Journal of Implant and Advanced Clinical Dentistry June 2013

Volume 5, No. 6 June 2013 The Journal of Implant & Advanced Clinical DentistryPeri-Implantitis Issue



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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 6 • June 2013 Table of Contents11 E xcess Cement and Peri-implant Disease Donald P. Callan, Charles M. Cobb21 Iatrogenic Peri-Implantitis: Treatment and One to Two Year Follow up Pradeep Adatrow, George Hilal, David Cagna, Paul Bland The Journal of Implant & Advanced Clinical Dentistry • 3

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 6 • June 2013 Table of Contents31 Bone Regeneration Around a Failing Implant in an Osteopetrotic Patient: A Clinical Case Report Eric G. Driver, Simon R. MacNeill, Charles M. Cobb41 T reatment of Peri-implantitis Using Open Flap Debridement and Iodine Solution with Autogenous Bone Graft: A Case Report Miki Taketomi Saito, Mauro Pedrine Santamaria, Karina Gonzales Silvério, Enilson Antônio Sallum The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDSMichael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MSThomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMDJohn Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDSLeon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMDStepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMDDavid Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhDCharles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDSSpyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDSSally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MATomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDSMassimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDSDouglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhDAlex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhDNicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhDPaul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDSDavid Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhDRonald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSDavid Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDSKenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDSIstvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 9

Callan et al DID YOU KNOW? Roxolid implants deliver more treatment options Roxolid is optimal for treatment of narrow interdental spaces. Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us Case courtesy of Dr. Mariano Polack and Dr. Joseph Arzadon, Gainesville, VA

Excess Cement Callan et aland Peri-implant DiseaseDonald P. Callan, BS, BA, DDS1 • Charles M. Cobb, DDS, PhD2AbstractBackground: Among the dental consumer Three different restorative dentists were utilizedpopulation, dental implants are an increasingly for the three patients. Occlusal evaluations andpopular option for replacing teeth and restor- adjustments were performed for each patient alonging function. Since implants became a common with proper home care instructions as needed.modality, assessments of their success haveincluded improved appearance, restored ability Results: The first recall visit showed no clini-to eat, and longevity of placement. By and large, cal signs of inflammation and all patients reportedthe most appealing appearance drives the choice no discomfort, bleeding during routine homeof dental implants for the patient. However, care procedures, normal function and accept-patients and dentists should be aware of pos- able esthetics. A radiograph was taken on eachsible complications that could affect the patient’s patient. Radiographic bone loss was notedoral and systemic health, even when excellent on the mesial or distal coronal portion of theesthetic results are achieved. This article dem- implant body. Mucogingival flaps were elevatedonstrates an excellent esthetic result even with on each implant and subgingival dental cementthe presence excess subgingival cement fol- was noted on the three dental implants. Thelowing placement of a fixed prosthesis associ- cements were not visible on the radiographs.ated with no clinical signs of inflammation butwith radiographic signs of peri-implant disease. Conclusion: When restoring dental implants, the restorative dentist must exert extreme care toMethods: Three healthy females sought tooth remove all dental cement about the implant body.replacement with dental implants. There were In the cases presented in this report, although theno contraindications for the placement of den- restorations displayed acceptable esthetics andtal implants and proper surgical protocols were normal function with no clinical signs of inflamma-followed as specified by the implant manufac- tion or patient discomfort, excess cement appearedturer. The implants were restored three and one to create a localized inflammatory response thathalf months post surgery with a cemented crown. resulted in bone loss about the dental implants.KEY WORDS: Dental implants, dental restoration, cement, inflammation 1. Private Practice limited to Periodontics, Little Rock, Arkansas, USA2. Professor Emeritus, Department Of Periodontics, School Of Dentistry, University of Missouri-Kansas City, Kansas City, Missouri, USA The Journal of Implant & Advanced Clinical Dentistry • 11

Callan et al INTRODUCTION a screw may have problems including loosen- ing of the screw, fracture of the screw, estheticAmong the dental consumer population, dental concerns, increased cost, and a complex res-implants are an increasingly popular option for toration.8-10 Utilizing dental cements may allevi-replacing teeth and restoring function from the ate most of these problems.11 Applying dentalmissing teeth. Since implants became a com- cements on the abutment of dental implant resto-mon modality, assessments of their success have rations is much the same as crown restorations onincluded improved appearance, restored abil- natural teeth. Little information has been providedity to eat, and longevity of placement and main- in the literature regarding the potential problems oftaining a healthy environment. By and large, excess cement being retained subgingivally aboutappealing appearance drives the choice of den- dental implants after the completion of the res-tal implants for the patient. However, patients toration.12-14 This report documents three casesand dentists should be aware of possible com- illustrating complications that may arise followingplications that could affect the patient’s oral and the cementation of dental crowns on osseointe-systemic health, even when excellent esthetic grated dental implants. One possible problemresults are achieved. Local inflammation associ- appears to be the inflammatory response as cre-ated with teeth and dental implants is a signifi- ated by not removing excess subgingival cement.cant clinical phenomenon and may pose systemicconcerns through the inflammatory response of MATERIALS AND METHODSthe host. The occurrence of infection, inflamma-tion, and bone loss about teeth and implants will Three healthy partially edentulous patients agedoften compromise long-term prognosis, esthet- 36 to 56 years were evaluated after the place-ics, function, oral health, and, if extensive, will ment of dental implants and the final cementationultimately lead to tooth and implant failure.1-4 of dental prostheses. All patients were in good health and had no contraindications for the place- Some researchers and implant companies ment of dental implants. Following completion ofhave indicated the crestal bone loss around den- oral hygiene evaluation, oral hygiene instructions,tal implants is a normal occurrence. Local bone and necessary periodontal therapy, one dentalloss about teeth and dental implants is the result implant was placed in each patient according toof inflammation. Gingivitis and periodontitis are the manufacturer’s protocol. All three patientsboth caused by a diverse population of oral bacte- were allowed to heal for a minimum of 3½ monthsria with similarities of microbial populations exist- to a maximum of 4 ½ months after implant place-ing between implants and natural teeth. Many ment. After implant placement, a second surgicalof the same periodontal pathologic bacteria procedure was performed to expose the implantshave been isolated from implants, thus conclud- to the oral environment for prosthetic connec-ing that Periodontitis and Peri-Implantitis are one tion. During the second stage surgery, no bonein the same5 and may have systemic concerns. loss was noted at the about the neck of any of the implants. Oral hygiene instruction was reviewed Implant supported restorations may be retained with each patient before and after implant place-by either dental retrievable screws or cements.6,7Attaching the restoration to the implant body with12 • Vol. 5, No. 6 • June 2013

Callan et alFigure 1: Six months after prosthetic procedures, note the Figure 2: Radiograph revealed bone loss on the mesial ofsoft tissues about the implants appearing normal in color, the implant being evaluated. No cement was noted on thetexture, and form. radiograph.ment and at the second surgical procedure. There pocket depths ranged from 6 to 7 mm in depthwere no complications following the first and sec- and there were no bleeding points. Radiographsond surgeries and all three patients healed as revealed bone loss on the mesial or distal of eachanticipated. Radiographs were taken prior to implant being evaluated (figure 2). The pocketimplant placement and 3½ months after implant depths were noted on the same side as the radio-placement. All radiographs showed no bone loss. graphic bone loss. Mucoperiosteal flaps wereAfter healing of the second surgery, the soft tis- elevated about each implant (figures 3,4). Den-sues appeared normal in color, texture, form, tal cement was noted at the most coronal area ofand the patients reported little to no discomfort. each implant that showed radiographic bone loss. On one of the patents, the bone loss so severe The patients were referred back to the restor- the implant was removed while removing the gran-ative dentist for the completion of the restor- ulation tissue and the excess cement (figure 5).ative procedures. The cements were selectedby each individual restorative dentist as to their To verify the identity of the material, a biopsypreference and were used according to the was taken from one of the patients and submit-manufacturer’s specifications. After cementa- ted to the oral pathology department at the Uni-tion of the prosthesis, the restorative dentists versity of Missouri at Kansas City for histological,attempted to remove excess cement about scanning electron microscopy (SEM), Secondarythe abutment/prosthesis in the usual fashion. Electron Imaging, and Electron Dispersion X-ray Analysis (EDS) evaluations. Four particles of a Six months following the prosthetic procedures, solid hardened material were chipped from thethe soft tissues about the implants appeared nor- implant abutment/prosthesis interface and placedmal in color, texture, and form (figure 1) and all in a 10% neutral buffered formalin solution. A softpatients reported no discomfort. Upon probing tissue biopsy consisting of gingiva and granula-with a periodontal probe (Williams markings), the The Journal of Implant & Advanced Clinical Dentistry • 13

