Guided bone regeneration or removal of the implant?

The cause of the recession is at least partially associated with the maxillary anterior frenum. But for sure if you are to repair this you will need to remove the frenum before repair is possible. Inform the patient that this will require more than one surgery. I would remove the frenum, detoxify the implant surface, graft with a putty mixed with granules, place a membrane if you like, coronally advance the flap to attempt to bury the implant. This will unlikely provide the final result but will hopefully get you closer to your goal so you can better assess what needs to be done as the final step. There are many ways to treat this and hopefully someone has a better approach. Greg Steiner Steiner Laboratories

Hello, More information is needed to help, like surgical history, x-rays, better photos, patient health info etc.. Both of these implants look as though they were placed too labially. Were they placed flapless? More info and we can tell you more.

Yes more information , How long ago where they placed and x-rays . But they look possibly to be too big as well , I alwys use under 4mm Implants in the aesthetic zone. Can this be repaired yes with difficulty and skill , thus may be easier to remove allow for soft tissue healing and then re-place narrower implants and peri-implant grafting ( bio-absorbable ) Peter

And yes Greg again has it , the Frenum is a big issue here and must be dealt with . Peter

Never put implants in central and lateral position. There is not enough space- this is well documented in the literature. Read Froum's text about complications in implant dentistry. Implant goes in central, and lateral is cantilevered. Regarding your case, some more info would be nice. Has this been loaded yet, or is the patient still in healing abutments? How long have the implants been in? pervious posters are correct, soft tissue is trouble here and needs to be addressed. Is your patient wearing a flipper? Choose your next step wisely, might be time to refer.

greg steiner implant dentistry is all about anecdotal evidence. what works in your hands vs. what works in mine. textbooks are basically obsolete in our field due to daily advances in techniques, technology, and materials. it takes years to compile a textbook and get it published and printed. so when it does come out, it's old news. however, there are certain pearls that can be gained by reading them and that's why I stick to it. froum's textbook on implant complications is a collection of recommendations based upon cases he and his co-authors have seen. one particular group dealt with this concept- the spacing required for adjacent implants in the anterior maxilla. i don't want to clog the blog, so i'll keep my points simple. 1. There are beginners reading this post and using it to form guidelines in their own offices. They should know that placing adjacent implants in the central/lateral positions or canine /lateral positions is not a good idea. While this may not be the sole reason for the labial dehiscence in this case, it is definitely an important issue to raise for the treating doctor. We just don't have enough info here to make recommendations. No x-rays, scans, etc... 2. Honestly, I find your recommendations to the treating doctor ridiculous. Do you really believe that you can fix this with graft putty and a frenectomy? The implants are practically on top of each other. There is no attached or keratinized tissue. This is not peri-implantitis. It is a wound break down and should be treated as such. 3. 25% of my practice is implant problems that are referred from other specialists. As expected, it is the most challenging aspect of my practice, but I treat these patients to try and learn about the shortcomings of implant dentistry. I can tell you, above and beyond anecdotal evidence, that placing implants in the central/lateral positions is not something that should ever be recommended to a novice. The lateral as a cantilevered pontic is a powerful tool both esthetically and functionally. It has taken me years to learn this. 4. In the above case one of the implants should be removed or put to sleep. I cant't give more specific info based on the lack of x-rays, etc... I would not try and graft here to save this implant.

I do agree with the frenum issue especially if the patient has a diastama before. second issue how thick was the the bucall bone plate and how far did you engaged it during implant insertion. regarding should we replace adjacent central and incisor by implants? the answer is simple and applied not only to central and lateral but to any adjacent implants, the available space putting in mined distance between implants and also natural tooth. for sure in the lower arch central and lateral space are limited but this not the case in upper arch

sboms, I do agree with you about this case. Aesthetic issues are very challenging. With this case I may be inclined to remove both implants perform hard and soft tissue grafting to develop the site. I would consider narrow body implants (not minis). It's unfortunate this treatment got this way. Proper planning would go a long way. Yes, a frenectomy may be in order. I do recommend Froum's text as a must read for the novice to the advanced implant doctor.

