Use of the Erbium laser in treatment of peri-implantitis
LivingWell Dental Hospital
LivingWell Institute of Dental Research
Ho-yeol Jang , Jang-yeol Lee , Young-kyun Chung , Hwa-su Koong ,
Hyoun-chull Kim , Il-hae Park , Sang-chull Lee
Ⅰ. Introduction
At the First European Workshop on Periodon
tology, peri-implantitis was defined as an infla
mmatory process affecting the tissues around an
osseointegrated implant in function, resulting in
loss of supporting bone. Peri-implant mucositis
was defined as reversible inflammatory changes of
the peri-implant soft tissues without any bone
loss1). The infectious etiology of peri-implantitis is
evident2). High levels of periodontal pathogens
including Actinobacillus actinomycetemcomitans,
Porphyromonas gingivalis, Porphyromonas
intermedia, Tannerella forsythia and Treponema
denticola, have been associated with peri-
implantitis3,4).
The retrograde peri-implantitis is defined as a
clinically symptomatic periapical lesion (diagnosed
as aradiolucency) that develops shortly after
implant insertion while the coronal portion of the
implant achieves a normal bone to implant
interface. The term retrograde peri-implantitis
has just recently been introduced through several
case reports5~9). The retrograde peri-implantitis is
often accompanied by symptoms of pain,
tenderness, swelling, and/or the presence of a
fistulous tract. It should be distinguished from a
clinically asymptomatic, peri-apical radiolucency,
which is usually caused by placing implants that
are shorter than the drilled cavity or by a heat-
induced aseptic bone necrosis6,10,11). Retrograde
peri-implantitis can result from bacterial
contamination during insertion, premature loading
leading to bone micro-fractures, or the presence
of a pre-existing inflammation (bacteria, inflam
matory cells, and/or remaining cells from a cyst,
granuloma). Such lesions start at the implant apex
but exhibit the capacity of spreading coronally,
proximally, and facially.
The presence of bacteria on implant surfaces may
result in an inflammation of the peri-implant
mucosa, and, if left untreated, it may lead to a
progressive destruction of the alveolar bone
supporting the implant and implant failure12,13).
Therefore, the principal objective of treatment is
the complete removal of all bacterial plaque
biofilms and calcified calculus from the implant
surfaces in order to stop disease progression.
Ideally, the bone-to-implant contacts should
increase and the implant undergoes re-
osseointegration.
Recently, in addition to conventional tools, the
Erbium laser has been proposed for treatment of
peri-implant infections. As the Erbium laser can
perform excellent tissue ablation with high
bactericidal effect, detoxification, and removing
49
50
plaque and calculus, they are expected to be one of
the most promising new technical modalities for
treatment of failing implants.
Ⅱ. Materials & Methods
A. CASE 1(Peri-implantitis)
A 56-years old male patient had been performed
implantation on left maxillary central incisor with
Tapered Screw-Vent implant(Zimmer, U.S.A) and
immediate loading. After 3 months, it was
observed an inflammatory process around the
implant. At first time, non-surgical treatments was
performed with the Er:YAG laser (Key3, Kavo,
Germany)(Fig. 1) during 2 months, but it was
continued inflammatory changes of the peri-
implant soft tissues and loss of supporting bone on
measurement of a probing depth and the
radiograph(Fig.2,3). So peri-implantitis was
diagnosed and surgical treatment was planned with
the autogenous bone graft. Probing depth was
measured from the mucosal margin to the bottom
of the probeable sulcus before treatment using a
periodontal probe. When a full-thickness flap was
raised, the implant was surrounded by granulation
tissue(Fig. 4). The Er:YAG laser(Anybeam E,
B&B, Korea)(Fig. 5) with the chisel tip was
performed removal of granulation tissue and
irradiation on the implant surface(Fig. 6). The left
maxillary tuberosity bone was harvested with bone
rongeur. The autogenous bone grafts were then
placed into the peri-implant bone defect(Fig. 7).
The flap was closed with interrupted sutures(Fig.
8).
Fig. 1. Er:YAG laser (Key3, Kavo, Germany).
Fig. 2. Deep probing depth.
Fig. 3. Pre-operative radiograph.
Fig. 4. Full thickness flap elevation.