Callan et alFigure 3: Excess cement was noted about the apical Figure 5: Implant as shown in figure 1 was lost during theportion of the prosthetic margin. removal of the excess cement about the apical portion of the prosthetic margin and on the implant body.Figure 4: Excess cement was noted about the apicalportion of the prosthetic margin. cold 0.1 M cacodylate buffer at pH 7.4 for three cycles of 2 hours each. The specimens weretion tissue was procured circumferentially from then allowed to dry and dehydrate in a dissectoraround the implant prior to removal of the implant for 24 hours. Following drying/dehydration thefrom the alveolus (figure 5). The soft tissue biopsy specimens were affixed to aluminum stubs andwas also placed in a 10% neutral buffered for- sputtered coated with a carbon film. The coatedmalin solution and later processed for routine specimens were then examined with the aid of alight microscopy, i.e., sectioned at 7µm thickness Philips field emission SEM (model XL-30 ESEM-and stained with hematoxylin and eosin (H & E). FEI, Philips Electronic Instruments, Inc., Mahwah, NJ, USA). In addition to routine morphology, the Following fixation in the buffered formalin particles were examined by: 1) x-ray microanaly-solution, the solid particles were washed in ice- sis using electron dispersive x-ray spectroscopy (a.k.a. EDS; Bruker AXS Microanalysis, Ewing, NJ, USA); 2) secondary electron imaging; and 3) x-ray mapping, the latter two procedures using 15 kV accelerating voltage at a 10 mm working distance. RESULTS Soft Tissue Light Microscopy Hematoxylin and Eosin (H&E) stained soft tissue sections revealed a moderately dense fibrosis sur- rounding numerous embedded foreign material (figure 6). The connective tissues were infiltrated14 • Vol. 5, No. 6 • June 2013

Callan et alFigure 6: H & E stained section from the soft tissue biopsy Figure 7: Higher magnification of area of interest fromembedded particles of solid material that are heavily figure 6 showing the amorphous structure of the solidhematoxylinophilic (arrow) adjacent to other solid particles particles. Again, note the fibrosis with an interspersedthat exhibit a mixed eosinophilia and low affinity for infiltrate of chronic inflammatory cells. Originalhematoxylin (forked arrow). The blue-purple area in the magnification of 200x.upper center of the specimen represents an impacted massof bacteria (star). Note the extensive fibrosis surrounding face features were induced craze lines (crack-the solid particles. Original magnification of 100x. ing), a result of the dehydration process. There was no evidence of soft tissue adherence (figuresby chronic inflammatory cells dominated by lym- 8,9). Secondary electron imaging of the samephocytes and plasma cells. The foreign material specimen revealed a more roughened and irreg-was particulate and presented two different stain- ular surface topography. However, both routineing affinities. There were particles that exhibited SEM and secondary electron imaging providedan overt affinity for hematoxylin, resulting in a deep sufficient morphologic evidence to allow differ-purple staining pattern while other particles exhib- entiation of the material from tooth root or bone.ited a slight affinity for the hematoxylin (figure 7)that resulted in a faint purple-pink staining pattern. Electron Dispersion X-ray Analysis (EDS)Lastly, isolated islands of embedded microbial The EDS scan of the particle surface showedbiofilm were noted near the tissue surface adja- peaks of varying intensities conforming tocent to the presumed peri-implant pocket area. the following elements: low peaks for sodium and potassium; moderate peaks for car-SEM and Secondary Electron Imaging bon and sulfur; moderately high peaks forAll particles were characterized by a relatively oxygen, calcium, aluminum, and phospho-amorphous surface topography. Under routine rus; and a high peak for silicon (figure 10).SEM examination, the surface appeared rela-tively smooth except for the presence of localizeddeposits of loosened debris. The primary sur- The Journal of Implant & Advanced Clinical Dentistry • 15

Callan et alFigure 8: Routine SEM of solid particle removed from the Figure 9: Secondary electron image of same specimenimplant collar/prosthetic abutment interface. Surface shown in figure 8 indicating a more undulating andfeatures consisted of dehydration induced crazing and roughened surface topography than can be seen usingloosened debris. Bar = 500 µm at an original magnification routine SEM imaging techniques. Bar = 500 µm at anof 40x. original magnification of 40x.Figure 10: EDS scan of surface of specimen pictured in figures 8 & 9 showing peaks that identify the presence of thefollowing elements (left to right): carbon, calcium, oxygen, sodium, aluminum, silicon, phosphorus, sulfur, potassium, and asecond calcium peak.16 • Vol. 5, No. 6 • June 2013

Callan et alFigure 11: X-ray mapping of the surface of the same specimen shown in Figures 8 & 9. Note the uniform distribution ofcalcium (Ca K), phosphorus (P K), aluminum (Al k), silicon (Si K), and sulfur (S K). The last image is a routine SEM to show thesurface morphology that corresponds to the location and distribution of the various elements.X-ray Mapping appointment. All three dentists stated they hadX-ray mapping confirmed the EDS observa- no indication the bone loss was occurring ortions by revealing a consistently uniform and the etiology of the bone loss prior to viewing theregular pattern of distribution of calcium, phos- radiographs. After advising the patients of thephorus, silicon, aluminum and sulfur (figure bone loss about the implants, the patients agreed11) on the surfaces of the various particles. to exploratory surgery to determine the cause of bone loss to correct the problem, if possible. DISCUSSION During the exploratory surgery on all 3 implant cases, excess cement was noted about the api-The surgical dentists and three restorative den- cal portion of the prosthetic margins (figures 3-5).tists involved with these cases had extensiveimplant experience. The restorative dentists Histologic evaluation of the biopsy samplewere surprised to see the amount of bone loss revealed solid globular masses, surrounded byas indicated by the radiographs at the six month fibrosis and a mononuclear inflammatory cell The Journal of Implant & Advanced Clinical Dentistry • 17

Callan et alinfiltrate consistent with a low-grade chronic conditions that resorb bone about the dentalinflammation. Both the morphology and multiple implants. It is recommended that clinicians uti-staining intensities were consistent with residual lize radiopaque cement to allow for radiographicdental cement. Interestingly, the biopsy exhib- visualization before dismissing the patient. ●ited several areas of embedded masses of bac-teria as well. The overall impression suggests Correspondence:the high probability of residual cement and bac- Dr. Donald P. Callanterial biofilm having been forced into adjacent 10319 West Markhamgingival tissues during instrumentation of the Suite 300peri-implant sulcus and/or periodontal pocket. Little Rock, Arkansas 72205 e-mail: [email protected] When viewed collectively, the various meth-ods used to examine the hard particles confirm Disclosure:the presence of a non-biologic material, most The authors report no conflicts of interest with anything mentioned in this article.likely residual dental cement. Routine and sec- Referencesondary electron imaging were used to provide 1. H eydenrijk K, Meijer HJ, van der Reijden WA, Raghoebar GM, Vissink A,high-resolution images of the surface morphol-ogy to rule out biologic origins that might include Stegenga B. Microbiota around root-form endosseous implants: A review ofbone or residual tooth structure (figures 8,9). the literature. Int J Oral Maxillofac Implants 2002; 17:829-838.Furthermore, the morphology appears inconsis- 2. Hultin M, Gustafsson A, Hallstrom H, Johansson LA, Ekfeldt A, Klinge B.tent with synthetic bone grafting material, such Microbiological findings and host response in patients with peri-implantitis.as hydroxyapatite granules or bioactive glass. Clin Oral Implants Res 2002; 13:349-358. 3. R utar A, Lang NP, Buser D, Burgin W, Mombelli A. Retrospective assessment EDS is an analytical technique used for of clinical and microbiological factors affecting periimplant tissue conditions.the qualitative elemental analysis or chemical Clin Oral Implants Res 2001; 12:189-195.characterization of a sample (figure 10). The 4. v an Winkelhoff AJ, Goene RJ, Benschop C, Folmer T. Early colonization ofhigh silicon peak, when coupled with the pres- dental implants by putative periodontal pathogens in partially edentulousence of aluminum, is conclusive evidence that patients. Clin Oral Implants Res 2000; 11:511-520.the specimen was of non-biologic origins. The 5. C allan, DP, Cobb, CM and Williams KB. DNA Probe Identification of Bacteriauniform distribution of the silicon and alumi- Colonizing Internal Surfaces of the Implant-Abutment Interface: A Preliminarynum within the specimen, as shown by the Study; J Periodontol 2005; 76(1):115-120.x-ray mapping technique (figure 11), is further 6. Weber HP, Kim DM, Ng MW, Hwang JW, Fiorellini JP. Peri-implant soft-tissuesupport for the presence of dental cement. health surrounding cement- and screw-retained implant restorations: a multi- center, 3-year prospective study. Clin Oral Implants Res 2006; 17(4):375- CONCLUSION 379. 7. S quier RS, Agar JR, Duncan JP, Taylor TD. Retentiveness of Dental CementsThis limited study demonstrates that dentists Used with Metallic Implant Components. Int J of Oral Maxillofac Implantsshould be aware of the potential problems with 2001; 16:793-798.cementing permanent restorations with subgingi- 8. J ent T, Linden B, Lekholm U. Failures and Complications in 127 Consecutivelyval margins on dental implants. Residual subgin- Placed Fixed Partial Prostheses Supported by Branemark Implants. Fromgival cement appears to establish inflammatory Prosthetic Treatment to First Annual Checkup. Int J of Oral Maxillofac Implants 1992; 7:40-44. 9. C arlson B, Carlsson G. Prosthetic Complications in Osseointegrated Dental Implant Treatment. Int J of Oral Maxillofac Implants 1994; 9:90-94. 10. K allus T, Bessing C. Loose Gold Screws Frequently Occur in Full Arch Fixed Prostheses Supported by Osseointegrated Implants after Five Years. Int J of Oral Maxillofac Implants 1994; 9:169-178. 11. H ebel K, Gajjar R. Cement Retained Versus Screw Retained Implant restorations. Achieving Optimal Occlusion and Esthetics in Implant Dentistry. J Prosthet Dent 1997; 77:28-35. 12. A gar JR, Cameron SM, Hughbanks JC, Parker MH. Cement Removal Restorations Luted to Titanium Abutments with Simulation Subgingival Margins. J Prosthet Dent 1997; 78:43-47. 13. Pauletto N, Lahiffe BJ, Walton JN. Complications associated with excess cement around crowns on osseointegrated implants: a clinical report. Int J of Oral Maxillofac Implants 1999; 14(6):865-868. 14. Gapski R, Neugeboren N, Pomeranz AZ, Ressner MW. Endosseous Implant Failure Influenced by Crown Cementation: A Clinical Case Report. Int J of Oral Maxillofac Implants 2008; 23:943-946.18 • Vol. 5, No. 6 • June 2013

