Journal of Oral Implantology

Surgical treatment of severe peri-implantitis using a round titanium brush for implant
surface decontamination: a case report with clinical re-entry
--Manuscript Draft--

Manuscript Number: aaid-joi-D-16-00163R1

Full Title: Surgical treatment of severe peri-implantitis using a round titanium brush for implant
surface decontamination: a case report with clinical re-entry

Short Title: Peri-implantitis treatment with a titanium brush

Article Type: Case Report

Keywords: Debridement; Dental Implant; peri-implant disease; regeneration.

Corresponding Author: Seong-Ho Choi, DDS, PhD

Yonsei University College of Dentistry
Seoul, Seoul KOREA, REPUBLIC OF

Corresponding Author Secondary

Information:

Corresponding Author's Institution: Yonsei University College of Dentistry

Corresponding Author's Secondary

Institution:

First Author: YINZHE AN, Ph.D. candidate

First Author Secondary Information:

Order of Authors: YINZHE AN, Ph.D. candidate

Jae-Hong Lee, DDS, MS

Young-Ku Heo, DDS, PhD

Jung-Seok Lee, DDS, PhD

Ui-Won Jung, DDS, PhD

Seong-Ho Choi, DDS, PhD

Order of Authors Secondary Information:

Abstract: The most common cause of peri-implantitis is the accumulation of plaque and the
formation of a biofilm on the implant surface. Terminating the development of the
disease requires the biofilm to be removed from the implant surface. This paper
describes two cases of severe peri-implantitis lesions treated through surgical
approaches. Complete mechanical debridement with a round titanium brush was
mainly performed to detoxify and modify the affected implant surface. A regenerative
approach was then performed. In both cases, the surgical procedure was effective in
arresting the peri-implantitis, and clinical re-entry revealed uneventful healing of the
existing bone defect. No further radiographic bone loss was observed over the 2-year
follow-up period. This technique has the advantage of effective cleaning the
contaminated implant surface and produces positive clinical and radiological results.
However, further studies involving more cases are necessary to verify the reliability and
validity of this technique.

Response to Reviewers: Dear Editor,

Thank you for your kind review of our manuscript entitled Surgical treatment of severe
peri-implantitis using a round titanium brush for implant surface decontamination: a
case report with clinical re-entry. We are grateful to the reviewers for their critical
comments and useful suggestions that have helped us to improve the manuscript
considerably. The following responses indicate that we have incorporated most these
comments into the revised version of our paper.

Responses to Reviewer #1:

1) The authors should discuss about the possible influence of the generation of loose

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 Ti particles which may contribute to the early marginal bone loss around well integrated
dental implants.
Response: We appreciate this comment. As you have suggested, we added a
paragraph about possible influence of Ti particles and early marginal bone loss.
The release of titanium particles from implant fixtures placed onto the peri-implant
bone during preparation of the implant bed has been reported. The number of particles
were correlated with the roughness of the implant and its topographical
configuration.27, 28 Previous studies have shown that the released titanium particle
debris is mainly concentrated at the crestal parts of the bone in contrast to apical
areas. Debris amounts reaching 0.2 mg to 3.0 mg may induce peri-implant osteolysis,
which manifests as early marginal bone loss around the implant.27, 29 In an animal
study, Schliephake et al.30 reported that loose particles attached to the surface of the
bone could be pressed into the bone microenvironment, and that intense rinsing of the
implant site would still not remove all titanium particles from the bone surface. In the
present study, contaminated implant surfaces were debrided using an R-brush and,
after thorough irrigation, a regenerative approach was applied with autogenous or
allograft bone. No bone loss was observed during a two-year follow-up period. Thus,
the direct effect of particle debris on peri-implant bone has, not been clearly defined. In
this case, mechanical debridement plus saline irrigation appears to have been useful in
reducing titanium concentration so that re-osseointegration was possibly achieved and
no bone loss occurred in the early phase. However, further investigation of the titanium
particles deposited on the peri-implant bone after debridement may contribute to the
recognition of a biological effect.

