DEVELOPMENT AND NONSURGICAL TREATMENT OF RETROGRADE PERI-IMPLANTITIS: A CASE REPORT

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Tunalı M, Koyuncuoğlu CK, Akman S, Selek B, Yıldırım E, Aydınbelge M

Sağlık Bilimleri Dergisi (Journal of Health Sciences) 2015 ; 24 (3) 193

SAĞLIK BİLİMLERİ DERGİSİ

JOURNAL OF HEALTH SCIENCES

Erciyes Üniversitesi Sağlık Bilimleri Enstitüsü Yayın Organıdır

DEVELOPMENT AND NONSURGICAL TREATMENT OF RETROGRADE PERI-IMPLANTITIS: A CASE REPORT*

OLUŞAN RETROGRAT PERİ-İMPLANTİTİSİN CERRAHİ OLMAYAN TEDAVİSİ: OLGU SUNUMU

Olgu Sunumu 2015; 24: 193-198

Mustafa TUNALI¹, Cenker Zeki KOYUNCUOĞLU², Serhan AKMAN³, Burak SELEK⁴ Ersin YILDIRIM⁵, Mustafa AYDINBELGE6

¹ Department of Periodontology, Gulhane Military Medical Academy, 34618 Istanbul

² Department of Periodontology, School of Dentistry, Istanbul Aydın University, 34245 Istanbul ³ Department of Prosthodontics, School of Dentistry, Selcuk University, 42250 Konya

⁴ Department of Clinical Microbiology, Gulhane Military Medical Academy, 34618 Istanbul ⁵ Department of Orthodontics, Gulhane Military Medical Academy, 34618 Istanbul

6_{Department of Pediatric Dentistry, Faculty of Dentistry, Erciyes University, 38039 Kayseri}

ABSTRACT

Retrograde peri-implantitis (RPI) constitutes an important cause of implant failure. Although several potential etiologic factors associated with RPI and po-tential treatment alternatives have been discussed in the literature, the etiology has not been fully investi-gated and there is no consensus regarding the treat-ment method.

Case Report: The following report presents the treatment of a 28-year-old man who developed a radiolucency around the apex of the implant in the maxillary incisor region after implant placement replacing tooth with histories of failed endodontic treatments. The radiolucency of the apical part of the left implant and a sinus tract associated with the apical area were detected three months after placement. The patient was placed on a course of antibiotics after the microbial susceptibility testing and monitored periodically over the next 12 months. The radiographic lesion gradually resolved without further treatment. The patient remained asymptomatic throughout the course of final restorative therapy.

Conclusion: The possible role of bacterial infection from replacing tooth with histories of failed endodontic and apicoectomy procedures may be a potential etio-logic factor in the development of RPI. Only antibiotic theraphy might be one of the treatment approaches to retrograde periapical implant lesions.

Keyword: Retrgrade, peri-implantitis, non-surgical treatment, dental implant

ÖZ

Retrograt peri-implantitis (RPİ) implant başarısızlık-larının önemli bir nedenini oluşturmaktadır. RPİ'in çok sayıda potansiyel etiyolojik faktörü ve tedavi yöntemi literatürde tartışılmış olmasına rağmen, nedeni tam olarak açıklığa kavuşturulamamıştır ve tedavi yöntemi konusunda da bir fikir birliği oluşamamıştır.

Vaka Raporu

Vaka raporu 28 yaşındaki erkek hastada, başarısız en-dodontik tedaviler sonucu kaybedilmiş üst çene keser dişler bölgesine uygulanan implantlardan birinin apikal bölge çevresindeki radyolosensi’nin tedavisini içer-mektedir. Bölgeye iki implant uygulamasından üç ay sonra, sol taraftaki implantın apikal bölgesinde ra-dyolosensi ve klinik olarak implant apikaline uzanan sinüs yolu teşhis edildi. Mikrobiyal değerlendirme son-rasında, hastaya antimikrobiyal tedavi uygulandı ve 12 ay boyunca takip edildi. Radyolosent alanın, başka bir tedavi uygulamasına gerek kalmaksızın, kademe kademe azaldığı gözlemlendi. Hastanın, son restoratif tedavisi yapılana kadar herhangi bir şikayeti tespit edilmedi.

