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1 The Impct of Implnt Design, Defect Size, nd Type of Superstructure on the Accessiility of Nonsurgicl nd Surgicl Approches for the Tretment of Peri-implntitis Dvid Polk, PhD, DMD 1 /Efrt Myn, DMD /Tli Chckrtchi, DMD 3 Purpose: The success of nonsurgicl or surgicl tretments of peri-implntitis is unpredictle, often without cler reson. The im of this study ws to investigte the efficcy of nonsurgicl nd surgicl clening, focusing on the impct of implnt design, defect size, type of superstructure, nd experience of the opertor. Mterils nd Methods: Conicl nd stright implnts were coted with iofilm-like mteril nd plced in shllow/s in n rtificil jw model. Tretment ws done y three opertors nd included either heling utments or crowns s superstructures. Anlysis ws done using stereomicroscopy nd ImgeJ softwre. Results: Nonsurgicl tretment of peri-implntitis defects ws inefficient in removing ll iofilm res, regrdless of the depth of the defect. The type of implnt, experience of the opertor, or type of superstructure did not hve significnt impct. Surgicl tretment ws more efficient thn nonsurgicl pproch with regrd to iofilm residues. However, the surgicl pproch filed to clen the picl portion of the exposed prt of the implnts. Conclusion: Nonsurgicl nd surgicl tretment were found to e ineffective in clening the exposed portion of implnts with peri-implntitis. Tretment of periimplntitis should therefore lso include other pproches, such s chemicl or iologicl modlities. Int J Orl Mxillofc Implnts 1 (7 pges). doi:.17/jomi.71 Keywords: clening, nonsurgicl tretment, peri-implntitis, surgicl tretment The peri-implnt re is more susceptile thn the periodontium to cteri, 1 indicting tht erly plque removl is essentil in ptients with dentl implnts. If perimucositis occurs, mintennce tretment ought to quickly nd efficiently resolve it. 3, However, periimplntitis poses different chllenge given the fct tht there is no cler tretment protocol with predictle fvorle outcome. A Cochrne systemtic review sttes tht peri-implntitis will reoccur in up to % of treted cses fter 1 yer. 5 1 Lecturer, Deprtment of Periodontology, Herew University-Hdssh Fculty of Dentl Medicine, Jeruslem, Isrel. Postgrdute Student, Deprtment of Periodontology, Herew University-Hdssh Fculty of Dentl Medicine, Jeruslem, Isrel. 3 Clinicl Instructor, Deprtment of Periodontology, Herew University-Hdssh Fculty of Dentl Medicine, Jeruslem, Isrel. Correspondence to: Dr Dvid Polk, Deprtment of Periodontology, The Herew University-Hdssh Medicl Center, P.O. Box 17, Jeruslem 91, Isrel. Fx: Emil: polk@mil.huji.c.il 1 y Quintessence Pulishing Co Inc. Peri-implntitis hs een shown to occur in % to 7% of ptients with dentl implnts. Therefore, peri-implntitis tretment is n integrl prt of the stndrd tretment nd mintennce of implnts. 9 The primry etiologic fctor for peri-implntitis inflmmtory conditions is the estlishment of iofilm on the implnt surfces. Accordingly, the im of ny cuserelted therpy is the effective mechnicl removl of the iofilm. 11 Vrious protocols for the tretment of peri-implntitis hve een tested over the lst decdes. These protocols use wide rnge of mechnicl instruments, 1,13 including mnul plstic, cron, or metl curettes; prophylxis instruments such s rush or ruer cup; sonic nd ultrsonic tips; nd ir polishing. 3,1 1 Some studies hve shown tht the use of sonic nd ultrsonic sclers with metl tips my e useful for implnt therpy. 17 Limited ccess to the iofilm deposits with these different tools is one of the min ostcles in the tretment of peri-implntitis due to implnt morphology (rounded shpe, conicl ody, mcro- nd microthreds, nd smll shoulder). These ostcles re more significnt in nonsurgicl techniques ecuse of the mucos presence, which mkes the opertor lind to the infected res. As consequence, this tretment modlity does not provide predictle nd successful outcome, especilly in dvnced cses. 3,1 Mny clinicl dpttions hve The Interntionl Journl of Orl & Mxillofcil Implnts 1 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

