Sinus Tract Next to Implant #8: Input?

The implants look well integrated. The infection appears to be coming from the sulcular area(PA with gp point). I would first remove the crown/abutment and see if food hasn't got impacted in the abutment area. It may be that there is an open contact on the distal of your crown #8? If you find all kinds of crap down there irrigate well with Peridex and try to gently remove any granulation tissue. Make sure you drain any pus from the area and put patient on an antibiotic like Augmentin bd 875mg. Make sure to redesign a new abutment/ crown to prevent food impaction. Take some follow up photos, would be nice to see how this resolves.

Shoot Arestin in the tract every 2 weeks for 3 sessions. That may resolve the issue.

If you have access to a laser I would place the patient on systemic antibiotics, then use the laser to open the fistula by deroofing it then sterilze the area by threading the laser into the sinus tract irrigate with with some saline mixed with a capsule of doxycycline. have the patient use warm salt water rinses 4x a day return in 3-4 days and see how healing is going. if its not fully resolved repeat with the laser. After resolution you may want to consider flap the area and place some osseous graft to thicken the facial wall to prevent future bone loss with thread exposure. if you dont have access to a laser then take a large endo file and thread into the sinus tract and use that to try to remove the tract, irrigate out with the saline with doxy mix get them back 3-4 days later to check healing.

I would like to see the xrays of the area when the natural teeth were present....was there pathology around the roots? Sometimes those endodontic lesions that necessitated extracting the teeth were not cleared up at the time of implant placement....this is why it is best to wait a few months after extracting teeth to see how the bone is before doing the osteotomies.

Just as with natural teeth, bacterial colonization can occur within any enclosed pocket space within the mouth. If you have a 6-7mm pocket, the patient cannot maintain that and so biofilm formation in that space is inevitable. It is only the patient's susceptibility to an adverse inflammatory response that defines the ensuing reaction. Remove the biofilm ( surgically if necessary ), then remove the pocket ( graft/membrane, etc. ). Any other approach should be considered temporary.

Surplus cement? Flap open and clean. Surplus cement cannot be removed from the sulcus. Flap necessary

it seems that the abutment has invaded the biological space...

If you place graft material on the buccal to thicken it just like Dr. Kurtzman suggested, you may find yourself exposing the implant in all areas of decortication. In addition, you may contaminate the entire area. Isolation is what we want. You mentioned that the buccal wall is thin. When infection is present, the first step is to find the source of infection, address the infection and wait for healing. This applies to everything that has infection written on it.

Excess cement is most likely culprit

Sorry to all, but I disagree. You cannot trust a gutta percha point to show you the problem all the time. This one has gone astray. This abscess is too apical to be coming from cement in the sulcus, in my opinion. Its hard to read the CBCT as it is presented, but I see insufficient buccal bone. I think that is the problem. I would flap, eval and graft if indicated. If implant exposed buccal, I'd manage via the NYU protocol or laser.

They were screw retained crowns. Extra cement cannot be the culprit

I'm sorry, but when I evaluate the top three scans I see almost complete lack of labial bone. Looks like the threads are exposed. The implant was placed either too labially and through the bone or the remaining bone was too thin and it dehisced. You simply can't just place more bone over the threads because it needs the blood supply to be successful. In my opinion you have a failed implant that is doomed.

Nice work. Implants could have been placed more palatally initially. Now , go with concentrated growth factors in the form of PRF membrane and sticky bone mixed with bovine and corticle/cancellous

