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Ultrasonic Cavitation and Peri-Implantitis by Dr. Giacomo Tarquini

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Categories: Periodontics;
Ultrasonic Cavitation and Peri-Implantitis 

A novel, promising approach decontaminates surfaces and reduces inflammation of soft tissue

by Giacomo Tarquini, DDS

Peri-implantitis is defined as inflammation of peri-implant soft tissues, associated with a progressive loss of supporting bone that occurs after the establishment of osseointegration.1

With regard to the therapy, which can be addressed through a resective or a regenerative approach according to the local anatomy, the most debated issue has been related to implant surface decontamination. Despite several protocols that have been proposed—mostly based on antimicrobial agents, power-driven tools, air abrasives, laser or manual instruments—no single method of surface decontamination has been found to be superior.2

Among these options, ultrasonic cavitation (the formation of vapor phase bubbles within a liquid, usually because of rapid changes in localized pressure) has been demonstrated to be highly effective in removing biofilms from a substrate at the microscopic level, with no damage to the underlying surface. Cavitation bubbles are in fact capable of yielding microstreaming, shock waves, high-speed jets and liquid heating, which cause biofilm disruption from both polished and micro-roughened surfaces.3 Several authors have showed the potential for this technique as a new method of bone defect debridement as well as dental implant decontamination.4,5

The aim of this article is to describe the biologic rationale of ultrasonic cavitation in biofilm removal and to show a clinical case of peri-implantitis treated by means of a novel ultrasonic cavitation device (Piezoclean by Dr. Giacomo Tarquini) associated with a guided bone regeneration (GBR) procedure.

State-of-the-art decontamination

Modifications in the micro- and nanotopography of dental implants have been proposed to increase bone-to-implant contact (BIC), but on the other hand, initial biofilm formation on roughened surfaces may be promoted when implant threads are exposed to the oral cavity.6

Biofilm removal from dental implants may be quite difficult, and decontamination protocols used to date, such as antimicrobial agents, power-driven tools, or laser or manual instruments, have showed limited success: Treated implants actually present a remaining contaminated area that may affect cell adhesion and proliferation. Moreover, some of these methods can damage the micro-roughened surface.7,8 Therefore, research is being undertaken into novel methods of biofilm disruption.9,10

A more recently studied protocol involves using cavitation occurring in the cooling water around ultrasonic scaler tips to allow a contact-free approach: By conveying the cooling liquid around the exposed part of the implant and making sure it cavitates, every crevice of its surface (such as macro- and microscopically irregularities) as well as the connection screw space can be reached. As a result, a complete biofilm disruption is achievable without modifying the implant surface, unlike what happens with other decontamination protocols.11

Why is complete decontamination so important?

It has been demonstrated that the chance to get a new osseointegration process (also known as reosseointegration) of previously infected implants is extremely limited around polished, physicochemically altered and/or incompletely detoxified surfaces while, on the contrary, it occurs far more predictably around properly decontaminated micro-roughened surfaces.12–15

In light of this, a complete and predictable decontamination is a prerequisite to achieve the reosseointegration of treated implants. The absence of any measurable changes to the titanium surface and the lack of an organic smear layer creates the ideal environment for osteoblast-like cell adhesion and proliferation, thus allowing for potential new osseointegration, which is in turn the ultimate goal of regenerative therapy.16,17

How is it performed?

From a practical point of view, the main challenge with ultrasonic cavitation is to succeed in creating a confined space around the exposed part of an implant where the cooling liquid would pool and change at low flow rates; during clinical use, the ultrasonic scaler operates in air, with cooling water flowing around the tip, and it’s hard to imagine the establishment of a truly effective cavitation inside this water mist. Therefore, it would be useful to have the ultrasonic tip fully immersed in a water flow.18 In this regard, the use of the Piezoclean ultrasonic cavitation device turned out to be particularly useful.

