Case 4
“The Soft Tissue Rules”
Neal Lehrman, DDS, MS
[email protected]
Much attention has been given to the notion that bone fill, both radiographically and clinically, is the ultimate determinant of healing in periodontal and specifically peri-implant disease. What then, can we learn from situations such as the two cases below, that present with significant peri-implant mucositis but no appreciable bone loss? How do we determine the success and or failure of a particular treatment?
In the first situation, a 29 year old female presented with significant erythema and edema peri-implant #8. The area had been purulent for almost 6 months, but radiographic evaluation shows no significant loss of bone around the fixture. Our options for treatment are curettage and or LAPIP. The former leaves us open to the possibility of shrinkage of the coronal tissues once the inflammation is gone. The same holds true for the second patient, a 27 year old male in excellent health with significant inflammation but no concomitant loss of bone. Taking into account both of their ages and the expected longevity of the implants currently in place… What is it that we should be looking for with regard to possible outcomes? In these cases, we look for no increased loss of bone but more importantly, resolution of and consistent tonal quality of the surrounding soft tissues. Given that the implants have no native connective tissue attachment, control of the epithelium becomes that much more important. Conversely, any loss of tissue due to surgical resection is that much more devastating to the longevity of the implant and it’s restoration.
LAPIP becomes a crucial approach in the treatment of these and similar cases as it allows for resolution of the inflammation but prevents the resultant recession and or disfigurement due to surgical removal of diseased tissue. It should be said, that this clinician’s opinion is that these patients must be apprised of the situation and care be given to explain that this approach to treatment of disease is to maintain, not necessarily cure the problem. With that in mind, we can better create an environment that will lend to the long-term stability of these patients and their lives.
The cases are as follows:
Case 1:
n.b. the inflammation at the gingival margin implant #8. The area bled upon probing and the patient reported pain upon percussion to the area. The emergence profile has been compromised due to the edema from the infection.
1 yr follow up- n.b. the return to “normal” of the gingival margin as it was when the initial crown was placed. The tissue has a healthy “pinkish” hue which wasn’t present at the time of intake . The parabolic gingival architecture has returned to a comparable contour to the adjacent maxillary central incisor.
pre LAPIP 9/2013
1 yr post LAPIP 9/2014
Case 2:
Pre-LAPIP – peri-implant mucositis #9.
1 month healing. The frenal pull has resolved, but in both of these cases, frenectomies should have been performed at some point prior to the restoration of the individual implants. Note that there is no recession in either case, something that would have occurred with just scaling and root planning of each case.
pre-LAPIP periapical #9 implant. No loss of bone noted associated with the above inflamed soft-tissue.