[Surgery]  implant graft concerns

I placed this Nobel Active 3.5 X 13mm implant on Oct 3, 2016.

When I flapped the area I discovered there was good B, M and L bone but it lacked any D bone at all. I could see about 6mm of the #46 mesial root and all the implant threads on the distal were visible. Initial implant stability was good at 25-30 N-cm. I placed a cover screw.

Unfortunately I did not anticipate this problem and did not have any membranes in stock. Also I just recently took the PRF course and do not have supplies yet, (on order). I placed Nobel Biocare Creos Cortical bone and I pressed a J. Morita collagen plug flat into a membrane and it looked pretty good. I sutured over top, some of the plug was visible, not full closure.

At the 1 week follow up, some of the sutures were torn and there was access into the graft. I decided to give local and I resutured and got good primary closure.

I am worried of contamination and the lack of D bone.

What do you recommend as course of tx?

Open, remove bone graft, irrigate with?, clean implant D threads with?, place mix of PRF and Hioosen powder bone, place collagen membrance, place PRF membrance and suture?

Any advice would be appreciated.


by Mike Budrewicz at Wed, Oct 19, 2016 10:43 PM

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Mark Kwon Replied at Thu, Feb 2, 2017 1:13 PM

Hi mike,

just came across the thread,

Best tool for the job so far in my opinion, is i-brush from surgical smart. 

It is a titanium metal brush you hook up to impkant handpiece to ckean the exposed surface before grafting. 

I-brish , stickybone prf, and surederm membrane works well for me. 


- mark

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Mike Budrewicz Replied at Tue, Oct 25, 2016 10:41 AM

Here is another angle of implant from same day as surgery, I think there is enough space from #44. I am still trying to find the video on implant thread cleaning but am having trouble. Thank-you for your feedback so far.

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Ho-Young Chung Replied at Mon, Oct 24, 2016 4:24 PM

Hi Mike, Thanks for posting this case. It's hard to look back on a case like this and accurately tell you why there was bone loss on the distal aspect of your implant and tooth 46. Having said that, once implant threads are exposed to the oral cavity, we need to treat the implant assuming it is infected (meaning it has to be decontaminated prior to regrafting). This is a meticulous process and is covered at the complication lecture/workshop by Dr. Kwon and Dr. van As. There is a segment on this in the lecture video section of the bites website. I would monitor this case and update us with a post-operative photos and radiographs. If it is not something you are ready to handle, then there's no guilt in referring to a colleague with more experience dealing with complications. It's also hard to tell based on PA (as it is often difficult to take one at a perfect perpendicular angle) but your implant appears to be too close to the adjacent premolar. There needs to be a minimum of 1.5mm from adjacent root. If you don't have bone loss yet at the distal of 44 then you are bound to have some in the next few months. The future bone loss on the distal of 44 (assuming it occurs) will be difficult to reverse with even a proper graft. I understand that delivering bad news is difficult and accepting one is even harder. You may be looking at a DIO (do it over) on this one based on information that we have here. Ho-Young