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Iatrogenic Peri-Implantitis: Padatrow et alTreatment and One to Two Year Follow upPradeep Adatrow, DDS, MSD, MPH1 • George Hilal, DMD, MDS2 David Cagna, DDS, MS3 • Paul Bland, DDS4AbstractBackground: Peri-implantitis may be associated Results: Peri-implant clinical signs of infec-with a number of variables ranging from patient tion abated and radiographic evidence ofrelated to iatrogenic factors. Peri-implant muco- bone regeneration occurred following sur-sal tissues may be more vulnerable to plaque gical intervention on the affected implants.induced inflammatory changes due to differences Patients were placed on three month main-in gingival attachment between implants and natu- tenance schedules. Clinically detectableral teeth. Local factors that encourage bacterial implant stability was discernable one andgrowth and reduce implant integration should be two years following active patient therapy.considered when diagnosing and treating inflam-matory lesions identified around restored implants. Conclusions: Factors that promote peri- implant bacterial retention can be detrimen-Methods: Two patients presented with clini- tal to long term success. Excess subgingivalcal and radiographic signs consistent with cement in close approximation to implant andinfection adjacent to restored dental implants. abutment surfaces appeared to be a signifi-During surgical therapy of the affected areas, cant causative factor in the two cases pre-dental cement was discovered adhering to sented in this article. Cement removalabutment and implant surfaces. Management during surgical intervention, decontamina-involved thorough debridement of granuloma- tion of involved surfaces, and bone graftingtous tissue, removal of subgingival cement, resulted in a clinically stable outcome overimplant detoxification, and regenerative therapy. the two years of post-operative maintenance. KEY WORDS: Peri-implantitis, iatrogenic causes, peri-implantitis treatment 1. Director, Pre-Doctoral Periodontics, Department of Periodontology, University of Tennessee College of Dentistry 2. Private Practice, Memphis, TN, USA3. Director, Graduate Prosthodontics, Department of Restorative Dentistry, University of Tennessee College of Dentistry 4. Chair, Department of Periodontology, University of Tennessee The Journal of Implant & Advanced Clinical Dentistry • 21

Adatrow et al Introduction: Figure 1: Initial presentation with abscess.Inflammatory lesions that develop adjacent to must also be considered and specific implantimplants are collectively referred to as “peri- design and surface characteristics may alsoimplant diseases” and may include peri-implant contribute to the risk and progression of peri-mucositis and peri-implantitis. Peri-implantitis implantitis.3 Failure to remove excess cementis characterized by the presence of inflamma- following placement of cement-retained pros-tion in the mucosa along with loss of support- theses may also contribute to the developmenting bone.1 The frequency of peri-implantitis and progression of peri-implantitis. This reporthas been reported in many long term studies. documents two patients in whom excess sub-However, due to variation in assessment meth- gingival cement was associated with signs ofodology, reliable consensus in the literature peri-implantitis. Clinical management strategiesis unavailable. Nevertheless, a recent system- and long term therapeutic results are discussed.atic review of cross sectional and longitudinalstudies with ≥ 50 subjects and ≥ 5 years of Case Reports:occlusal function, reported that peri-implanti-tis was identified in 12-46% of implant sites.2 Case 1: A 64 year old partially edentulous female was Peri-implantitis is often asymptomatic and referred for evaluation of a draining fistulatypically detected during routine recall examina- adjacent to implants #28 and #29. Her medi-tions. Several clinical indicators used to evalu- cal history was unremarkable. An implant inate periodontal health have also been used to area #30 had been in place for 14 years, andevaluate peri-implant health, including assess- the implants in area #28 and #29 had been inment of oral hygiene, peri-implant marginal place for 4 years. Several months following thetissues, and the bone implant interface. Rec- surgical placement of implants #28 and #29,ommended diagnostic parameters for assess- the patient complained to her general dentist ofing peri-implant health are: probing depth swelling and a bad taste in her mouth. The gen-measurements using conventional probing eral dentist removed the crowns and attemptedwith a light probing force (0.25N), presence orabsence of bleeding or suppuration on probingusing a light probing force (0.25N), and radio-graphic assessment of supporting bone levels.1 A number of patient-related and implant-related factors may contribute to the devel-opment and progression of peri-implantitis.Compelling evidence is available for increasedsusceptibility to peri-implantitis in patientswho smoke, have a history of periodontal dis-ease, and exhibit poor oral hygiene.3 Theimpact of IL-1 positive genotype and diabetes22 • Vol. 5, No. 6 • June 2013

Aadatrow et alFigure 2: Initial radiograph. Figure 3: Flap elevated showing cement film on the mesial of Implant in area of #29.Figure 4: Implants debrided and detoxified. Figure 5: Bio-Oss Bovine bone graft placed around the implants.non-surgical therapy around the implants. The implant #28 and vertical bone loss aroundperi-implant infection persisted and the gen- implant #29 (figure 2). The decision was madeeral dentist referred the patient for consultation. to perform an exploratory surgical procedureUpon clinical examination (figure 1), a fluctuant to investigate possible etiologic factors andswelling was noted on the buccal mucosa inter- determine the prognosis of involved implants.proximal to implants # 28 and 29, with bleedingand suppuration evident on probing. Probing Under local anesthesia, crestal and sul-depths ranged from 4-8mm around implant #28 cular incisions were made and full thicknessand 8-9 mm around implant #29. A periapical mucoperiosteal flaps elevated around theradiograph revealed horizontal bone loss around implants. A thin white film was found adhering to the mesial aspect of implant #29, extend- The Journal of Implant & Advanced Clinical Dentistry • 23

Adatrow et alFigure 6: Clinical Presentation at 6 months post surgery. ing from the implant abutment interface to the first thread (figure 3). On close examination,Figure 7: Radiographic Presentation at 6 months post the white film was determined to be glass iono-surgery. mer cement. The surgical area was thoroughly debrided and degranulated. Plastic curettesFigure 8: Radiographic presentation at 24 months. and a rotary rubber cup with pumice were used to completely remove the glass ionomer24 • Vol. 5, No. 6 • June 2013 cement from the implant surface. The implant surface was then decontaminated using H2O2,­ chlorhexidine 0.12%, and 50mg/ml tetracy- cline applied for 2 minutes. Decortications were accomplished on the peri-implant bone and Bio-Oss®, bovine cortical bone particles (Osteohealth, Shirley, NY) were placed in the osseous defect (figures 4,5). Two holes cor- responding to the implants abutments were made through a 20mm x 30mm Biomend® col- lagen membrane (Zimmer Dental, Carlsbad, CA) and the membrane was placed over the abutments to cover the bone graft material. The flaps were replaced and sutured with 4-0 Vicryl® sutures (Ethicon, New York, NY) and the patient was placed on 500-mg Augmentin (GlaxoSmithKline, Pittsburg, PA) three times a day for 7 days and a 0.12 % chlorhexidine rinse. Post-operative healing was uneventful. Implants/abutments remained unrestored dur- ing the healing period. At six months, firm keratinized gingiva was identified around both implants and radiographs suggested bone fill associated with implant #29 (figures 6, 7). New crowns were fabricated and deliv- ered. The patient was instructed on oral hygiene techniques and placed on a 3-month maintenance protocol. At 24 months fol- lowing surgical intervention, the implant was clinically determined to be functioning well without signs of recurrent infection (figure 8).

