I placed 3 Biohorizon dental implants in a 77 year old male. These will later serve as abutments for a bar retained overdenture.
During the healing phase immediately after the surgery, the patient loosened up the sutures by gargling very vigorously and using other oral hygiene techniques also with great vigor.
I have been unable to get the wounds to heal. I have prescribed antibiotics and attempted to close the flaps by repositioning and re-suturing but the wounds just will not heal. What can I do at this point? Should I do free gingival grafts to cover over the incision sites?
Is he diabetic by any chance and what are the timescales..
Just a thought – Chlorhexidine is NOT the best mouthwash to use in these cases as it inhibits fibroblasts. Try warm salty water instead…
Is there bone exposed, or just the healing caps exposed? If its the healing caps exposed, don’t worry – it will be fine. If bone is exposed you have problems.
It is my understanding that there is contraction during healing that may play a part. Also, the type of suture and the type of suturing technique plays a factor. If you did not score the periosteum, it will come apart, guaranteed. Ask me how I know. The flap HAS to be passive, as if you lay it up there and it doesnt move. If it tightens through contraction, the flap will just pull the sutures through the tissue and you end up as if you sutured it too loosely. Once its opened, you cant really pull it tight. All the while it takes about a month for the periosteum to reattach. And if its moving, it wont reattach until it has settled into whatever position is a tension-free position. It can be a real mess. It may be best to let it heal secondarily, but its hard to dx without seeing. How long has it been since the surgery? Flaps have to be passive and I finally figured it out after several attempts. Hope this helps. Bill
If this is for a mandibular denture,stop worrying.
First of all, to prevent this from happening again you have to use a horizontal mattress suture far and deep from the suture line. This mattress suture will support the two flaps and take the pressure off the incision line sutures.
This technique comes from Dr. Lee Silverstein who wrote a book on suturing.
Secondly, DO NOT EVER try to re-suture after flaps open up. If the patient was wearing a transitional denture then get it out of their mouth and put them on CHX rinses followed by warm salt water rinses. Contrary to what was said before by Dr. Crosby, you don’t have a problem if bone is exposed. Left alone, the problem area will granulate in slowly. Could take 1-2 months but it will heal just fine. You don’t need to put the patient on Antibiotics either. Forget about the free gingival grafts too. Put the patient on a soft diet and tell them you are sorry but these things happen. Have the patient in your office every two weeks to monitor the healing. JUst leave it alone and let nature take care of things. If the implants have good primary stability and well encased in bone then they should be fine. Good luck and buy Silverstein’s book. Check out http://www.montagemedia.com and order it online.
The patient should only use WARM WATER to bruch their teeth….no oral hygeine products at all as it will inhibit fibroblasts like MS said…
Get Lee’s book. By the way, he is working on a new one and he showed me some of his proofs and its going to be a great addition to everyones library. His suture book is great and shows exactly how to and what to do it with. Bill
just thinking of a few other scenarios…. any history of bisphosphonate use, diabetes, etc??
Some good suggestions have been posted. In addition, in the future, try platelet rich plasma. It will reduce swelling and accelerate healing and provide growth factors that can be beneficial for a compromised patient. Best wishes to you.
Had it happen to me many times on the same patient buccaly positiioned flap and low and behold her frenum kept on ripping the sutures finalll gave her peridex resutured with Silk and waited and it healed fine for an overdenture.
Good Luck
Jonathan Abenaim
If the implants are solid, you will probably still be ok. New cell growth will be slowed down or stopped if oral anti-bacterial rinses are used. Rinsing with Saline will strip the bacteria from the bone without stopping new cellular regeneration during secondary healing. The only other requirement normally needed is that the mucosa on all sides of the exposed bone in higher than the bone. You may have to reduce the level of bone to make sure secondary healing can occur.
You can apply a periodontal pack and leave it to heal by secondary intention.
I avoid these complications by doing flapless placement of mini and midi implants instead of regular implants
Try a round of penicillin not amoxicillin. #30 500 mg q.i.d. Penicillin is still more efective than other antibiotics in the mouth includining cases of biophosphate leisons. Assumes no allergy to penicillin!