Exposure of Threads on Implant: Best Course of Treatment?

Patient lacks attached gingiva which is the likely etiology here. I recommend a free soft tissue graft.

Not only is there lack of attached gingiva, but the implant is quite small if this is a left maxillary second premolar. Your radiograph looks like a mandibular second premolar. Yes a tissue graft would help with your tissue situation, however long term you may have a problem with further bone loss on the implant due to overload. If you are to restore this implant, make sure it is completely out of occlusion.

with respect to the previous comments, I do not think that implant size or overload have an important role. the implant placement was not perfect and there was not enough buccal bone to maintain soft tissues, I guess. anyway, bone graft or soft tissue graft are not predictable because it is vertical augmentation and the bone loss is not contained. I suggest implant removal and start over again, place the implant deeper and maybe more palatal (not sure because I can not see it clearly in the pics) good luck

If this is progressive recession, do a free gingival graft to add additional attached gingiva on the buccal part of the implant. This is assuming the implant is stable. As long as this site is not esthetic, it's not a big deal. The implant is fine and doesn't need to be removed.

The fixture has 50% bone loss which does not bode well after being restored. Would suggest remove the implant and place another fixture it appears you have additional depth that can be used may be good to get a CBCT to verify

I basically agree with Hamza: deepen the implant and soft tissue graft. There is another consideration: is the defect esthetically compromising? If not, then leave as is, after polishing. If not esthetically compromising, then will the abutment be a straight one or angled? If straight, the lab can easilly extend the crown to hide the exposed implant collar. Patient has to be higienically cooperative, of course. If angled abutment is to be used, you would have to prep perhaps too much, perhaps not, to hide the implant collar.

I agree with some of the comments above. I think the lack of attached tissue in this area probably allowed the tissue to retract slightly during healing which caused some reactive process and bone loss. If you look at the bone level on this implant vs the adjacent implant, the bone has scalloped down 1-2 threads. I would also be concerned about the amount of buccal bone along this implant which could be effected by lateral (occlusal) force on the implant. (hence the comment at not loading the implant-which would have a role long term) This could cause further bone loss and retraction over time. An attached tissue graft would help stabilize the tissue but is not always predictable since there is some bone loss and exposed threads which are hard to keep clean. The concern is long term (like 4-5 years down the road), to make sure you are not developing a progressive pocket with bone loss along the buccal even if you have attached tissue graft. The most predictable treatment is removal. You could present the patient with treatment options of graft vs removal.

Its not a problem to continue with the given current situation.However as mentioned earlier due to the un-ideal placement (too buccal, lack of buccal bone)and also the presence of thin tissue biotype has led to the apical displacement of the soft tissue. A soft tissue graft may help cover up temporarily (for a year or 2) but may not help in the long term stabilization of the buccal soft tissue. As mentioned by another colleague, go ahead with the prosthetic phase and place the buccal margin slightly submarginal (predicting some more apical displacement in time to come)and do not place it in active occlusion. The implant may serve for about more than 10-12 years without any trouble. But further bone loss bucally may occur.

If the fixture has these problems already and it has been recently placed, then I think the best service is to remove it while it may not be fully integrated, and after waiting several months, place another fixture, this time deeper, and more towards the palate. If you proceed with restoring this fixture, the patient is going to have a chronic problem forever. Would YOU want this...what would you do if this were your wife??

