Therapeutic Area: Peri-Implantitis

BIOBRIEF

Prosthetic-Surgical Approach to Regenerative Treatment for Peri-Implantitis

Andrea Ravidà, DDS, MS, PhD
Anu Viswanathan DDS, MDS

THE SITUATION

A 68-year-old male patient, who received an implant in tooth position #31 about 8 years prior, presented for an examination. He reports bleeding during brushing around the implant and some discomfort. Clinically, there was severe vertical bone loss, profuse bleeding on probing, and deep probing depths, but no pain. The condition was diagnosed as peri-implantitis according to the 2018 classification.

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune systemLight smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Infection at implant sightNoneChronicAcute
Restorative status of adjacent toothIntactRestored
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect

Additional Risk Factors: The patient exhibited bleeding on probing and deep pocket depths. He also reported occasional marijuana use and was inconsistent with periodontal maintenance and oral hygiene visits.

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THE APPROACH

The treatment goals were to eliminate peri-implant infection, regenerate lost hard and soft tissues, and ensure long-term implant stability. A closed regenerative approach was utilized, including crown removal, thorough implant decontamination with Perioflow®, an airpolishing technology, application of the correct bone grafting materials (Geistlich Bio-Oss®, vallos® and GEM 21S®), enclosed healing, and fabrication of a new crown to facilitate hygiene.

Clinical presentation of tooth #31 showing radiographic evidence of bone loss, profuse bleeding on probing (BOP), deep probing depths, and suppuration, indicative of peri-implantitis with a Class I-infraosseous (c) circumferential-type defect, as described in the study by Monje et al. (2019) Clin Implant Relat Res, 21(4)635-643.
Crown removal by the prosthodontist, followed by placement of a healing abutment for non-surgical therapy using PerioFlow®. After therapy, a cover screw was placed, and the tissue was allowed to heal over the implant for eight weeks.
Surgical treatment initiated with a midcrestal incision and full-thickness flap elevation. Granulation tissue was removed using a surgical curette, revealing a deep infrabony defect.
Implant thoroughly decontaminated using Perioflow® with erythritol powder to ensure a clean surface for regeneration.
rhPDGF-BB was used to hydrate bone grafting materials (vallos® Demineralized Cortical Granules and Geistlich Bio-Oss®), which were first hydrated with sterile water before rhPDGF-BB was added. The materials were mixed in a 1:1 ratio and allowed to sit for 10 minutes before being applied to the deep infrabony defect to promote regeneration.
Flap closed primarily with 5-0 PTFE horizontal mattress and single interrupted suture for secure closure.
Collagen membrane stabilized with 5-0 chromic gut sutures using the lasso technique.
After 5 months of healing, significant bone gain is evident. Geistlich Bio-Oss® was placed on the buccal site to enhance thickness, covered with an amnion-chorion membrane. A healing abutment was placed at this stage.
Two-year follow-up shows disease resolution with shallow probing depths, no bleeding or suppuration, and complete bone gain. A new crown was fabricated with an increased final abutment height (>2mm), contributing to optimal maintenance and long-term stability based on evidence supporting its role in promoting long-term success. A second surgery may be necessary to gain additional tissue thickness or cover residual thread exposure to achieve the desired long-term results.

“The implant presented with significant bone loss, deep probing depths, and bleeding on probing, placing it at risk of failure and requiring intervention to preserve function and longevity.”

— Andrea Ravidà, DDS, MS, PhD

THE OUTCOME

At the two-year follow-up, clinical and radiographic assessments showed disease resolution, complete bone gain, and stable peri-implant tissues. Probing depths were within healthy ranges, and no bleeding on probing was observed, confirming the long-term success of the treatment.

Enclosed healing, meticulous implant decontamination, appropriate selection of bone grafting materials, and customized crown design, combined with patient compliance and regular maintenance, contributed to disease resolution and complete bone regeneration.”

Andrea Ravidà, DDS, MS, PhD

The air polishing device with erythritol powder ensured thorough implant decontamination, while the bone grafting materials combined with rhPDGF-BB provided essential biologic support for regeneration and improved peri-implantitis treatment outcomes.”

Andrea Ravidà, DDS, MS, PhD

Andrea Ravidà, DDS, MS, PhD

Dr. Andrea Ravidà is the Director of the Graduate Periodontics Program in the department of Periodontics at the University of Pittsburgh. He conducts clinical research focusing on peri-implantitis, periodontitis and short implants. He has published more than 70 peer-reviewed articles and conference abstracts/presentations related to periodontics and implant therapy. He is section editor of the International Journal of Oral Implantology and the Journal of Translational Medicine.

Anu Viswanathan DDS, MDS

Dr. Anu Viswanathan is a Diplomate of the American Board of Periodontology and Implant Dentistry. She earned her Doctor of Dental Surgery degree from the University of Colorado School of Dental Medicine in 2019. Dr. Viswanathan completed a Certificate in Periodontics and earned a Master of Dental Science at the University of Pittsburgh School of Dental Medicine. She also obtained a Certificate in IV Sedation. Dr. Viswanathan is currently in private practice in Shoreline, Connecticut.