2 Polk et l Fig 1 Mndiulr model with edentulous re t the premolr nd first molr. () Two rounded ngulr defects were mde t the premolr sites using conicl ur nd () covered with mucos-like silicone envelop with -mm-dimeter holes locted ove ech defect. i α ii α Fig Cross-sectionl illustrtions of the model of () helthy implnt with helthy mucos, () implnt with shllow defect, nd (c) implnt with. α = picl ngle of the defects (5 degrees); i = shllow defect depth (3 mm); ii = depth (5 mm). c een suggested to llow etter ccess to the implnt surfces, such s replcing the crowns with heling utments efore tretment. The purpose of this study ws to investigte vrious fctors tht my ffect the ility to ccess the implnt surfce during nonsurgicl, s well s surgicl, tretment of peri-implntitis. The tested fctors were implnt design, superstructure, ony defect depth, nd experience of the opertor. MATERIALS AND METHODS Jw Model nd Criticl Defects Design A mndiulr model with n edentulous re t the premolr nd molr regions (Nissin Dentl Products) ws used s pltform for the study (n = ). The silicone mucos-like cover ws elevted, nd two criticl defects were creted using wide conicl-shped ur t the position of two djcent premolrs (Fig 1). Round holes, mm wide, were mde in the silicone mucos-like cover on the defects, imitting the soft tissue mucos on peri-implntitis defects (Fig 1). Hlf of the experiment included defects with 3-mm depth nd 5-degree ngle (shllow defects, Fig ), while the other hlf included defects with 5-mm depth nd 5-degree ngle (deep defects, Fig c). Implnt nd Superstructure Design nd Biofilm-like Model Conicl nd stright implnts (sndlsted nd cidetched surfces) with n internl hexgon connection nd dimeter of 3.75 mm nd length of 13 mm (provided y MIS Implnts) were used. The two implnt designs lso differed in terms of microthreds (not present in the conicl-shped implnts). The implnts were covered with iofilm-like mteril white correction fluid (Figs 3 nd 3). The mteril ws pplied evenly in thin lyer from the shoulder of the implnts nd corresponding to the depth of the defects (3 mm in the shllow-defect group nd 5 mm in the deep-defect group). Two implnts were plced in the prepred defects (conicl implnt in the mesil defect nd stright implnt in the distl defect) without disturing the iofilm-like mteril (Fig 3c). Two superstructure designs were used: (1) heling utments with stright profile nd length of mm (Fig 3d) nd () stright superstructures with provisionl crowns (Fig 3e). The superstructure emergence profile ws continuous with the implnt shoulder (not pltformswitching design). Nonsurgicl nd Surgicl (Control) Tretment The nonsurgicl tretment ws done on the mndiulr model with the implnts inserted nd the mucos-like cover in plce. The tretment ws done using n ultrsonic tip (No. 1 tip, Stelec-Acteon) with wter irrigtion for seconds/implnt y two periodontists (DP nd TC) nd doi:.17/jomi.71 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

3 Polk et l c d Fig 3 Biofilm-like nd superstructure models. () Stright nd () conicl implnts were coted with iofilm-like mteril. (c) The implnts were inserted into previously prepred one defects nd covered y mucos-like envelop. The superstructures were then connected to the implnts with (d) heling utments or (e) crowns. e one postgrdute student in periodontology (EM). The uccl spect of ech plced implnt ws then mrked in the internl hexgon spect of the implnt using high-speed ur. Control groups included the sme tretment prmeters ut without the mucos-like cover (ie, simulting flp elevtion during surgicl tretment). All experiments were repeted twice. Mesurement of Biofilm Residues The uccl, mesil, lingul, nd distl spects of the implnts were viewed under stereomicroscope (Stemi SV11, Zeiss) with mgnifiction. Quntifiction of the res with remnnts of iofilm-like mteril ws done using ImgeJ softwre. Dt Anlysis