2) The authors should improve the discussion regarding the limitations of the
presentation of case-reports on the evidence pyramid, and also suggest further
studies, both clinical or in animals, that could Best made in order to verify the use of
this technique to treat severe peri-implantitis and the its effects on the healing process.
Response: In the first paragraph of the discussion, we restated regarding limitation on
the present case reports, and further studies are needed to confirm this approach.
It has been confirmed that open debridement may result in re-osseointegration and
this integration is more pronounced on rougher implant surface.22 To date, there is no
literature describing the treatment of severe peri-implantitis using such a protocol.
However, due to the small number of cases considered, the efficacy of the described
method needs further investigation in animal studies or other clinical trials, ideally
leading to a predictable and reliable method of treating peri-implantitis, and
understanding its effects on the healing process.

Responses to Reviewer #2:

1) The following areas that need "rewording" are: Introduction: lines 35 - 44 (these
sentences are not clear).
Response: Thank you for your comment. As you have suggested, we described the
following sentences more detailly.
In a prospective human study, Roos-Jansker et al.15 reported that bone fill using a
bone substitute with or without a resorbable collagen membrane could arrest disease
progress for three years after decontamination. In an ongoing randomized clinical trial,
Wohlfahrt et al.16 describe a regenerative protocol incorporating open-flap
debridement of the implant surface, decontamination using 24% EDTA gel, grafting
with porous titanium granules, and resubmersion of the implant was effective during a
12-month follow-up period.

2) The following areas that need "rewording" are: Case 2: "complaint", not compliant .
Response: We appreciate this comment. As you have suggested, we changed the
misspelled word compliant to complaint.

3) The following areas that need "rewording" are: Surgical Procedure: lines 13 - 22
(these sentences are not clear).
Response: Thank you for your comment. As you have suggested, we restated the
following sentences.
After these surgical steps, a 6 mm diameter bone harvesting drill (ACM, Auto Chip
Maker, NeoBiotech) with a rotation speed of 50 rpm to 70 rpm was used without saline
irrigation to harvest fresh, bloody autogenous bone chips from the cortical bone of the
adjacent buccal shelf area (Fig. 6E, F). After drilling three times, approximately 1 cc of
autogenous bone chips was collected and bone was subsequently grafted into the

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 defect, which was covered with a resorbable collagen membrane (CollaGuideTM,
Bioland, Cheonan, Korea) and mucoperiosteal flap in stepwise fashion. Primary wound
closure was achieved using interrupted sutures (Fig. 6G-I).

4) Results: lines 30- 46 (these sentences are not clear).

Response: Thank you for your comment. As you have suggested, we described the
following sentences more detailly.
Uncovery surgery was performed three months after the debridement surgery. A
clinical examination revealed entire regeneration of the defect site. D2-like cortical
bone was detected, and bone grown over the cover screw was harvested as a biopsy
sample (Fig. 7A). Histological results revealed the deposition of new bone onto the
grafted autogenous bone (Fig. 7B). The prosthetic restoration was delivered
immediately after the uncovery procedure (Fig. 7C). The patient was followed-up at 3,
6, 12, and 24 months postoperatively, and gradually increased radiographic bone
density was observed. Figure 7D shows a periapical view 24 months after surgery. A
clinical examination performed at the 24-month follow-up revealed a probing depth of 3
mm on the buccal aspect (Fig. 7E). An additional re-entry revealed that the well-
matured regenerated bone around the implant had remained stable, and no bone loss
and no soft tissue engagement between the implant surface and the bone was
detected (Fig. 7F).

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Article File Click here to download Article File renamed_dc057.docx

1 Surgical treatment of severe peri-implantitis using a round titanium brush for

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4 implant surface decontamination: a case report with clinical re-entry
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Yin Zhe An, DDS,* Jae-Hong Lee, DDS, MS , Young-Ku Heo, DDS, PhD, Jung-Seok Lee, DDS, PhD,
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Ui-Won Jung, DDS, PhD, and Seong-Ho Choi, DDS, PhD

