Exposed implant: treatment suggestions?
My patient is a 52 year old male Caucasian in excellent health. Three months prior I extracted atraumatically #10 [maxillary left lateral incisor; 22]. See Photo #1- retracted flap ( interproximal, gingiva untouched ) to expose defect. Photo #2- atraumatic extration site. Photo #3- Implant placement, Legacy ( Zimmer type ) 4.7mm dia x 13mm. Photo#4- two week post-op. Photo #5- flap retaction to expose extent of implant.
Puros bone raft material was placed buccally to increase the thickness of the buccal bone and also on the lingual aspect. The bone graft was covered with a membrane. An 8 degree zirconium abutment with a 2mm collar and a polycarbonate temporary crown was placed. At this point, what do you recommend I do? Should I remove the implant and bone graft? Should I attempt bone graft and soft tissue graft? I am open to any suggestions.
#10-exposed buccal defect
Extraction site
Implant-4.7mm x 13mm
Post-op two weeks later
retracted flap to expose extent of failure
24 Comments on Exposed implant: treatment suggestions?
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CRS
5/26/2013
Remove it and prepare the esthetic implant site properly. Too much was done at once and the body healed exactly as the original tooth looked like, bone height etc but now there is is soft tissue loss since it won't cover an implant when there is no buccal plate. The immediate technique with immediate restoration was not a good idea in this case. You just reproduced the same result, look at the first and last photos. I'm assuming you grafted at implant placement not extraction, since he bone level is so low and there is no buccal plate or adequate soft tissue. Too many corners cut, remove it and start over it he situation will continue to degenerate. If the grafting was done at extraction the site was not adequately prepared and not enough bone and soft tissue was present. Thanks for reading
Bill Schaeffer
5/26/2013
Firstly, thank you for posting this case. It is much easier to show things when they go well than when they don't!
This case is not going to get better on its own and it is not going to get better with grafting. A 4.7mm implant is suitable for a molar, but is a little large for a lateral incisor. You have ended up too far to the labial. This is very common when one starts out doing immediates in this region and especially so when using an implant this wide.
I would also recommend removing the implant. Graft the "socket" if you want, but then STOP and allow some healing and reassess what's left once it has healed. Then decide if this is a case for you to re-place the implant or for someone more experienced to take this case over (there is no shame in acknowledging this, only in ignoring this!)
Let us know how this case turns out.
Kind Regards,
Bill Schaeffer
Dr. Charles Sutera III
5/26/2013
In reviewing your case, our hope is that the implant has not osteointegrated in its early healing. Do a reverse torque test of the implant. If you can remove it by backing it out...I would.
Otherwise, immediately remove the temp abutment/crown, place a healing abutment, and make the patient a flipper. By immediately loading the implant, the occlusion is only adding an additional source of potential failure.
The periodontium across the entire maxilla presents with severe inflammation in the pictures. Before considering anything else, get the patient's gingival health stable. Place the patient on antibiotics (ideally Keflex 500 qid for 7 days if there is no allergy), and place them on Peridex 0.12% qid for 2 weeks. Evaluate the site in 2 weeks. At that point, based on the implant position and osseous level/contour, you will need to determine if the site may be saved by a soft and hard tissue graft, or if it should be troughed out/socket preserved and reentered in 4-6 months for a new implant to be placed.
Pynadath
5/26/2013
Why would you ever place a 4.7 mm in a lateral incisor space???
Get it out and graft the site and start over.
ttmillerjr
5/26/2013
I think you can learn alot from this case but we have to give it to you straight. Firstly, I think your flap was inadequate and the tissue was traumatized. The flap shouldn't keep slipping and have to be retracted over and over. One might think a smaller flap is less traumatizing, but the tissue takes less trauma if we make a proper size flap. Second thought is that the lateral was positioned buccal to the central and canine resulting in thin bone and ultimately the bone loss in photo one. So the plan has to be to reposition to the palatal. Ideally if you make a straight line from the buccal of the canine crown to the buccal of the central crown the new implant will be ~2mm palatal to the line. You can see that the way the implant is placed, any grafting you tried to do is outside the plane where bone would naturally be, so difficult to do and no surprise it didn't work. It's always a good idea to find out why the natural tooth was lost. The third observation is the size of the implant, 4.7 is a big boy. The trend is toward smaller implants in the anterior, leaving some space between the buccal plate and implant that is grafted. Anyway, you better take this implant out and create a proper site. It seems as though there are several concepts you could have a better grasp of. Study, read Misch's books read the journals and take continuums so you have the knowledge and skills to succeed.
CRS
5/27/2013
Looking backward I suspect the 4.7 implant was used to obliterate the space, when they heal in this area it just doesn't look right and I am concerned for long term hygiene. I actually had to redo a case like this for a dds the implant developed periimplantitis. Also I stopped using the Straumann tapered effect "747-wide bodies " for the same reason they just don't look right. However I also hear and agree with the idea that titanium is a good graft it just has to be appropriate size for the area to allow enough living bone interaction, esthetics, hygiene and strength. I bet there are bell curves and learning curves for all these factors and parameters! Yikes! Thanks as always for reading
Sb oms
5/27/2013
CRS
The straumann wide bodies (747 as you call them) are great in the posterior. The tissue level implants with the polished transmucosal portion are the most peri-implantitis resistant fixtures I have in my arsenal. I have probably done about 1000 posteriors with the straumann standard plus, and I would want this placed in me if I needed a molar replaced.
Yes, they aren't great for anteriors. Here platform switching really is a plus.
