Exposed threads and perimplantitis: Treatment recommendations?

I placed these implants in early November 2017. A CBCT and surgical guide was used. Patient went on an extended vacation out of the country for 3 months, so I was not able to follow up. When the patient returned, there was inflammation, mucositis and beginning peri-implantitis. I removed the healing collars, flapped , curetted and irrigated the area . There was foreign debris, food particles etc, in  the implant sites. When I re-evaluated the sites in one week, the tissue was improving, but I am concerned about the exposed threads. One complicating factor was the retained root tip. I spoke to oral surgeon prior to placement and the surgeon said that the tip was intentionally retained due to its proximity to the unusual anatomy of the mental foramen and anterior loop. We decided that it would not be a problem if I stayed away from the area. The CBCT shows the root lateral to the implant.  What treatment do you recommend?

30 thoughts on: Exposed threads and perimplantitis: Treatment recommendations?

  1. Greg Steiner says:

    This in not periimplantitis. It is bone graft failure. The food particles you mention are bone graft particles. Two studies have confirmed that the biggest reason for marginal bone loss is implants placed in cadaver bone. Perimplantitis can be treated but cadaver bone graft failure in my experience is untreatable. This is why I refuse to place implants in sites grafted with cadaver bone.

  2. Robert Wolanski says:

    One really cannot make informed comments without all of the information required
    First of all is speculation based on 2 dimensional x-rays
    If the bone crest was either too narrow o heavily corticated (read poor blood flow), the implants would be set up for bone loss. A sagittal CBCT bone slice would give us this information. Of course there are so many other factors. If the implants are well p[laced and the patient’s OH is satisfactory there should not be this kind of bone loss in 3 months
    At this stage the implants are ailing and on their way to failing. Given the short timeline the prognosis is not good. If you want to try and save the implants I would consider implantoplasty and careful monitoring of the implants before restoring. Be careful of comparing periapical radiographs as a change in angulation will demonstrate artificial changes to the crestal bone levels. If the above treatment works I would consider restoring with screw retained splinted crowns. Definitely inform the patient at this time. Make sure the patient attends strict 3 month Perio maintenance. You cannot afford to loose any more bone.

  3. Doc says:

    Not sure how one can speculate that the food particles were in fact bone graft particles. I have placed implants into bone grafted sites (allograft, xenograft) without finding any incidence of greater implant failure. Block allografts appear to have some greater failure in some literature but not particulate- please someone correct me if they have found otherwise. As for the retained root tip and rationale for leaving it in – I don’t see any reason why it could not be removed but I was not the surgeon who removed the tooth and kept the root tip so this is my opinion only. I would get a CBCT to evaluate the root tip position, remove the root tip ( if possible), remove the implants, bone graft, and place two new implants after adequate healing.

    • Greg Steiner says:

      There are no legitimate published studies on the success rate of implants placed in allografts or Bio-Oss. No one never considers bone as a possible reason for implant loss. Look at the three case of marginal bone loss currently posted on the front page of osseonews. I don’t even have to ask if the implants were placed in cadaver bone because it is so predictable. But ask them and find out for yourself.

    • Dr. A says:

      Steiner sells synthetic grafts thru his company Steiner Biotechnology. He should post that as a disclaimer, as he is clearly quite biased. I think Steiner’s products are made from bTCP. But, I don’t remember off-hand. Nothing wrong with bTCP, of course, but nothing wrong with allograft either. Last I checked, there is study after study in related medical disciplines, including orthopedics (where the studies are much more rigorous then in dentistry) showing successful use of allografts.

      • Greg Steiner says:

        Dr. A
        Orthopedic studies can be just as fake as dental studies but there is one very big difference. They never put implants in cadaver bone. Also dental bone graft are more advanced than orthopedic grafts at this point because or our ability to evaluate graft performance every time we place an implant. You can not do this in orthopedics.

  4. Neil A Bryson DDS says:

    I have placed root form implants since 1984 into all forms of grafted sites. I just saw two implants placed in #4&5 area last week that have been in place over 25 years in a grafted defect Beautiful and strong with little bone loss. I agree that the root should not have been allowed to stay but at this point , I am not so sure that you should give up on these implants. I would flap and debried the area , recontour any bony defects, close, then follow monthly for 5-6 months before restoring. What is the hurry at this point?? Give the patient time and a chance to heal. Double-abutment splinted crowns retained by screws will be indicated if your tissue responds well. If not, remove them as well as the root tip , graft and wait again before replacing the implants.

