[Surgery]  Bone graft did not fully incorporate and some exposed threads around implant now

HI guys,

#36 and # 37 were planned for immediate molar implants based on the PA xray, CT scan and pics attached.  ON Sept 9 2014, #36 and #37 were atraumatically removed and #36 5 x 8.5 hiossen implant along with a Smartbuilder membrane BW8 and BL 7 with a 1mm extender was placed with Raptos Bone Graft with PRF mixed and PRF membrane over the Smartbuilder.  #37 5 x 7 Hiossen implant was placed with just Raptos Bone and PRF over which a PRF membrane was placed. One week postop showed all healing well.  ONe month later the Smartbuilder membrane became exposed and was removed within the the week.  The area was healing fine at postops but one month later at a postop, threads were visible on #36 and slightly around the 37.  Pa xray confirms that the bone graft did not fully incorporate the position desired at implant placement time.  I would appreciate suggestions on how to best handle this case taking into consideration we are 3 months post initial implant placement date.  My thoughts are:

1) Place smartbuilder again around both implants and try bone graft again


2) Remove #36 possibly 37 if felt needed and do a socket preservation and wait and place implants again to newly achieved crestal height


by San Bhatha at Thu, Nov 20, 2014 5:02 PM

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Bernard Jin Replied at Wed, Nov 26, 2014 2:24 AM

Usually aim for 4 months+ if you graft substantially. You can place the implants after. Yes - always shoot for primary closure. I realize the companies who sell them say otherwise. But I would recommend always shooting for primary.

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San Bhatha Replied at Mon, Nov 24, 2014 3:30 PM

Thank you again Jim and Bernard for your input on how to handle things moving forward. I would like to get some tips on the use of PTFE membranes. I was considering using a titanium reinforced one to help maintain the shape of the graft area. Would appreciate suggestions of brands and a company to order from as well as the kit for securing the screws as I do not have these at my disposal yet. I also wanted to know if complete primary closure is necessary with the PTFE MEMBRANES and also how long should the membrane typically be left in place and when approximately could the new implants be placed?

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Bernard Jin Replied at Fri, Nov 21, 2014 7:23 PM

Hi San - yes - likely you'll be able to reverse hand torque the implant out with your torque wrench. And because it is so recent - I anticipate you won't even have to break out your implant retrieval tool. FYI - Hiossen has an implant retrieval kit - do ask your rep about it - if you don't already have one. I seriously doubt you will have to use a trephine. As for re-grafting after your ex-plant, my thoughts are that you would likely choose to perform particulate grafting. PRF is going to help here (both in the graft & as a covering ontop of the graft). Again - as stated in my previous entry - I feel that flap design is going to be extremely important. I would recommend designing the flap such that it doesn't compromise the blood supply, as well you would need to ensure a tension free sutured site. In reality - you can use whatever technique you personally feel comfortable with. If you have had success in bloc grafts, then use it. If you like particulate - that's good too. If you want to use ePTFE membranes with TACs, that would work too. But again - the outcome will largely be dictated by graft immobilization & blood supply. Let us know if you need anything else. Cheers, B

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Jim Yeganegi Replied at Fri, Nov 21, 2014 6:58 PM

......and pardon my horrible spelling and grammar. English is my second language though I left Iran 36 years ago. I'll still stick with that as an excuse.........

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Jim Yeganegi Replied at Fri, Nov 21, 2014 3:43 PM

San to reiterate what has been said above, you sharing this case is a testiment to the care you have for your patients and your desire to perform the best. I have often siad that those have no failures are either blind to their faults or not doing enough of something. Expectations on us as dentists are more than most professions. The reality is patients usually dont have 2nd thoughts about redoing a medical procedure if it means getting a better outcome but when people have to pay for services then it becomes a different issue. This is a whole different can of worm and best left for another time. You have shared and we all thankyou for that. Everytime there is a post something can be learned from it and i am most certain even the most seasoned and precise surgeons like Dr's Lui, Van As and Jin would agree. You are two+ months into surgery on a grafted site with short implants and crestal bone loss. My guess is you will be able to hand torque these back out. You will have a good feel with your hand torque wrench and if not then you can use either long tapered fissure bur (high irrigation), hard tissue laser , or trephine to core around and then exo the implants but i am thinking you'll get them out fairly easily. Please follow up this case with us so we can see the progression and continue learning. Your parient will be grateful i assure you. Jim

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San Bhatha Replied at Fri, Nov 21, 2014 2:17 PM

I forgot to add that as these implants were only recently placed ON Sept 9 is there any chance of torquing these out by hand ?

