[Surgery]  bone loss around implant in 21 position

Hi - patient is M56, medically no issues. missing 21 for many years so not much natural bone left; planned short implant against my better judgement (poor crown/implant ratio).  the surgery went fine, it seemed to integrate ok, isq readings ok, but evidence of bone loss on CT taken recently, after about 4 months in place.  in retrospect; should i have done bone graft and ctg prior to placing?  i did buccally repositioned flap to capture some of the attached ging from palatal side of ridge, but maybe not enough.  such little bone to work with here; low hanging nasal sinus also, and pesky incisal foramen nearby.  plan B is exo implant and suck up cost of bridge  11(21)22.  he is having no symptoms.  is flap/decontamination of implant threads/re-graft an option?  i am doubtful on this case as poor crown/implant ratio remains. the screen grab of the CT is the most recent, showing bone loss interproximal and buccal.  occlusion is adjusted to shim clearance.  thoughts?

by Terry Grover at Wed, Jun 14, 2017 5:50 PM

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Ho-Young Chung Replied at Thu, Jun 15, 2017 7:58 PM

If attempting to rescue this implant or remove and graft, my suggestion is to put a cover screw on to allow soft tissue to grow over possibly.   

A frenectomy should be completed as well and allow to heal before doing any other surgery.   

Whatever option you choose, flap manipulation and suturing will be critical and most difficult as Dr. Jin has already noted.   Patient still has the papilla between the centrals but one cut over it and it will likely lead to a black triangle.  

This is a tough one for anyone    


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Bernard Jin Replied at Wed, Jun 14, 2017 7:20 PM

Hi Terry

thanks for sharing and for willing to ask for help!

My thoughts - any attempt to salvage the case will likely return to nip you in the behind.  
Though I understand that the patient is asymptomatic right now - i believe it will be a matter of time where the negative soft and hard tissue architecture around the fixture will bring on purulence, and the problems thereof.....

Flapping, decontamination, grafting and CTG around such a short fixture will require the highest of skills - especially the CTG part.  If I were to attack this case with this option in mind - I would most likely be using the i-brush, r-brush, sticky bone, and performing a massive vip-ctg.  I would also be throwing away the abutment and then consider making a new custom abutment when the underlying soft/hard tissue has matured.  Then I would follow it up with temporary prosthetics and soft tissue molding, etc..... well - you know...

Alternative option?

Re-treat the whole case.  Remove the fixture and graft (yes, even into the nasopalatine foramen) and the use of stick bone (depending on your comfort/skill levels), with possibly use of Ti-reinforced membranes = especially important if vertical dimension is an issue here).  Again - I would be augmenting this anterior largely with a vip-ctg to help re-develop the ridge.  During this time - the patient is edendulous and definitely not wearing a flipper denture..... if so, maybe a bonded temp. tooth to the adjacent natural dentition.

Of course... much of my input is based on the limited information we have.... we don't know if the patient has a high smile line, perio-status, engaged in myo-functional habits/forces?  Patient expectations of outcomes?

Just my 2cents worth....