Bucco-Lingual Resorption Exposing the Threads on Implants: How to Manage?

Bio-oss won't work out this way in fact no graft will work this way. Rather remove the implants and then put lateral onlay grafts or block grafts depending upon the size and location of the defect. Wait for some time and then put implants. Remember a graft needs precious blood supply to heal. With an implant on one side the graft is doomed. If the patient doesn't mind the esthetics you can continue as the implants as are now but be prepared to loos some more bone once the implants are loaded.

This is a great question. Depending on the amount of bone you need to augment, GBR may work to cover the threads. With some of the growth factors available today, I have had some success in regenerating the bone. I would recommend a stringent detoxification of the implant once exposed and to consider the amount of KG you have. Autogenous bone is most desirable in this situation and so is a space creating membrane. Also, primary closure is essential. However, for a predictable result I agree that removal of the implants, grafting, and reimplanting may be the most predictable especially if you have a large defect to fill.

How about raising a flap . Placing a slow resobing material like or fortross vital which hardens . Place on the buccal side , cover with periosteum or mebrane and wait. I would be careful to use autogenous bone without a membrane as I think the purpose is to have a graft which allows enough time for the soft tissue to stabilize, since you already have integration.

Unfortunately, there is no treatment to correct that situation. Neither Bioss, nor any other bone or soft tissue grafting material or procedure will work. I agree with SDJ, your best shot is to remove the implants, graft with a Block, either autologous or Puros, take a CT scan, place new implants, hopefully with the help of a surgical guide and even better if planned with simplant, wait 4 months at the most and restore. Good luck....been there, done that...several times. Bye.

How much of the implant is integrated still? are the threads exposed above the tissue? is it a cratered defect or total horizontal resorption? fmn

I have had this happen to me and the only right treatment at this young date is remove the implant and either immediately plce a bigger diameter implant to bone level or graft and wait to do it again. In the long run you will be happier and so will the patient.

since implants have excellent stability as you said DO NOTHING if there is no esthetic problem . Removing implants will leave you with no bone at all since threads of implants already fenestrated both buccal & lingual plates of bone . trephining implants will leave you with a thru & thru defect that will give you tough time to handle !!!!!!!!!!!

If you have an esthetic problem with metal of implants showing under thin gingival biotype use a connective tissue graft that might have non resorbable HA underneath covering the metallic color of implants . Again if no esthetic complaint ......DO NOTHING

If there is a vertical defect I have had much success with placing Atridox into the defect and leave for several months. The Atridox itself serves as a barrier membrane while the Doxy leaches out any bad bugs in the grooves. I actually get bone regeneration, but only if vertical defect. Let me know how it goes

if it is four wall deffect how you will get the blood supply for the graft maturation.

I'm quite sure your problem's source is from the ridge expansion: to much pressure on the bone (due to osteotomes action) or less than 1,5-2 mm bone width in buccal and/or lingual walls of the implants, and/or any combination of both leaves us with resorption . this is a issue we have to keep in mind in each procedure. treatment: I agree that if there is no aesthetic issue, the best way to manage is not to do anything: I have cases like this (I mean few threads above bone level) with more than 10 years follow up that are stable (perhaps depending of surface state of the implant and ability to retain dental plak. good luck

Helpful if you can provide more information. When the bone resorbed bucco-lingually 4mm, were the threads exposed on the buccal side only or on both the lingual and buccal aspects? Are there any soft tissue cover over the threads? And what are the diameters and length of the implants placed and how much of the surface of the implants were exposed both lengthwise and breadthwise? This information will be helpful to determine the best way to manage the complication. Regards.

Im in accordance with the colleagues that vote for leaving the implants alone if there is sufficient stability and enough implant osseointegrated threads ( length) . For me in these cases it is crutial to asses the amount of keratinized tissue around the implants and if not I would find a way of doing some minimally invasive soft tissue augmentation which will aid in the protection from further recession.

Good to hear of a Vital user Dr. Boshoff, this is a way of dealing with the problem that I have used sucessfully and shown at ADI Forums in my talks.Trephining out would cause too much truma an emotional upset for the patient. You can raise a flap then clean the implant surface with a prophy jet which will return it to a clean prepared state to place the Vital or easygraft material on. Both these products are Beta Tri Ca phosphate materials which set hard in different ways and thus allow us to not use a mambrane. This allows directcontact with the periosteum for improved blood supply and hence improved healing. Then reattach the flap tension free and wait 5 to 6 months and hopefully the body has done its work. I have many cases and over 200 photos incuding end results showing new bone growth with a new flap raised of this procedure which as I said I have shown at numerous forums. The cause may have been a result of ridge splitting and I always graft when I split the ridge and have noted a vast improvement in the loss of resultant bone height and width

Dr Peter Fairbairn could you show us some photos on your website where we could see for our selves this work out? I may have a case in waiting where I could try out this thing.

It is amazing to me how we can offer all those wonderful solutions without ascertaining exactly the clinical condition of the implants. Is the soft tissue covering or not covering the implants, etc.?

I know there are many variables but this this is just an idea which has worked for us. A soft tissue shortage can be corrected by a graft or by realeasing the flap extensively. Unfortunately hard to show on the web site as public can view but can maybe show on here if Ican work it out.

For long term soft tissue stability you need to have 2mm of buccal bone. Whenever you spread or split the bone to that degree you will need to graft the buccal and/or lingual. The implant is stable, I would not even consider removing the implant. I would flap, debride the soft tissue and graft. I don't have experience with the beta tri cal phosphatye materials, but I have grafted similar situations with bovine mixed with FDBA. I usually like to tack the membrane as well, followed by closing the tensionless flap. This has proven to be very successful and it's backed by the literature.

