Pustule 6 weeks after implant placement: recommendations?

The implants look nice, it appears this was done in a 2 stage approach which I also like especially with proximity to the sinus floor. If these were placed with a guide did you hole punch the implant site or did you design a flap or flapless?? I would assume that there could be some nidus of infection at the level of the implant, ie. necrotic bone. How was your primary stability? I would recommend opening a small flap around the fistula to debride, maybe flush with chlorhexidine, get it bleeding to re initiate healing if it doesn't go away. I've actually recently started dipping my cover screws in triple antibiotic ointment just to add another protective layer. Just my two cents on the case, keep us posted. Cheers, Patrick

I did raise the flap Icurreted the area and washed with saline Did.a follow up.with.pt After 2days there was no more pus so I will leave it alone and will do 15 days follow up if any signs of.infection will raise the flap and debride it and put some arestin I doubt opening it at this point will help me anyways Any comments about angle of #3 due to sinus proximity

Sorry I would remove the implant, six weeks is the critical time for osteointegration. Also number three will be a future problem with the large crown for hygiene. I would not have done the case without a sinus lift for both implants there most likely be a compromised result in future. Patients don't dictate treatment options that compromise the result unless they want to sign a waiver. I have seen this situation before. It is much easier to correct this at the get go vs chasing the failure. This will be a loss leader for the dds and the patient. Nobel Biocare doesn't dictate the treatment plan a good wax up does. Sorry that this happened.

Whilst it will work with the regeneration of bone being less complex now I tend to place the implants in the optimal restorative position and regenerated the bone so as CRS states simple sinus augmentation . Peter

I think that this case will be a failure! It is better that it is corrected as soon as possible by removing the implant and repeat the process with a sinus lift!

The implant appears to be contacting the root of the molar. remove it now graft the site and wait a few months before retreating and it needs a sinus lift and internal would work

The problem started when you decided to follow the patients lead and not do the sinus lift, which you obviously knew was needed. We cannot let patients dictate their treatment. Whenever I have in the past, it has put egg on my face. Treat this as a learning experience remove both of the implants do internal sinus lift augmentation with PRF, close for 4-6 months, and retreat by placing three implants. These things happen to all of us,we learn by our mistakes, we rarely learn by our successes. That's my opinion for what it's worth...thanks for posting.

A few questions: where did the gutta percha point trace back too? If it traces back the cover screw area then, that is your problem - a loose cover screw that can be easily corrected and subsequently waiting longer to restore the case. If the gutta percha traces below the head of the implant- then you have a case of osteonecrosis from either a buccal plate strip perforation or something entirely wrong with the implant to bone junction. I would consider removing and replacing the distal implant - seems like a hygiene nightmare, over time it will loose bone from stress. Best of luck...

I never place implants next to rubbish teeth. I recommend to remove any implant in involved and the premolar, graft, wait and replace implants. Asymptomatic endodontically treated teeth will drain through your new implant osteotomy and spoil them. Why not do the sinus lift? It's easy and predictable.

Pustule is not confirmatory sign of failing implant. It could be ailing implant but obviously we need to stop the cascade of events leading to implant failure. As per pictorial information it seems problem of cover screw of mesial implant (agreeing on part with ZS Tariq ) harboring food debris and source of infection. This you can correct easily. As far as angle of distal implant is considered I would recommend angled abutments or castable abutments to correct the line of draw and add pontic rather than making huge crowns which are hygiene nightmare. Hope these small corrections help you and your patient. Happy Implant!!

Plaintiffs lawyer, " Doctor, Why didnt you perform a sinus lift ? " Doctor , " The patient told me he did not want one"

The angles of the implants are not ideal, but look restorable. The use of two large crowns will likely cause the patient hygiene problems. Angled abutments with a three unit bridge ( 3 bicuspid teeth) on the implants would probably be better. A diagnostic wax-up before sending the case to the lab would be a help to decide this. A loose cover screw or tissue trapped between the cover screw and the implant at the time of the surgery could have been the cause of the drainage from the implant site. Yes, internal sinus lifts would have made this an easier case with the implants more parallel to each other . If these implants integrate in these positions they will work provided that the prosthetics is done very well.

I'm not sure I see the point of the gutta percha, but if it is at the cover screw, it's likely a loose coverscrew/trapped tissue. However, the proximity to the endo-treated tooth apex (though not apparently a problem) could be a problem if there was any residual infection at the apex of that tooth. Some things that you may have done when reflecting a flap to look: Check to see if the cover screw is loose. If so, that's the likely culprit. If you don't see frank granulation tissue along the side of the implant, take a probe and check along the implant for a good bone to implant continuity or is there continuation of the sinus tract (soft/granulation tissue instead of bone). You could put a fixture mount on and see if the implant is looser than when you put it in (just with light finger pressure). If it's loose, then just take it out and curette and graft. While sinus grafting is better and the patient should be informed, I don't think your plan is necessarily a bad one and doomed to failure if the infection was just a loose cover screw. If the patient doesn't have a strong bite/bruxism it might work out fine. However, I would follow fairly closely because if it wasn't just a loose cover screw, you can lose quite a bit of bone quickly. Good luck

I use GP points extensively to trace fistulae and very often the tooth that I think was causing the fistula was not the culprit. In this instance, the angulation of the PAX made the GP point useless. It would be nice to know if the GP point went to the apex of the adjacent tooth. As for screwing and unscrewing the cover screw, I would be inclined to recommend against this until 8-10 weeks; some tapping of the fixture would be ok but I don't think you want to subject this implant to any torquing forces until at least 8-10 weeks. Lastly, it is not so easy or reliable to take a probe at this point in time and try to evaluate the integrity of the bone adjacent to the fixture. Good luck with this case

First thing that comes into my mind when i see this radiograph is..... why this implant is soo close to the root of adjacent tooth? But i really appreciate the efforts of the doctor for work up in CBCT and all, but unfortunately the patient has decided the treatment plan. Well, maximum regular implant practitioners think it would definitely fail..... In my small experience of placing about 500 odd implants, i saw mixed results....... when i did curettage some healed and osseointegrated well (Believe me, i didnot even use a bone graft) and some failed... Mentioning of pustule ,you should have posted some clinical pictures as well along with radiographs...... For me, any erythematous swelling at crestal region at implant site during first 3 weeks could heal well with curettage...... But here in this case, its already 6 weeks, so enough damage should have already happened, you can appreciate the damage in 3D Imaging, not in RVG........ So fingers crossed, we should see how this responds...... Doctor please do post the follow up of this case... i hope everyone are curious..... Cheers

The angle.of the pa makes it looks close to root of the tooth next to it but it's far away There was no.pustule healing lookwd normAl 2 weeks out during suture removal I noticed when pt came 5 weeks visit a pustule on the ridge I curretted it and followed up after 2 days area was healing nornal Will have 10 day follow up in tuesday

Again CRS is correct. And, don't use chlorhexidine, it will delay healing. This is covered in the literature, I know that a lot of DDS say to use it--WHY? Sure it will kill bacteria, it will also affect the delay of fibroblast formation. Also, I have seen more problems when implants a place near root canal treated teeth. Many times if the implant surface has infected, it is usually a lost cause. Don't let patients dictate treatment, you are doctor. If it fails these patients will not be on your side. We should not let patients dictate their treatment