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San Bhatha Replied at Fri, Nov 21, 2014 2:16 PM

Thank you gentlemen for your empathy and great insights into this case. I'll be honest in that I did not even think twice about putting this failure up on the forum and the feedback that you have given is exactly why. I want to ensure that I learn from this one moving forward. I have already prepped the patient that the best course of action that I would prefer would be to remove the implants and regraft the area and wait and then place 2 new implants down the road. I have not had to remove any implants until now so I'm wondering if I could get some feedback on technique and instruments. I am concerned that there is only approx 7mm bone buccal lingually with size 5 implants not leaving alot of room buccal lingually. And also is using a non resorbable membrane tacked down my only option?

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Bernard Jin Replied at Fri, Nov 21, 2014 5:20 AM

Hi San Thanks for sharing your case. Ti-mesh exposure happens to all of us. And it sucks when it does. My thoughts - even though you could in theory salvage the case by converting the exposed threads to a machined surface, based on the history of the case, implant length and potential load expected of the implants, I might choose the approach of explanation and grafting. Then returning another time for the implant re-treat. Drs. Glenn, Jim and Albert all had good points and I would agree with them. If I were to retrace the reason for the exposure - I suspect that the flap design and closure - likely it was probably all under tension - especially with the tongue, buccinator, mass enter and platysmus all pulling away at the flap. Not to mention eating/speaking habits, etc. Re grafting on top of the existing implants probably wouldn't work too great - because the surface of the exposed implants are probably infected with biofilm - and that would compromise the graft success. My choice from this point would be to have a good talk with the patient and explain your desire for the best outcome for him. And to achieve that is to re-establish the bony foundation. And that even though it inconveniences both you and him, that you're committed to seeing him get a successful,outcome. I'm sure if you explain it in this manner, he would likely be more receptive to retreatment. Hope that helps San. Lemme know if I can be of further assistance. Bernard

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Glenn van As Replied at Fri, Nov 21, 2014 4:43 AM

Hi Sam: I reread my post and realized that my jet lag from my trip to India and the Maldives ( got back on Sunday) is affecting my mood. Albert as usual had a great reply and one that thanked you for posting. I wanted to say great documentation and sorry that this happened to takes a lot of guts to share these cases and believe me we ALL have them....but we learn from them. You were unsucessful in this case and I find sometimes we try to pack more and more into a single surgery and that sometimes when complications happen that we realize maybe one miracle at a time is best. Albert, and Jim had some really helpful advice and I like their replies alot better than mine. I wanted to say thanks for sharing and I apologize for the "harshness" of my previous reply. Glenn

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Jim Yeganegi Replied at Thu, Nov 20, 2014 6:41 PM

San, thank you for sharing this with us as there's so much learning for all. I would agree with Glen regarding treatment. Our goal is to provide the best long term outcome for our patients and be comfortable ourselves with the treatment we provide. Leaving a couple of exposed threads may not be the end of the world as you could polish them down and treat it like a smooth surface. That would have been an option had the anatomy allowed you to place longer implants but in your case this was not possible. In this region most of the forces on the implant will be on the top1/3 which means we don't have much room for losing bone etc. I have not worked with Smartbuilder but it's a formed titanium mesh, I gather, so closure of the flap over top is imperative. I am not sure if you achieved primary tension free closure and the PRF membrane may not have had enough time to provide protection of your graft prior to tissue granulation. So if there was incision line opening around the head of the cover then the PRF and graft were susceptible to bacteria etc. Maybe an option would've have been to place a PTFE Cytoplast on top of the smartbuilder and then PRF on top of that against the tissue. In any case Dr.Van As has given you what I would do if this was my case. Your patient will be appreciative of the care you're giving to ensuring the best treatment for him/her and while they may be disappointed in the short-term at the prospects of time and re-surgery they will be grateful for your ability and care. jim

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Glenn van As Replied at Thu, Nov 20, 2014 5:09 PM

Start fresh in my opinion and here are my thoughts. YOu really pushed the boundaries here in this case by 1. Immediates 2. Short implants 3. Healing caps ( the patient probably was chewing on them) I would have buried them. 4. No autogenous bone on the implants and bioOss over that. I would start fresh, remove , giant flap, graft autogenous ( scraper or cores from posterior ramus) mixed with xenograft 50:50 and non resorbable membrane tacked in place. Wait 9 months then go at it again with bigger implants..... Its going to be a long time now to fix this.... Just my thoughts Glenn

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San Bhatha Replied at Thu, Nov 20, 2014 5:05 PM

I forgot to add that on surgery placement, 50+ Ncm were achieved for both and for #36 ISQ were 86B, 66M, 72D,and 72L and for #37 77B,83M, 72 L and D.