Sonuç

Başarısız endodontik tedavi veya apikal rezeksiyon alanındaki bakteriyal enfeksiyon, RPİ’nin oluşumunda potansiyal bir etiyolojik faktör olabilir. Retrograt peri-apikal implant lezyonların tedavisinde antibiyotik uygu-lamasının tek başına bir tedavi seçeneği olabileceği düşünülmektedir.

Anahtar kelimeler: Retrograt peri-implantitis, diş im-plantı, konservatif tedavi

Makale Geliş Tarihi : 15.11.2013 Makale Kabul Tarihi: 07.12.2015

Corresponding Author: Mustafa Aydınbelge,

Department of Pediatric Dentistry, Faculty of Dentistry, Erciyes University, 38039 Kayseri, Türkiye

Tel: +90 532 7772570

E-mail: [email protected] *The case report was presented as poster in IADR Seatle, USA,

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INTRODUCTION

Retrograde peri-implantitis (RPI) can be defined as a clinically symptomatic periapical lesion (diagnosed as a radiolucency) that typically develops within first few months after implant insertion in which the coronal portion of the implant achieves a normal osseointegration (1). These clinical symptoms frequently include pain, tenderness, swelling and the presence of a fistula (2). The first case was introduced by McAllister et al.(3) in 1992 and in a retrospective study of 539 implants, found an incidence of 1.6% in the upper and 2.7% in the lower jaw exhibiting RPI, before or at abutment connection (4). Chan et al. (5), summarized potential etiologic factors associated with RPI: Residual bacteria, root particles or foreign bodies in implant site, endodontic periapical pathology associ-ated with either the previously extracted or neighbor-ing teeth, failed apicoectomy procedures, generation of excess bone heat during implant placement, implant surface contamination, excessive tightening of the im-plant with compression of the bone during imim-plant placement etc. All these factors cause which can be termed an active (infected) lesion from Reiser and Nevins RPI classification system. The inactive (not in-fected) lesion may mimic a periapical scar at the root apex and no clinical symptoms exist. For instance, an asymptomatic radiolucency can be seen at the radiog-raphy when the drilling depth during the preparation of the surgical site exceeded the length of the implant that is placed (6). RIP can be divided into two types according to the main infection pathways. Type I Im-plant-to-tooth (Type I: Placement of the implant at an insufficient distance from the tooth or direct trauma and bone overheating during the osteotomy results in tooth devitalization and periapically infected tooth inhibits osseointegration of the implant), and tooth-to-implant (Type II: due to nearby devitalized tooth’s peri-apical pathology leading to contamination of the im-plant) (7). There have been many reports that have discussed the etiology and treatment of RPI (2,4,5,7). However, the multifactorial etiology has not been fully investigated and there is no consensus on which treat-ment type is superior to another for the resolving of RPI. Surgical debridement of the lesion (8) and detoxi-fication of the exposed portion of the implant with tet-racycline (9,10) and bone substitute material without (5,11) or with the use of barrier membranes (5,12-14) were applied. Furthermore, more aggressive ap-proaches have been recommended such as an apicoec-tomy procedure (15) or even if the removal of the af-fected implant (16-18). The following case report represents utilizing only antibiotics for the treatment of a sinus tract and radiolucency apical part of the im-plant that developed in the maxillary incisor region. CASE REPORT

A 28-year-old male patient was referred to the Haydarpasa Gulhane Military Academy Department of Periodontology for placing two implants in the maxillary incisal region in 2011. The patient was systemically healthy and non-smoker. He has an Angle Class I occlusion with no occlusal trauma. The teeth had histories of endondontic treatment and the teeth

had histories of endondontic treatment and apicoectomy procedures with post-core restorations and metal-porcelain crowns for more than six years (Figure 1A). In clinical examination revealed that endodontic treatments were failed and grade III mobility were seen at maxillary central incisors. Also, periapical lesions were seen at panoramic radiography. Following atraumatic extraction of the maxillary central incisors, the sockets were debrided and no augmentation procedure was utilized (Figure 1B). One month after extraction, two 3.8 x 12 mm implants (Biohorizon; Tapered Internal Implant System, Bir-mingham, USA) were placed. The implants were placed to the bottom of the drilling loacations, and verified by periapical radiography. Temporary teeth bonded due to submerged healing protocol. The post-operative healing period was uneventful and the patient had no complaints after the operation.

