Peri-implant Mucositis with Straumann Implant: Best Treatment Option?

I would not remove implants now, because they are stable. Incisors look bulky and probably, overloading is the cause of the problem.

For your question No. 2 due to grafting (science): 1.) Bio-Oss has an indissolubility in the human bone. That means it is an unresorbable bovine hydroxylapatite with possible proteins (produced by low temperatures and alkaline solutions) from cows. Your patient will have cowbone for the whole life in the jaw. 2.) Fortoss Vital is betatricalciumphosphat. That means it is resorbable and an original synthetical graftmaterial whithout biological risks from animals. After the resorption your patient will have vital and human bone.

i think there are a couple of issues here. As you say the implants are called bone level, and as such they should be placed at the level of the bone, clearly these are not. The next issue is one of bone coverage in the buccal. I feel that on both implants you will probably find a lack of buccal plate, especially the 32 implant where a larger diameter implant has been placed. I am sure that you will need to place a bone graft to manage this issue. It looks like there is a graying of the tissue down 5mm to the MGJ and beyond on this implant. In my opinion the best thing to do would be: 1, remove bridge and abutments and place implant level healing caps. 2, allow the tissue to close over, use a filled exssix retainer for temp. 3, 3-4 weeks, open FTMPF and see what you have, periostial relieving incision. clean implant surfaces (blaster /lazer) and scrape bone for RAF. where the flap has a roll of epithelium and has not sealed over the implants cut this tag off, so you do not get a dehiscence. Place a Fortoss vital graft and allow to harden. suture up with 6/0 proline (not resorbable) interrupted, short and long mattress. 4, trim the temp so no pressure. 5, allow healing time 4 months. 6, use the sraumann gold bridge abutments for your bridge as they have minimal flare. ( think that the big flare of these abutments compounded the issue a bit) you may need to place a ctg to get attached tissue back, but this needs to be assessed after the bone graft. I have noticed with vital that I tend to get a bit more attached tissue after than I was expecting. Check the occlusion of the bridge especially the path of closure not just intercuspation, you could introduce an interference on the arc of closure in this case. (again May have been one of the compound factors) All the best, Mike

Thank you all for your comments. Thank You Mike for such an in depth answer for management. Much appreciated.

I am an OS and I would recommend referral to a Perio

ok .... problem is obviously the bone height and if you take a look at the adjacenet natural tooth and the level of the other implant it will be IMPOSSIBLE to get bone height that will stay long term by grafting because you will never get the bone higher around that natural tooth. You have 2 options. Remove implant (tough procedure and many months of treatment. or.. attempt the buccal roll technique AFTER removing the bridge and abutments and placing platform level healing caps. Make a flap on the bucccal with a good release and as long as you have good AG you can roll into the flap are toward the lingual and make nice sloft tissue contour. Wait 3 months for healing and then place the bridge back.. look up the buccal roll technique its out there and I used it with much success. If AG is lacking then the only optionin my opinion is remove fixture and graft and replace good luck

Thank you again. Which grafting do you prefer DR W?

I doubt this is a simple overloading issue. Often when I see cases presentied here there is too little diagnostic information. I think we would all agree it would be helpful to see preoperative and time of surgery radiographs probings etc. because what comments are often educated speculation. At the end of the day the issue IS PROBABLY (need to see time of surgery x-ray) the implant placement depth. If this is the case, grafting these cases is not highly predictable at least from a potential esthetic standpoint and may result in further complications. In my opinion, the only long term predictable treatement is to deal with the etiolology. Having said that, it will probably function as it is for a period of time but may loose bone in the process making further implant placement more difficult. If you remove it now and graft you will most likely still loose some bone.

This situation appears to me to be a "No-Win" situation for the patient. So you must realize that any treatment that you get involved with is more apt to make things worse rathert than better. And, once you begin any treatment, you are apt to be liable for any negative results that occur...and they most certainly will. Having said this, it would seem to me that both options #1 and #2 have no biologic rationale to them. I have yet to see osseous grafts of any type--including BMP, platelet derived growth factor, and stem cell sources--precitablly regenerate bone supra-crestally. In addition, I am not seeing many if any articles in the literature demonstrating successful CT grafts over implants that have several mm of their crestal threads exposed. So this leaves you, in my opinion, left with option #3. Unfortunately, it appears from the x-ray that the fixture is in fairly close proximity to the adjacent natural tooth. So, removal of this fixture is very apt to cause significant damage to the natural tooth, either in the form of endo or destruction of the root. And of course, there is always the option of doing nothing, as one of the posters has already suggested. This is probably the safest course of action, however, I think that it is your responsibility to inform the patient that this is an unstable situation, and at some point in the future, removal of the fixture may be (make that will be) necessary. By the way, the cause of the problem seems to me to be poor implant placement, both in a vertical as well horizontal plane; not to mention that the implants are way too wide. Occlusal overload?? most likely, but definitely not the primary etiology. Good Luck!! Whatever you decide, I strongly suggest being totally honest in your communication with this patient

Many good responses. I would try LANAP first. See recent research by Yukna. Learn so next one implants are placed better. Is this prosthesis cemented or screw retained? Cemented tends to balance fit. I have had very good success with assisting failing implants with LANAP procedures. Done it all and LANAP comes closest and is certainly easiest. Just to stir the controversy!