CRS
5/27/2013
Talking about Tapered Effect placed in Maxillary Molar-Bicuspid areas, not Standard Plus which I place routinely too, they look like aircraft carriers!
Dr Bob
5/29/2013
Thank you for the post. This can occur even months after final crown placement if the facial tissues are to thin to be maintained. The patient is not likely ever to be happy with this result. This is a problem that can not be repaired without implant removal. It can often be avoided by grafting after extraction to allow healing before implant placement. When a facial boney defect exists with the natural tooth there is a greater risk that healing will not be ideal with immediate implant placement. No graft can repair this problem at this time. In a lateral incisor position with the limited space the implant is probably to wide to allow for the developement of proper gingival contours even if placement was not immediate. The space may be larger than it appears in the photo I could be mistaken, but a narrower implant probably would have allowed for a more lingual placement and perhaps a graft over the facial at the time of placement.
If the patient insists on having a tooth fixed in place immediatly after the extraction a denture tooth or the extracted natural tooth could be bonded into place. When the risks involved with trying to save three months or so in treatment time is explained just about all of our patients thank us for caring to do the job the "right way".
Baker Vinci
5/29/2013
Am I the only one seeing the poor tissue health of the adjacent dentition? I would consider this, before doing anything! Bv
Dr H
5/29/2013
There is inflammation from sx and PO in these photos. Otherwise Perio was WNL.
Baker Vinci
5/29/2013
The flap design in my opinion, is a problem, especially in the dirty environment. Preoperative Perio treatment is an essential in this case. Bvinci
Dr H
5/29/2013
These photos were seen In the presence of a fracture tooth, a defect on the buccal aspect, and mobility ( eventually what convinced him to move forward w/ tx ), all this created the inflammation you see. PO photo is going to show inflammation. Perio is sound.
DrT
5/29/2013
Gingiva on tooth #9 is perfectly healthy. Tissue on #11 is two week post surgery and is adjacent to an exposed implant so I would expect to see some inflammation. Bv, what else are you seeing that concerns you periodontally?
Dr H
5/29/2013
The underlying defect on the buccal aspect of #10 affected gingivae on the distal aspect of #10 and the mesial aspect of #11. All which was exposed upon sx, and even more so upon healing. Perio condition was under control and healthy.
Peter Fairbairn
5/29/2013
Good comment BV , welcome back . lots of good comments , my question is the grafting and was the membrane placed with the small flap . but the OH is well not good maybe a denture for a while with standing a little closer to the toothbrush would be a solution .
but removal best as said .
Peter
Baker Vinci
5/29/2013
The tissue between the central incisors just appears red and" boggy". It could just be the photos and a local condition. Bv
DrT
5/30/2013
Bone on x-ray looks perfect. There are crowns present with subgingival margins..I am not surprised to see some gingival inflammation
lvh
5/30/2013
Why did you do a flap?
Dr H
5/30/2013
To understand the extent of this buccal defect ( Initially presented w/ fistulus tract ). I wanted to add bone graft to this implant to create stability and fill-in the defect. Once bone was added to site, a membrane was placed over defect and lingual aspect of socket to keep bone contents in socket and allow healing.
Andres Paraud
5/31/2013
I think if you dont have a buccal plate, its not a predictable case for inmediate implant, or if you want to try , you should use a narrow implant that goes more to the palatal to give more space to the graft material,i agree with the NO FLAP better because of the flap you loose more irrigation of the rest thin buccal plate so you loose more bone, i think other problem its the deep of the implant, a more deep implant too as i see on your pictures the implant its just 1 or 2 mm from CEJ, i would use a cone morse conection to place an subcrestal implant like ankylos 3.5, the big plataform switch of this kind of implant give you more space for the graft material, and place a provisional to protect the graft, still so in 90% of my cases i suggest one miracle at the time, first i would graft, and then do the implant, more safe way, many times we want to do everything fast, but the problem with that its, the implant place in a bad position (angulation or tridimentional position), and you cant control the resorbtion and the shrink of the tissue, if you just graft, is its shrink too much, you can graft again when you place the implant and compensate. Just my thoughts,
from this kind of failures its when we learn more, and no one who make a lots of implants its free of failures, so keep up the work and analyze what you did wrong with this case, or what you do diferent for the next.
Best regards and good luck, from chile
Andres Paraud
peter Fairbairn
5/31/2013
Dr H , too many things done too quickly and even for me too many miracles expected .
I follow a set protocol for the last 10 years for type of case after extraction allow 3 weeks for soft tissue closure , then raise a flap ( site specific ) , YES you were right to raise one to assess the bone situation correctly ( That is Visually ) and currette the sight thoroughly , then place a narrow ( 3.5 ) Implant slightly palatally so there is a space between the buccal plate and the Implant which you can then graft with a fully bio-absorbable synthetic material and then close the flap with no membrane which may hinder the healing .
Why , well the issue of bundle bone and blood supply to this critical area for success or failure is of great importance or else this thin bone will be lost leading to your situation.
Sounds easy ? but so does Golf , just walk up and hit a ball , practice makes you "luckier "
Good Luck
Peter
Gregori Kurtzman
7/23/2013
Looks like at placement there was no attached gingiva on the facial and the soft tissue was not in great shape which led to the recession and thread exposure. Remove the implant and place an osseous graft along with a free gingival tissue graft to develop attached gingiva then go back and place a new implant in the proper position and level
Oleg amayev
8/24/2013
Implant looks like was place too buccaly, not enough buccal bone thats why it's exposed. X-ray also show pap at apex. Possible bone perforation. This implant must be removed, grafted, and new implant placed in a proper position to achieve best esthetic result.
