[Others]  36 implant infection


60 yr old female with non complicated med hx.  I did implants  36, 46 four months ago, patient came back today for final impression.  46 doing great, but there is infection around the 36 implant with some bone loss on it and the adjacent 37.  No mobility on 36 implant, seems well integrated (I don't have an ISQ reading)

Wondering what the best way to proceed is?  My thoughts, lay a flap, debride the infected area, treat with a tetracycline slurry then... would it be advisable to graft the area and cover with membrane or smooth off any exposed thread? 

Afterwards my plan would be to place cover screw and obtain primary closure, what kind of follow up and how long to wait before proceeding with restorative phase.

Thanks for any suggestions.  Trevor

by Trevor Lake at Wed, Feb 19, 2014 10:39 PM

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Trevor Lake Replied at Wed, Feb 26, 2014 7:32 PM

Thanks for all the great suggestions. I converted the exposed surface to a machined surface and treated area with a tetracycline slurry before closing. I will keep you posted as to the outcome, fingers crossed, but I won't be surprised if I have to go back in and replace the implant. As for the 37 Jim, I do agree with you that the root canal fill does not look ideal and possible widening of pdl on mesial root. The tooth is asymptomatic when testing. Patient estimates rct was done 10-15 yrs ago. If I do have to replace the 36 implant I will strongly suggest to the patient that she have retreat/apico on 37 prior to that. Have a great day!

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Jim Yeganegi Replied at Thu, Feb 20, 2014 11:24 PM

Hello Trevor, All above points are excellent, and you certainly have options available to you. I will not have had the experience of above Dr's however in my pervious experience I have used a hard tissue laser at low pulse and low energy settings to clean out any tissue/ contaminant and bacteria on exposed threads and have tried covering with graft/ membrane and closing but truth be told I have had little success in re-growing bone around the threads. Polishing down the threads to give yourself a smooth a surface and decrease plaque and microfilm accumulation is probably the safest bet. From the picture your implant looks integrated as you can see evidence of bone in-between the threads. Are you getting any probing depths along the sides? Of concern to me is the state of the #37 behind. The Endo looks a little short on the mesial root with what appears to be formation of a lesion at the apecies of the roots. PDL on the mesial root looks a bit more widened than on the distal and compared to the #35 so check occlusion and check for potential probing around this tooth. Sometimes these endo teeth have a nasty habit of getting infected and the path of infection can drain in areas we least expect and potentially communicate with our implants. This I have experienced and it's gutting. Would be interested to see what treatment you take and the outcome. Best of luck. Jim

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Ho-Young Chung Replied at Thu, Feb 20, 2014 4:47 AM

oh and Trevor, I would start using the 6mm wide healing abutment. Nobel now has 6mm wide healing abutments. And if you only have Nobel in your office, I would start using their connical connection tapered groovy implants rather than the trilobe (that is if you are still using them). You'll get less bone loss with internal hex connections. Ho-Young

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Bernard Jin Replied at Thu, Feb 20, 2014 3:25 AM

If you happen to have a laser - you might be able to disinfect the implant surface to a point of accepting subsequent osseous grafting. Unfortunately I'm not all that familiar with lasers and perhaps Dr. Van As might share his expertise on this.

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Bernard Jin Replied at Thu, Feb 20, 2014 3:22 AM

Hi Trevor I think you would have quite a challenge to debride and disinfect the implant surface completely to a point of accepting osseous grafting. I suspect you might consider converting the exposed surface to a machined surface by performing polishing with a high speed diamond with copious water, followed by brownies & greenies. Then consider performing CTG to augment the site. If you want to perform disinfection slurry with tetracycline - that's good too. At best - I believe this would be your best bet to try to salvage the implant & bone loss. Before embarking on flapping and all that, I would try to figure out the etiology of the bone loss. Was there excessive torque? Overheating? Clearly something led to the bone loss. Figuring out the cause is important - because it may impact the overall outcome of the implant. If you have an option to remove the implant and replace it - this too is a viable option. Albeit a more predictable one because you're starting anew. Again - etiology of the original bone loss needs to be addressed.

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Ho-Young Chung Replied at Wed, Feb 19, 2014 11:58 PM

Hi Trevor, how are you? been a while since we last caught up. Is there exudate coming out? Threads exposed? how did you test for mobility? ISQ would have been nice. I had a case a while back where I had an implant that didn't integrate. pus coming out. ISQ was 57. I won't go into why this implant didn't integrate but there was a good reason. What I found out after flapping was that the whole implant was infected. I replaced it with a larger implant and the patient is fine now (I also got an hour behind schedule), If your implant is well integrated and there is just a bit of bone loss on the distal (and no pus) then I would be inclined to leave it. If there are threads showing then I would smooth out the exposed threads, place PRF and then suture up. If there is pus, then perhaps this implant is not integrated. PAs don't always tell the full story. I hope that helps. Ho-Young