Inter-radicular Bone Exposure following Implant Placement in Previous Smoker: Suggestions?

I have a patient who is a young man and a smoker who was a candidate for implants.  After discussing the treatment plan, the patient said he would stop smoking immediately.  I placed 2 Astra implants in immediate extraction sockets of the 2 lower right premolars.  Before closing the surgical wound, I placed particulate bone and membrane on the buccal side of the implants to cover over a limited defect in the buccal plate. Two weeks later the patient returned to my office with 3mm of inter-radicular bone exposed between the 2 implants. Besides that, 3 threads of each the 2 implants were exposed as well. The patient insists that he did not smoke and neither had he traumatized the implant site.  Any suggestions on  management of this case?

17 thoughts on: Inter-radicular Bone Exposure following Implant Placement in Previous Smoker: Suggestions?

  1. Timothy C Carter says:

    At this point just wait it out for 8-12 weeks. In the lower premolar area we often find thin mucossa with little to no attached gingiva which is likely the case here. Easy to say in hind sight but perhaps a soft tissue graft and a delayed approach would be better. I have found through experience, which is a fancy word for collection of errors, that immediate placement in mandibular premolars is rarely the best option due to the absence of attachment. I would like to see soft tissue grafts done as frequently as bone grafts around implants but apparently that doesn’t sell products.

  2. Dennis Flanagan DDS MSc says:

    Good comment from Dr Carter. Attached tissue or immoveable mucosa is a requirement. Smokers are famous for lying about quitting. Nonetheless, the damage has been done by the previous smoking. Quitting for a few days helps a little but not much.

  3. Dr. Moe says:

    Several things could have happened.
    1) This is hind sight of course, but smoker, depending upon how long, does not make a difference if they found religion for 2 months. If the Pt is 1 Pack/day smoker, long term damage is done to the capillaries that supply the bone. Bone might not remodel because of lack of blood supply.

    2) why healing abutments? He could be touching them with his tongue all the time causing micro-movement. I am not an expert by any means but I would figure for a smoker, whether they are telling the truth or not, burying the implant might be a better approach.

    3) X-ray will show how close the implants are to each other. If you are encroaching on at least 3mm between implants then that could be the other reason.

    And, lastly, thanks for posting this case, because we are all in this together, learning and placing implants. If with the crowdsource we can figure out the problem in this case, we all learn and avoid future complications.
    Just my $0.02

  4. Dr. Gerald Rudick says:

    If the poster did not say that this patient is a young man, I would never have guessed it……just look at the abnormal wear of his natural teeth…..I would have guessed this to be a person over 65.
    I agree with the above comments that healing collars should not have been placed; and that the implants are too close together.
    You cannot take a smoker’s word at face value when they tell you they have stopped smoking completely…..smokers are addicted people….who have a tendency to exajurate and lie a little bit….don’t blame yourself

  5. Timothy C Carter says:

    I agree that the implants could be spaced farther apart but they are not too close together. They appear to have flared healing abutments and there seems to be at least 3mm between the collars of the actual fixtures so I don’t think that is a problem. I also don’t see a problem with placing healing abutment initially in this case. I do probably 95% of my cases in a single stage approach (not that it matters but I use Zimmer TSV, Zimmer Swiss Plus, and Blue Sky Bio One Stage in my practice) and have not found that to be an issue. Remember Straumann/ITI has been tissue level, with either 2.8mm or 1.8mm transmucossal collars, since the beginning and they have been extremely successful. I place about 400/year and I really dislike doing second stage surgery and only submerge if there is a reason such as aesthetic area with a removable etc.. I think in this case you got bit by thin mucossa and if you attempted to graft with a membrane you probably placed too much tension on the thin flap. There is a good chance that you will be pleasantly surprised with the outcome as long as you augment the soft tissue in about 8 weeks.

  6. Oleg Amayev says:

    First thing I want to say: there no way in the world anyone who smoke and when they come to a dentist and will say I will stop smoking now.
    Second: this causes not because of smoking, patient smoke pack or more and will not cause that.
    This issue causes because implant was placed very close to buccal bone and there was not enough buccal bone around the implant. You must have minimum 1-1.5 mm of bone, I prefer 2mm.
    That will always happen when there not enough buccal bone.
    Just remove this implant, and graft the area. Take CT scan, fabricate surgical guide and place implant.
    Things happen to everyone, don’t panic, next time you know what to do, that’s how we learn. Good luck

    • Anon

      The healing abutment are too much flared; the implants are not too close.
      i was considering to remove the implants and graft the socket; but my concern is that i might not be able to advance the buccal flap to achieve primary closure over the grafted sockets as tissue might be friable at that stage. any thoughts in this respect ?

      • Timothy C Carter says:

        Don’t be in such a hurry. Regardless of the next step you have to augment the deficient mucosa. This is a soft tissue problem more than it is a hard tissue problem. I blame the CE providers for not teaching soft tissue grafting/management. Apparently connective tissue grafts don’t generate enough revenue for the companies funding the weekend education.

      • Oleg Amayev says:

        You can achieve primary closure by making releasing incision, and place mattress type suturing to keep the wound closed.
        In case if you can not do this, just remove these implants, remove all granulation tissue, place allograft bone graft( just pack it), if you have tissue adhesive then you can put it on top of the bone graft and and you won’t nees any sutures. Let it heal for 4 -5 months, take CT scan, fabricate surgical guide, and place implants again.

        • Kariem Elhelow says:

          I have 3 mm of inter- radicular bone exposed. I am considering to keep the 2 implants, decorticate the exposed inter-radicular bone, grafting the exposed threads of the implants, remove healing abutments and cover up the implants by advancing the buccal flap or cover the wound with tissue glue (periacryl) if I couldn’t advance the flap enough. My concern is would the grafting of exposed thread work after 2 weeks of exposure (provided no infection is evident) ?

          • Kariem says:

            Or shall I simply decorticate the exposed inter-radicular bone then place connective tissue graft to cover up:
            the exposed threads and
            the exposed inter- radicular bone

          • Timothy C Carter says:

            First you need to do a connective tissue graft to augment the thin mucosa. Bone grafting is a waste of time as long as you have a soft tissue deficiency. After soft tissue augmentation you can attempt to graft over the exposed threads, if you still think it is necessary. Once again the issue here is the deficiency of the mucosa. Once that is corrected this case will be fine.

      • Oleg Amayev says:

        You making your situation more difficult if you planning to keep these implants and graf it. But if you decided to go this route then you must treat this implants with polyphosphoric acid before you placing bone graft on the implant. Implant repair it’s not that easy, I don’t know how much experience do you have, but I think you making more complicated. You better off just remove them and replace them. Don’t worry about the tissue, the tissue will grow back after you remove them. You can again attached gingiva buy making incision more lingualy when you placing healing caps.

        • kariem says:

          if i decided to remove the implants, is it enough to pack particulate bone in the socket and seal the top of the socket with periacryl oral adhesive or i still should place a membrane ?

  7. Dr Dale Gerke, BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    All the comments have been good, but I would suggest that a radiograph of the site is required before too much can be accurately said about the problem/s.
    My first thought is that the implants are probably too close together, but how can I tell from a single angulated photo?
    I have used Astra implants extensively and my experience would indicate that when the two healing caps are too close, then the soft tissue has problems healing well and forming a good gingival cuff. In fact (again hard to see from the photo) the healing caps maybe touching and therefore one or both may not have been screwed down properly – thus allowing bacteria and soft tissue to do undesirable things during the healing process.

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