The above answers are all good. I have had similar situations but most often when a long term temporary acrylic crown has been placed. In these cases I place a permanent porcelain crown and the problem usually resolves. My guess is that over time the acrylic crown get microscopically colonised with bacteria which caused inflammation and infection. Replacing with a glazed porcelain crown reduces the bacterial numbers and seems to resolve the problem. In your case this has happened the other way around. My best guess would be there has been food or bacteria introduced into the deep sulcus during crown placement. Of course it could be a bony defect but this is much less likely (judging on the radiographs provided). Normally the soft tissues produce a sealed cuff around the crown to prevent bacteria infiltration. In your case, most likely the bacteria was introduced when the crown was inserted and the soft tissue formed a sealed cuff which actually kept the bacteria in the sulcus and a resultant soft tissue abscess developed and tracked into the oral cavity. I always treat these cases conservatively. Simply remove the crown and clean around the implant platform with an appropriate instrument. At the same time, probe the attachment area around the implant and evaluate if there is a deep pocket somewhere (presumably buccal). My guess is that you will not find any pocket and the integration of the implant is good. If this is the case, decontaminate the crown and soft tissue area with an appropriate irrigating solution and replace the crown with strict oral hygiene instructions given to the patient. If necessary irrigate the sinus tract but usually this is not needed. Almost always this treatment method will resolve the problem and it will not reoccur. If the problem does not resolve (after 2-3 weeks) then you will probably need to raise a flap to investigate what other problem maybe present (eg bone loss, exposed threads, etc). If this is the case then you will need to decide the most appropriate treatment at that time.

Both implants look well integrated and the beautiful crowns appear well made and placed. Papillae look nice too. Assuming there are no occlusal high spots, then only cause for such a buccal draining sinus tract is an area of locked in infection that found the thin buccal bone wall the easiest route to vent and now you have a fistula. Periosteum will not stay on rough implants surface unless there is living bone in between. These are platform switched implant abutments, so crestal bone can be maintained even when there is dehiscence lower down the root. My theory is something is rotting inside the implant channel or the abutment screw channel and is draining out slowly. Maybe a cotton pellet was used before the crown got cemented. Maybe the crowns or abutments were not thoroughly disinfected prior to inserting? Maybe the abutment is not fully torqued down on #08, leaving a microgap for necrotic debris inside the implant channel to slowly leach out? As someone posted above, a deep seated piece of cement can also cause deep non healing pockets. If all else if fine and no other source is found, then assume some of that thin buccal bone plate is probably slowly necrosing due to lack of blood supply. In which case, while on antibiotics, under full surgical protocol, raise a semi-lunar buccal full thickness flap, debride the dehiscing bone, disinfect with laser, if available, and pack with autogenous bone mixed with prf or similar, then cover with membrane, then suture back. My 2 cents. Good Luck!

This is exactly what we used to see years ago when using the flat top hex Branemark implants. The screw would occasionally loosen and a parulus would form. Once the screw was tightened the lesion would resolve. Something is happening with your abutment which is creating bacterial growth. I looks like the zirconia abutment has a titanium base which likely has an adhesive and or the contour of the abutment is overcontoured, creating bacteria and debris trap right at the platform switch. I would attempt to gain access to the abutment screw through the crown, remove the crown inspect the abutment/titanium base joint. Look for any resin cement or voids. I would reshape the abutment contours slightly deep down at that junction, disinfect and retorque the crown. (check proximals for heavy contact which could keep it from seating all the way) If it is an abutment issue it will be gone in a matter of days. How much did the tissue blanch when you delivered the crowns. Did you need anesthetic ?

Even though these restorations are screw retained the design of the abutments needlessly places a microgap well below the gingival sulcus. There is now a space for bacteria to colonize in this potential microgap. The abutments should have been designed with the crown margin much closer to the gingival sulcus. I would have new abutments fabricated with smaller diameter at the implant/abutment interface and the restorative margin elevated to near the gingival sulcus. The design of the existing abutments is simply not appropriate. .