Hi guys, I am the person who sent this photo, I am a Msci student but I have been placing implants for some time . In this particular situation, since the patient came for examination I thought that the case was not for me as the smile line was high, there were substantial periapical lesions, and the queratinized gingivae was minimal. I then had a colleague that is said to be very experienced, with a doctorate in America and claiming to have more than 20.000 implants placed. I then called him and sent some photos , he said that the case was very straight forward and he could come to my surgery and perform the surgical stage. In the middle of the surgery , I started to feel that something was not right, as he started to remove the whole buccal cortical on both teeth saying that it was too thin and it would resorb anyway, I did not agree with that but as a beginner I thought I should not say anything , I also did not agree with the placement of two implants but again he was the "experienced" surgeon . The situation now is that he is not in the country anymore and both implants are very well integrated, the surgical part was done 3 months ago and I have talked to several colleagues including Sposito and Wang , both having several articles on Bone Regeneration and the frennun seems to be a big problem as well as the primary closure after the graft . My thoughts now are to remove the implant on the central incisor position fill with granulated bone and cantilever the central incisor as on the lateral region there are no soft tissue issues . For the beginners : do not rely only in "experience" and try to follow the evidence based articles, If I had follow what I have learnt on the Msci I would not be on that situation. Thank you very much for all the answers

ds, Thank you for sharing this case with us. It would be very helpful if you post some of the xrays from this case in order to get better opinions from the group. Preferably pre and post surgical xrays if possible. Just like previous doctors have stated, implant complications have become a big part of all implant practices and we have treated similar cases before. Again, as stated before, this looks like multiple surgeries will be required regardless if you decide to remove or maintain the implants. Soft tissue grafting is probably unavoidable but it is hard to treatment plan strictly off of a photo. But to answer your questions based on previous experiences if you're not removing the implants: 1) I would prefer autogenous bone either completely or mixed in with your graft of choice. I've been using a DFDBA/FDBA mix but whatever works in your hands. 2)You need a space maintaining membrane. I have used titanium reinforced membranes with grafting around implants with good success. Also SonicWeld works well. 3) you may consider a connective tissue graft during the first surgery and then reassess after healing. I expect the soft tissue will need multiple surgeries and corrections. I also agree the frenectomy may need to be done prior to beginning anything. I hope this helps and by no means is this the only way or even best way to treat this case. Good Luck and please keep us posted on the outcome.

Remove them they failed due to poor site preparation (3mm between implants 1mm between natural tooth and implant, too large too close together) Can you send this back to the skilled surgeon who placed 20,000 implants kinda like the us pro basketball player who stated that he slept with 10,000 women.

I would remove it and restart again specially this early in the game. The esthetic results would be awful if GBR doesn't work(which probably won't). Take out the implant and graft and replace in a few moths!

ds , a truely scary story , do you work in the UK? Amar , I stiil believe what David Garber said many years ago , Soft tissue is the issue but bone sets the tone and then an add on that the buccal plate will seal your fate. After many years of trying I find soft tissue grafting unpredictable so I do the hard tissue correction and let the body deal with the soft tissue . As for autogenous and membranes I have not used them for the last 1,200 grafts and can achieve very satisfactory results from dire cases. In Dentistry many things can work as long as you work with the bodies healing agenda. Regards Peter

When someone tells you they have placed 20, 000 implants, you should have congratulated him and moved on. I don't think you can get a satisfactory result, with the information at hand. If the implants are well integrated with bone at all four areas, then you could consider a frenectomy, followed by an augmentation type procedure, a la M. Block, from the July JOMS issue. You can not effectively treat the frenum and perform the graft in the same surgical setting. I have had some succes in salvaging cases such as this, but this will always be compromised at best. I have used mineralized bone and alloderm, but will give bioss a try soon. Remember nothing will integrate to the implant at this stage. All your efforts will effect cosmetics and possibly hygiene, only. B Vinci. Baton Rouge, La.

hi people, just trying to upload new photos from today. How do i do that? DS

To upload new photos, simply go to the Post a Case link and upload the photos. Be sure to reference this case and use the same email you have used to post the original case.

Very sad to read about the surgical experience. Please post the results of your fix of this case. You seem to have first the well being of your patient at heart. Wish you the best.

Autologous graft is gold standard but events like this happens because of a stimuli irritant etc. pathologically speaking, make sure the bone tissue and surrounding periodONTIUM is infection free, fibrous tissue free, it’s good to use autologous grafts mixed with xenografts putty to fill in defect, also a membrane is a must, it prevents resorption, resorption always starts from the connective tissue to bone NOT vice versa, a good coranally repositioned flap tightly secured a little prayer and your good to go

Frenum??the problem is the 3D position of the implants..too close and too big for that space! Restart removing the implants and try again! A surgical guide maybe will help you to sharon out the space..

"Soft tissue is the issue but bone sets the tone and then an add on that the buccal plate will seal your fate." nice, think I'll memorize this one. in summary, an exageration. implants are too wide, too close and perhaps avoidable; teeth 21 + 22 look like crowns, could have just prepared Canine and made a bridge, simple and reliable, but perhaps too cheap for those wh just want to make money and not apply ideal solution for respective paients. Implants are a solution for many problems but should not be considerd the begining nad end of dentistry. RM.