Photos and radiographs can be difficult to interpret, but this case is confusing insofar as your description and the posted images are concerned. You referred to an implant at ADA #13 position. I see no anatomy that clearly indicates the implant is in the maxilla. The more posterior implant (presumably ADA #14) does not show any evidence of sinus floor on the radiograph as well. Regardless, the most anterior implant is placed such that there is little doubt that a significant buccal side bone defect is present, as well as inadequate bone vertically against the fixture. I suspect the ridge was too narrow for a standard implant to start with. Although the soft tissues do not appear highly inflamed or infected, one would certainly not consider the soft tissue picture around this implant "normal". As previously noted, there is grossly inadequate attached gingiva. The implant is also positioned too far posterior for a anatomically correct second premolar crown. Soft tissue grafting for increased width of keratinized mucosa will not work, as the flap required would expose implant body and eliminate the important blood supply required under the graft. I suspect it would make the situation worse. You could consider bone and soft tissue grafting (remove healing abutment and "sleep" the fixture), but you will not gain vertical bone height with any predictability, particularly now that the surface is contaminated. Your best option for long-term success is probably to remove the fixture and start over. A lengthy discussion with the patient is in order. We have all been there, but you appear to be stuck between a rock and a hard place with this one.

As mentioned above, the photographs and radiograph do not clearly indicate where this implant was placed...the radiograph seems to me that of a mandible, showing the inferior dental canal...there is no evidence of a sinus cavity. In any case, since the implant is stable,causing no problems, then why not restore it with a nice temporary crown extended to cover the exposed threads, saving the patient a lot of money, and the dentist not having to justify a less than perfect result. Gerald Rudick dds Montreal, Canada

I would proceed with making splinted composite crowns. It depends on how powerful antagonists are (natural or artificial). Loading moment will decide a future of these implants I would not remove ones, because they are stable and without signs of inflammation.

I understand why in some cases, when a compromise situation arises after an implant has been in a patient's mouth for awhile, why one would look for a "bale-out" solution. However, I just don't think that in this instance, where the implant clearly has both an osseous as well as a mucogingival problem, and it has just recently been placed, why we are talking about any sub-standard treatment other than removing the fixture and placing it for a second time, this time the RIGHT way. This can be done in a very predictable fashion. If any other course of action is followed, we are building in FAILURE in the future, when we will very likely have osseous and/or mucogingival problems of a nature that will require multiple surgical procedures, and quite possibly never be resolved to an optimal result. Mistakes happen...this is certainly understandable. However, to perpetuate this mistake is not only understandable, but it is unethical, and just plain not right.

I am unsure about the type of implant used, but with newer generation implants with surface ehancement, it is unaccepatable to have any thread exposed as the longterm prognosis is poor.Remove the healing abutment, replace the healing screw and augment together with a non resorbable membrane. There should be reasonable chance of success. If unsuccessful, remove and start again. It is unacceptable in any circumstance to have the enhanced surface exposed as failure will ultimately occur. The radiograph doesn't show any obvious saucerization of the bone around the crestal bone which would tend to indicate the implant wasn't fully placed in the first place.

As I mentioned previously, we have a tissue issue, there is substantial bone loss. In previous comments the size of the implant in length and diameter, as well as where in the mouth has very big importance for long term success. Have we not heard Carl Misch talk about F=S/A....well this implant does not have much bone to implant contact as it can have. Therefore there is poor surface area which would not be able to withstand the forces that will potentially be placed on it, which would eventually cause more bone loss and failure. Don't compromise and take the implant out and go for at least a longer implant.

hamza already said. its not very important of the size or overload. the radiograph and picture is very clear, its left maxillary premolar only. it seems quite healthy. no need of replacement. simple free gingival graft will increase the esthetics .its quite stable need not to worry.well no association of allograft at all. absolute nothin to worry.

Show me the radiograph from the day of placement, and it would make commenting on the prognosis much easier. If the X-ray looks similar, and the implant is integrated, and it's cosmetically not a concern, then you could polish the threads and restore. That is a lot of if's, but it would also explain "why" there is no bone and thread exposure. If there was bone before, then this case becomes very unpredictable. The aesthetic concerns might also be to big an issue.

I believe the patient will be best served by: 1) implant removal 2) bone grafting / widen ridge 3) Increase attached gingiva / lip switch vestibuloplasty 4) frenectomy to reduce pull on gingiva/mucosa 5) place implant ( minimum 10mm.)