Case of Swelling on Mesio Buccal of the #10 implant: Best Treatment?

Detoxification of the implant with citric acid 1% or EDTA and GTR with resorvable membrane and reopen it in 8 weeeks. Good luck.

Dear Dr I: Without getting into the question of why this happened so we can learn from our complications, you need to assess the condition of the bone and the implant. You will find different opinions, depending on who you ask, but Flagyl is recommended in the periodontal literature in combination with Amoxicillin, not alone. One option to treat is with antibiotics to see if the infection goes away. I have seen that happen. If you need to improve the bone level around the implant, then you must elevate a flap to asses the damage. If there are no osseous walls to provide cells, bleeding surfaces for RAP, and vertical space maintenance, it will be difficult to impossible to gain bone back around the implant and it would require meticulous debridement/detoxification of the surface (tetracycline in this case would be more useful than citric acid), grafting an osseoinductive material and covering it with a titanium reinforced membrane and primary closure. Any pressure on the grafted area may cause a failure. Good luck. Hope this helps.

It seems that you have an incipient case of periimplantitis. There are many approaches to deal with this situation. Topical treatments such as detoxification or decontamination with many different chemical agents has been proposed. Authors like Drs. Matteo Chiapasco and Eugenio Romeo in their book called Implant rehabilitation in complex cases (literal translation), recommend AB therapy systemically (metronidazole 250mg tid for 10 days, or, metronidazol 500mg daily combined with Amoxicillin and Clavulanic acid for 10 days) as well as topical and mechanical decontamination of the implant surface. According to their studies, the best substance for the chemical decontamination of the implant's surface is Citric Acid (pH 1) applied for 30-60 seconds on the exposed surface of the implant, which will be enough time to detoxify without damaging the porous surface (which according to them later aids in the bone reformation around the implant). Other authors, on the contrary, recommend the complete removal of the contaminated surface, not only using chemical agents but also using diamond burs to remove the threads that are exposed, and next using polishing tips and abrasives to smoothen and polish the surface as best as possible, in an attempt to avoid bacterial recolonization in the surface of the implant. I personally would try decontamination with citric acid and GTR first. If that doesn't work, I would proceed to the smoothing out and polishing of the threads technique. Hope this helps

Hello Dr. I. Dr. Ares suggestions are complete and in my experience very effective. This is a 3 wall pocket so removing the threads and polishing the surface will be almost impossible without substantial bone damage and simply shouldn't be attempted. Treating with metronidazole 250, Augmentin 250 tid for 10 dys with Peridex irrigation without a flap might well clear this up but more often than not the bone does not regenerate and you are looking at an unpredictable refractory problem. It is best to flap, debride,treat with citric acid or tetracycline [I prefer citric acid],graft with MFDBA or material of your choice, cover with Biomend Extend or resorable membrane of your choice, and wait for 4 months to assure that you have been successful before proceeding with restorative. I start with metronidzole 250 and Augmentin 250 tid three dys before the procedure and continue for seven dys after. The most, actually only, difficult part of this is debriding the area thoroughly. It is not easy in such a small pocket. If you use your lopes, take your time, and do that well you can expect great results every time. Good Luck!

I think the main reason why what's happened is the not good quality fit of the healing screws,which allouded bacterial colonization from neighbourinng natural teeth. In this very critical situation,what I would try is to change the outcome:transforming first of all the situation from screwed in cemented,with 2 abutments supporting a fixed temporary acrylic bridge,and in this new biological situation,try to detoxify and regenerate without the fear of any compression of a surrounding temporary plate.

I agree with the comments above. Another method of decontamination of the implant surface which hasn't been mentioned, is less invasive, relies less on empirical treatment with chemotherapeutics and is the one I use in my practice is using the Waterlase laser to debride and detoxify the implant surface and the peri-implant affected tissues. Although all the reports have been anecdotal in nature, the results have been very promising.

I agree with the earlier mentioned comments. Local debridement in the effect of LA,followed with good betadine solution irrigation has helped me.Also Amox-clavunic acid combination along with flagyl t.i.d.for 5 days helps systemically.

Dear Fellow Colleagues, The use of citric acid and tetracycline for the purpose of surface detoxification for an implant may be slightly outdated. A recent article(JOI 2009)mentions the use of calcium hydroxide and chlorhexidine gel on the surface of the implant after surface debridement with plastic or titanium currettes. The pH of citric acid and tetracycline is about 1.8..which is very corrosive on the surface of the implant which may cause defacing of the surface. On the other hand, the pH of calcium hydroxide is about 12..which due to its alkaline nature is bactericidal. Newer therapies include the use of carbon dioxide and ER;YSGG lasers for surface decontamination.

Dr Joshua Shie, I am very interested in reading the article you mention. Can you please cite the complete title of this article? Thank you

WE having made implants since 1985 still think merely th use of a prophy jet on the surface is the best solution to restore the surface . As to grafting the use of synthetic material ( Easygraft) that is very stable on setting ,bacteriostatic ( only BTcp and a polylactide coat ) and even bacterio-scidal initially ( Due to the bio-linker). have led to some reasonble results. The mixing of anti-biotics in the graft material or use on the implant surface may contaminate it. Just our thoughts..

I agree with Dr Boudet's comments, especially using a non-reasonable membrane. In the anterior are you will get more predictable regeneration this way. My question is why do you want to regenerate the bone? With these types of implants you get die back anyway, so how much bone do you expect to get back? 1 mm? Another question is, why did you bury the implants for 6 months? Rx: treat the infection with antibiotics. Temporize the implants. Call it a day.

My opinion is : Removed Implant, bone graft , use membrane them put again another implant 6 0 one year late. Is most predicteble and secure. than try in lesion , and implant , the bone and gum are more recovery in this moment becouse doesn't made the prothesis yet.

I treat one or two cases of perimplantitis a week. A periodontist I know claims reasonable success with his laser. I don't have one so a can't attest personally to it's success. If this case was complete with a definitive restoration I would debride as thoroughly as possible with teflon currettes, place Arestin, have patient rinse tid with Peridex, and prescribe Augmentin 250mg and Flagyl 250mg qid for 10 dys. The normal dose for Augmentin 250 would be tid but the extra dose won't hurt and it's easier to remember and more likely to garner compliance when it is taken with the Flagyl. As it is I would be more aggressive. Flap and debride. If it is possible to remove the threads do so and polish with a "brownie" as best you can especially on that portion of the implant that is likely to be above your bone. You don't have to be perfect. Anything you accomplish is smoother than the threads and less likely to remain contaminated. Apply citric acid for one minute. If you have PRP and PRF use it. If not fill the void with Osteocell or Infuse and cover with a resorable membrane such as Biomend Extend. Get rid of the flipper and fabricate a well fitting provisional fixed bridge for all of the reasons mentioned by others and to make sure there is no pressure against the graft site. If this patient is a smoker try to get them to stop for a least one week before and 2 weeks after. I would use the same Rx's as above but I would use a simple saline or hydrogen peroxide rinse rather than Peridex. You can treat it non-surgically, you can not remove the threads, you can use MFDBA or a myrid of other products and get good results but if you do this your success is almost assured.