Peri-Implantitis: How Would You Manage this Case?

It appears that the crown margin is not adapted to the implant surface, as it should be on the Strauman type implant. Either the screw is loose or the bridge was not seated with a passive fit, causing a gap between the crown and the implant and bacterial accumulation. It would be helpful to have an X-ray of the opposing side. This type of threaded post is notorious for causing root fractures and this one is undersized in diameter and in length for a cuspid that bears such a heavy load. There appears to be a radiolucent area on the distal margin of the crown on the cuspid and the post is not seated to the full depth of the canal preparation, perhaps a fracture occurred and the post moved out of the canal. There is definitively bone loss on the distal of the cuspid. Best to refer this failing case, to a qualified specialist, since he may be able to save the implant with proper management.

Problem list: cuspid is failing, not suitable as a bridge abutment and is probably split, occlusion may be a problem, margin gap is probably not a serious issue. Think about a major rehabilitation.

Refer back to the original restoring dentist. Have them compare to radiographs obtained when they finished delivering the FPD. There may be occlusal issues that they need to address if they are able to replace the loose screw and seat the FPD completely again. Is the patient using a nightguard? The selected restorative dentist should refer the patient to a periodontist to address the peri-implantitis that has developed once the restorability of #7 - 10 FPD is determined. I would inform the patient of the questionable prognosis of #6 and likelihood for failure in the future (endodontic failure, mechanical failure if there isn't already a fracture on the distal, periodontal breakdown, and potentially catostrophic bone loss around implant #7 if endodontic flareup occurs). They can wait for catastrophic failure of #6 and only treat #7 or address all the issues now. There is a fair chance #5, 6 and #7 sites will need to be assessed for new implants to restore #5-10 in the future. Minimal treatment may be reasonable since they are asymptomatic at #6 for now. I'd treat #7 implant for peri-implantitis and address the 7-10 FPD seating problem (with the original dentist). You can get them back in your chair to replace #5-10 in the near future by recommending conservative steps and respecting the care provided by the original restorative dentist. They probably will stay with you anyway.

Hi Dr M: In my opinion, the problem in this case is related to the poor fit of the bridge superstructure. It is quite obvious from the provided radiographs, that there is a substantially wide open margin associated with both abutments. In this case, this open margin has created a MACROgap with the consequent bacterial accumulation and constant irritation and low grade infection. My recommendation to you would be to remove the bridge( fortunatelly it is screw retained as you mentioned), then place a well fitted provisional bridge and reinforce proper oral hygiene and the daily use of a chlorhexidine 0.12% rinse or gel applied with a new toothbrush for a few weeks and then reassess the periodontal condition. If there is a noticeable improvement, then proceed to the fabrication of a new bridge. Make sure to take post-insertion radiographs to ensure that you have obtained a proper fit of the bridge. Good luck

This is something the original restoring dentist should fix or pay to have fixed. It is a shame for this patient to pay for replacement of the FPD if in fact this was delivered with open margins by the restoring dentist. How would you take care of this patient if she was your mother? I certainly would have her pay a second time for an FPD if she received substandard care by another dentist. I'd not skirt around the issue and let her know she needs to go back to the orginal dentist to show what happened and find out how to address this problem. Regardless, the dentist should learn to take radiographs after deliveries and be learn from the issues that popped of from this case. Be a good colleague and discuss it with the original dentist.

From the radiograph that you showed, it appears that the implant in the site of tooth #7 has violated the nasal sinus. I would therefore be especially concerned about the deep pocket on this fixture as there might be communication between the oral cavity and the nasal sinus. I think a CT scan would be in order to evaluate the extent of this problem.

