Soft tissue dehiscence after uncovery: recommendations?

I have a 50-year old patient who has a chronic smoking habit but otherwise non-contributory medical history.  I had placed 6 implants in the maxilla 4 months ago with 2 in the right and left maxillary posterior after sinus lifts.  Patient returned and is healing well and I uncovered the implants.  2 implants had been overgrown by bone which I cut away to uncover them.  I then placed healing caps.  I scheduled the patient for impressions. After 1 week, the patient has come back for the impressions, and I see bone is visible on the lingual side of the healing abutments (2 implants), though threads are not visible.  I debrided with plastic tipped scalers and irrigated with chlorhexidine and hydrogen peroxide.  Any recommendations on how I should precede at this point?

13 thoughts on “Soft tissue dehiscence after uncovery: recommendations?

  1. Ninja says:

    The goal is to cover exposed bone by whatever option available and there are a few. One would be coronal repositioning of the flap, PTFE membrane, tissue graft.

  2. Larry Silverman says:

    Just wondering why an impression is required after soft tissue is manipulated 1 week prior?
    Is this for final prosthesis?

    • Ninja says:

      With all due respect Dr. Ghotbi, in four weeks you can be surprised by bone resorption and implant exposure. It will depend on who wins the race, the bone resorption or the soft tissue healing. Obviously, the thickness of the bone plate in that are will have something to do with that race. Is it worthy the risk? That depends on the gambler.

  3. WJ Starck DDS says:

    Interesting case, thanks for sharing.

    How much exposed bone are we talking about? A sliver? 1 mm? 2 mm? More?

    How did you remove the bone that was covering the cover screw? A drill? I suspect that if you used a drill you overheated that palatial bone -or- you beat up the palatal flap too much when doing your dissection? When I have to uncover something I only use a room heir and/or a 15 blade.

    Anyways, you have a region of dead bone. I don’t think covering it with any kind of advancement flap at this stage will work because it will just dehisce. I think you will have to wait until the dead area declares itself an sloughs. That will most likely leave you with exposed threads. At that point you could reflect a flap, etch the exposed area, then regrant the exposed area. Be generous with the size of your flap and score the periosteum on the underside of the flap to release tension. Then make sure you have a tension-free closure.

    And tell that patient to quit smoking 😉

  4. CRS says:

    Can’t give any useful advice without an X-ray or clinical picture. I suppect that after exposure either a thin maxilla with implants placed too far to the lingual, rough exposure during healing head placement, smoking, manipulation by the patient’s tongue. I do know one thing I would not have scraped the area with plastics scalers and used H2O2 and CHX to further traumatize the area. The appearance of the bone is key. Exposed bone is usually dead bone which will slough. Any healing granulation tissue most likely was removed by your premature intervention. Most of the listed comments won’t help you, show a lack of understanding of surgical healing process. Hope you have a good informed consent. Let it heal and restore, palatial exposure is difficult to fix. Clinical judgement.

    • David says:

      Agree with CRS. Palatal tissue is fixed/attached tissue. There is no mucosa to allow you to advance it like with facial tissue. Good luck!

  5. Ninja says:

    CRS would like to see an x-ray to evaluate palatal exposure. A periscope would do better.
    We tend to exaggerate just about everything for whatever reason. Call it professional liability. We all had experiences like this and everything ended well. Open limb fractures are treated without complication and a little bone exposure in the mouth will heal as well.
    Removing healing abutment and non-resorbable membrane like PTFE will solve the problem for sure. We take teeth out, graft bone and place a PTFE membrane according to protocol for the use of that type of membrane and much more bone gets covered.
    With the knowledge you most likely already have, you will find a solution.

  6. Haydar G. Alkhatib says:

    Exposed bone is dead bone , grafting over it will do nothing and will fail , you can’t do anything right now just wait and see secondary healing takes place and hope for the best (been in the same situation with a smoking patient their lack of soft tissue healing potential will leave you frustrated sometimes), schedule weekly appointments to remove dead bone sloughs and make the patient use cotton swabs with CHX in this particular area.

  7. Kevin says:

    A picture would be helpful, but I agree that discretion makes sense. Let it heal and see what happens. Definitely, stop or reduce smoking ASAP. In general, I would wait at least 3-4 weeks before taking an impression. Good luck

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