Buccal cortictal plate perforation: recommendations?
I have a 21-year old patient who needed a retained right mandibular deciduous first molar extracted and replaced with an implant. I did the extraction and installed a Myriad implant with single piece construction. When the patient returned 3-weeks post-op, as I was palpating the buccal cortical plate, I could feel the threads of the implant. The patient has been asymptomatic and has no pain (even on palpation). The implant is firm, and had good primary stability at placement. I am assuming that I may have gone buccal at the time of surgery because of limited opening. My plan now is to to de-torque the implant, re-orient the osteotomy angulation to re-install the implant completely within the alveolar ridge, and augment the buccal defect ( also use PRF). Can I re-use the same implant to do this or do I have to use a new implant? Is this the best way of treating this situation or do you have any recommendations on how to proceed? What could be the possible complications?
14 Comments on Buccal cortictal plate perforation: recommendations?
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Sb oms
10/21/2014
This is a 21 year old patient. Your treatment needs to last 60 years.
Take the implant out. Do not try to fix this. Tell your patient that you want a better outcome so that the implant will last longer. Send to a specialist, and work with them on the case.
Congenitally missing tooth sites usually have deficient bone stock for implants.
When the specialist scans the patient, look at the scan, understand and appreciate the anatomy and the challenges of a case like this. Learn from this one so the next case will go better.
sergio
10/21/2014
Take it out and use another implant, possibly a smaller one with grafting. Buccal plate grafting tends to be not so predictable especially if it's done on previous surgical site in my opinion. So go with a bit smaller implant ( Not sure what the diameter of the original ).
Gregori Kurtzman, DDS, MA
10/21/2014
If the implant is positioned correctly on the occlusal then you can flab the site and remove any soft tissue off the exposed threads and graft it place membrane and close it if its not positioned well remove the implant graft the site to widen the ridge let heal 6 weeks and place a new implant at the proper position. NEVER reuse an implant that has been placed at a prior appointment as it is contaminated surface
Manuel
10/25/2014
How are you doing your grafting procedure that you can place your implant after 6 weeks of healing? Or did you mean wait 6 months? Thanks.
Gregori Kurtzman, DDS, MA
10/25/2014
You have a circumferential bone around the site to the crest and the purpose is to get vascular bone on the center so that when the implant is placed the blood wets the implant and cells that will form bone coat it to start the integration process going. Your also not immediately loading it then you let it heal for 3-4 months
Carlos Boudet DDS
10/21/2014
You fail to mention some very important pieces of information.
1- Is the implant in the correct position now for restoring it with a crown?
If it is, removing it and reinserting it reorienting it at a different position will not be a prosthetically driven implant placement. It may also destroy additional crestal bone.
If it is in the correct position now, you can do a guided bone regeneration procedure and it should heal fine completely covered under the flap.
If it is not in the correct position to begin with, then remove it, graft and wait.
Reenter the site with another implant after the buccal plate has regenerated.
We have colleagues that are very comfortable placing implants and grafting the missing buccal plate at the same time, but you may not have their experience and definitely don't need another complication.
I hope this helped and good luck
Dr. John
10/23/2014
Thank u all.. really appreciate the responses. I think I would remove the implant and graft the site. Wait for the response and then decide to place the implant. When I was asking about reusing the implant. ..I meant re inserting it at the same appointment of removal and also grafting the site. I have performed block grafting for upper lateral incisor site.But yes we had placed the implant six Months later. But I guess I should wait and watch this time and not attempt placement immediately. Thank u all again.
CRS
10/25/2014
If you are wise refer to a specialist since the case is compromised already. These cases are deceptive since the alveolar bone never developed it is usually just cortical plate very little cancellous. What works in the maxilla has no bearing on this case. Otherwise start over and chase this difficult case as a loss leader now.
Gregori Kurtzman, DDS, MA
10/25/2014
As CRS stated these mandibular sites where no perm tooth developed tend to have little vascularity and we see higher implant failure rates here due to lack of integration (speaking from experience) the way to avoid that is flap the area use a trephine to core out a 4mm wide core (if the width of the ridge can accommodate that) fill the core area with any inexpenesive resorbable graft material and close the site wait 6 weeks then go in and prep and place the implants into a site that has some vascularity due to the body vascularizing the graft
Richard HUghes, DDS, FAAI
10/26/2014
Gregori, you made a great point as per stimulating the vascularity of the site.
Manuel
10/26/2014
I completely agree with the comments regarding the poorer/less vascular bone in the site. However, I don't see the need to place any "graft"/bone biomaterial in the site in an attempt to improve the vascularity. You are essentially doing an early implant placement as described by Buser (waiting 4-8 weeks after extraction to place an implant) and placing anything into the site during that healing phase will contribute little to nothing. Simply "injuring" the bone at the site will accomplish the same thing by stimulating the innate wound healing potential of the patient thereby avoiding any additional costs or complications involved with placement of any materials into the site. If inadequate bone volume is present, then augmentation (whichever technique works best in your hands) would be warranted with a 4-6 month healing interval. Just my $0.02.
k e wirth
10/28/2014
If placed correctly or in good position, I'd consider leaving it and grafting.
Re: reusing the same implant...
I just did a case where I screwed the implant in too far. Also, I had to angle toward lingual in order to avoid the mental foramen. I did not flap the buccal or lingual.
I placed the 13 mm HA coated Screwvent too deep and hit the mental foramen. The patient had minor localized facial swelling and complained for a week of pain at night. I opened it up, removed the implant, irrigated the socket and rinsed off the implant screw with IV grade 0.9% sodium chloride and replaced the same screw but 3mm less debth. I compressed the bone prior to discharge. Symptoms improved. That was just 2 weeks ago. Will this work?
My expectation is that the swelling was caused by bleeding through the mental foramen to the facial tisue......... comments? kw
DRB
10/28/2014
All great comments and spot on. My only additions is that unless the implant is positioned poorly then don't remove. A thin coverage of buccal plate bone can persist and be just fine. If you have a dehiscence then make some adjacent bone perfs to get osseous stem cells to move outside the plate and graft using a resorbable membrane. We all know further surgeries in the same site can lead to less than desirable results.
Don Callan
10/28/2014
Cut your loss. Remove the implant, bone graft with a membrane, wait 3-4 months place a NEW implant, wait 3-4 months to restore.