How will covering exposed threads with biomaterial: Enhance implant prognosis as this will not increase the surface area which has osseointegrated?

Assuming that there is outright exposure of the threads buccally. An attempt should be made to cover the threads even though the implants are osseointegrated and stable because the implants inevitably get covered with plaque and even calculus. The fear is that it will cause infection of the implant threads leading to loss of the implants in the future, though there are many implants which exist successfully in such a condition for many years. Yes, a fair attempt should be made and if it fails, to leave the implants alone and maintain cleanliness and hope that they will last for a long time. Reactivate the titanium surface by a 10 second etching with 10% hydrofluoric acid. Flush thoroughly with sterile saline. Then place on a bone graft preferably mixed with some autogenous bone. Then slide a full periosteal flap from both sides of the defect over the graft and get primary closure to ensure minimum contaminants and hopefully adequate blood supply. If it works, well and fine. If it fails, then leave the implants alone to last as long as they can.

The majority of the implant is osseointegrated this is merely to hopefully create a area however thin over the implant to allow for soft tissue attachment which cannot be achieved on the exposed threads..

Dr Murray, I am a relatively a newer practitioner of the trade. But I can say this with conviction:---- Covering of exposed threads with bone/connective tissue grafts will not increase the actual load bearing osseointegrated surface, so may have little consequence in terms of strength of the implant retention and load distribution capacity. Even regarding the point about preventing plaque retention around implants may be argued by some smart dentist to be not so serious matter as evidence proves that thread exposure is not the end of the implant. If the implants are in the posterior zone hiding behind the cheek and lips the aesthetic point dissolves away in to thin air. So with three issues of 1) amount of actually osseo integrated bone and strength of implant 2) Bacterial attacks on fixture and 3) aesthetics all not warranting serious attention once post operative thread exposure takes place, one would think there were no reasons to seriously attempt to cover the threads up. But there is one issue beyond science that forces you to seriously consider making an attempt to cover threads. --Your dentist next door! If the dentist next door tells your patient that thread exposure is seriously detrimental to the longeivity of that fixture all your scientific arguments come to a naught. Not all patients are rational and with the kind of money they spend over implants they want "their money's worth" or else you loose your patient and may be facing a court trial shortly! You can't argue that thread exposure is in-consequential! Inspite of evidence on hand who would believe you? May be even the court may believe you, but only after "raping" what ever little is left of your dignity. I have had exposure last month (the day after my first enlightened post on this thread 13 April) ten days later I removed the implant just as I advised the good doctor D to do! Conclusion:- In practice covering your patients threads covers your arse! And keeping them exposed, exposes youe arse! Hope this matters!

Question for everyone: In July 2008, I extracted the maxillary right canine and central and placed 2 immediate implants (the lateral was already missing). I engaged the palatal walls of the sockets like I often do and grated the void between the implants and buccal walls....there was no buccal bone loss at time of extraction. I placed a resorbable collagen membrane over each implants and closed the areas. Everything healed fine, no infection, no pain, no suppuration...regular xrays at 3 months and 5 months showed no bone loss. Today as I'm doing my 5-month postop, I see darkness through the buccal mucosa on the buccal of the canine area. It looks like the implant. So I decided to do stage-2 today on the spot....I open the flap to discover that the implant in the canine position is completely dehisced on the buccal, but the mesial, distal, palatal is completely covered to the top of the implant with bone. Only the buccal was dehisced all the way down....the implant is osseointegrated.....solid as a rock The central incisor implant is fine... So I decided to put tetracycline on the buccal surface of the implant, then place an allograft bone grat (Oragraft) and covered it with a collagen resorbable membrane...and closed everything back up...and wait another 5-6 months. Should I have removed the implant, which would have meant trephining it and creating a through-and-through bone defect buccal-lingualy ??? I chose to graft, and hopefully get soft tissue coverage to mask the color through the gums....hopefully getting some bony coverage...note that I decided not to rinse the tetracycline like I would usually do...I placed the powder on the implant, which quickly mixed with a blood clot and then covered the whole thing with the bone graft... I forgot to place emdogain with the graft (which i usually do)...it was the end of the day on Friday... What will likely happen ??? Worst case scenario ??? Best case scenario ??? Thanks guys...

Hi, I have 3 LifeCore implants(19, 20, & 29) done about 6-7m ago. Tooth #29 expose thread 3mm, tooth # 19, & 20 expose the part below the margine 2mm. I went back to Maxilarryoral facial surgeon to have a correction. His suggestion was to leave them alone. Or he refers me to other surgeon for shorter implant, after he remove them because he doesn't believe short implant works well. What I should do if my Maxillaryoralfacial surgeon would not want to do any things, except if I request for removal I have to take all risk of fracture/ broken mandible bone?. Apreciate your opinions

TO A.B.,MD: You may want to consider a poncho graft with alloderm and a particulate graft material, inorder to regain the lost bone and gingival tissue.

Hi The teeth #29 & 30 were lost for a long time and the bone loss prevented him from implanting #30. The best the surgeon could do is to implant tooth #29 with the available bone height, >10mm above the mandibular nerve canal. The Oral & Maxillofacial surgeon recommended for me to see a Periodontist for bone graft & soft tissue graft for all implant expose below the margine. He also said that with this procedure it would also help implants #19 & #20. Though implant #29 only has temporal relief because there is a missing adjacent #20. Are Bio-oss large granules used for this poncho graft + palatal tissue to regain the height/cover the exposed part below the margine? Who will do this work? Oral Maxillofacial or Periodentist? Thank you.