The dt were nlyzed using sttisticl softwre pckge (SigmStt, Jndel Scientific). One-wy repeted mesure nlysis of vrince (RM ANOVA) ws pplied to test the significnce of the differences etween the treted groups. If the results were significnt, intergroup differences were tested for significnce using the Student t test nd Bonferroni correction for multiple testing. RESULTS Nrrtive Anlysis All of the vrious settings for nonsurgicl clening filed to properly clen the implnt surfces. The most noticele res tht were left unclen were the inter-thred vlleys. This ws most evident in the microthreds y compring the cervicl re of stright nd conicl implnts (due to the fct tht only stright implnts hve microthreds) (Fig ). While the smooth cervicl re of the conicl implnts ws clen, the cervicl re of the stright implnt microthreds showed cler residues of iofilm-like mteril within ll inter-thred vlleys (Fig ). All spects of the implnts (uccl, mesil, lingul, nd distl) showed similr mounts of iofilm-like mteril residues. However, the uccl spect ppered to e less clen compred with the other spects of the implnts (Fig ). Comprison y defects (shllow vs s) reveled tht the cervicl spect of the implnts in the s ws clener thn tht of the implnts in the shllow defects. However, the picl spect of the implnts in oth defects remined unclen in similr mnner. Also, the incresed inter-thred width of the stright implnt design did not chnge the ility to rech nd clen these res (Fig ). The superstructure used (heling utment vs crown) did not influence the ility to clen the implnts. Furthermore, the results did not differ when different opertors performed the tretment. The ove results re confounding in comprison with the results of open-flp tretment. The open-flp clening ws more successful in the smooth surfces s well s the inter-thred res (Fig ). However, in the s there were remnnts of iofilm-like mteril in the picl portion of the implnts, regrdless of implnt design or superstructure (Fig ). In ll implnt surfces, microdmge scrs cused y the ultrsonic tip could e esily oserved. The most prominent res with these scrs were the smooth cervicl res nd the peks of threds. The Interntionl Journl of Orl & Mxillofcil Implnts 3 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

4 Polk et l Conicl Implnt/ shllow defect Buccl view Distl view Lingul view Mesil view Conicl Implnt/ shllow defect Buccl view Distl view Lingul view Mesil view Stright Implnt/ Stright Implnt/ Conicl Implnt/ Conicl Implnt/ Stright Implnt/ shllow defect Stright Implnt/ shllow defect Fig Stereomicroscope view of implnts following () nonsurgicl tretment nd () surgicl tretment. The implnts were retrieved fter tretment nd viewed under stereomicroscope ( mgnifiction). The iofilm-like residues re clerly visile s white remnnts Stright Conicl Student Specilist Heling Crown Implnt type Opertor Superstructure Stright Conicl Student Specilist Heling Crown Implnt type Opertor Superstructure Fig 5 Quntittive nlysis of iofilm-like residues of () shllow defects nd () s following nonsurgicl tretment y implnt type, opertor, nd superstructure. Dt presented in ritrry unitsnd represents three experimentl repetitions. Sttisticlly significnt difference etween groups (P <.5). Quntittive Anlysis Comprtive nlysis ws done sed on the type of defects (shllow nd deep). Nonsurgicl tretment of implnts with shllow defects resulted in similr mount of residul iofilm-like mteril regrdless of implnt design or opertor (Fig 5). There ws sttisticlly significnt difference etween the superstructure groups, fvoring heling utment (Fig 5). However, the mgnitude of this difference ws smll nd my e cliniclly insignificnt. In the deep-defect groups, the mount of iofilm-like mteril ws greter thn tht oserved in the shllowdefect groups (Fig 5 vs 5). Tking into considertion tht the implnts in s hd greter re with iofilmlike mteril, such comprison is not relevnt. There ws no difference in the residul iofilm-like mteril etween ll groups (implnt type/opertor/superstructure; Fig 5). Brekdown of the results ccording to spects of the implnts (uccl/distl/lingul/mesil) showed similr results s ove. Residul iofilm-like mteril in doi:.17/jomi.71 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

