A fractured implant was removed from the molar site and a fractured natural tooth was removed from the bicuspid site.
βTCP Air Abrasion For RegeneratingPeri-implantitis Lesions
In the molar site, the lesion was too large for immediate implant bone-to-implant contact, so the implant was floated in Socket Graft. The bicuspid implant was a standard immediate implant with good bone contact and the voids were filled with Socket Graft.
10 years after placement. Contrary to what you are thinking, it was not the implant that was floated in Socket Graft, but instead it was the bicuspid where the bone is failing. This was a simple, easy, predictable bicuspid immediate implant with little question about its long-term success. The diagnosis is peri-implantitis, but why was the bone failing around this implant when the challenging molar implant is still perfect after 10 years?
The crown was removed, but the abutment was left in place. The plaque, calculus, and extensive bone loss is obvious.
Evaluation of the lingual gives us the reason for the development of peri-implantitis. The lingual surface of the implant restoration is uncleanable. After 10 years of bacterial accumulation, peri-implantitis had progressed to the point of requiring bone regeneration or implant removal.
The decision was made to regenerate the bone loss and create a cleansable restoration. The most important step for regenerating bone on a surface contaminated with plaque and calculus is to clean the surface completely. Any residual inflammatory residue will result in failure of bone to migrate to and integrate to the implant surface. The only method that has been thoroughly investigated for the ability to clean an implant surface is air abrasion using βTCP particles.
Multiple implants lost due to peri-implantitis were tested for surface purity. Post air abrasion with OsseoConduct™ βTCP Micron produced a negative result, indicating an endotoxin level below 0.25EU/ml, which is within the acceptable limits for new medical devices as determined by the FDA.
The implant surface was cleaned an air abrasion product using a βTCP powder developed specifically for the purpose of cleaning implant surfaces. The powder is called OsseoConduct Micron, produced by SteinerBio. The surgery was performed on 12/06/19. Note that the bone porosities are filled with the micron powder. Air abrasion will drive the particles into the bone and also the βTCP particles will remain on the implant surface. For this reason, a resorbable βTCP powder is ideal for this process.
12/06/19
The site was grafted with Ridge Graft Kit, which is a combination of our putty and our OsseoConduct βTCP granules. The site was covered with a Teflon membrane.
12/06/19
Because the implant was 10 years old, we did not have a cover screw to place under the membrane. As a result, the decision was made to perforate the membrane and place a healing abutment through the membrane.
12/06/19
Day of surgery. Note the graft density. Because the putty has not been invaded by cells and vascular tissue, the graft appears as dense as the surrounding bone.
01/02/20
Three weeks after grafting. The graft now has less density as regenerative cells and vascular supply invade the graft site.
01/16/20
Five weeks after grafting shows the maximum loss of graft density as the βTCP particles are obvious. However, the density is increasing at the base of the graft as mineralization of this area increases.
01/16/20
The healing abutment is removed and a portion of the membrane is exposed.
01/16/20
Membrane removed 5 weeks after grafting.
03/13/20
3 months after grafting, mineralization of the graft is occurring and many of the graft particles are reducing in size as resorption occurs at the base of the graft site.
03/13/20
At three months, the surgical site is exposed to gain access to the microthreads for removal and polishing and evaluate the graft site. The ridge is well mineralized with resorption of the putty portion of the graft, which is replaced by mineralized bone, but many βTCP granules remain.
While resorption of the βTCP granules will occur, it is initially very slow while it is encased in the newly formed woven bone. Rapid resorption of the graft material occurs when the bone is loaded and the bone remodels into lamellar bone. The patient was referred for restoration.
05/29/20
The restorations were placed approximately 1 month after removal of the microthreads. This radiograph was taken approximately one month after the restorations were placed.
A magnification of the prior radiograph shows the graft site with increased density and nearly complete resorption of the βTCP granules.
05/29/20
The restoration shows a reduced lingual contour allowing for proper oral hygiene.
05/29/20
A lack of keratinized gingiva may require gingival grafting.
When the restorations can be removed using βTCP air abrasion in combination with a science-based graft material and a d-PTFE membrane, regeneration is predictable. However, a much larger challenge is presented when the restorations cannot be removed.
Peri-implantitis has developed to within a few millimeters of the apex of this implant.
Deep peri-implant lesions are difficult to regenerate, mainly due the inability to access the deeper areas of the implant for complete removal of all surface toxins. However, the rotatable nozzle on the air abrasion gun allows for deep application of the particles to the implant surface.
Two weeks after surgery, mineralization is seen progressing from the bone toward the implant surface. The graft material used was Socket Graft Injectable. This graft material does not contain βTCP granules and loses radiopacity in the early days after grafting as the material is invaded by osteoblasts and vascular supply. Any granular material will mask this process.
6 weeks after grafting, the membrane is removed. The loss of radiopacity is reversed as the graft material is resorbed and replaced by vital healthy bone. The membrane used was d-PTFE and cut to wrap around the mesial of the implant. This may explain why regeneration was nearly complete on the distal surface, but the mesial surface did not have the same result, with a few millimeters of implant surface not covered with bone. More time may show additional bone growth on the mesial. No probing defects were noted.
While other graft materials may fill the bone defect radiographically, only SteinerBio bone graft materials have been proven to produce integration to the implant surface.
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American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)