic collagen matrix (CM) to
augment the keratinized tissue around implants supporting
prosthetic restorations at 6 months when compared with the
standard treatment, the connective tissue autograft, CTG).
Method
 This randomized longitudinal parallel controlled clinical trial
studied 24 patients with at least one location with minimal
keratinized tissue (≤1 mm).
Main outcome measures
 The 6 month width of keratinized tissue. As secondary
outcomes the esthetic outlook, the maintenance of
periimplant mucosal health and the patient morbidity were
assessed preoperatively and 1, 3, and 6 months
postoperatively.

Results
 At 6 months, Group CTG attained a mean width of
keratinized tissue of 2.75 (1.5) mm, while the corresponding
figure in Group CM was 2.8 (0.4) mm, the intergroup
differences not being statistically significant. The surgical
procedure in both group did not alter significantly the mucosal
health in the affected abutments. There was a similar esthetic
result and significant increase in the vestibular depth in both
groups as a result of the surgery. In the CM group it changed
from 2.2 (3.3) to 5.1 (2.5) mm at 6 months. The patients
treated with the CM referred less pain, needed less pain
medication, and the surgical time was shorter, although these
differences were not statistically significant when compared
with the CTG group.
Conclusion
 These results prove that this new CM was as effective and
predictable as the CTG for attaining a band of keratinized
tissue.

II. Treatment of soft tissue recessions at titanium implants
using a resorbable collagen matrix: a pilot study.
Schwarz F et al. Clin Oral Implants Res. 2014
Objectives
 To histologically assess the effectiveness of a porcine derived
collagen matrix (CM) and a subepithelial connective tissue graft
(CTG) for the coverage of single mucosal recessions at
osseointegrated dental implants.
Method
 Chronic type mucosal Miller Class I like recessions (mean clinical
defect height: 0.67 ± 0.331.16 ± 0.19 mm) were established at
the buccal aspect of titanium implants with platform switch in six
beagle dogs. The defects were randomly allocated to either (1)
coronally advanced flap surgery (CAF) + CM, (2) CAF + CTG or
(3) CAF alone. At 12 weeks, histomorphometrical measurements
were made (e.g.) between the implant shoulder (IS) and the
mucosal margin (PM) and IS and the outer contour of the

Results
 All treatment procedures investigated were associated with
an almost complete soft tissue coverage of the defect area
(i.e. coronal positioning of PM relative to IS). Mean IS - PM
and MT values tended to be increased in both CAF + CM
(1.04 ± 0.74 mm/0.71 ± 0.55 mm) and CAF + CTG (0.88 ±
1.23 mm/0.62 ± 0.66 mm) groups when compared with CAF
(0.16 ± 0.28 mm/0.34 ± 0.23 mm) alone. These differences,
however, did not reach statistical significance.
Conclusion
 Within the limits of this pilot study, it was concluded that all
treatment procedures investigated were effective in covering
soft tissue recessions at titanium implants.

journal club on Combined Surgical Resective and Regenerative Therapy forAdvanced Peri-implantitis with Concomitant Soft Tissue Volume Augmentation: A Case Report

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