5 Polk et l B D L M Crown B D L M Heling utment B D L M Crown B D L M Heling utment c B D L M B D L M Conicl Stright d B D L M Conicl B D L M Stright Fig Quntittive nlysis of iofilm-like residues y implnt spect (B = uccl; D = distl; L = lingul; M = mesil) of () shllow defects nd superstructure; () s nd superstructure; (c) shllow defects nd implnt design; nd (d) s nd implnt design. Dt presented in ritrry units nd represents three experimentl repetitions Surgicl Nonsurgicl Fig 7 Quntittive nlysis of iofilm-like residues of () shllow defects nd () s following surgicl nd nonsurgicl tretment. Dt presented in ritrry units nd represents three experimentl repetitions. Sttisticlly significnt differences etween groups (P <.5) Surgicl Nonsurgicl shllow defects did not differ significntly with respect to superstructure (Fig ) or implnt design (Fig c). Deep defects lso showed similr results without cler difference with respect to superstructure (Fig ) or implnt design (Fig d). Comprison of the results following nonsurgicl vs surgicl tretment showed cler pttern. The mount of residul iofilm-like mteril in the shllow defects nd in the s ws sttisticlly significntly lower following flp ccess (Figs 7 nd 7, respectfully). In the shllow defects, the mount of residul iofilm-like mteril ws lower in the conicl-type implnts (Fig ), while in the s the stright implnts showed lower mounts of residul iofilm-like mteril (Fig ). The Interntionl Journl of Orl & Mxillofcil Implnts 5 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

6 Polk et l Stright Conicl Student Specilist Stright Conicl Student Specilist Implnt type Opertor Implnt type Opertor Fig Quntittive nlysis of iofilm-like residues of () shllow defects nd () s y implnt type nd opertor. Dt presented in ritrry units nd represents three experimentl repetitions. Sttisticlly significnt differences etween groups (P <.5). DISCUSSION This study demonstrted tht nonsurgicl nd surgicl pproches using ultrsonic tips for the tretment of periimplntitis sites were ineffective in their ility to cler iofilm deposits from implnt surfces. Furthermore, the impct of implnt design, defect size, opertor dexterity, nd type of superstructure hd little influence on the ility to clen the implnts. In n effort to increse the success rte of peri-implntitis tretment, vrious suggestions hve een mde y clinicins, such s replcing the crown of the implnts with heling structures efore tretment. Tht pproch fcilittes etter ccessiility for instrumenttion during tretment nd llows proper clening of the implnt-utment junction. The current study ttempted to single out most convenient setting tht would mximize the efficiency of the tretment outcome. Vriles tht were looked t in the current study included implnt design (conicl vs stright), superstructure (crown vs heling utment), clinicin dexterity (periodontist vs postgrdute student) nd defect depth (shllow vs deep). Nonsurgicl tretment ws found to e ineffective in clening the implnt surfces t ny tested setting. Heling utments showed mild superiority in shllow defects compred with crowns. However, this difference seems cliniclly insignificnt. Strtifiction ccording to implnt spect (mesil, distl, uccl, or lingul) lso showed tht ll spects hd similr levels of iofilm residues. In the current study only n ultrsonic device ws used. However, there is evidence of similr effectiveness with the use of other instrumenttion. For exmple, Renvert et l compred the efficcy of nonsurgicl tretment with either titnium hnd-instruments or n ultrsonic device in humns nd did not find difference etween the two methods. 