  5. Vipul Shukla says:

    Completely agree with Dr Bryson,
    Give these implants a second chance. IMO, clean and debride around the exposed threads, graft with your choice of particulate material in fresh bleeding bone, and this time use just the cover screws to completely bury them and try for primary closure, although may not be possible at this stage. Follow up monthly with clinical check and X Rays and uncover in 3 months. It should work out.
    Remember, when you removed the healing collars, that itself is a test of osseointegration and these passed the test.
    Just a query, when doing the guided surgery, did you raise a full flap before the osteotomy or use a tissue punch for both sites?

  6. mick says:

    I used guide but raised flap so I could see bone. The site is challenging due to the slope of the ridge. It’s difficult to keep the platform parallel to the ridge line. Yes, you’re right…when I replaced the healing collar, osseointegration was evident. …tight seat. She told me that when she was away, the healing collar of the distal implant came out. She saw a dentist there who replaced it and told her everything looked good…..for what that’s worth. I am seeing her again this week. Depending on how she is doing, I will either do implantoplasty ( which literature supports) or bone graft or a combination of both. I have a CBCT in my office so I will try to post a coronal view. When you see the mental foramen anomaly, you will understand why the surgeon left the root tip. Thanks

  7. Greg Steiner says:

    I have been telling the profession about implant loss in sites grafted with cadaver bone for years. Now, however, academia is catching on. Just a few weeks ago a professor presented to the graduate periodontal department at Stony Brook his findings of an increased incidence of implant loss when the site is grafted with cadaver bone. Another Professor who specializes in bone research and is head of a graduate specialty department at one of our elite school is writing a paper on the type of bone produced by cadaver bone and how it results in implant failure. In my opinion implant loss because of sclerotic bone failure is more common that periimplantitis. Just on this page of osseonews you have three cases of marginal bone loss posted and I have no doubt they are all in sites grafted with cadaver bone.

  8. DrAZ says:

    Steiner, I guess you have found that one case with bone loss to attempt to make your point (without cbct, clinician experience, the fact that the patient was traveling for a few months, hygiene….) I don’t like being sold to. This is a great forum with great professionals who take time out and give really helpful advice. I’d really hate for this to become another sales pitch trap.

    • Greg Steiner says:

      One case? How about finding our what the other two cases that are being discussed were grafted with and you will find that it is 3 out of 3. What amazes me is the it is the bone that is failing and no one ever considers that the bone could be the problem. Truly amazing.

      • Dr. Cohen says:

        I have placed 2500 implants in the last two years, 50% in cadaver grafted sites. The failure rate has been 4-6%. I don’t see how you can say that it leads to failure in all cases. According to Moy at UCLA, you can use just about anything to graft as long as you give the bone adequete healing time.

  9. Robert Wolanski says:

    Loose healing collar??
    Did you use healing caps or healing abutments at the time of surgery?
    If they were transmucosal abutments and came loose for a period of time and there was bone grafting, that was pretty much most likely the cause of the bone loss
    When I responded to your post I mentioned “so many other factors”, well a loose transmucosal abutment would be one of these factors.
    If you are doing transmucosal abutments at the time of surgery you will have a greater risk of exactly this kind of sequelae,
    If you placed only a healing cap and submerged the implants then I am mistaken

    • mick says:

      Yes, I placed transmucosal healing collars at time of surgery. There was no bone graft placed at time of implant placement and the implant was torqued better than 35ncm. In retrospect, I believe a covered healing cap (cover screw) should have been placed. Had I known that patient was leaving for 3 months I would have done so. But that brings up a good question….healing collars or covered healing caps? I think it depends on the situation. I have placed many transmucosal healing collars with success. But I have monitored these patients carefully….once a week for 4 weeks then every two weeks. Several times I found a loose collar. …with inflammation, irrigated and tightened it and it resolved well. From articles I have read, if there is good primary stability, no bone graft, good tissue approximation and good OH, a TM healing collar works. (A lot of if’s) Thoughts?