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15 Post-graduate Student, Department of Periodontology, Research Institute for Periodontal Regeneration,
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17 College of Dentistry, Yonsei University, Seoul, Korea.
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19 Assistant Professor, Department of Periodontology, Daejeon Dental Hospital, College of Dentistry,
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21 Wonkwang University, Daejeon, Korea
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23 Director, Global Academy of Osseointegration, Seoul, Korea.
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Clinical Assistant Professor, Department of Periodontology, Research Institute for Periodontal
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27 Regeneration, College of Dentistry, Yonsei University, Seoul, Korea.
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Associate Professor, Department of Periodontology, Research Institute for Periodontal Regeneration,
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31 College of Dentistry, Yonsei University, Seoul, Korea.
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Professor, Department of Periodontology, Research Institute for Periodontal Regeneration, College of
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35 Dentistry, Yonsei University, Seoul, Korea.
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39 Running Title
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41 Peri-implantitis treatment with a titanium brush
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45 Corresponding Author
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47 Prof. Seong-Ho Choi, Department of Periodontology, Research Institute for Periodontal Regeneration,
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49 College of Dentistry, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea. Tel.: +82-2-
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22283189, Fax: +82-2-3920398, E-mail: shchoi726@yuhs.ac
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Y.-Z. An and J.-H. Lee contributed equally to this study.
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 1
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3 Acknowledgments
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5 We are grateful to the President of NeoBiotech Co., Ltd. for his permission to publish this work. We thank
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7 the entire staff at the local clinic in Seoul, Korea for their excellent management of the patients. The authors
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9 also thank Hye-Jung Byun, NeoBiotech Co., Ltd. for providing relevant data on the R-Brush instrument.
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14 Abstract
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16 The most common cause of peri-implantitis is the accumulation of plaque and the formation of a biofilm
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18 on the implant surface. Terminating the development of the disease requires the biofilm to be removed from
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20 the implant surface. This paper describes two cases of severe peri-implantitis lesions treated through
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22 surgical approaches. Complete mechanical debridement with a round titanium brush was mainly performed
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24 to detoxify and modify the affected implant surface. A regenerative approach was then performed. In both
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26 cases, the surgical procedure was effective in arresting the peri-implantitis, and clinical re-entry revealed
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28 uneventful healing of the existing bone defect. No further radiographic bone loss was observed over the 2-
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30 year follow-up period. This technique has the advantage of effective cleaning the contaminated implant
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32 surface and produces positive clinical and radiological results. However, further studies involving more
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34 cases are necessary to verify the reliability and validity of this technique.
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39 Keywords
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41 Debridement, dental implant, peri-implant disease, regeneration.
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 1 Introduction
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3 Peri-implantitis is an irreversible inflammatory disease that affects both the soft and hard tissues of a
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5 dental implant, and if left untreated it will result in implant failure in most instances.1,2 There have been
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7 wide variations in the previously reported prevalence rates of peri-implantitis, due to the use of different
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9 study designs and limited patient populations.3,4 In a Recent systematic review, Derks et al.5 found that peri-
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11 implantitis was present at 14-30% of implant sites.
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14 The most common cause of peri-implantitis is the accumulation of dental plaque and the formation of
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16 a bacterial biofilm on the implant surface.6-8 Terminating the development of the disease requires the
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18 bacterial biofilm to be removed from the implant surface. Various conservative and surgical therapies have
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20 been introduced for decontaminating the implant surface.9-13 Although conservative therapies that include
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22 the use of metallic curettes with an adjunct of local or systematic antibiotics, and laser and ultrasonic
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24 devices were effective in removing the bacterial biofilm from the surface of an implant, difficulties with
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access and visibility impeded the thorough debridement in cases with moderate or severe infection.14
