Radiolucency around coronal portion of the implant: next steps?

I would flap the implant see if there is granulation tissue at the crestal if so clean it out and detox it with citric acid then place cover screw (not healing abutment) pack osseous graft place a piece of collagen membrane and get primary closure wait 2 months and you can then expose the implant and start restoring

I've had this happen to me at four months post op, in my case the bone loss continued and I needed to remove the implant. What was common is that the removed tooth also was a failed endo and the bone loss started before loading on the implant. What I try to do now is disinfect the extraction site with the 1064 yag laser and place a bone graft, let it heal then place the implant. I think it is residual bacteria but this is anecdotal. What I would suggest in this case is open the area, disinfect it and graft sort of treating peri implantitis. See if that helps then restore. I think you need to do something since this is so early in placement. Good luck!

I feel this is out of hands so to say , Patient physiology , Host response to resident bacteria and oh issues can lead to this . As to treatment the fine gentlemen above have dealt with that ..... Peter

What you have is bone loss and it is because your graft didn't take and what you have to do is the following: remove the healing abutment and place a cover screw so the gum can close as much as possible. About 15 days later, open a flap and do the debridment of all granulation tissue and soft bone. Place a bone graft (FDBA works great) and a cross link collagen mb (cytoplast works great) and close. wait 4-5 months and do the fase II. Good luck.

Great comments and fixes. The implant extends into the sinus about 1mm. I have read research that 3 mm or less with integration is just fine - is this implant "the standard of care"? Just asking.

Looking at the radiographs, most dentists would probably say that is normal.... we expect to lose a small amount of bone........ but CRS hit the nail on the head, when mentioning the possibility of pathogens that were there when the natural tooth was in trouble....have been awakened. CRS who was with me at the Implant Review course for the ABOI this past February, will agree with me when I say that there are some excellent dentists who frown on the use of Citric acid for detoxification, because it is harmful to the bone; but all will agree that Peridex is an excellent way to detoxify....in my opinion, use both.....curette the area around the implant, L-PRF alone or in combination with a particulate biologic material could be placed in the defect....close the area, and hope for the best. Gerald Rudick dds Montreal

It is not residual bacteria, because the graft would had failed then before the implant was placed. I think it's caused either by overheating during osteotomy or by to much bony compression at the neck of the implant with subsequent necrosis. I would remove this implant and placed a slightly bigger one.

I don't think the success of a graft would absolutely guarantee that there are no longer pathogens present in a filled grafted site.....more research has to be done on this subject, but from personal experience and that of CRS who has seen many cases over the years...it leads us to believe that residual bacteria may awake and come back to do damage. I di agree with you that pressure necrosis and overheating while drilling may have caused this as well...but do not discount the bacteria that comes back to haunt us from time to time.

Yes, it is very possable to have bacteria and or fungi that have been homesteading in the bone. The usual culprits are Micrococcus sp. Staphylococcus sp and Streptococcus sp., and Candida albicans. Bacteria can lie dormant for decades. Even orthodontic movement can kick up an old infection. All the posters have made valid points.

I can see in the PA taken at the time of implant placement the outline of an IBD crestally. From this I conclude that there was incomplete bone fill with the graft.

I like Greg's initial response... to correct the problem. However, I will have to state that a PA radiograph tells us little of what is really going on. How do we know how much width of bone was at the crest at the time of implant placement. 2mm circumstantially..? Probably not... even with the bone graft. Where was the implant placed in a buccal-lingual aspect? Also, were there other patient factors like smoking..? The healing collar was placed at the time of placement..? Perhaps this was a factor based upon patient factors...

All good comments highlighting factors that merit consideration. I tend to favor the peri-implantitis theory and am concerned that if the mesial inclination of tooth #2 isn't corrected prior to final restoration of #3 implant, this will be an ongoing issue.

Frank...you are correct...best to align tooth #2....and that can be very easily accomplished either with a removable Hawley Retainer, or by increasing the width of the plastic temporary crown over a few weeks....tighten the contact point.....a week later, tighten....and so forth until the tooth is moved into the position required.