BIOBRIEF

Clinical Efficacy of Geistlich Mucograft® in Regeneration of Oral Mucosa Combined with the Surgical Treatment of Peri-implantitis in Implants with Lack of Keratinized Tissue

Dr. Alberto Ortiz-Vigón
Dr. Erik Regidor Correa

THE SITUATION

Adult patient, non-smoker and without relevant systemic history, attends to clinic referring peri-implant tissue inflammation, bleeding and brushing discomfort around her implant in the upper jaw. Clinically peri-implant pocket depth > 5 mm, bleeding and suppuration on probing were observed. Furthermore, the implant presented < 2 mm of keratinized mucosa and radiographic horizontal bone loss.

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system 
Non-smoker		Light smokerImpaired immune system 
Heavy smoker
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
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THE APPROACH

Intrasulcular incision was made and a mucosal partial thickness flap was raised. The recipient site was prepared by sharp disection in order to create a periosteal bed free of any muscle attachment. Peri-implant granulation tissue was removed and implantoplasty was performed. Finally, Geistlich Mucograft® was used to support the gain of keratinized tissue. Thus, the collagen matrix was sutured with the resulting flap apically at the base of the newly created vestibulum.

Pathological peri-implant pocket depth combined with bleeding on probing.
Partial thickness flap in order to create a periosteal bed free of any muscle attachment and apically positioned.
Implantoplasty of the exposed rough implant surface using burs and silicon carbide polishers.
Xenogeneic collagen matrix structure (Geistlich Mucograft®).
Future position of the xenogeneic collagen matrix facilitated by prosthodontic abutment.
Suture of xenogeneic collagen matrix around the abutment and over the recipient bed.
Buccal view of xenogeneic collagen matrix and apically positioned flap.
Occlusal view of xenogeneic collagen matrix and apically positioned flap.
Lateral view of xenogeneic collagen matrix and apically positioned flap.
Peri-implant tissue health and maintenance of keratinized tissue after one year of surgical treatment.
Periimplant tissue health and maintenance of keratinized tissue after 2 years

Absence of > 2 mm of keratinized mucosa was associated with peri-implant soft-tissue inflammation, bleeding and discomfort on brushing.

THE OUTCOME

After two years follow-up, the successful outcome can be observed in terms of clinical peri-implant parameters, gain of keratinized mucosa without significant graft shrinkage and stability of vertical position of the mucosal margin.

The use of Geistlich Mucograft® xenogeneic collagen matrix for regeneration of oral mucosa, combined with the surgical respective approach to peri-implantitis provides an improvement in clinical parameters and increase of the peri-implant keratinized mucosa minimizing the risk of recession in the esthetic area.”

Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

The use of soft-tissue substitutes may play an important role in patient perception and satisfaction without jeopardizing the final clinical outcome.”

Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

Dr. Alberto Ortiz-Vigón

  • DDS from the University of the Basque Country
  • MSc and PhD in bone regeneration from the University Complutense of Madrid (UCM)
  • Master in Periodontology and Implant dentistry from the EFP
  • Research fellowship at the University of Gothenburg
  • MBA from the Deusto Business School
  • Assistant professor and clinical researcher at UCM and ThinkingPerio Research
  • PerioCentrum Clinic in Bilbao
  • Co-founder of ARC Healthtech Innovation Holding
  • Socially engaged & NGO co-founder of Smile is a Foundation

Dr. Erik Regidor Correa

  • DDS from the University of the Basque Country
  • MSc from the U. of the Basque Country
  • Master in Periodontology and Implant Dentistry U. of the Basque Country
  • PhD student in the U. of the Basque Country
  • Assistant professor and clinical researcher ThinkingPerio Research

WEBINAR

CLINICAL CASE

Initial situation, patient presented with radiographic and clinically traditional signs of peri-implantitis, including bleeding on probing, suppuration, radiographic progressive bone loss and clinical pathologic probing depths.
Mechanical debridement was achieved using titanium scalers, an ultrasonic device with an implant protective cap and titanium brushes to remove all of the visible contaminants of the implant surface. Citric acid was then placed on shreds of a non-woven gauze and applied to the surface for approx. 1min. Copious irrigation was done using saline solution and the surface was ablated using the Er:YAG laser at 20pps/50mj.
After the surface was prepped and no signs of residual granulation tissue was noted, the defect was grafted with Geistlich Bio-Oss®. Attention was given towards not augmenting beyond the bony envelope.
A protective Geistlich Bio-Gide® membrane was placed over Geistlich Bio-Oss®.
Geistlich Fibro-Gide® was placed over Geistlich Bio-Gide® to enhance soft-tissue volume and quality. Geistlich Fibro-Gide® was trimmed and adapted to the defect site ensuring a tension free closure.
Geistlich Fibro-Gide® was place on the top of the bone graft to enhance soft-tissue thickness. Geistlich Fibro-Gide® is porous. We can observe the rapid penetration of blood through the matrix.
Closure with a tension-free flap was achieved by releasing incisions and secured using 4-0 chromic gut sutures.
1.5 year post-operative photo and radiograph show the healing of the soft-tissues with no signs of peri-implantitis and adequate tissue thickening. Radiographic bone levels have maintained stable over the course of the year.