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29 Surgical approaches are commonly more appropriate and suitable for the thorough decontamination of
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31 moderate or severe peri-implantitis. Several decontamination protocols had been presented in the literature.
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33 In a prospective human study, Roos-Jansker et al.15 reported that bone fill using a bone substitute with or
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without a resorbable collagen membrane could arrest disease progress for three years after decontamination.
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In an ongoing randomized clinical trial, Wohlfahrt et al. 16 describe a regenerative protocol incorporating
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open-flap debridement of the implant surface, decontamination using 24% EDTA gel, grafting with porous
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42 titanium granules, and resubmersion of the implant was effective during a 12-month follow-up period.
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44 However, there is currently limited evidence of the effective of these surgical procedures.17
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47 A round titanium brush comprising titanium alloy bristles (R-Brush, NeoBiotech, Seoul, Korea) was
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49 recently developed for detoxifying and modifying an implant surface contaminated with severe peri-
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51 implantitis. The instrument can be used for bone defects of Class Ie (circular bone resorption while under
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53 maintaining the buccal and lingual bone) or Class II (supracrestal defect).18 Treating peri-impantitis using
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55 an R-Brush was found to be easier, faster, and more effective than any other conventional instrument.
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58 The purpose of the present case report was to describe the surgical procedure for treating severe peri-
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 1 implantitis with a regenerative approach, focusing on decontamination of the implant surface using the R-
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3 Brush.
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8 Case 1
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A 52-year-old male patient was referred to a local clinic in March 2014. His chief compliant was a dull
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aching pain from an implant in the maxillary posterior region. The patient initially received implant
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16 treatment in July 2006. Three external-connection implants were placed and then fixed using a screw-
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18 retained prosthetic restoration from the maxillary left second premolar through to the maxillary left second
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20 molar (Fig. 1A). All three implants had a diameter and length of 4.0 and 13 mm, respectively. The patient
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22 had a bone density of D319 at the implant positions. The three fixtures were inserted with good primary
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24 stability: implant stability quotient of 40, 60, and 55. However, the patient had not been followed up after
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26 the prosthetic restorations were delivered. The implant had been in function at least for 7 years. Clinically,
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28 no swelling, purulence, or mobility was recorded in any of the implants, but a probing depth of 10.0 mm
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30 was found in the implant positioned at the maxillary left first molar. A radiographic examination showed a
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32 crater defect at this implant position (Fig. 1B). No bone loss was observed in the two neighboring implants.
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35 Surgical procedure
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38 In order to access the bone defect and allow mechanical debridement of the infected implant surface,
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40 the 3 unit prosthesis was removed (Fig. 2A). Surgery was performed under local anesthesia (1:100,000
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42 epinephrine), and a mucoperiosteal flap was reflected buccally in the implant positioned at the maxillary
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44 left first molar. The 8 threads of the fixture was exposed by removing a large formation of granulation tissue
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46 (Fig. 2B), and then a protective cap was attached over the implant platform (Fig. 2C). An R-Brush
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48 connected to a low-speed handpiece was used at a rotation speed of about 8000 rpm for 30 sec per thread
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50 for not only eliminating the old implant surface but creating a new rough surface. Thorough irrigation with
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52 physiological sterile saline from a monojet syringe was also applied during preparation for diluting the
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54 microbial species in the defect and reducing the heat generated by metal friction (Fig. 2D, E).
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57 It took about 4 minutes to treat the 8 exposed threads with the R-Brush. The treated surface was
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59 thoroughly examined with magnifying glasses to detect any untreated area (Fig. 3A). After final rinsing, a
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 1 cover screw was placed and the defect was grafted with freeze-dried allograft (RegenossTM, Cellumed,
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3 Seoul, Korea), and a resorbable collagen membrane (Genoss, Seoul, Korea) was placed over the grafting
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5 material to protect it from penetration by the surrounding soft tissue cells. To achieve primary wound