B. CASE 2(Retrograde peri-implantitis)
A 52-years old male patient had been performed
implantation on right and left mandibular lateral
incisors with Tapered Screw-Vent implant
(Zimmer, U.S.A) and immediate loading. After 4
months, a fistula was presented on buccal gingiva
and the radiograph was showed a clear
radiolucency around the apical part of right
mandibular lateral incisor implant, while the bone
apposition at the coronal part seemed intact(Fig.
9,10). At first time, non-surgical treatments was
performed with the Er,Cr:YSGG laser(waterlase,
Biolase, U.S.A)(Fig. 11) during 2 months, but a
fistula was not disappeared. So retrograde peri-
implantitis was diagnosed and surgical treatment
was planned with the DFDB allograft. When a full-
thickness flap was raised, a perforation of the
buccal bone plate was present(Fig. 12). It was
performed a trepanation of the defect with the
piezoelectric device(PIEZOSurgery, Mectron
Medical Technology, Italy)(Fig. 13). It was
removed granulation tissue of the bony cavity
walls except the implant surface with hand
instruments(Fig. 14). The Er,Cr:YSGG laser
(Waterlase, Biolase, USA) was performed removal
of granulation tissue and irradiation on the implant
surface(Fig. 15,16). PRP(platelet-riched plasma)
gel was sprayed on implant surface(Fig. 17) and
all defects were filled with DFDB allograft(Puros,
Tutogen, USA) mixed in PRP gel after making
multiple perforations of the bone surface(Fig.
18,19). PRP gel membrane was covered the
graft(Fig. 20). Primary wound closure was
achieved with mattress and interrupted
sutures(Fig. 21). Post-operative radiograph was
taken immediately thereafter(Fig. 22).
Fig. 5. Er:YAG laser(Anybeam E, B&B, Korea).
Fig. 6. Remove of granulation tissue and implant
surface detoxification with Er:YAG laser
(Anybeam, B&B, Korea).
Fig. 7. Autogenous bone graft (harvested from left
maxillary. tuberosity).
Fig. 8. Suture .
51
52
Fig. 9. Fistula on buccal gingival of #42.
Fig. 10. Pre-operative radiograph.
Fig. 11. Er,Cr:YSGG laser(waterlase, Biolase,
U.S.A).
Fig. 12. Full thickness flap elevation.
Fig. 13. Trepination of the defect with piezo
electric device.
Fig. 14. Mechanical curettage on bony wall.
Fig. 15. Removal of granulation tissue and implant
surface detoxification with Er,Cr:YSGG laser.
Fig. 16. Complete elimination of granulation tissue.
Fig. 17. PRP spray on implant surface.
Fig. 18. Cavity filling with DFDB allograft (Puros,
Tutogen, USA) mixed in PRP gel.
Fig. 22. Immediate post-operative radiograph.
Fig. 23. 11 days after surgery.
Fig. 24. 50 days after surgery.
Fig. 19. After bone graft
Fig. 20. PRP gel placement on graft.
Fig. 21. Suture.
53
54
Ⅲ. Result
In these cases, no complications such as
abscesses, or infections were observed, and
implants and grafts were stable. In case 1, there
are a significant reduction of pocket depth and gain
of clinical attachment level(Fig. 23,24,25). In case
2, a fistula was disappeared and implants
osseointegrated as confirmed by post-operative
radiograph(Fig. 26).
Ⅳ. Discussion
Most titanium implants feature a rough surface to
increase areas of implant-bone contact and
anchorage force in alveolar bone. However surface
roughness makes elimination of bacteria from
implants difficult. Several treatment regimens have
been proposed for cleaning and decontamination of
implant surfaces in order to treat peri-implantitis.
However, some of the recommended cleaning
methods have been reported to change or damage
the surface properties of implants14~17).
Mechanical debridement is usually performed
using specific instruments made out of materials
less hard than titanium (i.e. plastic curettes,
polishing with rubber cups) in order to avoid a
roughening of the metallic surface which in turn
may favour bacterial colonization18~21). Since
mechanical methods alone are insufficient in the
elimination of bacteria on roughened implant
surfaces, adjunctive chemical agents (i.e. irrigation
with local disinfectants, local or systemic antibiotic
therapy) were examined clinically and proven to
enhance healing following treatment12,22).