Adatrow et alCase 2: Figure 9: Initial radiographic presentation.A 50-year-old partially edentulous female pre-sented to the clinic complaining of pain in the Figure 10: Cement adhering to the abutment.mandibular right posterior sextant. Her medi-cal history was positive for Type II Diabetes with Figure 11: Immediate post surgical radiographicthe condition being well controlled with oral presentation.hypoglycemic medications. She had an implantplaced and restored in the area #30 one yearago. She reported developing a swelling aroundthe implant about 4 months prior, which then dis-appeared after a only few days. Upon examina-tion, probing depths ranging from 7-10mm withbleeding and suppuration were noted. Radio-graphic examination revealed severe verticalbone loss adjacent to the implant (figure 9). Inci-sion and drainage of the fluctuant mass wasperformed and the patient was placed on 500mg Augmentin (GlaxoSmithKline, Pittsburg, PA)three times per day and 0.12% chlorhexidinemouth rinse for 7 days. Ten days later, heal-ing progressed with minimal complications. A determination was made to surgicallyexplore the area of concern and attempt boneregeneration around the implant. Upon pre-operative removal of the implant crown, a whitematerial film was noted adhering to the apicalaspect of the abutment along the implant-abut-ment interface. Closer examination revealedthat the white material was glass ionomercement (figure 10). A full thickness mucoperi-osteal flap was accomplished local anesthe-sia. Upon flap reflection, all granulation tissuewas removed and the implant was decontami-nated using H2O2,­ chlorhexidine 0.12%, and50mg/ml tetracycline applied for 2 minutes.Decortications were made in the peri-implantbone and Bio-Oss® bovine cortical bone par-ticles (Osteohealth, Shirley, NY) were placed The Journal of Implant & Advanced Clinical Dentistry • 25

Adatrow et alFigure 12: Radiographic presentation at 6 months. Figure 13: Radiographic presentation at 14 months.in the osseous defect. A hole correspond- Discussioning to the center of the implants was madeon a Biomend® collagen membrane (Zimmer Attachment of peri-implant tissues to implant andDental, Carlsbad, CA) and the membrane was abutment surfaces occurs by junctional epithe-placed over the implant using a healing abut- lium mediated through basal lamina and hemides-ment to secure the membrane in place (fig- mosomes.4 In contrast to the dento-gingival unit,ure 11). The flaps were replaced and sutured there are no connective tissue fiber insertionswith Vicryl® sutures (Ethicon, New York, NY). into the implant surface and connective tissue fiber orientation is predominantly parallel to the Post-operative healing was unevent- implant surface.5 Coronally, connective tissueful and the implant remained unrestored dur- fiber orientation is circumferential and it exhib-ing the healing period. Six months after its a lower degree of vascularization comparedsurgery, firm keratinized gingiva surrounded to periodontal attachment.6 It has been theo-the implant and radiographs suggested suc- rized that these differences between peri-implantcessful bone fill (figure 12). Clinically there and dento-gingival tissues render the formerwere no signs of peri-implant infection and more susceptible to plaque induced inflamma-probing depths decreased to 3-4 mm. At this tion. The peri-implantitis cases identified andpoint, the original abutment and implant crown managed in this article were characteristicallywere replaced. The access opening was filled rapid in development and progression, and maywith flowable light cure composite and occlu- have been a pathologic response to residualsal adjustments were completed. The patient subgingival cement serving as a local plaquewas instructed in oral hygiene techniques and retentive factor at the bone-implant interface.was placed on a 3 month maintenance pro-tocol. At 14 months following treatment the Treatment of peri-implantitis may include non-implant was determined to be functioning well surgical and surgical phases. Non-surgical ther-without signs of recurrent infection (figure 13). apy consists of mechanical debridement using ultrasonic or laser devices, either alone or com-26 • Vol. 5, No. 6 • June 2013

Adatrow et albined with antiseptic and/or antibiotic agents. This information provides a basis for determiningSurgical intervention may involve either resective therapeutic approach; implant removal, resec-or regenerative techniques. To date, no meth- tive surgery, and/or regenerative procedures.odology has been established as the gold stan-dard for the treatment of peri-implantitis. Based Resective therapy is used to reduce pock-on the Consensus Statement of the Sixth Euro- ets, correct negative osseous architecture,pean Workshop on Periodontology,1 non-surgical smooth rough implant surfaces (implantoplasty),therapy for peri-implantitis is unpredictable. Nev- and improve the dimensions and/or locationertheless, the use of systemic and local antibiot- of keratinized gingiva. Regenerative therapy isics in conjunction with non-surgical mechanical used to reduce pockets with the goal of regen-debridement has been shown effective in reduc- eration of favorable bone dimensions. A recenting bleeding on probing and probing depths in review,7 addressing open debridement, surfacecases of mild to moderate peri-implantitis.1 In the decontamination, and peri-implant regenera-first case presented in this paper, even though tive procedures, revealed encouraging results inthe peri-implantitis was qualified as moderate, it animals, but a paucity of data in humans. Adid not respond to non-surgical therapy. Subse- prospective cohort receiving access surgery,quent surgical intervention revealed the apparent implant decontamination, and systemic antibi-etiology and removal of residual cement success- otics recorded favorable defect resolution forfully established peri-implant tissue health. In the 58% of the implants treated.8 With regard tosecond case reported in this paper, the patient occlusive membranes, varying degrees of bonepresented with peri-implantitis of greater sever- regeneration and re-osseointegration have beenity and non-surgical therapy, consisting of inci- reported for regenerative procedures with orsion/drainage and systemic antibiotic therapy without the use of barrier membranes.7 In bothfollowed by surgical intervention was required. of the cases presented in this article, regenera- tive procedures incorporated barrier membranes The primary objective of surgical treatment of and favorable radiographic bone fill resulted.peri-implantitis is to gain access to the implantsurface for debridement and decontamination Conclusion:in order to facilitate resolution of inflammatorylesions. The determination of appropriate surgi- Two partially edentulous patients with restoredcal treatment is influenced by the amount of bone and functional implants presented for evaluationlost, the nature of the osseous defect, and the of peri-implant tissue problems identified by theaesthetic impact of the implant in question. Sur- patients and their restorative dentists. Upon refer-gical techniques used to manage peri-implant ral, surgical access revealed subgingival cementlesions are essentially modifications of surgical on the implant and abutment surfaces. Removalperiodontal techniques. Peri-implant probing and of the cement, decontamination of the implantbone sounding of suspected peri-implant osseous surface, and bone grafting resulted in resolutiondefects in conjunction with radiographic evalu- of the infections, reduction of probing depths,ation should be accomplished early in therapy. and radiographically apparent bone fill. Using a three month maintenance schedule, favorable The Journal of Implant & Advanced Clinical Dentistry • 27

Adatrow et al The Journal of Implant & Advanced Clinical Dentistry post-operative results have been maintained for one to two years. An important local factor in ATTENTION the development of peri-implantitis in the patientsPROSPECTIVE treated appears to have been excess subgingi- val cement on implant and abutment surfaces. AUTHORS This observation underscores the need for care- ful control of luting agents and thorough supra- JIACD wants and subgingival removal of excess cement when to publish placing cement-retained crowns on implants. ● your article! Correspondence: For complete details Pradeep Adatrow, DDS, MSD, MPH regarding publication in 875 Union Ave, C 312 Department of Periodontology JIACD, please refer University of Tennessee College of Dentistry to our author guidelines at Memphis, TN- 38163 Phone: 901-448-4756 the following link: Fax: 901-448- 6751 http://www.jiacd.com/ Email: [email protected] authorinfo/ Disclosure author-guidelines.pdf The authors report no conflicts of interest with anything mentioned in this article. or email us at: References: [email protected] 1. L indhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol. Sep 2008;35(8 Suppl):282-285. 2. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol. Sep 2008;35(8 Suppl):286-291. 3. H eitz-Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators. J Clin Periodontol. Sep 2008;35(8 Suppl):292-304. 4. L istgarten MA, Lang NP, Schroeder HE, Schroeder A. Periodontal tissues and their counterparts around endosseous implants [corrected and republished with original paging, article orginally printed in Clin Oral Implants Res 1991 Jan-Mar;2(1):1-19]. Clin Oral Implants Res. Jul-Sep 1991;2(3):1-19. 5. R uggeri A, Franchi M, Marini N, Trisi P, Piatelli A. Supracrestal circular collagen fiber network around osseointegrated nonsubmerged titanium implants. Clin Oral Implants Res. Dec 1992;3(4):169-175. 6. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular systems in the periodontal and peri-implant tissues in the dog. J Clin Periodontol. Mar 1994;21(3):189-193. 7. C laffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. J Clin Periodontol. Sep 2008;35(8 Suppl):316-332. 8. Leonhardt A, Dahlen G, Renvert S. Five-year clinical, microbiological, and radiological outcome following treatment of peri-implantitis in man. J Periodontol. Oct 2003;74(10):1415-1422.28 • Vol. 5, No. 6 • June 2013

