The TwinLight® approach to peri- implantitis
As the number of dental implants being placed increases, reported cases of peri-implantitis are becoming more frequent. The available data suggest that one in five implant patients will develop periimplantitis, an irreversible inflammatory condition characterised by bone loss around the site of an implant, while four in five will exhibit peri-implant mucositis, an early stage of the disease in which the inflammatory reaction is still reversible.
With peri-implant mucositis, the inflammation is limited to the peri-implant mucosa, while with peri implantitis the infection also spreads to the peri-implant bone. Both conditions include the presence of bacterial plaque and calculus, oedema and redness of tissues, and involve bleeding on probing. In the majority of cases, classical treatment methods for peri-implantitis are inadequate due to a number of complicating factors, including resistant bacterial strains, difficult debridement procedures and the presence of biofilm on the implant surface.
The most prevalent reason for the development of peri-implantitis appears to be poor occlusal load distribution, with either primary contacts or cantilever bridges in implant-supported prostheses. Good oral hygiene on the patient’s part is mandatory, however, the position and design of prostheses that are difficult to manage may limit the effectiveness of mechanical cleaning. Once the underlying reason has been determined and recurrence is prevented, laser therapy can help to treat peri-implantitis.
The TwinLight® peri-implantitis treatment
A new laser treatment called TwinLight® from Fotona is proving to be one of the most effective methods for fighting peri-implantitis, successfully meeting the objectives of controlling infection by surface decontamination and halting the disease’s progression. TwinLight® is a minimally invasive technique combining dentistry’s two gold-standard laser wavelengths (Er:YAG and Nd:YAG) in a synergistic process designed to improve peri-implantitis treatment success rates and shorten healing time.
With TwinLight®, the Er:YAG laser is used in a non-surgical procedure to remove microbial composition and in a surgical procedure to treat the damaged alveolar bone around the implant. Using Er:YAG, it is possible to clean the granulation tissues, both on the bone and implant surfaces, and thoroughly decontaminate the site. Removal of granulation tissue from the alveolar bone and connective tissue with Er:YAG laser is highly effective. The erbium laser targets the water content to remove the granulation tissue selectively, due to its long pulse duration and lower peak power, while ablating the microorganisms on the surface of the bone.
The bactericidal effect of Er:YAG on the surgical site is effective against lipopolysaccharides, and the implant surface is completely cleaned without chemicals. The subsequent Nd:YAG treatment step promotes faster healing by bacterial reduction and biostimulation of the bone tissue. The same principles apply also with more severe treatments that require surgical therapy.
The TwinLight® procedure
The TwinLight® procedure is performed according to the following five steps:
- Step 1: Removal of the soft-granulation tissue with Er:YAG in LP mode (Fig. 1).
- Step 2: Removal of the bacterial biofilm on the implant surfaces with Er:YAG in MSP mode (Fig. 2).
- Step 3: Ablation of the infected bone with Er:YAG in QSP mode (Fig. 3a).
- Step 4: Bacterial reduction of the bone with Nd:YAG in MSP mode (Fig. 3b).
- Step 5: Biostimulation with Nd:YAG in VLP mode (Fig. 4).
For treatment of peri-implant mucositis, only step 2 is performed.
Because the Er:YAG wavelength is used with an optimal modality, there is no danger of thermal damage to the highly fragile surrounding bone and no significant alterations of the implant surface, as is frequently the case with other lasers.[3,4] The effect of the laser energy on the implant surface is dependent on the amount of energy density, power and pulse duration. The parameters should be chosen cautiously—lowering the settings may make the procedure slower but safer for re osseointegration. Non-surgical use of Er:YAG is also possible if the problem is not extensive.
In the accompanying clinical case, a removable prosthetic with two ball attachments was planned. Due to the patient’s request, the implants were immediately loaded, which most probably is the reason for the resorption seen around the implant on the right lower jaw (Fig. 5). The site was directly accessed to clean the granulation tissue and disinfect the implant surface with Er:YAG laser, while bacterial reduction and biostimulation were executed with Nd:YAG laser (Fig. 6). The defect was augmented with synthetic bone substitute.
After 3 years of follow up with very good healing (Fig. 7), the patient demanded a fixed prosthetic, which was delivered with an additional placement of implants in both jaws. X–rays taken 5 years after the peri-implantitis treatment can be seen in Fig. 8. Two more implants were placed distally when the patient could afford more treatments after one year.
There are a number of advantages of using lasers in this type of case. One of them is that there is no mechanical, chemical or any other means of trauma while removing the granulation tissue around the implant—neither to the implant nor to the bone tissue. In addition to being safe, both wavelengths are known to promote healing by bacterial reduction and biostimulation of the tissue. Shorter pulses are used on the surface of the implant to avoid thermal effects, but with lower energies, so as to not have a too high peak power and thereby damage the surface. With short pulses and higher peak power (higher energy), we can create bleeding spots on the bone to improve healing of the augmentation material.
The penetration of Nd:YAG through bone helps the achievement of bacterial reduction and biostimulation. Care should be taken to avoid contacting the implant surface with Nd:YAG because the absorption in titanium is high and could cause a rise in temperature. It is also important to use a fast, sweeping motion with high suction to avoid heat accumulation on one spot. Too much bleeding would block the penetration of the Nd:YAG laser. Nd:YAG can also be used on the incision line, vestibular, the oral side of the surgical site and extra-orally after suturing, and every second day for faster and better healing, with less pain and swelling.
Editorial note: A list of references is available from the publisher. This article was published in laser - internationalmagazine of laser dentistry No. 01/2015.