Bactericidal chemicals such as chlorhexidine
digluconate or iodine solutions are useful adjuncts
in the treatment of peri-implantitis. And therapy of
peri-implantitis by local delivery of tetracycline
had a positive effect on clinical and microbiological
parameters. Fiber therapy seems particularly
suited for the therapy of not too advanced peri-
implantitis lesions assuming the typical defect
morphology of a circumferential saucer.
Furthermore, surgical therapy in combination with
systemic antibiotics resulted in a resolution of the
peri-implantitis lesion23). Air-powder flow may be
Fig. 25. 150 days after surgery.
Fig. 26. Post-operative radiograph after 4 months.
used for implant surface decontamination24).
However, there are limitations in its application
because they can be associated with an increased
risk of emphysema25).
In addition to these conventional tools, the use of
lasers has been proposed for cleaning and for the
detoxification of implant surfaces. The interaction
between laser light and metal surfaces is mainly
determined by the degree of absorption and
reflection. Each metal features a certain spectral
reflection capacity, which is dependent on the
specific wavelenght of the laser. The reflection
capacity of titanium for the Er:YAG laser with its
wavelenght of 2940 nm in the near infrared
spectrum is 71% and rises up to 96% for the CO2
laser at 10,000nm26). In this situation, the implant
surface does not absorb the irradiation and
subsequently there is no temperature increase,
which would damage the implant surface. The
results from recently published studies have
indicated that among all lasers used in the field of
dentistry, only the carbon dioxide(CO2), the diode
and the Er:YAG laser may be useful for the
instrumentation of implant surfaces because the
implant body temperature does not increase
significantly after laser irradiation27~32). In contrast,
the use of an Nd:YAG laser resulted in extensive
melting and damage of the porous titanium surface
and coating27,28,32).Therefore the carbon
dioxide(CO2), the Diode and the Er:YAG lasers are
recommended, since it appears that they do not
exert a negative impact on the implant surface.
Since, neither CO2 nor diode lasers were effective
in removing plaque biofilms from implant surface,
both types of lasers were only used adjunctive to
mechanical treatment procedures33~35). In contrast,
as described above, several investigations have
reported on the promising ability of the Er:YAG
laser for calculus removal from implant surface
without producing major thermal side-effects to
adjacent tissue36,37).
Ⅴ. Conclusion
In recent years, the use of the Erbium laser has
beenexpected to serve as an alternative or
adjunctive treatment to conventional, mechanical
periodontal therapy. Among all lasers used in the
field of dentistry, the Erbium laser seems to
possess characteristics most suitable for peri-
implantitis, due to its ability to ablate both soft and
hard tissues as well as bacterial biofilms and
calculus without causing major thermal damage to
the adjacent tissue and implant surface. This study
demonstrates that surgical treatment involving the
combined use of the mechanical instruments and
the Erbium laser might to have more bactericidal,
detoxification, and removing calculus and plaque
effects in the peri-implantitis treatment. And it is
suitable to promote re-osseointegration at
contaminated implant surfaces. However it needs a
careful and controlled using, because laser
irradiation can result in morphological alterations of
implant surfaces when defined energy settings are
exceeded.
REFERENCES
1. Albrektsson T, Isidor F. Consensus report of
session IV. In: Lang NP, Karring T (eds)
Proceedings of the First European Workshop on
Periodontology.
55
56
2. Roos-Jansaker A.M, Renvert S, Egelberg J.
Treatment of peri-implant infections: a literature
review. Journal of Clinical Periodontology 2003;30:
467-485.
3. Hultin M, Gustafsson A, Hallstrom H, Johansson
LA, Ekfeldt A, Klinge B. Microbiological findings
and host response in patients with peri-implantitis.
Clinical Oral Implants Research 2002;13:349-358.
4. McAllister BS, Masters D, Meffert RM.
Treatment of implants demonstrating periapical
radiolucencies. Practical Procedures & Aesthetic
Dentistry 1992;4:37-41.
5. Shaffer MD, Juruaz DA, Haggerty PC. The
effect of periradicular endodontic pathosis on the
apical region of adjacent implants. Oral Surgery,
Oral Medicine, Oral Pathology, Oral Radiology &
Endodontics 1998;86:578-581.
6. Ayangco L, Sheridan PJ. Develop ment and
treatment of retrograde peri-implantitis involving
a site with a history of failed endodontic and
apicoectomy procedures: a series of reports.