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Bone Regeneration Around a Failing Driver et alImplant in an Osteopetrotic Patient: A Clinical Case ReportEric G. Driver, DDS1 • Simon R. MacNeill, BDS, DDS2 Charles M. Cobb, DDS, MS, PhD3 AbstractBackground: The exact pathogenic mechanism surgical intervention due to significant bone loss.of osteopetrosis is unknown although a deficiency Treatment of the bony defect involved degranula-in the osteoclastic enzyme carbonic anhydrase tion, implant detoxification, bone decortications,has been observed. Osseous regeneration placement of a particulate osseous graft material,around failing implants remains a challenging and and coverage with a resorbable barrier membrane.unpredictable problem. Thus, the pathobiology ofosteopetrosis presents an additional complication Results: Radiographs taken eight months afterwhen treating an osteopetrotic patient presenting the osseous graft procedure demonstrated sta-with peri-implantitis requiring surgical intervention. ble bone levels and 100% osseous regeneration.Methods: A single case report is presented that Conclusions: Regeneration of osseous sup-involved a 61 year old Caucasian female with an port around a failing implant in a patient withextensive medical history that included a mild form mild osteopetrosis is possible using the surgi-of osteopetrosis and peri-implant disease requiring cal techniques described in this case report.KEY WORDS: Dental implants, osteopetrosis, bone graft 1. Former resident, Graduate Periodontics, School of Dentistry, University of Missouri-Kansas City2. Associate Professor & Director, Graduate Periodontics, School of Dentistry, University of Missouri-Kansas City 3. Professor Emeritus, Graduate Periodontics, School of Dentistry, University of Missouri-Kansas City The Journal of Implant & Advanced Clinical Dentistry • 31

Driver et al INTRODUCTION der is generally diagnosed through skeletal x-rays with confirmation by bone density tests and/orOsteopetrosis (a.k.a. Albers-Schönberg disease bone biopsy.6 Full blown osteopetrosis can leador marble bone disease) was first described in to anemia and leukopenia due to encroachment1904 by Albers-Schönberg.1 Traditionally, two of osseous structure upon the marrow spaces.6major clinical forms of the disease are noted:The disorder is generally discussed as having Although the clinical severity of the dis-two distinct clinical presentations: an autosomal ease varies widely, given the osteoclastic dys-dominant adult (benign) type that is associated function inherent to osteopetrosis, it may bewith relatively few symptoms2 and the autoso- argued that results of intra-oral osseous graft-mal recessive infitile (malignant) type that is typi- ing may be compromised. Even with allograftcally fatal during infancy or early childhood if materials, osteoclastic mediated bone resorp-untreated.3 Although a diversity of clinical and tion must precede osteoblastic mediated bonehereditary types of osteopetrosis shows that apposition. Thus, the pathobiology becomes adefects in several different genes and a vari- potential complication to consider when treat-ety of biological disturbances cause this dis- ing an osteopetrotic patient presenting with peri-order, the pathogenesis involves failure of implantitis that requires surgical intervention.osteoclastic-mediated resorption of host bone.4,5 Several techniques and modalities have been Normal bone growth and physiologic turnover proposed for regenerating the supporting struc-is achieved by a balance between cell mediated tures around implants demonstrating peri-implan-bone formation (osteoblasts), and cell mediated titis.7-11 Treatment of peri-implantitis, dependingbone resorption (osteoclasts). Although the on severity of bony involvement, may involve aexact pathogenic mechanism of osteopetrosis is simple non-surgical therapy with the adjunctiveunknown, a deficiency in the osteoclastic enzyme use of local and/or systemic antibiotics or maycarbonic anhydrase has been observed.5-7 The require more aggressive therapy such as accessabsence of carbonic anhydrase results in a defec- flap surgery, implant decontamination via ultra-tive proton (H+) pump which, in turn, prevents sonics, air-abrasion or lasers followed by osse-the development of the localized acidic environ- ous grafting.7-11 The purpose of this article is toment required for effective resorption of bone.5-7 present a case report showing osseous regen- eration around an implant with peri-implantitis Because osteoblastic function is unaf- in a patient with a mild form of osteopetrosis.fected, bone formation continues and eventuallybecomes excessively dense. Bone thus affected METHODStypically exhibits increased radiographic den-sity characterized by a chalky white presentation Patient Presentationthat, paradoxically, is unable to resist average The patient, a 61 year old Caucasian female pre-stressors and thus easily fractures.6,7 The inci- sented to the University of Missouri-Kansas City,dence of osteopetrosis has been reported at 1 School of Dentistry, Graduate Periodontics Clinicin 20,000 to 500,000 for the dominant form and on February 2, 2009 for evaluation of peri-implant1 in 200,000 for the recessive form.6 The disor- disease involving a dental implant in the #19 posi-32 • Vol. 5, No. 6 • June 2013

Driver et alFigure 1: Pre-treatment view of maxillary and mandibular Figure 2: Pre-treatment view of lingual tissues in area ofleft posterior sextants showing generalized poor oral hygiene. #19 (implant) and #20.Implant in #19 area exhibits chronic inflammation.tion. The patient related an extensive medical density was 7-8 standard deviations above thehistory including a physician-diagnosed osteope- reference population norm. In October of 2006trosis. The patient had been seen in 1993 by an the patient was involved in a second motor vehicleorthopedic specialist after a motor vehicle acci- accident and suffered a fractured left femur. Opendent to rule out an incidental finding of sclerotic reduction and internal fixation with titanium platesvertebrae. Subsequent long bone surveys were and screws were utilized to stabilize the frac-performed and demonstrated sclerosis bilater- tured segments. In June of 2007 this hardwareally in the proximal femur and skull. The patient had to be removed and replaced due to a non-denied a family history of bone disease and per- union of healing. In July of 2007 the new hard-sonal history of fractures. The presence of scle- ware was removed along with much of the femurrotic changes in the vertebrae as well as the and replaced with a substitute titanium femur.metaphysical areas of the long bones was consis-tent with a diagnosis of osteopetrosis tarda. Two In December of 2006, the patient had threeseparate measurements of serum and urine NTX endosseous implants placed in the areas of #19,(N-telopeptide of type 1 collagen) revealed levels #29, and #30. Implant #19 was restored inat the upper limits of the normal range, suggesting December of 2007 with a cement retained resto-the presence of osteoclastic activity. However, ration using self-curing resin cement (RelyX 3Mbone density values were significantly elevated ESPE). The initial periodontal evaluation revealedwith T-scores of 7.7 and 8.8 for the spine and hip, probing depths of 6-8mm around implant #19respectively. These findings indicated that bone with bleeding on probing (Figures 1,2). Occlusal evaluation revealed no heavy centric contacts, lat- The Journal of Implant & Advanced Clinical Dentistry • 33

Driver et aleral, or non-working interferences. Radiographic Figure 3: Pre-treatment radiograph showingevaluation revealed bone loss to the third major circumferential vertical-angular intrabony defect withthread on the distal of implant #19 (Figure 3). exposure implant threads.Various treatment options were presented to thepatient with her consenting to have surgical based was decorticated using a small round bur to helpguided tissue regeneration (GTR) performed. stimulate the regional acceleratory phenomenon (Figure 8). Once numerous bleeding points wereTreatment visualized, the osseous defect was grafted withAnesthesia was obtained by mandibular inferior Puros Allograft® (Zimmer Dental, Carlsbad, CA)alveolar and long buccal injections, using 72mg and covered with a resorbable cross-linked col-of Lidocaine 2% with 0.036 mg epinephrine. The lagen membrane (Figure 9), BioMend Extend®abutment and cemented restoration on implant (Zimmer Dental, Carlsbad, CA). Passive primary#19 were removed as one unit, following which a closure was achieved utilizing a periosteal releasefetid odor and the presence of highly inflamed and and resorbable sutures. Detailed home careirritated sulcular tissues were noted (Figure 4). instructions were delivered and the patient wasIn addition, overextended porcelain and excess appointed for post-operative suture removal atresidual cement were observed on the abutment, two weeks. The patient was prescribed appropri-extending in some areas to the junction betweenthe abutment and implant platform (Figure 5). Full thickness buccal and lingual mucoperios-teal flaps were reflected via sulcular incisions witha distal release. Granulation tissue was removedusing ultrasonics and manual instrumentation.After degranulation, bone loss to the third majorthread was noted on the distal of the implantand extended to the buccal and lingual (Figures6,7). The exposed implant surface was detoxifiedusing micro air-abrasion followed by applicationof a tetracycline paste. The tetracycline (TCN)paste was prepared by mixing the contents of asingle 250 mg capsule with just enough sterilesaline to give it a thick but adaptable consistencywhen applied with cotton pellets. The TCN pastewas allowed to sit for 5 minutes and then wasrinsed with copious amounts of sterile saline. Anew sterile implant cover screw was placed andtorqued to the manufacturer recommended speci-fication. The area distal and buccal of the implant34 • Vol. 5, No. 6 • June 2013

