Loss of Membrane Case: Can This Be Salvaged?

If the implant is stable and asymptomatic, then use "Tincture of Time". Let it continue to heal and have the patient care for the implant as you normally would (Chlorhexidene applied with a Q-Tip b.i.d.?). I bet that in 3-4 months it will look good.

If the membrane became exfoliated it means that the site beneath the membrane got infected, therefore most of the graft you placed must have been lost. Eventhought the implant can become integrated in the remaining bone, the area exposed will cause problems in the long run. The best advice I can give you is to pull the implant out place another dense ptfe membrane for 20 days, leave the site heal for about three month, then reenter and place the implant in sound bone. Probably the mistake was to place two membranes, one overlaping the other, when the membranes got exposed, the space between both membranes was used by bacteria as a pasage to colonize the underlying tissues.

Putting 2 membranes in that fashion can be done, but not with yuor flap design. We forget now adays that the flap margin should not be close to the membrane margin. If it is this large, a flap with remote margins, 1 tooth either side, is much more predictible and lessens the change for dehiscence. If the bone is that compromised, I wouldn't do an immediate. I would probably graft and come back. I didn't answer your questions. You can salvage this case. You have 3 options you should discuss with the patient: 1. Wait and see. If the tissue looks fine, just see if the implant is integrated at the appropriate time. If it needs to be grafted later, or removed later, you can do this. 2. Graft now. You can go in and decontaminate the implant and place another bone graft with a resorpable membrane. 3. Remove the implant and start over. I would say the first 2 are preferable.

I completely agree with the comment above. The extension of the flap should have been larger (at least one tooth away from the area of the graft), especially when non-resorbable membranes are used. Probably a matress suture would have performed better in keeping the wound closed. If no infection is present (no swelling, no suppuration), I would wait and see. In minor horizontal bone augmentations I usually use resorbable membranes. They perform well and there are fewer risks of exposure. Can you post a photo of the healing? Thank you for submitting your case.

Dr.L What graft material was used? Greg Steiner

Iadvice u to remove the implant and make cortage for site then fill it with osteoinductive bone graft and u must skillyfull made that the bone graft has covered completly by blood which ensure for the graft to still in the site and to start the vasculezation again which help it to stay in place and wait4-6months untill riping the graft then insert new implant and follow the normal protocols

You can salvage it, but these are the factors to be considered: 1)Is there enough soft tissue left for another primary closure ? 2) Use autogenous graft for regraft, it will be faster and lot more predictable then any graft available in the market today. 3) Yes, carry out the flap one tooth beyond for wider flap and away from the membrane. When in doubt, remove it regraft and reentry later, this always work . Hope this help.

dear sir : this is 3wall defect, with one side implant, in this milieu you had to use autogenous bone graft with submucosal space technique inorder to soft tissue full coverage without any tension . as you know, incision line opening is the most common post op.complication. any way, in this case you have to remove any bone substitute particle, then rinse with copious normal saline, after that insert autogenous bone block with good rigid fixation ,GBR and full soft tissue coverage. dont hesitate.do it hasty!!!

I HAD VERY SIMILAR CASE WHERE places ankylos implant in 25 site,25 was extracted more than 7 years ago and the buccal bone was lost at that time i places the implant 4 month ago and grafted the exposed threads of the implant on the buccal side and covered it with resorbable membrane. the membrane was exposed the next day and i have discussed all the mentioned options with my patient ,so we waited and obseved it every week. it healed well and the implant was successfully integrated considering that lukily the implant did not get infected, the gingival margin was not closed totally and the implant was 1 mm subgingivally so all what i can say that the implant will integrate but the long term prognosis is quesionble. best option wait and see, if any persista tsymptoms,swelling.pain more than 2 weeks nremove the implant and the graft,then graft the site ,three month lted insert the implant

in such cas ei think it is better to remove the implant , beccause most probably the graft material is lost and not in the site , currete the site enhance bleading at the site but graft material and goood flap sealing and wait for the next 4 month and re insert another new implant .for the long run the problem will be more traumatic to treat .

In a case like this I would use titnaium mesh to allow tenting and maintaining the shape during healing. Also am not a big fan of nonresorpable membranes as the tissue doesnt like the materials and exposure tends to occur during healing. Better to use long term resorbable like Ossix. Also PGA sutures in my hands have always worked better then any of the nonresorbable sutures tissue response wise. In this case with a defect that large would have been more prudent to graft then come back later to place the implant and get a more predictable result. I would concider reflapping the area now. clean out any loose graft if implant is loose remove it and graft the site, if its not then treat the exposed threads with citirc acid the pack Regenform or Dynagraft around the implant and completely cover it including the cover screw. Place a peice of Ossix and close the site with no tension on the flap.

I read a lot about "tension free closure" but what and how is this actually done? Thanks

Hi , I have had a very similar case ,I 'll tell you what I've had done : - first- very good decontamination , also used Nd:Yag laser - second - I' ve used composite graft : BondBone and 4Bone 2:1 ( BondBone hardens by itself , and you do not need membrane over graft ) - third - good flap coverage That's it - simple and effective . Good luck!

agree totally with buldo - I'd probably blast the surface too, and use fortoss vital with the bonndbone - goes rock hard therefore no membrane.

tension free closure is where you replace the flap after an implant or graft and if you can let go and it stays put, so the sutures do not "hold" the wound closed, they just stop it from being displaced in function. This is probably the single biggest factor in predictable implant and graft sucess. (though i can think of one or two others...)

This is a 2-wall defect. You have lost buccal and palatal bone in a "through-and-through" defect. You have mesial and distal bone only. You could have also had apical bone, but you put an implant into that! This was always going to be a very challenging situation to place and graft in one go - whatever graft and membrane you use. If you leave it, then AT BEST it's always going to be a compromised implant, even if it's still solid. Grafting the case at this stage is never going to produce a predictable improvement - WHATEVER PEOPLE WITH VESTED INTERESTS OR WITH LIMITED EXPERIENCE STATE HERE. Openly discuss the situation with the patient and explain their options. You will need to keep the patient on your side with this case. Personally, from the information you've given here, I would remove the implant and any loose graft and allow it all to heal. I would then re-graft without placing the implant and only place once I had got the healed grafted site right. Let us know how you get on. Kind Regards, Bill Schaeffer

how do you decontaminate the surface with Nd:Yag laser ???

IS Fortoss available in US? Where can it be purchased?