The device is made of two parts (Fig. 1):
  1. An ultrasonic tip (which must be connected to a piezoelectric handpiece), provided with three microholes to promote the circulation of cooling water (ES004E, Esacrom, Imola, Italy).
  2. A medical-grade silicone cavitation chamber specifically designed to pool the cooling water and perfectly fit any shape of crestal bone (Piezoclean, Esacrom).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 1

The device is assembled by inserting the cavitation chamber onto the ultrasonic tip (Fig. 2).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 2

After removing all the prosthetic components, the cavitation chamber is placed around the exposed part of the implant and the piezoelectric device is then activated (Fig. 3); this creates a secluded space where the cooling liquid cavitates without being dispersed. Thanks to the presence of the medical-grade silicone cavitation chamber, the cooling liquid is locally concentrated around the exposed portion of the implant, thus allowing for a complete decontamination of those areas (e.g., implant threads, surface microgrooves and connecting screw housing) that would otherwise be inaccessible to the traditional tools such as Gracey’s curettes, power-driven brushes or glycine airflow.

Ultrasonic Cavitation and Peri-Implantitis
Fig. 3

The optimal running time for a complete biofilm disruption is about three minutes; it is recommended to take a short break every 60 seconds to prevent overheating of the cooling liquid. (The temperature was found to increase by about 10 degrees Celsius after operating for three consecutive minutes.19)

Clinical case

A 55-year-old patient with no medical history was referred for suspected periimplantitis affecting the implant on #11. Peri-implant probing and preoperative periapical X-ray examination confirmed the diagnosis of peri-implantitis, suggesting the presence of a large bone defect on the buccal side (Figs. 4 and 5).

Because of its limited ability to prove a detailed view of the three-dimensional anatomical structures, periapical X-ray examination may not provide full information about important parameters such as alveolar bone thickness, anatomy, size, extension and location of bone defects. To overcome this limitation, clinicians must cross-correlate the data from X-ray examination and peri-implant probing (Fig. 6). Clinical parameters such as mBI, mPlI, PD and implant mobility (IM) were registered at baseline.
Ultrasonic Cavitation and Peri-Implantitis
Fig. 4
Ultrasonic Cavitation and Peri-Implantitis
Fig. 5
Ultrasonic Cavitation and Peri-Implantitis
Fig. 6

After removing both fixed partial prosthesis and abutments, two cover screws were placed on implants #11 and #13 to ensure a spontaneous soft tissue regrowth, allowing for a submerged surgical procedure (which is scheduled after two weeks).

Surgery was performed as follows: Antibiotic prophylaxis with 2 g amoxicillin/clavulanic acid (Augmentin) one hour before surgery, and then every 12 hours for six days. Patient was also advised to rinse mouth with 0.2% chlorhexidine for two weeks after surgery. In addition, 100 mg of nimesulide was administered one hour before the surgery, then twice a day for three days.

The surgical area was anesthetized using 40 mg/mL of articaine hydrochloride with epinephrine 1:100,000.

According to the local anatomy, access to the peri-implant defect is achieved using a trapezoidal full-thickness flap delimited by two slightly divergent vertical incisions; the crestal incision is always carried out within the keratinized tissue (Fig. 7).

After flap elevation, a large peri-implant defect with the presence of nonintegrated biomaterial granules, perhaps remaining from a previous surgical procedure, was detected (Fig. 8). Accurate debridement of the granules embedded in reactive tissue was carried out by means of a dedicated ultrasonic tip (Fig. 9).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 7
Ultrasonic Cavitation and Peri-Implantitis
Fig. 8
Ultrasonic Cavitation and Peri-Implantitis
Fig. 9

Horizontal bone thickness (HBT) and vertical bone defect (VBD) around the exposed part of the implant were measured at the baseline with a periodontal probe, then the cover screw was removed to decontaminate both outer and inner surface of the implant.

The ultrasonic cavitation device was placed onto the exposed part of the implant—there’s no need to create a tight seal between cavitation chamber and crestal bone—and the device was then activated (Fig. 10). A non-contact approach (without the metal tip contacting the implant) is advisable to avoid damaging the implant.