I am curious...what is the LNAP procedure going to do to improve on the lack of keratinized gingiva?? likewise for the several mm of crestal bone loss

in this situation we are not trying to vertically augment and bury the implant, we are trying to gain 1.5-2mm of buccal bone around the implant. If there is then a lack of attached tissue a graft will be possible and effective in creating a stable and aesthetic result, in this siuation you will not be dealing with exposed threads as you will have obtianed 1º closure at the time of hard tissue grafting. With a big collar of buccal bone this implant reverts back to being a simple supracrestal placement (think straumann normal etc). In short you don't need to aim for vertical, the horizontal component will do the job for you.

Is this a case of peri-implantitis or peri-mucositis? As a previous poster mentioned, seeing pre-op data would be helpful to say. How is the plaque control? Any pain? Mobility of prosthetics? Probing depths? Bleeding on probing? The picture alone suggests placement and site of placement are of primary aetiology - too far buccal, not bone level, in a thin biotype with minimal/zero keratinized tissue/attached gingiva, and all this in a thin biotype (look at the recession elsewhere). Refer to perio was suggested, and that is what I recommend. Grafting this will not work - as a previous poster mentioned, look at the interproximal bone on the adjacent teeth. Also, how do you expect to graft beyond the alveolar housing on the buccal, on infected implants. Soft tissue grafting on this is unlikely, with the situation as it is now (again infected implants). This is a cast of implantoplasty with subsequent grafting (e.g. free gingival graft) - less traumatic - or take everything out and start again - quite traumatic and costly. Hope that helps.

As always, there are a lot of good suggestions by the doctors lending their experience and expertise to this forum. When this case was started, there was an orthodontic compromise to start with, because there was space for three lower incisors here, and the bone is compromised. Inflammation of the mucosal tissue around the implants is a telltale sign of damage to the underlying bone, which will progress and get worse with time. Grafting to try to regrow bone on top of implant surfaces usually does not work, and there is the risk of damaging the periodontal tissues of the adjacent teeth. Best is to inform the patient, and make sure he/she fully understands that dentists are not Gods, and sometimes treatments performed by the best well intentioned professionals do not always work out the way we would like them to..... as well, sometimes implant therapy is not the best approach to solve the problem. In this case, I would advise attempting to reverse torque both the implants, and get them out with as little trauma to the adjacent natural teeth as possible. If this can be accomplished, then bone grafting can be predictable to rebuild the edentulous ridge with autogenous block/particulate grafting, or particulate grafting enclosed in a titanium form. Once the ridge is developed to an acceptable starting point with healthy gingival tissue, then narrower implants placed at a lower level can probably be placed. Gerald Rudick DDS Montreal, Canada

The LANAP procedure is only a method of reduction of inflammatory response. While eliminating inflammation can lead to a remineralization of osteoid, it will not grow crestal bone. As I understood the complaint was primarily about the inflammation. If the case is one where esthetics are a concern, then I agree that the best way is to remove implants, graft, and start over. If the concern is only the inflammation, then it is worth considering laser treatment. GR above is correct.

As with so many of the cases gone wrong that are presented on this site, the problem starts with failure to make the proper diagnosis. Sadly, some (too many) dentists are too quick to get into treatment, perhaps for what appears to be quick and easy financial gain. Clearly placing implants involves more than drilling a couple of holes in bone...that is if you want the implants to be successful.

Any body can drill a hole and put an implant in. It takes training and years of experience to be able to take it to the next level. My concern over any GP putting in implants is what happens when the oddity or complication occurs? Don't anyone believe that the implant companies are very concerned about that. It is the financial bottom line that is the driving factor with them. But that is the way it is. Everyone needs the opportunity to learn. Just make sure you do. Common sense will prevent most of these problems. Unfortunately, common sense is not all that common. Having been in the business of dental implants since 1982, I've seen it all. As the book in the 1960's said, "Don't eat anything bigger than your head".