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7 closure, the flap was repositioned with a vertical releasing incision and sutured with a 4-0 monofilament
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9 suture material (REXLON Supramid, SM Eng, Busan, Korea) (Fig. 3B-D). The patient received antibiotic
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11 therapy (500 mg of amoxicillin three times daily) for 7 days. The patient was also advised not to brush the
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13 surgical site and to rinse with 0.12% chlorhexidine solution for 2 weeks in order to prevent postsurgical
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15 infection caused by plaque accumulation.
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18 Results
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21 The sutures were removed 14 days after the surgery. The implant remained without a prosthetic
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23 restoration for a 5-month healing period. Maintenance was performed at 3, 6, and 12 months. The patient
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25 did not report a complaint or discomfort. At a 5-month check-up, a clinical examination revealed
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27 uneventful healing of the surgical site (Fig. 4B). At re-entry in 5 months after the treatment, although a part
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29 of one thread was exposed on the buccal aspect of the implant, solid abundant bone was regenerated, and a
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31 periapical radiograph showed that the boundary between the graft and the existing bone was unclear (Fig.
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33 4A, C). The final prosthetic restoration was placed again at 5 months after the bone graft surgery. Figure
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35 5A, 5B, and 5C show the periapical views at 6, 12, and 24 months after surgery, respectively, indicating
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that the bone density increased gradually and that no further bone resorption was observed mesially and
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distally for 2 years.
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Case 2
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49 A 54-year-old male patient presented at a local clinic in January 2014. His chief complaint was food
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51 impaction at an implant in the mandibular posterior region. The 3 implants had been inserted 7 years
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53 previously in another clinic. A radiographic examination showed a crater defect at the implant positioned
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55 at the mandibular right second molar (Fig. 6A). Clinically, the implant was stable, but there was a probing
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57 depth of 7.0 mm and gingival redness and swelling were observed.
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 1 Surgical procedure
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4 Surgical treatment was applied, comprising reflection of a mucoperiosteal flap, removal of granulation
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6 tissue, debridement with an R-Brush, and irrigation with saline (Fig. 6B-D). After these surgical steps, a 6
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8 mm diameter bone harvesting drill (ACM, Auto Chip Maker, NeoBiotech) with a rotation speed of 50 to
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10 70 rpm was used without saline irrigation to harvest fresh, bloody autogenous bone chips from the cortical
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bone of the adjacent buccal shelf area (Fig. 6E, F). After drilling three times, approximately 1cc of
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autogenous bone chips was collected and bone was subsequently grafted into the defect, which was covered
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by a resorbable collagen membrane (CollaGuideTM, Bioland, Cheonan, Korea) and mucoperiosteal flap in
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stepwise fashion. Primary wound closure was achieved with interrupted sutures (Fig. 6G-I). After the
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21 surgery, the patient received antibiotic therapy for 7 days and was informed about important postoperative
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23 protocols.
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26 Results
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29 Uncovery sugery was performed three months after the debridement surgery. A clinical examination
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31 revealed entire regeneration of the defect site. D2-like cortical bone was detected, and bone grown over the
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33 cover screw was harvested as a biopsy sample (Fig. 7A). Histological results revealed the deposition of
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35 new bone onto the grafted autogenous bone (Fig. 7B). The prosthetic restoration was delivered immediately
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37 after the uncovery procedure (Fig. 7C). The patient was followed-up at 3, 6, 12, and 24 months
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39 postoperatively, and gradually increased radiographic done density was observed. Figure 7D shows an
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41 periapical view at 24 months after surgery. A clinical examination performed at the 24-month follow-up
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43 revealed a probing depth of 3 mm on the buccal aspect (Fig. 7E). An additional re-entry revealed that the
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45 well-matured regenerated bone around the implant had remained stable, and no bone loss and no soft tissue
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47 engagement between the implant surface and the bone was detected (Fig. 7F).
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50 Discussion
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52
53 The current treatment methods for peri-implantitis are based on the methods used to treat natural teeth
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55 with periodontal disease.20 Several surgical approaches are used to treat peri-implantitis. However, although