3 Also, Persson et l did not find microiologicl superiority of nonsurgicl tretment with curettes vs n ultrsonic device. In dog model, Schwrz et l reported limited effect of nonsurgicl mechnicl deridement on the tretment of peri-implnt diseses, irrespective of the type of djunct tretment used. 5 The uthors rgued tht different mounts of residul plque iofilm res on implnt surfces might hve influenced peri-implnt wound heling. Thierch nd Eger found similr results in humns in their comprison of the efficcy of nonsurgicl tretment in peri-implntitis sites; their results showed tht sites with pus efore tretment did not respond to the tretment. These results lign with the results of the present study, which indictes tht nonsurgicl pproch leves contminted implnt surfces, leding to nonidel environment for proper heling. Recently, Muthukuru et l systemticlly reviewed nonsurgicl pproches for the tretment of peri-implntitis; they concluded tht sic mechnicl tretment is insufficient nd tht there is evidence tht djunctive methods (such s locl delivery of ntiiotics, sumucosl glycine powder ir polishing, or Er:YAG lser tretment) my increse the efficcy of the tretment. 7 A cler difference ws found etween nonsurgicl nd surgicl pproches. The surgicl pproch ws superior with regrd to the ility to ccess the implnt surfces for proper clening. Nevertheless, the surgicl tretment ws incomplete nd iofilm residues could e found t the picl res of the defects. Shrmnn et l looked t the clening potentil of different implnt deridement methods in n in vitro model mimicking surgicl pproch. In their study, it ws found tht etter clening of the implnt ws fesile in wide defects. Similr to the nonsurgicl tretment, none of the tested methods (Grcey curette, ultrsonic device, or ir-powder rsive device) ws le to properly clen the implnt surfces. These results lign with those of the current study, showing the vgue efficcy of mechnicl clening of implnts in osseous defects. Furthermore, the fct tht no difference ws found etween the opertors (specilist vs postgrdute student) lso sustntites the findings doi:.17/jomi.71 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

7 Polk et l of Shrmnn et l, which showed limited effect of the opertor experience. Overll, the dt from the current study demonstrtes the limittion of mechnicl deridement of peri-implntitis sites. An effort, therefore, should e mde to discover novel pproches for tretment or djunctive mterils tht will led to positive nd predictle results of tretment of peri-implntitis. The current study limittion should e stressed. An in vitro design does not llow inclusion of ll vriles present in rel clinicl cses (such s limited visiility of the treted site, leeding nd inflmmtion, microorgnism dhesion to implnt surfces, etc). Furthermore, the current study ws done using stndrd ultrsonic tip, which is not designed for clering inter-thred vlleys. CONCLUSIONS This study highlights the prolemtic circumstnces tht occur in the course of clening infected peri-implnt sites. Although positive correltion could e oserved etween defect size nd mgnitude of unclened implnt surfce, none of the tested vriles (including implnt design, type of superstructure, nd opertor dexterity) resulted in higher clening ility in nonsurgicl tretment setting. Although surgicl pproch incresed the ccessiility nd efficiency of the tretment, the implnt surfces still hd residul deposits. Additionl clening mesures (eg, chemicl, photodynmic, nd iologic gents) should e tested nd possily included in the tretment pln of peri-implnt infections. ACKNOWLEDGMENTS The uthors declre tht there is no conflict of interest in this study. The study ws self-funded. REFERENCES 1. Ericsson I, Berglundh T, Mrinello C, Liljenerg B, Lindhe J. Longstnding plque nd gingivitis t implnts nd teeth in the dog. Clin Orl Implnts Res 199;3: Quirynen M, vn Steenerghe D. Bcteril coloniztion of the internl prt of two-stge implnts. An in vivo study. Clin Orl Implnts Res 1993;: Renvert S, Roos-Jnsåker AM, Clffey N. Non-surgicl tretment of peri-implnt mucositis nd peri-implntitis: A literture review. J Clin