Figure 1. A: Endondontic treatments, and metal-porcelain

crowns were seen at the maxillary central incisors on the pano-ramic radiography.

B: The healed alveolar rigde was seen one month after the extraction of hopeless teeth on the panoramic radiography.

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The radiolucency of the apical one third of the implant and a sinus tract associated with the apical area was detected three months after placement (Figures 2, 3). The implant and the adjacent teeth were dull to percussion and vitality of the lateral incisors was confirmed. The suggestions of open flap curretage with guided bone regeneration or periodic monitioring starting with antibiotics were given to the patient. The patient preferred antibiotic treatment with periodic evaluation rather than surgery. He was prescribed metranidazol (500 mg, two times daily for seven days) and combined with ciprofloxacin (500 mg, two times daily for seven days) after microbial susceptibility testing was done. The patient was monitored periodically over the next 12 months continued to be asymptomatic and showed no clinical signs of infection or inflammation (Figure 4). The radiolucency in the apical part of the implant disappeared gradually following 12 months without further treatment (Figure 5). Final prosthesis has functioned satisfactorily with no further complications in the follow up time (Figure 6).

DISCUSSION

This case report describes a symptomatic retrograde

Figure 2. The radiolucency of the apical one third of the left

implant was seen on the panoramic radiography. Figure 3. A sinus tract associated with the implant peri-apical

area was detected 3 months after the placement. A: Intra-oral frontal view, B: Intra-oral palatal view.

Figure 4. No clinical signs of infection or inflammation was

seen after the antibiotic usage. A: Intra-oral palatal view, B: Intra-oral frontal view

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peri-implantitis patient treated only with systemic antibiotics. The prevention and treatment of implant apical lesions has been paid more attention by clinic researchers in recent years. However, most reports are case studies due to the low prevalence of RPI (10) and the etiology of RPI lesions remains controversial due to its multifactorial origin (19,20).

Bacterial endotoxins, inflammatory cells, or microor-ganisms may persist around endodontically treated

teeth with a normal radiographic view, due to the un-complete seal (4,21), and as such can be responsible for the early contamination of an implant surface (4). The adjacent teeth may be asymptomatic before the place-ment of implants, however it should be noted that sub-clinical necrosis or partial necrosis of an adjacent tooth as a source of bacteria (22). In a recent study, RPI inci-dence on implants adjacent to an endodontically treated tooth was 7.8% (23). In this case report, the maxillary left tooth adjacent to the implant was as-ymptomatic, and tested positively to an electric vitality test. Also, there was no distinguished peri-apical lesion on the tooth in radiography.

Residual microorganisms in a radiographically healed socket (6,9,16) or the adjacent teeth with endodontic pathology (4,21) are the main causes of RPI was re-ported in most of the case studies. A more comprehen-sive evaluation of the radiographs was needed before implant placement due to prevent RPI. Unfortunately, residual pathologies both in the mandibula and maxilla are often not detectable on radiographies (4). Ayangco and Sheridan (9), presented that 3 patients with a his-tory of failed endodontic and apicectomy procedures. This teeth were extracted and implants were placed after adequate healing time.