I just can't help myself.. I must say this also... a bit of heresy here, if you can listen for a moment. Another option in such a case, is to treat the inflammation however you want, as long is it is successful. Then, prepare the implant abutment below the level of the tissue (or below, to the level of the bone, which is also a method of reducing the inflammation via elimination of microenviroments for the accumulation of bacteria) and then place the margin of a new FPD to that level. This eliminates the visual aspect and also eliminates the inflammation. The lower lip covers the longer length of the teeth and everyone can be much more comfortable. Correction of these cases is not always about the ideal, it can also be about compromise.

There seems to be multiple options here. Is the patient symptomatic? One option is to do nothing to the implant. Bv

These implants are designed to be within the bone, (bone level). If part of implants is outside of the bone, the rough surface will be retained plaque bacteria, and produce mucositis or peri-iimplantitis.treat patients first: prophylaxis, periotreatment,good intrusions implants hygiene.avoid the formation of plaque ,trapped food,around implants surfaces and get better gingival health.the best is redo cases :get implants out,bone graft, and new bridge.

By the way , for those who questioned the rule of thumb measurements between natural teeth and implants,PAY ATTENTION !!!!!!!! Bv

Dr. Rudick, You are so diplomatic. Dr. S, this relatively straight forward case was badly mismanaged. You need to take a step back, slow down and properly treatment plan. Your implants are too big, too far facial, not deep enough, too close to the adjacent teeth and have no attached gingiva. Trying to "repair" this case will be much more challenging than the placement. You cannot grow bone vertically. Grafting bone to threads once exposed is not predictable. You've been given some advice that makes it sound like if you follow the recipe it a slam dunk, NOT SO. These comments are not meant to discourage you, but to make you think. You really made about every mistake you could have, do you think it's fair to the patient. I am guessing you haven't had any real training in implant dentistry. In dentistry we have the luxury of policing ourselves, but if we take advantage of this we may not always have that luxury. Get some real training under your belt and make these mistakes on cadavers or replicas.

We all know how and why implants are designed. It is blatantly clear that this is an all out cluster, but would you want to have two well integrated implants removed from your anterior mandible, with the possibility of compromising the natural adjacent teeth? I bet if this pt was well informed he would most likely defer any care. I can't say that I would blame him! Just don't know what the "implantologist" was thinking. Maybe these teeth drifted posteriorly , into once ideally placed implants??? Bv

Hello I think that u got many suggestions. Do start the treatment & please submit your results here later for others. Thnx

Ttmiller Jr, you make sense . Refreshing to see someone get the " big picture"! Leave this man alone, unless he begs for it , then get a second opinion from a busy surgeon! Bv

One more suggestion. Get a cbct, sometimes the next pa may allow you to take a breath. It's possible that there is more bone than we think b/w the natural teeth and implant! Bv

Ok i'm with opinion and recomandation of dr. Mike

I keep seeing the suggestion , just reverse torque the implants out. Am I missing something? You may as well have a time machine! In 20 years I have never seen an " integrated" implant just back out. Please respond. Bv

Is this important from the aesthetic point of view? I mean, the lower lip cover that area and, with the normal function, it cann't be seen?? Because, from a funcional point of view, I belive that a good option could be a fullthickness flap, exposing the implant threads and, because I do not belive that you could eliminate bacteria from the implant surface with any tecnique or material, you should cut out the threads and make the implant surface as polished as you could, using burs and polishig cups. In a secound fase, you could try a conective tissue graft just to gain some gum thickness. At the same time, I would instruct the pacient with oral higiene. I can see, from the cervical lesions on the upper teeth, that he brushes very hard. He should use superfloss. The crowns shouldn't be so thick. make a new ones. I do not belive that you could acheive a good aesthetic result in any case.

I think that Dr. Ferreira's suggestions have the most merit. Smooth the exposed threads and apically reposition the soft tissue, perhapsd using autologous c.t. or dermal allograft, so that the implants are housed in thick connective tissue. Removing the implants isn't easy, unless the BTI (?) kit works as easily as advertised, and can easily devitalize the adjacent teeth. The buccal surfaces of the implants are beyond the alveolar housing and bone resorption has exposed the threads. The restoration will no longer be anywhere close to esthetically pleasing, but it can be maintained long-term with the suggested treatment.

Good comments Mike , as well as BV , Millar and Ferriera , we will and do see cases like this referred in and they are difficult to correct . So best to plan better , and use scans to assess the bone prior to placement. Yes the 1 implant is too big and too close to adjacent tooth , there is a shortage of attached gingiva and possibly buccal bone , but it is often easy in hindsight and one learns from these issues occuring. BUT we nust treat as though we were the patient , would you remove integrated implants in this situation if was your mouth I think not ! Having worked with Vital on a daily basis for 8 years I would say with the new 500 variant you could hopefully repair the buccal defect to an extent but forget any vertical improvement on the 32 implant which was not placed deep enough. 4 months post re-grafting you can then approach the soft tissue aspect and here Dr Ferriera has polish the threads that are exposed and CT graft ( FGG is too much of a lottery ) or move tissue ( attached Gingiva) from the adjacent area. But both of these procedures are tchically difficult and may best be done by a Periodontist. Good luck Peter

There is obviously a lack of buccal bone with both implants. I am a periodontist and I recommend referring this to an oral surgeon to do a proper bone graft to restore the missing buccal bone !!