Periodontol ;35: Serino G, Ström C. Peri-implntitis in prtilly edentulous ptients: Assocition with indequte plque control. Clin Orl Implnts Res 9;: Esposito M, Grusovin MG, Worthington HV. Tretment of peri-implntitis: Wht interventions re effective? A Cochrne systemtic review. Eur J Orl Implntol 1;5(suppl):s1 s1.. Mrrone A, Lsserre J, Bercy P, Brecx MC. Prevlence nd risk fctors for peri-implnt disese in Belgin dults. Clin Orl Implnts Res 13;: Momelli A, Müller N, Cionc N. The epidemiology of peri-implntitis. Clin Orl Implnts Res 1;3(suppl):7 7.. Koldslnd OC, Scheie AA, Ass AM. Prevlence of peri-implntitis relted to severity of the disese with different degrees of one loss. J Periodontol ;1: Schmidlin PR, Shrmnn P, Rmel C, et l. Peri-implntitis prevlence nd tretment in implnt-oriented privte prctices: A crosssectionl postl nd Internet survey. Schweiz Montsschr Zhnmed 1;1: Heitz-Myfield LJ, Lng NP. Comprtive iology of chronic nd ggressive periodontitis vs. peri-implntitis. Periodontol ;53: Momelli A, Lng NP. Microil spects of implnt dentistry. Periodontol 199;:7. 1. Dmytryk JJ, Fox SC, Morirty JD. The effects of scling titnium implnt surfces with metl nd plstic instruments on cell ttchment. J Periodontol 199;1: de Wl YC, Rghoer GM, Huddleston Slter JJ, et l. Implnt decontmintion during surgicl peri-implntitis tretment: A rndomized, doule-lind, plceo-controlled tril. J Clin Periodontol 13;: Lng NP, Berglundh T, Heitz-Myfield LJ, et l. Consensus sttements nd recommended clinicl procedures regrding implnt survivl nd complictions. Int J Orl Mxillofc Implnts ;19(suppl):s15 s Esposito M, Worthington HV, Coulthrd P, Thomsen P. Mintining nd re-estlishing helth round osseointegrted orl implnts: A Cochrne systemtic review compring the efficcy of vrious tretments. Periodontol 3;33: Trejo PM, Bonventur G, Weng D, et l. Effect of mechnicl nd ntiseptic therpy on peri-implnt mucositis: An experimentl study in monkeys. Clin Orl Implnts Res ;17: Sto S, Kishid M, Ito K. The comprtive effect of ultrsonic sclers on titnium surfces: An in vitro study. J Periodontol ;75: Rühling A, Kocher T, Kreusch J, Plgmnn HC. Tretment of sugingivl implnt surfces with Teflon-coted sonic nd ultrsonic scler tips nd vrious implnt curettes. An in vitro study. Clin Orl Implnts Res 199;5: Gntes BG, Nilveus R. The effects of different hygiene instruments on titnium surfces: SEM oservtions. Int J Periodontics Restortive Dent 1991;11: Prk JB, Lee SH, Kim N, et l. Instrumenttion with ultrsonic sclers fcilittes clening of the sndlsted nd cid-etched titnium implnts. J Orl Implntol 15;1: Romnos GE, Weitz D. Therpy of peri-implnt diseses. Where is the evidence? J Evid Bsed Dent Prct 1;1:.. Alni A, Bishop K. Peri-implntitis. Prt 3: Current modes of mngement. Br Dent J 1;17: Renvert S, Smuelsson E, Lindhl C, Persson GR. Mechnicl nonsurgicl tretment of peri-implntitis: A doule-lind rndomized longitudinl clinicl study. I: Clinicl results. J Clin Periodontol 9;3: 9.. Persson GR, Smuelsson E, Lindhl C, Renvert S. Mechnicl nonsurgicl tretment of peri-implntitis: A single-linded rndomized longitudinl clinicl study. II. Microiologicl results. J Clin Periodontol ;37: Schwrz F, Jepsen S, Herten M, et l. Influence of different tretment pproches on non-sumerged nd sumerged heling of ligture induced peri-implntitis lesions: An experimentl study in dogs. J Clin Periodontol ;33: Thierch R, Eger T. Clinicl outcome of nonsurgicl nd surgicl tretment protocol in different types of peri-implntitis: A cse series. Quintessence Int 13;: Muthukuru M, Zinvi A, Esplugues EO, Flemmig TF. Non-surgicl therpy for the mngement of peri-implntitis: A systemtic review. Clin Orl Implnts Res 1;3(suppl): Shrmnn P, Rony V, Hofer D, et l. In vitro clening potentil of three different implnt deridement methods. Clin Orl Implnts Res 15;: The Interntionl Journl of Orl & Mxillofcil Implnts 7 1 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

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