At the end of the decontamination process, a new sterile cover screw was positioned (Fig. 11).

Because the bone defect has a space-keeping morphology, a PLA/PLGA resorbable barrier membrane (Activioss, Lyon, France) was positioned to exclude certain cell types, such as rapidly proliferating epithelium and connective tissue, thus promoting the growth of slower-growing cells capable of forming bone (Fig. 12).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 10
Ultrasonic Cavitation and Peri-Implantitis
Fig. 11
Ultrasonic Cavitation and Peri-Implantitis
Fig. 12

Alloplastic biomaterial (Activioss) was grafted into the defect to support the membrane and promote blood clot stabilization (Fig. 13); the membrane was folded on the graft, then stabilized with Ustomed titanium pins (Fig. 14). A tension-free flap closure was achieved, then sutured using 5-0 nonresorbable PTFE sutures (Fig. 15).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 13
Ultrasonic Cavitation and Peri-Implantitis
Fig. 14
Ultrasonic Cavitation and Peri-Implantitis
Fig. 15

Suture were removed after 14 days and the patient was followed up with every three months until healing had occurred with no complications or adverse events. After six months of undisturbed healing (Fig. 16), a surgical reentry procedure was planned. At the moment of flap elevation, peri-implant bone defect appeared completely filled and previously exposed implant threads are fully covered with newly formed tissue (Fig. 17).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 16
Ultrasonic Cavitation and Peri-Implantitis
Fig. 17

HBT and VBD around the implant were measured with a periodontal probe, along with periapical X-ray examination and intraoperative evaluation of the new regenerated tissue density using a periodontal probe at a pressure of approximatively 0.25 N to confirm a satisfactory quality and quantity of this tissue (Fig. 18). Healing abutments were then placed over the implants (Fig. 19).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 18
Ultrasonic Cavitation and Peri-Implantitis
Fig. 19

To increase the keratinized tissue width, the flap was apically positioned and sutured with crossed horizontal mattress sutures (Fig. 20). Sutures were removed after seven days and the patient was sent back to the referring dentist. Supragingival professional tooth cleaning was performed every week for 60 days and the patient was followed up with every three months until healing had occurred with no complications or adverse events.
Ultrasonic Cavitation and Peri-Implantitis
Fig. 20

Clinical parameters such as mBI, mPlI, PD and implant mobility (IM) were registered at the 12-month follow-up visit, confirming a state of peri-implant health (Fig. 21).
Ultrasonic Cavitation and Peri-Implantitis
Fig. 21

The results:
  • Clinical parameters before and after treatment are summarized in Table 1.
  • The mBI, mPlI and PD values at the follow-up visit were significantly lower than those from baseline.
  • IM remained unchanged.
  • HBT was significantly higher at re-entry surgery, compared with baseline.
  • VBD was significantly lower at re-entry surgery, compared with baseline.
The data indicates that after one year, the treated implant could be considered healthy.

Conclusions

Bacterial biofilm accumulation around dental implants is a significant problem, leading to peri-implant diseases and implant failure.

The most critical issue in regenerative therapy of peri-implant vertical bone defects is related to the possibility of obtaining a predictable implant surface decontamination. Though several methods have been described so far, the literature does not clearly indicate superiority of a specific decontamination protocol. Cavitation occurring in the cooling water around a dedicated ultrasonic tip can be used as a novel solution to disrupt bacterial biofilm without any surface damage.

Although clinical results with the Piezoclean device are very promising, more randomized, controlled clinical trials as well as histological confirmation are needed to corroborate the current preliminary data.