Driver et alFigure 4: Coronal view of implant and soft tissue wall of Figure 5: View of prosthesis and reflected mirror imagethe associated gingival pocket showing clinical signs of showing over-extended porcelain on to abutment collarsevere inflammation. and residual dental cement.Figure 6: Surgical exposure of circumferential bony defect. Figure 7: Coronal view of circumferential vertical-angular intrabony defect.ate analgesics, antibiotics, and 0.12% chlorhexi-dine gluconate (CHX) rinse for the healing period. At the two-week post-operative appoint-ment, all sutures were in place, no signs of infec-tion were present, and the patient reported The Journal of Implant & Advanced Clinical Dentistry • 35

Driver et alFigure 8: View of bony decortication prior to placement of Figure 9: Placement of barrier membrane coveringosseous graft material. osseous graft prior to closure of surgical wound.Figure 10: Radiograph taken at time of uncovering Figure 11: Clinical confirmation of complete boneimplant (5 months post-surgery) showing complete bone regeneration.regeneration. patient was appointed for the uncover procedure.minimal discomfort with no post-operative com- A new periapical film was taken (Figure 10)plications. All sutures were removed and thesurgical site was irrigated with 0.12% CHX. and the grafted area uncovered after 5 months ofHome care instructions were reinforced and the healing via a crestal incision that was designed to36 • Vol. 5, No. 6 • June 2013

Driver et alFigure 12: Delivery of previous restoration following Figure 13: Radiograph taken at 3 months followingremoval of porcelain overhang and residual dental cement. delivery of prosthesis (8 months post-surgery) showing complete bone regeneration.preserve a band of keratinized tissue on the buc-cal. Excellent osseous integration was observed graft to improve the band of keratinized gingiva.on the distal, buccal, with new bone formation upto the occlusal aspect of the implant platform on Post-treatment Resultthe distal and lingual (Figure 11). The cover screw A post-operative peri-apical film was taken inwas removed and the previous restoration was October 2009 to verify bone levels 3 monthsdelivered after correcting the deficiencies involv- after placement of the restoration (Figureing retained cement and over-extended porce- 13). Radiographs indicated that bone levelslain (Figure 12). The restoration abutment screw were stable and that 100% osseous regenera-was torqued to the manufactures recommended tion was achieved around the failing implant.level, and a peri-apical film was taken to ensurethat the abutment was fully seated. A cotton pel- DISCUSSIONlet followed by composite filling material was usedto close the occlusal access. The occlusion was Although an increasingly common procedure,verified to ensure that no heavy centric contacts, osseous regeneration around failing implantslateral, or non-working interferences were pres- remains a challenging and unpredictable problem.ent. Resorbable interrupted sutures were used It will continue to become more prevalent andfor tissue closure on the mesial and distal of the necessary as an increasing number of implantsnewly placed restoration. The patient returned 6 are placed in a wide variety of practice settings. Itweeks later for placement of a buccal free gingival should be emphasized that proper treatment plan- ning should be performed at all levels of implant therapy to help minimize preventable causes of The Journal of Implant & Advanced Clinical Dentistry • 37

Driver et alimplant failures.12 In the current case presenta- tal cements.17,18 Cemented implant restora-tion, 100% osseous regeneration was achieved tions have become the restoration of choicearound a failing implant in a patient with a mild due to their relative simplicity.17,19 Advantagesform of osteopetrosis but, never-the-less, with of cemented implant restorations include elimi-reduced osteoclastic activity. By utilizing pre- nation of potential loosening of the prosthesisdictable and tested GTR techniques13 com- screw, better esthetics, and control of occlu-bined with adjunctive detoxification techniques, sion. If not managed properly, there is a riskan excellent result was obtained. Micro air- of residual excess cement on apical portionsabrasion as discussed by Dennison14 has of the abutment, the implant itself, or in thedemonstrated effectiveness in eliminating bac- surrounding soft tissues. These factors haveterial contaminates from microporosities of the been associated with peri-implant disease.17,18roughened and/or plasma-spray coated implant Indeed, Wilson17 reported the presence ofsurface. When exposed to the subgingival envi- retained cement on 34 of 42 implants, all exhib-ronment, the irregular implant surface topog- iting peri-implant disease. Excess retainedraphy promotes colonization by bacteria but is dental cement acts similar to calculus in thealso resistant to manual instrumentation or ultra- sense that it facilitates colonization of bacteriasonics.15 Manual and ultrasonic instrumentation similar to those involved in chronic periodontitis,cannot access the bacteria and their by-prod- thereby suggesting that periodontitis and peri-ucts located within surface porosities. On the implantitis have a similar pathogenesis.17-22 Theother hand, the small particles (100 microns) of inability to effect subgingival oral hygiene due tosodium bicarbonate used in air-abrasion instru- the excessive dental cement likely facilitates aments are capable of penetrating surface poros- shift from a microbial complex normally associ-ities and thereby help to eliminate bacteria and ated with health to a complex of gram-negativetheir toxic by-products. TCN has long been bacteria generally associated with disease.17-22used as a local and systemic medication to helpcontrol periodontopathic bacteria. The manner In the present case report, it was knownin which TCN was used in this case report is that there was a reduced level of osteoclasticsimilar to that presented by Zablotsky et al.16 function secondary to the systemic osteope-The TCN paste had enough consistency to stick trosis. It was therefore decided that decortica-to the exposed implant surface but still main- tion using a round bur would help stimulate thetain enough aqueous property to infiltrate the regional acceleratory phenomena thereby stimu-micro-porosities of the roughened implant sur- lating healing and bone formation.23 In theory,face. The dual detoxification technique used the decortication technique creates channelsin this case may have helped promote a more through the cortical plate into the underlyingpredictable GTR result by eliminating both cancellous bone which, in turn, allows migra-the presence of bacteria and their endotoxins. tion of osteoprogenitor cells into the grafted bony defect. It should be noted, however, that Implant supported restorations may be Greenstein, et al.24 have challenged the bene-retained by either retrievable screws or den- fits of decortication with respect to increasing38 • Vol. 5, No. 6 • June 2013