As i am a young periodontist, i have treated some cases of peri-implantitis in the past ( surgically or not ), but this one, it appears more comlicated for many reasons( medical, ethical, economic, managment ).This work is only 2 years old and the patient is very disappointed about losing those implants. As i said there is even a soft tissue problem that needs to be solved ( no fotos yet ),occlusion may be a problem and obviously the poor fit of the bridge superstructure.Unfortunately i dont have any radiographs when this implant-bridge was delivered.I must for sure call the colleague and tell him about all those problems, but how can i force him to pay a new prosthesis? Because -certain- all my treatments will be in vain if not? p.s. A violation of the nasal sinus -as Dr.Steven mentioned- is an option? Is this possible? ( need CT scan ), cause i didn't notice it. Thank you all for your valuable comments.

You are not violating the nasal sinus as is apparent on the first xray. A ct and photos would help evaluating the current condition. A lack of keratinized tissue and a frenum pull would account for some of these issues however the current restoration is allowing bacterial penetration in the micro gap.  Take a second look at the second X-ray there may be an implant fracture on the mesial aspect. You cant make the original dentist pay but you will be surprised how a simple phone call can help. Generally we are all inclined to aid a colleague especially when poor restorative dentistry is involved as no one wants an angry or litigating patient.  Good luck.

I suggest removing the bridge, next clean and detox the implant and graft. Evaluate the occlusion and the adjacient tooth. Remake or evaluate the FPD. It may not be seated properly.

That is what i have in mind to start with. Then i wiil call the restorative dentist.....Thanks doctor Hughes

There is a poor fit of the bridge. But first things first. If you have to flap he are, gently debride and disinfect the implant with powdered doxycycline. After completion, a new bridge should be restored and fit properly to close the open margins...which, btw, are contributing to the inflamed gingiva.

What protocol do you generally use, to detox the implant surface?

Thanks for sharing. As a fellow periodontist who have treated (or attempted to treat) a few peri-implantitis cases I concur with my colleagues above that this is a difficult case to manage for all the reasons stated. This is how I would approach this: 1. Call the GP, have him fabricate a flipper. 2. Have him remove the bridge. 3. Flap the area, place a cover screw, degranulate, use tetracycline impregnated cotton pellet to detox, graft with autogenous and cancellous BioOss or Puros, release the flap, try to get primary closure (it will be difficult in this case with tissue level Straumann). 4. Allow at least four months before uncovering. You should inform the patient that what you are doing is an attempt to save an ailing implant and don't bring his hopes up. The alternative is removing the implant which, in this case will be a nightmare as you will create a larger defect. Do what you can to save it. Good luck.

I agree with Dr B except instead of a flipper and full closure, I might go back to a well fitting fixed provisional on the synocta rather than taking those apart too. I'd take all other steps as described and cross your fingers. Deal with the soft tissue problem once the infection is better. As an aside, there may be a simple solution to the bridge misfit. It looks like the crown is hung up on the synocta abutment. There are two parts - one is indexed for single units and one is not indexed for multiple units. It is possible that the single crown parts were used - they will never align fully no matter how many times they are cut and soldered. Simply removing the index 'notches' with a 557 bur being careful not to touch the mating surface may allow the bridge to fully seat. The moral? Always take a seat film... Best Regards, Ryan

Apart from the poor fit of the bridge, and associated inflammation, I would aseess the quality of the soft tissue, in my experience, the issues here are mostly related to a buccal dehiscence of the implant, or lack of attached gingivae, or a combination of both. The problem often with straumann is that it is more difficult to submerge graft and re-enter to regain soft and hard tissue. Another little theory...this issue may be related to stress breaking /flexure. As the implant abutment is taking more load than it is designed to, and the crown is not sitting on the implant ferrule, the implant body in the coronal 1/3 will be flexing under load and hence loading the bone more. If the bridge has not "sat down" properly as it was designed to, the problem may be compounded by a premature contact, if there is a lateral component to this then the flexure may be greater. this will cause bone loss, and possibly symptoms (though these tend to be asymptomatic) In conclusion, look at the bite (CR as a reference) Look at the quality and quantity of attached tissue. Look for any cement in the pocket. Possibly do a culture to look for any nasties? re do the bridge, a temp will suffice for now. Mabey do a HQ CBCT like a newtom, to see if there is a buccal dehiscence... hope this helps.