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57 these methods are universally applied, there is still no strong consensus or recognized treatment method for
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59 completely eradicating peri-implantitis.21 The present case study applied mechanical decontamination
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 1 combined with sterile saline to treat the contaminated surface of implants, with the results indicating that
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3 utilization of an R-Brush was highly effective at removing the dental plaque and biofilm from the implant
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5 surface. Furthermore, this technique has been developed to eliminate the contaminated original rough
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7 surface and create a new rough surface. Figure 8A, 8B, and 8C show the difference of the surfaces between
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9 before and after treatments with the R-Brush. It has been confirmed that open debridement may result in
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11 re-osseointegration and this integration is more pronounced on rougher implant surface.22 To date, there is
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13 no literature describing the treatment of severe peri-implantitis using such a protocol. However, due to the
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15 small number of cases considered, the efficacy of the described method needs further investigation in
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17 animal studies or other clinical trials, ideally leading to a predictable and reliable method of treating peri-
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19 implantitis, and understanding its effects on the healing process.
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21 Several studies have shown that re-osseointegration can occur on surfaces previously contaminated by
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23 dental plaque and surrounded by a bone defect. The results obtained in the present case study were
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25 consistent with these previous studies.22- 24 However, in those studies, induced peri-implantitis artificially
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27 in animal models, and the partial implant surface was exposed in the oral environment for a period of time,
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29 with the bone defect produced mechanically by a drill when preparing the implant sites. It should be noted
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31 that the microbial species populating the implant surface could differ from those for an implant located in
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the human oral environment.
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In the present case study, after debridement with an R-Brush, a regenerative approach was applied with
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autogenous bone or allograft bone. In such circumstances, the geometry of the bone defect critically affects
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the clinical outcome.25 A bone defect characterized by circular bone resorption with the buccal and lingual
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42 bone plates preserved, provides a more predictable and effective outcome following the regenerative
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44 approach. In this 2nd case, the bone defects were all crater-like defects with preserved circular bone plates.
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46 The patients were followed up at 3, 6, 12, and 24 months. The periapical radiographs revealed that the
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48 alveolar bone height was stable and no bone resorption could be observed mesially and distally. However,
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50 in the 1st case in this study, the defect was quite large and there was no bony wall bucco-lingually.
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52 Surprisingly, this case showed an acceptable vertical bone augmentation (6mm) and 2-year maintenance
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54 without further bone loss and any peri-implant radiolucency. This means that re-osseointegration might be
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56 obtained in the grafted implant surface. This result shows that re-osseointegration could be established if
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58 the contaminated surface is totally detoxified and decontaminated.
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 1 The aim of implantoplasty is to produce a smooth and polished implant surface so as to reduce the
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3 amount of dental plaque that attaches to it, and also to remove the implant threads, thereby providing a less
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5 attractive environment to bacteria.14,26 However, the obvious disadvantage of this technique is that any
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7 further re-osseointegration is considered unpredictable. In contrast to implantoplasty, decontamination with
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9 an R-Brush can produce a well-distributed and rough surface, and moreover preserve the implant threads;
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11 this makes the success of the regenerative approach more predictable. Another advantage of this technique
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13 is that decontamination with an R-Brush not only reduces the chair time for the clinician but also reduces
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15 muscle fatigue in the patient associated with prolonged opening of the mouth.
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17 The release of titanium particles from implant fixtures placed onto the peri-implant bone during
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19 preparation of the implant bed has been reported. The number of particles were correlated with the
20
21 roughness of the implant and its topographical configuration. 27, 28 Previous studies have shown that the
22