International Journal of Oral & Maxillofacial
Implants 2001;16:412-417.
7. Chaffee NR, Lowden K, Tiffee JC. Cooper LF.
Periapical abscess formation and resolution
adjacent to dental implants: a clinical report.
Journal of Prosthetic Dentistry 2001;85:109-112.
8. Jalbout ZN. Tarnow DP. The implant periapical
lesion: four case reports and review of the
literature. Practical Procedures & Aesthetic
Dentistry 2001;13:107-112.
9. Quirynen M, Gijbels F, Jacobs R. An infected
jawbone site compromising successful
osseointegration. Periodontology 2003;33:129-
144.
10. McAllister BS, Masters D, Meffert RM.
Treatment of implants demonstrating periapical
radiolucencies. Practical Procedures & Aesthetic
Dentistry 1992;4:37-41.
11. Reiser GM. Nevins M. The implant periapical
lesion: etiology, prevention, and treatment.
Compendium of Continuing Education in Dentistry
1995;16:768-772.
12. Mombelli A, Buser D, Lang NP. Colonization
of osseointegrated titanium implants in edentulous
patients. Early results. Oral Micro biology and
Immunology 1998;3:113-120.
13. Becker W, Becker BE, Newman MG, Nyman
S. Clinical and microbiologic findings that may
contribute to dental implant failure. International
Journal of Oral & Maxillofacial Implants 1990;5:
31-38.
14. Bergendal T, Forsgren L, Kvint S, Lowstedt E.
The effect of an abrasive instrument on soft and
hard tissues around osseointegrated implants.
Swedish Dental Journal 1990;14:219-223.
15. Koka S, Jung-Suk H, Razzoog M, Bloem T.
The effects of two air-powder abrasive
prophylaxis systems on the surface of machined
titanium: A pilot study. Implant Dentistry 1992;1:
259-265.
16. McCollum J, O’Neal R, Brennan W, Van Dyke
T, Horner J. The effect of titanium implant
abutment surface irregularities on plaque
accumulation in vivo. Journal of Periodontology
1992;63:802-805.
17. Zablotsky MH, Wittrig EE, Diedrich DL,
Layman DL, Meffert RM. Fibroblastic growth and
attachment on hydroxyapatite-coated titanium
surfaces following the use of various detoxification
modalities. Part II: Contaminated hydroxyapatite.
Implant Dentistry 1992;1:195-202.
18. Augthun M, Tinschert J, Huber A. In vitro
studies on the effect of cleaning methods on
different implant surfaces. J Periodontol 1998;
69:857-64.
19. Fox SC, Moriarty JD, Kusy RP. The effects of
scaling a titanium implant surface with metal and
plastic instruments: an in vitro study. J Periodontol
1990;61:485-90.
20. Ru¨hling A, Kocher T, Kreusch J, Plagmann
HC. Treatment of subgingival implant surfaces
with Tefloncoated sonic and ultrasonic scaler tips
and various implant curettes. An in vitro study. Clin
Oral Implants Res 1994;5:19-29.
21. Matarasso S, Quaremba G, Coraggio F, Vaia E,
Cafiero C. N.P. L. Maintenance of implants: an in
vitro study of titanium implant surface modifi
cations, subsequent to the application of different
peophylaxis procedures. Clin Oral Implants Res
1996;7:64-72.
22. Schenk G, Flemmig TF, Betz T, Reuther J,
Klaiber B. Controlled local delivery of tetracycline
HCl in the treatment of periimplant mucosal
hyperplasia and mucositis. A controlled case
series. Clin Oral Implants Res 1997;8:427-33.
23. Ericsson I, Persson LG, Berglundh T, Edlund
T, Lindhe J. The effect of antimicrobial therapy on
periimplantitis lesions. An experimental study in
the dog. Clin Oral Implants Res 1996;7:320-8.
24. Augthun, M., Tinschert, J. & Huber, A. In vitro
studies on the effect of cleaning methods in
different implant surfaces. Journal of Periodon
tology 1998;69:857-864.
25. de Velde E, Thielens P, Schautteet H,
Vanclooster R. Subcutaneous emphysema of the
oral floor during cleaning of a bridge fixed on an
IMZ implant. Case report. Rev Belge Med Dentaire
1991;46:64-71.