They concluded even after intense debridement, irriga-tion of the extracirriga-tion sockets and passing of adequate healing time, bacteria may have survived in the bone, and guide to the initiation of RPI. Quirynen et al. (4), reported three times or more higher incidence for im-plants suffering from RIP when a history of a peri-apical pathology on the extracted tooth and endodontic pathology/treatment on both extracted and adjacent teeth. In the present case the patient had a history of failed endodontic treatments at the site developing retrograde peri-implantitis. In the present report, the extracted teeth had histories of failed endondontic treatment and periapical lesions were seen at pano-ramic radiography before the implant surgery. Bone overheating caused by excessive force and inade-quate cooling of drills (24), excessive tightening of the implant with compression of the bone chips (16,25) could result ischemia, necrosis, and formation of a bone sequestrum that affecting the osseointegration process. Also, Bousdras et al. (24), suggested that if the implant length exceeded 12 mm, the risk of RPI lesions would increase due to overheating of dense cortical bone. Furthermore, Flanagan (26) reported that perforation or thinning from the medullary side of the cortex by the implant drills at the apical part of the osteotomy could ensure a way of least resistance for an infectious proc-ess. Subsequently, infection could move through the cortex and into the soft tissue and constituted a drain-age tract. However, in a recent case series, Zhou et al. (10), explained that the RPI in the mandibula might be due to the difficulties in implant placement in dense compact mandibular bone without causing bone over-heating. In the present case, the osteotomy was pre-pared under copious irrigation with saline at 750 rpm for preventing any bone heating. Also, bone chips in the osteotomy site was cleansed and 3.8 x 12 mm implants were placed.

Several treatment alternatives have been

demon-Figure 5. Panoramic radiography, 12 months after the final

restorations.

Figure 6. Final prosthesis has functioned satisfactorily with no

further complications over the 12 months. A: Intra-oral frontal view , B: Intra-oral palatal view

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strated for the RPI however there is no consensus re-garding the treatment method. Chan et al. (5), pro-posed decision-making flowchart for the treatment of RPI and it needs diagnosis of the most likely etiopatho-genesis. Radiographic examination and vitality testing on adjacent teeth are required due to the RPI has been mostly linked to apical pathology from adjacent teeth. The affected implant should be removed and the socket completely debrided, if it is mobile. Sussman (7), rec-ommended that the affected implant should be re-moved immediately to prevent irreversible bone loss and osteomyelitis. However, many authors suggested that if the extent of the pathology or the degree of im-plant mobility was curable, the source of infection must eliminated by periapical surgery to prevent further compromise of osseointegration (6,16,25). It should be noted that the elimination of infection, resolution of the pathology, and ultimately implant survival are the treatment goals of RPI (5). The apical part of the im-plant should be surgically exposed but there is less agreement about how the treatment should be contin-ued (2). Some authors suggested surgical debridment (8) and detoxification of the implant surface (9,10), while others combine this bone grafts with (5,12-14) or without (3,5,11) the use of barrier membranes. Also, more aggressive approaches have been suggested such as an apicoectomy procedure (15,20,24).

Systemic antibiotic administration alone usually cannot achieve complete resolution of the RPI due to the problems in the eradication of microorganisms from the RPI site.

(12,15,19,27,28). Ateullah et al. (12), suggested that performing local debridement and removing infected tissue by the surgery for allowing to regenerate the bone is essential for RPI area. However, in a a recent report by Wasdorp et al. (29) demonstrated that asyp-tomatic cases of RPI can be successfully treated by anti-biotic therapy (amoxicilin 500 mg, three times daily for ten days). Also, Cheng et al. (30) suggested that sys-temic medication may be sufficient to resolve the RPI lesion In the present report, case was symptomatic and treated successfully only with combined antibiotic therapy after microbial susceptibility testing. No signs and symptoms were informed and the periapical radio-lucency gradually disappeared through 12 months. CONCLUSION

The teeth with histories of endodontic pathology or failed endodontic treatment procedures on the ex-tracted or adjacent teeth sites are potential etiologic factors in the development of RPI. In the present re-port, patient selected only antibiotic theraphy, and the lesion resolved without surgical intervention. How-ever, this patient should be monitored periodically for the recurrence of the pathology. Further studies and data are required to reach a consensus, on the exact etiology and well-defined treatment approaches for retrograde periapical implant lesions.

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