Breakdown Over the Head of the Dental Implant / Cover Screw

Richard, a dentist from the UK, asks us:
I have the following situation on my hands. The tooth in question is an upper canine (cuspid). I used an immediate delayed approach ( 8 weeks post-extraction) and placed a NobelReplace tapered groovy 16mm x 4.3(RP). The 1st stage surgery was done 10 days ago.

The dental implant is to be used as the mesial abutment for a 3 unit bridge. I
placed a similar dental implant of 10mm length in the 2nd pre-molar
(bi-cuspid) position at the same time. This was submerged and has
healed over fine after 10 days.

For the cuspid, there appears to have been some wound breakdown over
the head of the dental implant /cover screw, confined to the palatal side as
far as I can see. The collar microthreads (remember this has ti-unite
and microthreads right to the top of the implant head) are exposed for
about 1.0-1.5mm. On the bucccal side and partly over the cover screw,
the soft tissue flap (which looks pink and healthy) is concealing the
full situation.

Since there is no machined collar on this type of dental implant I am considering my options:

Option 1: Remove the dental implant as soon as possible assuming I will be able to
unsrew it say 2-3 weeks post op? and immediately replace it with a 13mm
fixture set a little deeper and then advance flaps and get primary
closure?
Option 2: Leave the dental implant, re-open flaps to expose, if only the palatal
aspect is exposed then take a fine bur to the palatal surface to remove
superfical ti-unite and close-up leaving a polished area exposed.
Option 3: As above but in addition use citric acid or tetracycline to
decontaminate and then locally scraped bone chips and a resorbable
membrane (Bio-Oss) cover the exposed area

Any other option anyone cares to suggest !!

All advice gratefully accepted.

Richard

14 Comments on Breakdown Over the Head of the Dental Implant / Cover Screw

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Anon

2/21/2006

Don't worry about it for now to see what happens in the next couple weeks. Messing with it now other than removal will be fruitless.

Dr. R Mosery

2/21/2006

leave it alone for now let it heal for 2months. keep pt on excellent oral hygiene regimen with peridex rinsing. you may be pleasantly surprised.

Harry Karna DDS

2/21/2006

I would agree with leaving it alone for now and letting it heal for at least 4-6 months. Chlorhexidine with good uncompromised oral hygiene would certainly be great. Also, in the future it may be helpful to use a PTFE membrane fixed with the cover screw extending buccal and palatal with some DFDB graft under the membrane so that even if the tissues do open up , the PTFE with the DFDB will prevent the threads being exposed. It will work like a GBR procedure in conjunction with the implant insertion.

Anon

2/22/2006

I have had many cover screws of Nobel Replace tapered groovy fixtures visible during the osseointegration phase and all have been solid at "uncovering" six months later, with only one having one thread on the buccal aspect exposed. You do, however, need to keep close watch on this process to insure that the gingival position is stable and not progressing further.

Peter Gilfedder

2/22/2006

Richard, I would fit a permanent abutment and then prep the exposed palatal margin to take it subingival again. If you are not used to this; place large size retraction cord first (its much easier with implants than teeth)and don't worry about titanium particles or heat (i've prepped plently of NobelDirects and have not had any problems with these)(also prepped various other designs without problems). In view of the problems with exposed Endopores it would be prudent to be wary of leaving exposed threads(grooves). Peter Gilfedder. UK.

fabrizio

2/22/2006

Richard, I would let the esthetics be your guide. I do not think that the cover screw exposure will have any impact upon the osseointegration of the implant. however if the implant is very superficial you could have esthetic issues in terms of metal exposure or emergence profile in the future. If the esthetic could be a compromise in my mind it is easier to deal with it now by replacing it with a 13 mm and use a healing abutment instead of a cover screw. Just keep a 3 mm healing abutment flash with the soft tissue. Hope this is helpful.

Anon

2/23/2006

I agree with leaving if you think the buccal tissue will leave you with and aesthetic final. I would be a little more aggressive and remove the bad tissue irrigate well and curretage the area and it will still integrate even if the screww remains exposed

Anon

2/24/2006

I would remove this implant now before you have a real problem of an integrated implant with poor esthetics and fully integrated. The exposed cover screw is not the real problem- it is the exposed threads and why this happened. There's a bone dehiscence on the palatal now which could also be present on the buccal but covered with tissue. If the buccal has a dehiscence, I think there is a risk of getting soft tissue recession over time. Just my opinion. Good luck

Anon

2/27/2006

First, Stop placing the Nobel Implants--Life will be much better for you and patients. Listen, I have been there!!!!!!!!!!

Anon

2/27/2006

Many thanks for this advice. I have taken additional advice from UK implantologists. The consensus was not to worry and not to disturb the site, although one well known name in the UK said It was a judgement call & I could consider removal of the 16mm implant and replacement with a 3mm shorter implant + healing abutment without raising a flap. My concern with this was not to disturb the 1 month augmented buccal aspect in case of unpredictable recession. I'll report the results in a few months time ! Richard

Anon

3/5/2006

I have placed many many Nobel implants of all types. Many have been immediate and/or flapless placements. I have, in my own experience seen, and now read about cover screw exposures, particularly with Nobel implants. I would like to know if this truly is common with this type of approach or whether it may be related to this company's product. Also in regards to thread exposure. I have had good success treating by decomtaminating the surface with tetracycline for 30 sec and placing a connective tissue graft.

Adrian Watkinson

3/21/2006

you have had some good advice but the best advice anyone can gave you is to switch systems in future to the worlds leading implant system - Straumann- and you will not have this problem again. Straumann now have the best and longest record of scientific documentation of any currently marketed system.Nobelbiocare groovy is relatively untested. Branemark now has a ti unite surface and as such, is without documentation of any substance.

Anon

3/21/2006

I use Straumann, however it is not esthetic in any away. It functions but I use it only in posterior regions. I am finding boneloss on the Straumann after 1 to 2 years. This makes no sense as there is no microgap? I used Nobel for many years but I do not agree with what they are teaching in the GD field. I think GD's should be placing implants I feel the training needs to be more in depth. Cover screws expose from time to time. No big deal. See the patient more frequently to observe.

Gary D. Kitzis DMD

3/28/2006

Leave the implant alone. Do not be concerned about the exposure, especially on the palatal side. If the facial were to have a significant exposure, then it would be an esthetic concern, but you haven't described that for now. Have the patient gently keep the area clean. Do not bother trying to cover it with a gingival graft, it probably won't truly cover it (you'll be left with a visible or invisible pinhole in the gingiva anyway, which can be more difficult to manage than a frank exposure) and it isn't necessary. Next time place the fixture a little deeper.

Breakdown Over the Head of the Dental Implant / Cover Screw

14 Comments on Breakdown Over the Head of the Dental Implant / Cover Screw

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