Topic

[Surgery]  Thread exposure


Hi.  


I took your PRF course in Toronto recently. I need your valued feed back about a case I did about 2 months ago.The Client had missing 24 and 25.I did 2 implants and sinus bump with 25 implant. and placed healing abutments at same time as I had primary stability..At same time I did Horizontal GBR with FDBA( Sureoss-Powder)and PRF as the buccal bone was little thin but No thread show through at that time.I made sure to release flap  about muscle level for tension free closure.1 week Post op I saw little loose flap  in between healing abutments.I did want to touch soft tisues at that time and asked Client to come back after 1 week for another follow up.Now I saw 4-5 mm recession of Soft tissue and visible loss of all grafting material But intact bone at 25.24 soft tissue was fine.I raised the flap again with more release of muscle tension and did GBR again and replace the Healing abuments with Healing screws .1 week alter I again saw little recession and I did PRF and Tuck with Healing screw and repeated 1 week later,to aid healing. 1 week later ,at this point I see bone loss at 25 Implant and show through of 24 Implant head.There is bone loss of upto 4-5 Threads.At this point I was thinking GBR with Smart membrane or take out the 25 implant and redo later on.What are your suggestions.If taking the implant out shall I be concerned about sinus bump I did at that time or If keeping the implant any special suggestions.What will be best way to decontaminate the implant surface or any other suggestions.


by Bernard Jin at Tue, Jan 6, 2015 4:39 PM

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Glenn van As Replied at Thu, Jan 8, 2015 2:01 PM

Hi there: Third time to try and post....arrggh. First off thanks for sharing your tough case. I feel for you. Several thoughts briefly as my day is starting. 1. A photo and current radiographs would be vital for any suggestion. Is this patient having a high smile line or not. In my office a cBCT would help me determine if its time to explant and regraft. Remember that this is a vital esthetic area in a smile so can you afford to have threads showing. 2. What sutures did you use initially. One reason I like PTFE is that with swelling from periosteal release they dont tear so that is what I like to use. Combination of horizontal mattress and individual sutures. 3. How much bone loss % wise do you have if its 50% or more its time to remove them. 4. Do you have an ISQ machine.....this also could help. With respect to disinfection, I use an erbium YSGG laser ( Biolase) as there are now 4 great studies from very reputable people in great journals to show that it provides disinfection, it cleans the threads of soft tissue ( a huge problem) , it does not heat up the implant, it can even remove the infected SLA surface, and bone can reosseointegrate onto the threads. Others use Tetracycline etc to disinfect but the issue is how to get the tissue out of the threads. Froum has done some long term research on saving implants ....you can find his 6 step protocol which involves alot of air abrasion ( not a big fan of this). I am lecturing a lot on this topic at various plaes this year ( AACD, Dental XP) so its a very very Hot topic. I hope that my email helps and if you post a photo of the site and also radiographs I can tell you what I would do....its tough to salvage this case.......sometimes its best to start over. Glenn



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Bernard Jin Replied at Tue, Jan 6, 2015 4:58 PM

I just realized I didn't answer your question about implant surface disinfection: I use tetracycline slurry as a disinfection agent for my implant surfaces.



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Bernard Jin Replied at Tue, Jan 6, 2015 4:55 PM

Good question. I suspect if the buccal osseous wall was very thin - and you raise a flap - the vascularity of the thin bone would be compromised. This could lead to substantial osseous remodelling and eventual loss of the buccal bone. And thread exposure would ensue. Now that there is substantial recession, I would consider the following options: 1. explant and graft the sites. Only to revisit several months to place new implants. 2. convert the exposed threads to a machined collar but this would compromise aesthetics 3. regraft the exposed threads (but this is VERY difficult to perform considering that the implant surfaces are now heavily contaminated with bacteria. You would have a very hard time to make this work out. I believe Dr. Van As has some insight on regenerating bone on implant surfaces AFTEr treating it with laser therapy. Dr. Glenn - I'd love for you to chime in with your expertise here. 4. do the same as option 2 & 3 but only augment the site with soft tissue (connective tissue graft). I would question the long term prognosis of this. At the end of the day - much of how you approach this depends largely on your patient's expectations and requirements. Hope this helps you. Bernard