23 released titanium particle debris is mainly concentrated at the crestal parts of the bone in contrast to apical
24
25 areas. Debris amounts reaching 0.2 mg to 3.0 mg may induce peri-implant osteolysis, which manifests as
26
27 early marginal bone loss around the implant.27, 29 In an animal study, Schliephake et al.30 reported that loose
28
29 particles attached to the surface of the bone could be pressed into the bone microenvironment, and that
30
31 intense rinsing of the implant site would still not remove all titanium particles from the bone surface. In the
32
33
present study, contaminated implant surfaces were debrided using an R-brush and, after thorough irrigation,
34
35
a regenerative approach was applied with autogenous or allograft bone. No bone loss was observed during
36
37
a two-year follow-up period. Thus, the direct effect of particle debris on peri-implant bone has, not been
38
39
clearly defined. In this case, mechanical debridement plus saline irrigation appears to have been useful in
40
41
42 reducing titanium concentration so that re-osseointegration was possibly achieved and no bone loss
43
44 occurred in the early phase. However, further investigation of the titanium particles deposited on the peri-
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46 implant bone after debridement may contribute to the recognition of a biological effect.
47
48 Conclusion
49
50
51 The results obtained in the present two cases emphasize the importance of mechanical decontamination
52
53 by eliminating the contaminated surface and creating a new rough surface for a regenerative approach in
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55 the treatment of severe peri-implantiits. This technique has the advantage of effective cleaning of the
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57 contaminated implant surface and produced positive clinical and radiological results during the 2-year
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 1 follow-up period. However, further studies are necessary to verify the reliability and validity of this
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3 technique.
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References
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13 1. Froum SJ, Rosen PS. A proposed classification for peri-implantitis. Int J Periodontics Restorative Dent.
14
15 2012;32:533-540.
16
17 2. Lang NP, Berglundh T. Periimplant diseases: where are we now?--Consensus of the Seventh European
18
19 Workshop on Periodontology. J Clin Periodontol. 2011;38 Suppl 11:178-181.
20
21 3. Atieh MA, Alsabeeha NH, Faggion CM, Jr., Duncan WJ. The frequency of peri-implant diseases: a
22
23 systematic review and meta-analysis. J Periodontol. 2013;84:1586-1598.
24
25 4. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol.
26
27 2008;35:286-291.
28
29 5. Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J
30
31 Clin Periodontol. 2015;42 Suppl 16:S158-171.
32
33 6. Alcoforado GA, Rams TE, Feik D, Slots J. Microbial aspects of failing osseointegrated dental implants
34
35 in humans. J Parodontol. 1991;10:11-18.
36
37 7. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP. Experimentally induced
38
39 peri-implant mucositis. A clinical study in humans. Clin Oral Implants Res. 1994;5:254-259.
40
41 8. Singh P. Understanding peri-implantitis: a strategic review. J Oral Implantol. 2011;37:622-626.
42
43 9. Karring ES, Stavropoulos A, Ellegaard B, Karring T. Treatment of peri-implantitis by the Vector
44
45 system. Clin Oral Implants Res. 2005;16:288-293.
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47 10. Romeo E, Ghisolfi M, Murgolo N, Chiapasco M, Lops D, Vogel G. Therapy of peri-implantitis
48
49 with resective surgery. A 3-year clinical trial on rough screw-shaped oral implants. Part I: clinical outcome.
50
51 Clin Oral Implants Res. 2005;16:9-18.
52
53 11. Romeo E, Lops D, Chiapasco M, Ghisolfi M, Vogel G. Therapy of peri-implantitis with resective
54
55 surgery. A 3-year clinical trial on rough screw-shaped oral implants. Part II: radiographic outcome. Clin
56
57 Oral Implants Res. 2007;18:179-187.
58
59
60
61
62
63
64
65
 1 12. Serino G, Turri A. Outcome of surgical treatment of peri-implantitis: results from a 2-year prospective
2
3 clinical study in humans. Clin Oral Implants Res. 2011;22:1214-1220.
4
5 13. Yamamoto A, Tanabe T. Treatment of peri-implantitis around TiUnite-surface implants using Er:YAG
6
7 laser microexplosions. Int J Periodontics Restorative Dent. 2013;33:21-30.
8
9 14. Alani A, Bishop K. Peri-implantitis. Part 3: current modes of management. Br Dent J. 2014;217:345-
10
11 349.
12
13 15. Roos-Jansker AM, Persson GR, Lindahl C, Renvert S. Surgical treatment of peri-implantitis using
14
15 a bone substitute with or without a resorbable membrane: a 5-year follow-up. J Clin Periodontol.
16
17 2014;41:1108-1114.
18
19 16. Wohlfahrt JC, Aass AM, Ronold HJ, Lyngstadaas SP. Micro CT and human histological analysis of
20
21 a peri-implant osseous defect grafted with porous titanium granules: a case report. Int J Oral Maxillofac
22
23 Implants. 2011;26:e9-e14.
24
25 17. Bassi F, Poli PP. Surgical Treatment of Peri-Implantitis: A 17-Year Follow-Up Clinical Case Report.
26
27 Case Rep Dent.2015;2015:574676.
28
29 18. Schwarz F, Sahm N, Iglhaut G, Becker J . Impact of the method of surface debridement and
30
31 decontamination on the clinical outcome following combined surgical therapy of peri-implantitis: a
32
33
randomized controlled clinical study. J Clin Periodontol. 2011;38:276-284.
34
35
19. Lekholm U, Zarb GA. Patient selection and preparation. In: Brnemark P-I, Zarb GA, Albrektsson T.
36
37
Tissue-integrated prostheses : osseointegration in clinical dentistry. Chicago: Quintessence; 1985:199-209.
38
39
20. Thierbach R, Eger T. Clinical outcome of a nonsurgical and surgical treatment protocol in different
40
41
42 types of peri-implantitis: a case series. Quintessence Int. 2013;44:137-148.
43
44 21. Bidra AS. No reliable evidence suggesting what is the most effective interventions for treating peri-
45
46 implantitis. Evid Based Dent. 2012;13:50-51.
47
48 22. Renvert S, Polyzois I, Maguire R. Re-osseointegration on previously contaminated surfaces:
49
50 asystematic review. Clin Oral Implant Res. 2009;20 Suppl 4:216-227.
51
52 23. Persson LG, Bergulndh T, Lindhe J, Sennerby L. Re-osseointegration after treatment of peri-
53
54 implantitis at different implant surfaces. An experimental study in the dog. Clin Oral Implant Re
55
56 s.2001;12:595-603.
57
58 24. Mohamed S, Polyzois I, Renvert S, Claffey N. Effect of surface contamination on osseointegration of