It appears the implants are about 1 mm too apical. While buccal plate is thin, I don't think this is causing the problem...yet. The likely culprit is your overcontoured abutments, and possibly cement issues depending on how you delivered the emax crowns. To confirm this, compare the shape of the current abutments especially next to the bone to the acrylic temps next to the bone. Also, not all materials are well tolerated deep under the gingiva or near bone. For example, zirconia, titanium, alumina, and PMMA seem to be well tolerated being placed near or in the bone, and deep under the gingiva. However, glazed zirconia hides the zirconia and is not as well tolerated under the tissues. Here is a summary of what I would do: 1) Remove both crowns by finding the screw access channel. 2) Inspect the margins and repair any gaps with porcelain etch on the emax, followed by silane. Roughen the zirconia side of the defect and apply zirconia primer or universal primer (must contain MDP, such as All Bond Universal - Bisco) to both zirconia and silanated emax, dry and cure. Fill the defects with opacious flowable composite, cure and polish with fine diamonds and rubber points. 3) De-bulk the cervical areas of the abutments with coarse diamond burs, until they are significantly concave, 360 degrees around, making sure you leave as much room for bone and overlying, healthy soft tissue to grow, especially on the facial, where the problem is currently presenting. When you're done, the abutment should resemble the stem of a champagne glass as it emerges from the platform of the implant. 4) Polish the zirconia with ultrafine diamonds, then a diamond impregnated polishing wheel until it has a pearly lustre. 5) Steam clean the abutment. 6) Carefully degranulate the site of any obvious pathologic tissues and disinfect with chx or diluted iodine. 7) Replace the modified crowns and close the screw access channels with PTFE tape and composite. 8) Initiate 7 day amoxicillin therapy and discourage flossing of the area for at least 3 weeks. 9) Re-evaluate the site for a few months. If the lesion goes away, order new emax crowns, cut off the old crowns and bond the new crowns. If the lesion recurs, consider connective tissue graft. Hope this helps.

I hate to over simplify here, but has anyone considered the possibility that #7 has become necrotic. Pulp testing? Percussion?... etc. There are a lot of valid and interesting comments here, but sometimes the obvious eludes us. A necrotic pulp will not always present as a periapical radiolucency. Ask me how I know. Good Luck.

Don't do the patient a disservice by aggressive treatment. Initially try the following: excise the fistula with a pair of Castroviejo scissors, irrigate the fistulous tract copiously with saline, curette the periodontal pocket to eliminate any possible debris, re-irrigate, and call it a day. If you want to insure resolution, place the patient on Clindamycin 150mg tid for 7 days.

Oversized abutment/crown appears to be probable etiology of periodontal defect....unless you are willing to do something permanently about this etiology, then initial conservative therapy would still be pragmatic initial treatment....obviously, antibiotic therapy, alone, is not solution to periodontal disease; however, this is a chronic problem that has become acute and antibiotic therapy, in conjunction with conservative treatment, will resolve the immediate problem.

Thank you all scholars and colleagues for contributing towards this discussion. I want to share with you the outcome of my patient’s treatment. After one week post Op of sulcular as well all sinus track debridement in addition to systemic antibiotic treatment with Chlorhexidine oral rise the lesion has completely resolved. I will continue to monitor the patient for the next couple weeks to ensure that healing continues uninterrupted and will report any changes. Thank you again and your help as well as understanding in this matter was greatly appreciated.

I concur with Dr Kim in his suggestion that the abutment shape may well be the culprit. I think we al have seen enough CBCTs that look like no bone on the facial, yet when opened surgically have very healthy bone. Whereas as PA angles can be deceiving, it doesn't seem to be a coincidence that the only wall of the abutments that is straight is the distal of #8, and also seems to be about the farthest subcrestal. If there was a PA of provisional to compare it would be interesting. So. I would also take out the screw retained crown and recontour to get the desired "tulip" shape for the abutment. Good luck!

I would be willing to bet the Implant is Fractured. The fistula will return and return until you flap and find the fractured implant.

If it happened just two weeks after permanent crown/ abutment placement, could it be some occlusal interference or abutment movement? Heavy occlusal forces can lead to buccal bone dehiscence or implant fracture.

Most likely cause is granulous and infected tissue near apex of the extracted tooth that was left behind. Open the site debride, place bone graft, cover with PRF, Alloderm or your favorite membrane.