Palatal Dehiscence: Recommendations?

I would wait but I'am worried that you used bio oss to attempt to form bone - you may have to wait a looong time for bone to be established. Iam also afraid that when you enter you may just find some dry granuls of graft materials. Antibiotics may reduce the spread of the sepsis but - as the graft material has no blood supply - it cant get into the graft material.If the palatal mucosa is nice and thick I dont see the point of a membrane there. A lot of the time people use membranes as a means of graft containment and in my opinion it just reduces a blood supply source. I hope your implant will survive but if not I would remove it and graft first (not bio oss)in an infection free site and do the implant at a later stage. Once bitten ,twice shy in my hands and if you explain the concerns to your patient they will appreciate it. Good luck.

Thanks Dr. Cason. Here's an update. Supporation continued, so I re-entered site and curetted infected granulomatous tissue. Implant is integrated, however bone loss to third thread circumferentially noted. It's an 11.5 long implant (Replace Select). I'm considering grafting in a month to allow for primray closure, but not sure I'll get any results with that either. If I remove an integrated implant on the other hand I'm afraid I'll create a bigger defect. Catch 22 as they say.

Because you report bone loss to the third thread that is circumferential and because this site is within the "esthetic zone" I think it would be wise to remove the implant, attempt to regenerate bone and gain closure with a pediculated palatal CT graft per Mathews and Osterberg. If p.o. radiographic analysis shows that you have lost significant ridge height, you may wish to consider an alternative prostheic approach.

What would you do if this were in YOUR mouth??

I personally would concentrate on getting the area sepsis free; a radiograph would help really to assess, when you say 3rd thread ie past the micro threads and then 3 threads or ??!! I wouldnt worry too mnuch if in doubt if its on your mind reverse torque and provided sepsis free bio-oss biogide or wait 6 weeks and re-enter and augment with the view 5-6 months later re-entering?!! Cheers

HI sir: I recomend , leave implant , then curette and detotoxify surgical site and finaly use ring autogenous bone graft .

Some interesting ideas. My concern is how to get the implant surface sepsis free. Curettage wont do it so what is the current thinking in terms of chemical cleaning - -is tetracyline still in vogue. unless the upper threads are totally free of bugs I dont hold out much hope for a graft to intrgrate onto the surface. It will be a case of an ailing implant with a "long junctional" type of tissue response as opposed to a failing implant. At least Iam not the only one this has happened to.

I agree, I would try to eliminate the bacterial contamination/biofilm and graft with something that would turn over at a proper rate. Do not use BioOss. Osteogen will work nicely here. I would also protect the graft with periopack or better yet with a stent for a good period of time. I had a similas situation on a Vietnamese female (#9). I remofed the root form and placed a single toooth two stage blade. Worked like a champ and did not have to BS around with grafting.

I agree that I will prabably not get any osseointegration with a bone graft on a previously contaminated surface. The only studies I know of are that of Simion's histologic studies which showed integration, however his implants were not contaminated. In my opinion, even if I don't get integration at the coronal level, preventing a 7 or 8 mm pocket may improve the prognosis. Ofcourse I would have to involve the patient in any decision making and provide him with all options. Thanks.

In my humble opinion the only thing to do here is clean the implant. you can place as much bio-oss or any other bone substitute material along with membranes you will never form bone. Any one that thinks they can I would love to see the results and not just a periapical that gives 2D pictures. the only way I have found successful in eliminating bacteria from implants is with prophyjet and laser together. one can use sodium bicarbonate which cleans beautifully. there are studies that show how well it works but they worry about further integration. As you are not going to get any anyway is it a major concern. I think not. That coupled with the laser will work wonders and soft tissue will heal well. this will also allow you to re-sink the implant and then re-epose bringing more tissue from the palate. You may still have to take the implant out if the closure does not work but it is difficult to give advice when one has no x-rays or photos to work on. good luck