      • R Handa says:

        no cadaver bone in this case?. need to look at each aspects of grafting. Lack of gold standards lead to confusion. personal comments are good to learn from each others experience but to claim that one treatment is better than the other i think should be evidence based, I use diff options and cannot see much difference. although no audit has been done.

      • Matt Helm DDS says:

        With a torque of 35 ncm at time of placement and no need for a graft, this should’ve been clear sailing. Based on everything you’ve stated, instinct and logic both tell me that it’s OH related, specially if one of the healing caps came off. The patient herself also may not have stellar OH. I find that many patients just don’t keep up with it in the beginning, even after they’ve been thoroughly instructed. They just don’t develop that discipline until later, after they’ve been “bugged” or “scolded” a few times and the importance of it sinks in.
        I think that you should not give up on these implants just yet. Open, debride, add bone-filler, preferably do not do implantoplasty at this time, and close completely, with the implants completely submerged.
        I never — repeat, never — place transmuccosal healing caps at time of initial implant placement, no matter how straightforward the procedure is. I always cover the implant with its cover screw and bury it under the tissue. It saves a lot of headaches, and eliminates a lot of unwanted variables, specially since not all patients are compliant enough to come in for checks as often as I would like. As it is, we have many more variables to deal with, above and beyond what’s been mentioned here, not the least of which is host response, which I find is not talked about enough. But it’s very doubtful host response is the problem here.
        That said, I think these implants still have a good chance of success, that is unless there are other missing details.
        As for that retained root, I would love to see a CBCT of it, because I’ve never left a root in deliberately no matter what. It’s a point I’ve always insisted on, and I’ve been closer to the mental foramen (or other critical anatomy) than this x-ray looks.

      • Vipul Shukla says:

        Dr Mick,
        I place healing collars almost every time I place an implant. Even with concomitant particulate grafting. Just remember to torque it down well. Research supports this technique, and patients love that there is no Uncovery surgery.

        • Matt Helm DDS says:

          Dr. Vipul, you call a small incision to uncover an implant to place a healing cap “uncovery surgery”? Oh please, let’s be serious. If that’s surgery, then what’s a a sinus lift? A flight to Mars in the USS Enterprise in warp drive? Thanks for the good laugh.
          Humor aside, I think your technique is asking for trouble and not keeping the patient’s best interests at heart. Read Dr. Robert Wolanski’s last sentence in his post right below yours: “If it were your mouth, what would you prefer?” What is it with all you guys in such a hurry? You never heard that haste makes waste?
          Keep doing it Vipul and one day you’ll post here with the same problem, asking us for advice. Then again, maybe you won’t, since you think you’re so “smart”.

  10. Robert Wolanski says:

    I think you have had rather good guidance in this case. Matt suggests grafting the case and not doing implantoplasty at this time. I would not disagree and it is worth a shot but bone growth over contaminated threads (rough surface) is not predicable. Just be prepared to do implantoplasty if the treads become exposed after the bone grafting heals. I understand why people want to place transmucosal abutments at time of implant placement. You will have success doing this but I feel you will also have more failures and complications for the exact reason this case has had issues. Matt is right about reducing the variables that sometimes end up beyond your control. I leave you with this thought, If it were your mouth, what would you prefer?

    • mick says:

      Sounds like a plan. Its interesting to get different perspectives on a case. My final take…..Bone loss was due to hygiene issues. When pt returned, there was food, not bone in the site…I’m talking lettuce particles. Placing a cover screw and burying would have prevented this problem in this case, I believe. I should have done that. Im going to do flap, bone graft, cover if possible, and wait. Will do implantoplasty if needed as you recommended. I’ll send to guys some cbct shots when I get back to the office. Thanks for your help. Im going to be doing more 2 stage implants from now on!

      • Matt Helm DDS says:

        Lettuce particles? WOW! Just as I thought! You do know what that means! This patient chewed over the freshly implanted site with absolute and total disregard! She didn’t pay attention to your post-op instructions, didn’t think, didn’t care. One of those nasty variables — the unfortunate slob. Always happens. Now do you see why I always do 2-stage? After all, what does it set me back time-wise? Nothing practically! But the potential problems can set you back a lot more, like in this case. We have advanced so much, and implantology has become so painless, that patients just take it for granted that it’s “minor” and they don’t appreciate the importance of guarding the post-surgical area. This is also a point of patient management: I always make a big deal out of it, so they understand.