26. Lide DR. Handbook of chemistry and physics,
83rd ed. Boca Raton, FL: CRC Press; 2002.
27. Kreisler M, Al Haj H, Gotz H, Duschner H, d’
Hoedt B. Effect of simulated CO(2) and GaAlAs
laser surface decontamination on temperature
changes in Ti-plasma sprayed dental implants.
Lasers Surg Med 2002;30:233-9.
28. Kreisler M, Go¨ tz H, Duschner H. Effect of
Nd:YAG, Ho:YAG, Er:YAG, CO2, and GaAIAs
laser irradiation on surface properties of endosse
ous dental implants. Int J Oral Maxillofacial
Implants 2002;17:202-11.
29. Oyster DK, Parker WB, Gher ME. CO2 lasers
and temperature changes of titanium implants. J
Periodontol 1995;66:1017-24.
30. Kato T, Kusakari H, Hoshino E. Bactericidal
efficacy of carbon dioxide laser against bacteria-
contaminated titanium implant and subsequent
cellular adhesion to irradiated area. Lasers Surg
Med 1998;23:299-309.
31. Kreisler M, Kohnen W, Marinello C, Gotz H,
Duschner H, Jansen B, d’Hoedt B. Bactericidal
effect of the Er:YAG laser on dental implant
surfaces: an in vitro study. J Periodontol
2002;73:1292-8.
32. Romanos GE, Everts H, Nentwig GH. Effects
of diode and Nd:YAG laser irradiation on titanium
discs: a scanning electron microscope examination.
J Periodontol 2000;71:810-5.
33. Moritz A, Schoop U, Goharkhay K, Schauer P,
Doertbudak O, Wernisch J, Sperr W. Treatment of
periodontal pockets with a diode laser. Lasers Surg
Med 1998;22:302-11.
34. Tucker D, Cobb CM, Rapley JW, Killoy WJ.
Morphologic changes following in vitro CO2 laser
57
58
treatment of calculus-ladened root surfaces.
Lasers Surg Med 1996;18:150-6.
35. Bach G, Neckel C, Mall C, Krekeler G.
Conventional versus laser-assisted therapy of
periimplantitis: a fiveyear comparative study.
Implant Dentistry 2000;9:247-51.
36. Aoki A, Ando Y, Watanabe H, Ishikawa I. In
vitro studies on laser scaling of subgingival
calculus with an erbium:YAG laser. J Periodontol
1994;65:1097-106.
37. Eberhard J, Ehlers H, Falk W, Acil Y, Albers
HK, Jepsen S. Efficacy of subgingival calculus
removal with Er:YAG laser compared to
mechanical debridement: an in situ study. J Clin
Periodontol 2003;30:511-8.
Abstract
임프란트 주위염 치료에서 Erbium laser의 활용
장호열, 이장렬, 정 균, 궁화수, 김현철, 박일해, 이상철
리빙웰치과병원
리빙웰 치의학 연구소
치근 심미적이고 기능적인 장점 때문에 임프란트 치료는 보편화 되었고 환자들의 요구도 또한 높아지고
있다. 하지만 시술의 증가와 더불어 술후 관리의 소흘로 인한 실패의 증례도 많이 보고되고 있다. peri-
implantitis는 급격한 골 소실을 동반한 임프란트 주위 연조직의 염증 상태를 나타낸다. 그 중 치관 부위의
골유착은 정상이지만 임프란트 치근단 부위의 방사선 투과성 병소를 보이는 경우는 retrograde peri-
implantitis라고 분류한다. 일반적으로 peri-implantitis의 치료를 위해 기계적, 화학적 요법 및 항생제 요
법이 병용되어 사용되고 있다. 부가적으로 조직에 한 흡수성이 뛰어난 Er:YAG laser의 높은 살균 및
detoxification효과, 그리고 치태 및 치석 제거 효과는 임프란트 주위염의 치료에 활용할 수 있다. 하지만
높은 에너지를 사용할 경우 임프란트 표면에 변성을 초래할 수 있으므로 주의가 필요하가. 본 증례들을 통
해 임프란트 주위염 치료시 Er:YAG laser를 활용할 때의 장점과 잠재성에 해 고찰하고자 한다.
59