Nwacholews r Management of Per With a a bined oor Graftinc Introduction ?eri-implantitis is characterized by soft tissue inflammation around an implant with progressive loss of supporting bone beyond biological bone remodelling. Loss of the implant may ultimately occur if this condition is not properly managed." A surgical approach is frequently used in the management of moderate to severe peri-implantitis. Surgical treatment modalities may include access flap and de- bridement, resective surgery or regeneration of lost osseous tissue.’ Soft tissue recession Is a frequent sequelae of peri-implant surgery.‘ Surgical therapy in combination with soft tissue grafting may be uti- lized to limit recession and to augment the peri implant mucosa. This case report describes a com- bined approach involving surface decontamination, osseous regenerative therapy and a connective tissue grafting procedure in the management of a case of peri-implantitis The Case A Si-year-old male patient had two implants placed in the maxillary right first and second molar positions (1.6 and 1.7). The implants were subse quently restored with cement-retained porcelain fused to metal splinted crowns. The patient underwent peri- ‘odontal maintenance every three to four months. Twenty-seven months after implant loading, the patient presented for his routine maintenance visit. Both im: bleeding on probing and suppuration (Figure 1). Periapical radiographs showed interproximal bone loss around both implants (Figure 2). A 28 Ontario Dentist + jive 20) £ Ee, Omonkhele Gertrude Heda Hosseini Anastasia Kelekis-Cholokisdiagnosis of peri-implantitis was made and guided bone regeneration and a connective tissue grafting pro- cedure were treatment planned. During the surgery, the patient was anesthetized with two percent lido: caine in 1:100,000 epinephrine. Buc cal and palatal intrasulcular incisions were made. Raising of full thickness buccal and palatal flaps revealed bony craters and buccal bone dehiscences around both implants (Figure 3). The 1.6 implant had three exposed threads while the 1.7 implant had five exposed threads. A significant amount of black granules that might have been excess cement were also seen around both implants, Thorough mechanical removal of debris was performed. Both implant surfaces were scrubbed thrice using a tetracycline-saline slurry. This was fol- lowed by the use of sterile gauze soaked in 0.12 percent chlorhexidine placed over both implants for two minutes (Figure 4). Mineralized bovine bone (Bio-oss ®) mixed with, chairside reconstituted two percent doxycline solution was packed into the bony defects (Figure 5) and a re sorbable collagen membrane (Bio-gide ) was adapted over the osseous graft (Figure 6). Finally, a 10 mm long con- nective tissue graft was harvested from the palate and used to augment the buccal soft tissue of the most pos- terior implant (Figure 7). The im- plants were not submerged and flaps were coronally positioned using a combination of horizontal mattress and interrupted sutures. Patient was placed on 500 mg amoxicillin thrice daily for seven days, and ibuprofen 600 mg pr. To control plaque, 0.12 percent chlorhexidine mouthwash twice daily was recommended. The sutures were removed two weeks after surgery. Maintenance appointments for supragingival implant and teeth cleaning with reinforcement of oral hygiene instruction was scheduled for three and six months after the surgery. Case Report Figure 3. Flop tflecton showing bony defects coround both implants ie Figure 6. Figure 5. Procement of resorbable Placement of mineralized bone wih chaired callagen membrane reconsivted doxycycline solution sail Figure 7. Placement of connective tiswve graf. continued page 30 June 2015 * Ontario Dentist 29Case Report Six months after the regenerative surgery, a clinical examination of implants 1.6 and 1.7 revealed clinical probing depths of two mm to three mm around both implants with no bleeding on probing and no suppuration. There was an increased width /thickness of keratinized mucosa (Figure 8). Radiographic ex amination revealed an increase in radiopacity around the dental implants which would correlate with the type of osseous grafting material used (Figure 9). There ‘was however, some recession along the buccal surfaces of both implants that ‘was acceptable to the patient. Follow-up clinical examination at nine months showed that both implants maintained this asymptomatic state Conclusion The use of a combined surgical regenerative and connective tissue grafting ap- proach in the management of a case of peri-implantitis led to satisfactory short term (nine-months) clinical and radiographic results, References 1. Lindhe J, Meyle J. Per-implant diseases: Consensus Repott ofthe 6th European Workshop on Periodontology. J Clin Periodontol 2008; (Suppl. 8):282-285, Sanz M,, Chapple LL, Clinical research on peri-im Jant diseases: Consensus Report f Working Group 4, J Clin Per dontol 2012;39 (Suppl. 12):202-206, 3. Chan HLL, Lin G.H., Suarez F, Maceachern M., Wang H.L, Surgical management of Per-implantitis.A systematic review and meta analysis of treatment outcomes. JOP 2013 Nov 21. [Epub ahead of print] 4. Schwara , Sahm N,, Becker J. Combined surgical therapy of advanced peri- Implantitis lesions with concomitant soft tissue volume augmentation. A case ries. Clin Oral Implants Res. 2014 Jan;25 (1):132-6. Dr. Omonkhele Gertrude Nwachukwu is a 2004 graduate of the University of Benin, Nigeria, She practised general dentistry in Dublin, Ireland before con degree in Dental Public Health at the University of Mani 4 second-year Periodontics Resident pleting a Masters er, United Kingdom. She the University of Manitoba. Dr. Hoda Hosseini isa periodontist and maint ins a private practice in London, Ont Dr. Anastasia Ke of the Gradu -kis-Cholakis isthe Division Head of Periodontics and the Director te Periodontal Program at the University of Manitoba, College of Dentistry. She is a fellow of the Royal College of Dentists of Canada and a member of the Canadian and American Academy of Periodontists, Canadian Dental Association and Winnipeg Chapter of the Seattle Study Club. She lectures nationally and internationally and has published articles in peer-reviewed journals. Her areas of interest are periodontal microsurgery and biologic implant complications 30 Ontario Dentist « Figure 8. Shemonths postoperatively Postoperative radiograph of implonts #16 and #17.