Dr Patel, I'm a periodontist too, why do you think it should be referred to an oral surgeon instead of a periodontist? With all due respect to my oral surgeon colleagues whom I refer to on a regular basis, I believe this is an ideal case for a periodontist's expertise, whether in regards to the bone grafting or the soft tissue grafts.

I am not saying that a periodontist cannot treat this problem. I just feel that the underlying problem here is a lack of buccal bone. This patient has already had one failure. Why not have someone who can do a bone graft treat this, whether they be an oral surgeon or periodontist. In my experience, I don't feel comfortable that I can graft this area predictably and would rather that an oral surgeon do it. This is my opinion.

Fair enough. I think anyone with experience in grafting (soft or hard tissue) should get this referral. Although bone grafting around an implant, regardless of experience, is unpredictable.

If it were refered to me ,despite the fact that I feel Very proficient in autogenous grafting( I harvest cranium, hip, tibia and femoral bone), I don't think I could help this guy. I would encourage q 3 month oh protocol, and would discourage doing anything else. Unfortunately I see posterior implants that my restorative colleques consider successful, very similar to this. Since this is below the lip line, I would tx as per posterior tooth protocol. That's one omfs opinion. Maybe the guy placing the implants was trying to duplicate the pre-existing perio compromised scenario. If so he succeded! Unfortunately my reference is skewed, one day I'm placing Implants in a young healthy patient, and the next I'm placing them in an irradiated jaw. I agree , a periodontist should tx this. I SAID IT!!! Bv

Due to the difference in height between the fixtures will be hard to osseous graft and get a good long term result. Since this is an esthetic issue I would recommend a connective tissue graft. do a partial thickness flap down to the mucigingival line then make it full thickness beyond there with vertical releasing incisions then mobilize the flap place the Alloderm or Purous Dermis and suture the flap more coronal.

Dr. Kurtzman, one reason I suggest referring to a perio guy is because I'm uncomfortable soft tissue grafting over areas with no nutrient supply. I'm afraid that attempting to graft either with alloderm or autogenous mucosa Is futile at best. Assuming any of the graft succeeds , I think the patient is going to have an even greater oh problem. Again , just the opinion of one omfs. Bv

Having slogged around the implant arena since the early 70's, I've seen a lot of non-ideal cases made "livable". I am thinking some sort of non-risky therapy might be tried before removing the implants, although I certainly do non contest the validity of that recommendation. Tired of fighting other ppl's problems off and on, I once sent a similar case involving upper cuspids to a periodontist who treated the girl with Perio chips, then some of the antibiotic threads and gels over about 4 years. The visible inflammation was controlled, but a very slow bone dissolution was taking place. At one point, one of her crowns broke while I was out of town and she had been concerned about the gray gum shadow previously, so she went to a local prosthrodontist who just polished the supra bone threads off, prepped the tops of the implants directly, and placed two porcelain fused to gold crowns atop the once problem implants. That was about 8 years ago... The bone looks good, the tissue looks good, the crowns look good... I understand this is not what the experts advise, but maybe, as mentioned above, some perio therapy and re-evaluation for a compromise solution could buy some time for this patient while preserving the adjacent teeth and bone? One could always advise the patient a time of reckoning is inevitable when one or more of these implants will need removal/replacement/exotic grafting. John

Having said all that, it's certainly worth a try to see if one could just unscrew larger implant. The bone does not look so dense and it must have a huge F dehiscence... John

Dr. Manuel, how many well integrated implants have you unscrewed ? I continue to raise the question regarding reverse torque of one of these implants, with no legitimate response. Don't you stand a chance of fracturing the interface?. then the patient is all out screwed and has to have in fixture removed. I would be careful throwing that suggestion out to the novice. Bv

In my oppinion there is NO!!!!! chance whatsoever to get bone to the exposed parts of the implants again. I would take the bridge off (maybe with the CORONAFLEX made by KAVO you might be able to get it off with only damage to the ceramic parts).Then I would polish the exposed threads and put the repaired bridge back.So you might win a couple of years,but the aesthetic will not be much better. Alternative:EXPLANTATION,augmentation and try to avoid the mistakes made before. Good luck