Driver et althe success of bone regeneration techniques. CONCLUSION Occlusal analysis was also scrutinized for Regeneration of osseous support around aany heavy centric contacts, lateral interfer- failing implant in a patient with mild osteope-ences, and non-working interferences. Stud- trosis is possible using the combined tech-ies by Salvi and Bragger25 and Adell et al.26 nique of degranulation with manual andhave demonstrated the destructive effects of ultrasonic instrumentation, detoxificationocclusal disharmony on implants. In this sce- with air-abrasion and tetracycline paste, fol-nario a short 8.0 x 5.0 mm diameter implant lowed by decortication and grafting withwas placed in December of 2006. A short allograft bone augmentation material. ●(< 10mm) implant was necessary due to closeproximity of the inferior alveolar canal to the Correspondence:alveolar crest. The short implant was then Dr. Charles M. Cobbrestored with a tall restoration leading to a 424 West 67th Terrace1:1 crown:root ratio. A pre-prosthetic vertical Kansas City, MO 64113ridge augmentation would not have improved Phone: 816-444-3167the situation due to normal ridge heights. An Fax: 816-444-8673inferior alveolar nerve repositioning surgery E-mail: [email protected] recommended to facilitate placement ofa longer implant but declined by the patient.Disclosure 10. Lang NP, Berglundh T, Heitz-Mayfield LJ, Periodontol 2009;80(9):1388-1392.The authors report no conflicts of interest with Pjetursson BE, Salvi GE, Sanz M. Consensus 18. Callan DP, Cobb, C.M. Excess cement andanything mentioned in this article. statements and recommended clinicalReferences procedures regarding implant survival and peri-implantitis. J Implants Adv Clin Dent1. Whyte MP. Sclerosing bone disorders. In: Favus complications. Int J Oral Maxillofac Implants 2009;1(6):61-68. 2004;19(Suppl.):150-154. 19. Mombelli A, van Oosten MAC, Schurch E, Lang MJ, ed., Primer on the Metabolic Bone Diseases 11. Romanos GE, Nentwig GH. Regenerative NP. The microbiota associated with successful and Disorders of Mineral Metabolism. 6th ed., therapy of deep peri-implant infrabony or failing osseointegrated titanium implants. Oral American Society for Bone and Mineral Rsearch, ddeecfeocnttsaamftinear tCioOn.2 laser implant surface Microbiol Immunol 1987;2(4):145-151. Washington, D.C., 2006, pp. 398. Int J Periodont Restor Dent 20. Leonhardt A, Berglundh T, Ericsson I, Dahlen2. A skmyr M, Flores C, Fasth A. Richter J. 2008;28(3):245-255. G. Putative periodontal pathogens on titanium Prospects for gene therapy of osteopetrosis. Curr 12. Chuang S.K., Wei L.J., Douglass C.W., Dodson implants and teeth in experimental gingivitis and Gene Ther 2009;9(3):150-159. T.B., Risk Factors for Dental Implant Failure: A periodontitis in beagle dogs. Clin Oral Implants3. D el Fattore A, Cappariello A, Teti A. Genetics, Strategy for the Analysis of Clustered Failure- Res 1992;3(3):112-119. pathogenesis and complications of osteopetrosis. time Observations. J Dent Res 2002;81(8):572- 21. Callan DP, Cobb CM, Williams KB. (2005) Bone 2008;42(1):19-29. 577. DNA probe identification of bacteria colonizing4. W hyte MP. Osteopetrosis. In: Royce PM, 13. Mellonig JT, Triplett RG. Guided Tissue internal surfaces of the implant-abutment Steinmann B, eds., Connective Tissue and Its Regeneration and Endosseous Dental Implants. interface: A preliminary study. J Periodontol Heritable Disorders, 2nd ed., Wiley-Liss, New York, Int J Periodont Restor Dent 1993;13(2):108- 2005;76(1):115-120. NY, 2002, p. 789-907. 119 22. S hibli JA, Melo L, Ferrari DS, Figueiredo LC,5. Tolar J, Teitelbaum SL, Orchard 14. Dennison DK, Huerzeler MB, Quinones C, Faveri M, Feres M. Composition of supra- and PJ. Osteopetrosis. N Engl J Med Caffesse RG. Contaminated implant surfaces: subgingival biofilm of subjects with healthy 2004;351(27):2839-2849. an in vitro comparison of implant surface coating and diseased implants. Clin Oral Implants Res6. Stark Z., Savarirayan R. Osteopetrosis: Review. and treatment modalities for decontamination. J 2008;19(10):975-982. Orphanet J Rare Dis 2009;4:5-17. Periodontol 1994;65(10):942-948. 23. Garg AK. The regional acceleratory7. B uchter A, Kleinheinz J, Meyer U, Joos U. 15. G atewood RR, Cobb CM, Killoy WJ. Microbial phenomenon: an up-to-date rationale for Treatment of severe peri-implant bone loss using colonization on natural tooth structure compared bone decortication. Dent Implantol Update autogenous bone and a bioabsorbable polymer with smooth and plasma-sprayed dental implant 1997;8(8):63-64. that delivered doxycycline (Atridox). Br J Oral surfaces. Clin Oral Implants Res 1993;4(1):53- 24. G reenstein G, Greenstein B, Cavallaro J, Maxillofac Surg 2004;42(5):454-456. 64. Tarnow D. The role of bone decoortications8. D eppe H, Horch H-H, Neff A. Conventional 16. Z ablotsky MH, Diedrich DL, Meffert RM. in enhancing the results of guided bone ivmerpslaunstCdOef2eclatssewr-iathsstihsetecdotnrecaotmmietannttoufspeeorif- Detoxification of endotoxin-contaminated regeneration: A literature review. J Periodontol pure-phase $-tricalcium phosphate: A 5-year titanium and hydroxyapatite-coated surfaces 2009;80(2):175-189. clinical report. Int J Oral Maxillofac Implants utilizing various chemotherapeutic and 25. S alvi GE, Brägger U. Mechanical and technical 2007;22(1):79-86. mechanical modalities. Implant Dent risks in implant therapy. Int J Oral Maxillofac9. Lang NP, Mombelli A, Tonnetti MS, Bragger 1992;1(2):154-158. Implants 2009;24(Suppl):69-85. U, Hammerle CHF. Clinical trials on therapies 17. Wilson TG, Jr. The positive relationship between 26. Adell R., Lekholm U., Rockler B., Branemark P.-I. for periimplant infections. Ann Periodontol excess cement and peri-implant disease: a A 15-year study of osseointegrated implants in 1997;2:343-356. prospective clinical endoscopic study. J the treatment of the edentulous jaw. Int J Oral Surg 1981:10(6):387-416. The Journal of Implant & Advanced Clinical Dentistry • 39



Treatment of Peri-implantitis Using Open Wilcko et al Flap Debridement and Iodine Solution with Autogenous Bone Graft: A Case ReportMiki Taketomi Saito, DDS1 • Mauro Pedrine Santamaria, DDS, MS, PhD2 Karina Gonzales Silvério, DDS, MS, PhD,1 Enilson Antônio Sallum, DDS, MS, PhD, Professor3 AbstractPeri-implantitis is characterized by bone with povidone-iodine and fill of the adjacent destruction around dental implants osseous defect with autogenous bone graft. due to the host immune-inflamma- After 20-month follow-up, the pocket depthtory response induced by biofilm accumula- reduction and radiographic fill of the defecttion. Several approaches have been proposed could be observed. Therefore, it can be con-to treat peri-implantitis, including mechanic cluded that this therapeutic approach coulddebridement, antimicrobial therapy, and resec- promote clinical and radiographic improve-tive or regenerative surgical therapy. The pres- ments to the patient. However, more random-ent case report describes a peri-implantitis ized controlled clinical trials are necessarycase treated by a surgical open flap debride- for further understanding about the bestment, decontamination of the implant surface approaches for the treatment of peri-implantitis.KEY WORDS: Peri-implantitis, dental implants, guided bone regeneration1. Assistant Professor, Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, São Paulo, Brazil. 2. Assistant Professor Department of Periodontology, College of Dentistry, State University of São Paulo - UNESP, São José dos Campos, São Paulo, Brazil. 3. Professor, Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, São Paulo, Brazil. The Journal of Implant & Advanced Clinical Dentistry • 41

Saito et al Introduction establishing protocols treatment for peri- implantitis, there is no consensus about thePeri-implant diseases are characterized by best way to perform the implant surfaceinflammatory lesions that involve tissues debridement, decontamination, and regen-around dental implants, which is a result of eration of the bone defect.12 In this con-biofilm accumulation. They can be classified text, the aim of the present paper is to reportinto peri-implant mucositis or peri-implanti- a case of peri-implantitis treated with a sur-tis.1 Peri-implant mucositis corresponds to an gical approach of open flap debridementinflammatory reaction in the implant surround- for implant surface decontamination withing soft tissues, whereas peri-implantitis is the iodine solution associated with a regenera-inflammation of the soft tissues and involves the tive approach using autogenous bone graft.loss of supporting bone around an implant.2,3Clinically, this inflammation is detected by the Case Reportpresence of bleeding on probing;1 other clini-cal signs (e.g., suppuration, redness, and swell- A 43-year-old white male, presenting a gooding) may be observed.4 Radiographs may be general medical condition was referred to therequired to evaluate bone loss around implants Graduate Clinic of the Piracicaba Dental Schooldue to peri-implantitis and differentiate it from reporting bad breath as chief complaint. He alsothe normal bone remodeling.5 In studies about reported he had difficulty maintaining hygieneperi-implantitis prevalence, the reported esti- on a dental implant placed 2 years before, asmate is that it occurs in about 28%6,7 to 56%8 well as bleeding in this area. Clinical examina-of individuals and between 12%7 and 43%8 tion revealed a dental implant (replacing theof the implants. Therefore, the peri-implantitis inferior left first molar) that has never receivedtreatment is a topic of increasing interest. How- crown reconstruction; the implant presented aever, only a few studies have provided data on probing depth (PD) of 5 mm and bleeding onthe prevalence of peri-implant diseases; there- probing (BoP). Additionally, there was a bridlefore, these data may be underestimated.3,9 that made proper implant cleaning very demand- ing (Figure 1). Radiographs showed a crater- For treating peri-implant mucositis, the like peri-implant bone defect (3 mm) involvingnon-surgical mechanic therapy is effective in three implant screws (Figure 2). Thus, the diag-reducing the tissue inflammation; the adjunc- nosis of peri-implantitis was established. Thetive use of antimicrobial mouth rinse can patient was informed about his problem andimprove the results of this therapy.10 With all the treatment options for the case; thereaf-respect to peri-implantitis, the non-surgical ter, he consented for the treatment as follows.mechanic therapy has not demonstrated to beequally effective.10 Therefore, surgical therapies The initial treatment consisted of oralhave been proposed for treating peri-implan- hygiene instructions, mechanical treatmenttitis, including open flap debridement as well with intrasulcular brushing and subgingivalas resective or regenerative approaches.3,11 10% povidone-iodine Riodeine® (Rioquímica™, São José do Rio Preto, SP, Brazil) irrigation, Although some studies are aimed at42 • Vol. 5, No. 6 • June 2013