References
1.Albrektsson T. Statements from the Estepona Consensus Meeting on Peri-implantitis, February 2–4, 2012. Clinical Implant Dentistry and Related Research, Volume 14, Number 6, 2012
2. Romanos G and Weitz D Therapy of peri-implant diseases. Where is the evidence? The Journal of Evidence-Based Dental Practice, vol. 12, supplement 3, pp. 204–208, 2012.
3. Tarquini G. Ultrasuoni in chirurgia parodontale: effetti clinici. Cap. 1. In: Tarquini G. Tecniche di chirurgia parodontale: dalla diagnosi alla terapia”, Edizioni EDRA (Settembre 2017): 25-26.
4. Tarquini G. Il ruolo degli ultrasuoni in terapia chirurgica delle periimplantiti: presentazione di un caso clinico. Implant Tribune, Novembre 2017 - anno VI n. 4, pagg 1-7
5. Gartenmann S, Thurnheer T, Attin T, Schmidlin P. (2017). Influence of ultrasonic tip distance and orientation on biofilm removal. Clinical Oral Investigations, 21(4):1029-1036.
6. Tran C. Walsh LJ. Novel Models to Manage Biofilms on Microtextured Dental Implant Surfaces. Cap. 20. In: Microbial Biofilms - Importance and Applications. InTech Open
7. Tran C. Novel methods for debridement of dental implant surfaces contaminated by biofilm. Thesis submitted for the degree of Doctor of Philosophy at The University of Queensland in 2017. School of Dentistry
8. Vyas N. Improved biofilm removal using cavitation from a dental ultrasonic scaler vibrating in carbonated water. Ultrasonics Sonochemistry,Volume 70,2021,105338
9. Zhang, Siyuan. Biofilm removal with acoustic cavitation and lavage. (2013). Theses and Dissertations. 243.
10. Carmen JC. Treatment of Biofilm Infections on Implants with Low-frequency Ultrasound and Antibiotics. Am J Infect Control. 2005 March ; 33(2): 78–82.
11. Vyas N. et al. A quantitative method to measure biofilm removal efficiency from complex biomaterial surfaces using SEM and image analysis. Sci. Rep. 6, 32694; doi: 10.1038/ srep32694 (2016).
12. Persson LG, Berglundh T, Sennerby L, Lindhe J. Reosseointegration after treatment of peri-implantitis at different implant surfaces. An experimental study in the dog. Clin. Oral Impl. Res. 12, 2001; 595–603
13. Persson LG et al. Carbon Dioxide Laser and Hydrogen Peroxide Conditioning in the Treatment of Periimplantitis: An Experimental Study in the Dog
14. Sennerby L. Implant Stability during Initiation and Resolution of Experimental Periimplantitis: An Experimental Study in the Dog. Clinical Implant Dentistry and Related Research, Volume 7, Number 3, 2005
15. Mouhyi J. The Peri-Implantitis: Implant Surfaces, Microstructure, and Physicochemical Aspects. Clinical Implant Dentistry and Related Research, Volume 14, Number 2, 2012
16. Blus C, Szmukler-Moncler S, Orru G, Denotti G, Piras A, Piras V. Bactericide effect of vibrating ultra-sonic (piezosurgery) tips. An in vitro study. Clin Oral Implants Res 2009; 20:905.
17. Arrojo S, Benito Y, Tarifa AM. A parametrical study of disinfection with hydrodynamic cavitation. Ultrason Sonochem 2008;15:903–908.
18. Vyas N. How does ultrasonic cavitation remove dental bacterial biofilm? Ultrasonics Sonochemistry,Volume 67,2020,105112
19. Vyas N, Pecheva E, Dehghani H, Sammons RL, Wang QX, Leppinen DM, Walmsley AD. High speed imaging of cavitation around dental ultrasonic scaler tips, PLoS One 11 (2016) e0149804

Author Bio
Giacomo Tarquini Giacomo Tarquini, DDS, graduated with honors in dentistry and dental prosthetics from the Sapienza University of Rome in 1994, and has been practicing dentistry for about 25 years. Today he practices in Rome with particular interest in the disciplines of periodontology and implantology. He is also a consultant, professor, tutor and lecturer for a variety of dental specialties. Along with various articles, Tarquini is the author of the textbook “Techniques of Periodontal Surgery: from Diagnosis to Therapy.” 
 

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