59
60
61
62
63
64
65
 1 dental implants surrounded by circumferential bone defects. Clin Oral Implants Res. 2010;21:513-519.
2
3 25. Schwarz F, Sahm N, Schwarz K, BeckerJ. Impact of defect configuration on the clinical outcome
4
5 following surgical regenerative therapy of peri-implantitis. J Clin Periodontol. 2010;37:449-455.
6
7 26. Valderrama P, Wilson TG, Jr. Detoxification of implant surfaces affected by peri-implant disease: an
8
9 overview of surgical methods. Int J Dent. 2013;2013:740680.
10
11 27. Meyer U, Bhner M, Bchter A, Kruse-Lsler B, Stamm T, Wiesmann HP. Fast element mapping of
12
13 titanium wear around implants of different surface. Clin Oral Implant Res. 2006;17:206-211.
14
15 28. Senna P, Antoninha Del Bel Cury A, Kates S, Meirelles L. Surface damage on dental implants with
16
17 release of loose particles after insertion into bone. Clin Implant Dent Relat Res. 2015;17:681-692.
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19 29. Shin DK, Kim MH, Lee SH, Kim TH, Kim SY. Inhibitory effects of luteolin on titanium particle-
20
21 induced osteolysis in a mouse model. Acta Biomater. 2012;8:3524-3531.
22
23 30. Schliephake H, Reiss G, Urban R, Neukam FW, Guckel S. Metal release from titanium fixtures during
24
25 placement in the mandible: an experimental study. Int J Oral Maxillofac Implants. 1993;8:502-511.
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 1 Captions
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5 Figure 1. (A) Panoramic view after delivering the prosthesis in 2006. (B) The 7 years later, re-operative
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7 radiograph showing a severe vertical peri-implant defect around the implant positioned at the maxillary left
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9 first molar.
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12 Figure 2. (A) Intraoral view after removing the prosthesis. (B) After opening the flap, a large vertical defect
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14 without bucco-lingual bony walls was seen. (C) A protective cap was attached to protect the implant
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16 platform. (D) A round titanium brush with titanium alloy bristles (R-Brush) was used to decontaminate the
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18 implant surface at a rotation speed of about 8000 rpm for 30 sec per thread. (E) Three-dimensional view of
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20 the R-Brush instrument.
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23 Figure 3. (A) The implant surface looked smooth and clean after debridement with the R-Brush. The
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25 original rough surface was removed and created by a new surface. (B) The bone defect area was filled with
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27 freeze-dried allograft bone. (C) The grafting material was covered by a protective collagen membrane. (D)
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Primary wound closure was achieved using interrupted sutures.
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33 Figure 4. (A) Periapical radiograph obtained at 5 months after surgery. (B) Clinical view at 5 months after
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35 surgery. (C) Clinical view at re-entry showing the formation of solid bone in the original bone defect.
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38 Figure 5. (A) Periapical radiograph obtained at 6 months showing that the bone density had increased. (B)
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40 Periapical radiograph obtained at 12 months, showing a stable alveolar bone height without any bone
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42 resorption. (C) Periapical radiograph obtained 2 years after surgery. No further radiographic bone loss was
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44 observed.
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47 Figure 6. (A) Pre-operative radiograph showing a crater defect around the implant positioned at the
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49 mandibular right second molar. (B) Granulation tissue around the implant was removed after opening the
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51 flap. (C) Debridement of the Implant surface using the R-Brush. (D) View after debridement. (E) Utilization
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53 of a bone harvesting drill to harvest autogenous chip bone. (F) Autogeous chip bone harvested from the
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55 buccal shelf area of the second and third molars of the mandibular body. (G) Harvested autogenous bone
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57 was grafted into the defect. (H) The grafting material was covered by a resorbable collagen membrane. (I)
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59 Primary closure with interrupted sutures.
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 1 Figure 7. (A) Clinical view at re-entry after surgery showing solid and newly formed bone over the cover
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3 screw. (B) Biopsy sample obtained from the grafted site (H&E stain, 20). The large piece of compact bone
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5 showed the new bone attached to the grafted autogenous bone (yellow arrows). This lesion was competent
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7 with favorable bony remodeling. (C) Periapical radiograph after the uncovering procedure and delivery of
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9 the prosthesis. (D) Periapical radiograph obtained at 24 months after the debridement surgery. (E) At the
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11 24-month follow-up there was a probing depth of 3 mm on the buccal aspect. (F) The newly formed bone
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13 around the implant remained stable at the 24-month re-entry.
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16 Figure 8. (A) SEM image before R-Brushing (Magnification 500). (B) SEM image after R-Brushing
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(Magnification 500). (C) 3D surface display after R-Brushing.
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figure7 Click here to download Figure Fig. 7.tif
figure8 Click here to download Figure Fig. 8.tif
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