Saito et alFigure 1: Initial clinical aspect of the dental implant that Figure 2: Initial radiographic aspect of the dental implantwas diagnosed with peri-implantitis. that was diagnosed with peri-implantitis.Figure 3: Peri-implant defect visualization after Figure 4: Peri-implant defect visualization aftermucoperiosteal flap elevation. Note the presence of granulation tissue removal.extensive granulation tissue. signs after 1-month of follow-up. Then, a sur-which was performed during 5 to 7 minutes in gical approach was proposed for implant sur-a single session. Despite the improvement of face decontamination and filling of peri-implantthe general oral hygiene observed afterwards, defect with autogenous bone graft. Under localthe dental implant still showed inflammation The Journal of Implant & Advanced Clinical Dentistry • 43

Saito et alFigure 5: Peri-implant defect filled with autogenous bone Figure 6: Radiographic aspect in 20-month follow-upgraft obtained from adjacent area. after regenerative surgical approach suggesting defect bone filling.anesthesia Alphacaine® (DFL™, Rio de Janeiro,RJ, Brazil), two incisions were made mesi- control was achieved with a 0.12% chlorhexi-ally and distally to the dental implant; a muco- dine rinse twice a day. After this period, gentleperiosteal flap was raised to allow implant and toothbrushing with a soft-bristle toothbrush wasbone defect visualization (Figure 3). After com- allowed. Sutures were removed after 7 days;plete granulation tissue removal, the implant the patient was enrolled in a periodontal main-surface and bone defect could be observed tenance program (i.e., professional plaque con-(Figure 4). The implant surface decontamina- trol and oral hygiene instruction) weekly duringtion was performed using gauze soaked with the first month, then monthly during the con-10% povidone-iodine. Afterward, autogenous secutive months. After 20-mouth follow-up, abone graft was obtained from an adjacent reduction of probing depth to 3 mm and radio-area and placed into the peri-implant defect graphic bone fill could be observed (Figure 6).to cover all implant screws (Figure 5). The flapwas then repositioned and sutured (Nylon 5.0, DiscussionEthicon™, São José dos Campos, SP, Brasil).After this surgical procedure, the patient was Because of the similarities between the inflam-instructed to take analgesics (500 mg sodium matory diseases induced by biofilm accumula-dipyrone every 6 h for 2 d) and to discontinue tion on teeth and implants, some approachestoothbrushing around the surgical site for 15 that have been proposed to treat peri-implantdays after surgery. During this period, plaque diseases were initially based on previous evi- dences for treatments of periodontal dis- eases.10 In this context, the primary goal of44 • Vol. 5, No. 6 • June 2013

Saito et alperi-implant disease treatment is the reduc- associated with local application of metroni-tion of microbial challenge and control of dazole gel) and submerged healing was evalu-the inflammatory reaction to re-establish a ated in peri-implantitis lesions in dogs.14 Thehealthy peri-implant tissue.13 The therapeu- authors observed that all treatments resulted intic modalities for peri-implantitis comprise a improvement of clinical parameters; however,non-surgical approach and surgical approach. the surgical approach associated with implantThe non-surgical approach includes mechani- surface decontamination and submergedcal debridement alone or combined with anti- healing leads to better radiographic improve-septic agents or laser devices. The surgical ment. Moreover, when the specimens wereapproach includes open flap surgery that may evaluated histologically, surgical approachesbe associated with resective or regenerative also demonstrated better bone–implant con-techniques. Although the non-surgical ther- tact compared to non-surgical approach.apy could be effective for treating peri-implantmucositis, it does not seem to be as effective In the present case, the surgical approachfor peri-implantitis as it is for teeth.10 In peri- was performed and associated with decon-implantitis, the surgical approach has shown to tamination of the implant surface using gauzeperform better than non-surgical techniques.11,14 soaked with 10% povidone-iodine solution. Povidone-iodine solution is considered an inex- The surgical approach allows better access pensive and nonhazardous broad-spectrumto defects and provides a better access for antiseptic that has been used as an adjunct inimplant surface decontamination. In this con- periodontal therapy; it has demonstrated by atext, the literature reports that only mechanical systematic review that it may improve PD reduc-debridement on roughened implant surfaces tion during scaling and root planing.16 Thecontaminated with bacteria may have limited application of povidine-iodine with gauze waseffect; the adjunctive use of chemical agents chosen to avoid damage to implant surface byis recommended to improve treatment out- metal curettes and ultrasonic tips or risk of sur-comes.12,15 However, there is no evidence gical emphysema by air powder abrasives.11,13in the literature to demonstrate a superiordecontamination method.11 In order to decon- Additionally, the correction of peri-implanttaminate the implant surface, a wide range defect should be one of the treatment objec-of methods have been proposed in the litera- tives to allow efficient biofilm control by theture, such as mechanical debridement, the patient and to eliminate micro-environmentsuse of antiseptics/antibiotics and laser ther- favorable for a pathogenic microbiota.3 Theapy.3,11 In an experimental study, the influence correction of these defects can be obtainedof the non-surgical approach associated by resective or regenerative techniques; how-with non-submerged healing and the surgi- ever, the latter are preferable because the ulti-cal approach associated with various implant mate goal of peri-implantitis treatment is tosurface decontamination methods (laser ther- regenerate lost tissue11,17,18 and re-establishapy; ultrasonic debridement; plastic curettes the osseointegration along the previously con- taminated implant surface.11,17 Autogenous The Journal of Implant & Advanced Clinical Dentistry • 45

Saito et albone, xenografts, alloplastic materials and effect on the use of membranes associated withmembranes have been used in regenerative grafts,11,19-21 membrane exposure as a frequenttechniques, which demonstrate variable lev- complication,11,20,22 and the use of autogenousels of bone fill and re-osseointegration.11,17,18 bone graft is effective for treating peri-implant bone defects.18 Therefore, it was decided to In an animal model study, the regenerative use autogenous bone graft alone in the pres-treatments for bone defects around implants ent case to avoid complications related towere evaluated. The defects were randomly membrane exposure during the healing period.assigned to receive the following: a bioabsorb-able membrane; a mineralized bone xenograft; Regarding the amount of defect boneor a combination of both. The results showed fill, the chosen material as well as the peri-non-significant difference regarding the range implant defect configuration are importantof bone fill among all the three treatments.19 In and play a key role in treatment.11,23 A clinicala clinical study, the treatment of peri-implan- study investigating the impact of defect con-titis defects using autogenous bone grafts figuration on the clinical outcome of surgicalwas evaluated in 25 implants diagnosed with regenerative therapy using a xenograft in com-peri-implantitis from 17 patients.18 During the bination with a collagen membrane in peri-observation period of up to 3 years, the use of implantitis lesions demonstrated that intra-bony/autogenous bone graft demonstrated to be an circumferential defects tend to obtain higherefficacious treatment approach for restoring improvements in probing depth reduction andhard tissue lost by peri-implantitis. In another clinical attachment level when compared withclinical study, three different techniques of bone circumferential defects or semi-circumferentialregeneration in peri-implantitis lesions were associated with buccal dehiscence at 6 andcompared: autogenous bone graft alone or 12 month follow-up.23 In the present report, theassociated with resorbable or non-resorbable peri-implant defect presented a favorable ana-barrier.20 At the 3-year follow-up evaluation, it tomical configuration. Despite a buccal bonywas observed that all treatments revealed signif- dehiscence, the mesial, distal and lingual boneicant improvement of peri-implant probing depth crest still remained in the level of the top offrom baseline; however, differences in surgical the implant, which could allow the autogenousapproach did not affect the treatment outcome. graft placement and reposition of the mucoperi-Therefore, this study concluded that the addi- osteal flap in an adequate position. The radio-tional application of barrier does not improve graphic examination after 20 month follow-upthe overall treatment outcome. This is in accor- reveals the defect filling (Figure 6). However,dance with a case-control study comparing the the radiographic image cannot elucidate theuse of a bone substitute alone or associated type of healing or if re-osseointegration haswith a resorbable membrane with a follow-up occurred in fact. Nevertheless, this result doesover 3 years where no significant difference in not discredit the clinical benefits obtained indefect bone fill was observed.21 The current lit- this case by the regenerative approach, sucherature demonstrates no additional beneficial as probing depth reduction and peri-implant46 • Vol. 5, No. 6 • June 2013

Saito et aldefect filling, which can promote better con- Disclosureditions for adequate hygiene and a less favor- The authors report no conflicts of interest with anything mentioned in this article.able environment for anaerobic pathogens. References 1. Z itzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. Conclusion J Clin Periodontol. Sep 2008;35(8 Suppl):286-291.The therapeutic approach for treatment of peri- 2. Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixthimplantitis using open flap debridement andiodine solution associated with autogenous European Workshop on Periodontology. J Clin Periodontol. Sep 2008;35(8bone graft was able to promote clinical and Suppl):282-285.radiographic benefits in the case reported. How- 3. Esposito M, Grusovin MG, Coulthard P, Worthington HV. 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