        I agree with Robert Wolanski completely. You can do implantoplasty if and when you end up with exposed threads again. No rush now. You would prefer to have threads that the graft material can catch, if there’s a chance, and I think that there might be a decent chance. This is definitely not peri-implantitis and, since the crestal bone loss looks minimal (note that the x-rays have slightly different angulations), I would bet you won’t have to even add that much grafting material. In fact, I think that once you raise the flap you’ll find the crestal bone loss to be quite localized, and certainly less than what you expect. Graft into sound, bleeding bone and if you have any doubts you can even add a small piece of resorbable membrane over it before you suture. It’ll be fine. Good luck and please keep us posted. And teach — better yet, firmly scold — that woman to pay attention and to maintain OH and not eat on that side at all for 3-4 months.

  11. Robert Wolanski says:

    Some comments were made about cadaver bone potentially the problem. I want to clarify this point you you are not misled. Is all bone the same? , obviously not. Type 1 and 4 will give you more failures. Is cadaver bone as good as natural bone? No, but it works and is very predictable. Do some of us like to mix harvested autogenous bone in the mix, yes, when I can I use as much as possible. Do grafted cases get more post op supervision and is the patient made clearly aware of this, Yes.
    Given that you then said no grafting was placed there is really no need to talk about cadaver bone being the problem as was suggested but I thought I would contribute a bit to clear misleading statements.
    You did mention that the bone was sloped as is often the case. If you did not graft and left any threads exposed to tissue this would also be what I term, “setting the implant up for ailing to failing”.To maximize your successes and predictability, you must cover all threads with bone, either in the alvelous or by grafting.

    • Matt Helm DDS says:

      Excellent comment Robert. Ditto! I never leave any threads uncovered if I can help it. It’s one of those details that I insist on.

  12. FES, DMD says:

    I think the last few comments are valid and are leading to the logical direction of how to best treat this. Don’t lose focus with the retained root tip. It is a red herring and has nothing to do with the crestal bone loss. Will it cause future problems? Possibly, but the initial finding won’t be crestal bone loss around the implants.

  13. Neil A Bryson DDS says:

    I have watched this conversation over the last two days and have been impressed with most of the advice. We had a young doctor who needed some guidance and overall there has been a great response. I am 68 years old and as I noted in my first response I have been placing implants for a long time. My greatest learning point has been that there are multiple ways to skin the cat. We all have things that work in our hands and with which we are comfortable. I always use healing caps and submerge….EXCEPT when I decide to immediately load. It seems to my way of thinking that transmucosals are just a step in direct loading without the load.
    What DOES concern me is the attitude by a few of our colleagues that there is one way and it is their way only. We should be more gentlemanly or ladylike as the case may be on these sites. We are all doctors and should show each other respect and gentle guidance. There is no place for warning and assuring someone else of their impending doom nor is their room for sarcasm in speaking of another’s intelligence I would also caution against a repeated effort to sell one’s own products on the site.
    We are all in this to help our patients and in so doing, helping our practices prosper. Education is the key and all of you help me with my continuing education each time I read your ideas. Dentistry is so great because it is so variable and we should try to embrace the variables. Be gentle. Be respectful

    • smiledr says:

      Dr. Bryson-
      Very well said, everyone should really take note of this post. I too, have been placing implants for more than 20 years. What works for me may not work for someone else and vice versa. That being said, this is not the place for egos.

  14. Doc says:

    I have been a periodontist for 11 years, and will offer my opinion only based on my experience. I use multiple implant systems and find bone remodelling around implants greater in some implant types over others. I have learned that I can get away with a 2-stage technique under some specific circumstances and also with certain implant systems. With one specific implant system (which I won’t mention here), I don’t dare do 2-stage. I always place a cover screw and allow adequate healing first. Know your patient, understand your implant system, understand loading and type of bone, torque at insertion, etc…

    In this case, with the two implants placed in an otherwise edentulous posterior lower left sextant, personally I would have placed cover screws. The patient will intentionally and unintentionally chew on these healing abutments. I am not sure if the root tip is a red herring here, as the implant that is placed by the root tip displays the most bone loss.

    Dear Doctor that placed these implants: please post a CBCT that you have. If you have a CBCT of the implants placed, I would be curious to see it.

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