Discovered fistula during implant restoration: suggestions?

As a follow up to my post, the patient came in yesterday and the pain and numbness turned out to be a slightly tight contact from the new crown. But the question still remains about the fistula.

It looks like you have had a buccal plate fenestration without realizing it.get a CBCT.

Remove implant, wait two months, replace (BTW, clinda 1200mg may lead to nasty GI sequelae.....should limit it to max 900 mg/day).

Dear Doc, We are asked not to be obnoxious in our comments but you obviously have not paid attention to that request. Giving 2700mg /day of clindamycin? Three tabs tid? Where did you get your info? I guess that your spectacular practice administers I.V. clinda. Very impressed. Stick to paddle ball. Oral: Serious infection: 150 to 300 mg orally every 6 hours More severe infection: 300 to 450 mg orally every 6 hours Parenteral: Serious infection: 600 to 1,200 mg via IV infusion or IM injection per day, in 2 to 4 equally divided doses Severe infection: 1,200 to 2,700 mg via IV infusion or IM injection per day, in 2 to 4 equally divided doses More severe infection: Up to 4,800 mg via IV infusion per day

This is most likely caused by infection due to dehiscence of the buccal wall which was initially undetected or very thin with infected socket. if the implant is integrated and the dehiscence is less than 3 mm to the platform of the implant should be treated as an ailing implant with prep of the implant surface and bone graft with membrane after the removal of the crown and place a cover screw for 3-4 months. good antibiotic coverage like Vibramycin 200mg/day. hope the defect small. good luck

grwez doesn't need the needle , give the guy a break ! He had the guts to show his problem, so putting him down is not on. Why condemn the patient to implant loss, when there is every possibility that - as doc himself said in his initial post, in fairness - possibly lifting a flap - cleaning the area, place some ethoss, cover it up, antibiotics, see how it goes....there's nothing to lose and everything to gain. At this stage I would have refunded 100% costs and had the patient rooting for me...

There is one valuable little bit of info that you didn't provide, and that is whether or not the implant was torque tested. I suspect that it was not, nor would it pass, if it was. Regardless, I cannot justify placing the final restoration with an obvious fistula present, that clearly is associated with the implant. Don't need gutta percha to see that. You really only have one option here and that is an open flap procedure. I agree with doc's comments above, you probably have a buccal plate perforation, with a failed implant. One final remark, here. Antibiotics aren't going to eliminate a fistula, regardless of dose or class. First principal of dealing with odontogenic ( or related) infections is to find and eliminate the source of infection. Antibiotics are useful as adjunctive treatment for minimizing fascial space involvement of the infection, but they aren't to be prescribed as sole treatment. Doing so, will just lead to antibiotic resistance. Prescribing antibiotics without documenting (and treating) the source of infection is not good practice.

Thoughts on immediate implant placement in failed endo?

1) I assume the implant is fairly good integrated and when you did screw the crown to a torque of 35 Ncm. 2) You can raise a flap and clean the area where the fistula and fenestration is and wait and see if the infection goes away or not. 3) you should not use any bone graft material or membrane when placing the flap back. The bone graft material absolutely does not work with infection in the site. 4) If after a few months if you are lucky and the infection in the site disappear then you have the opportunity to raise a second flap and do some bone augmentation in the fenestrated area. 5) Considering all the above options I think that it is unlikely that the infection clears just by raising a flap and cleaning the site. 6) I think the most likely outcome will be to remove the implant and perhaps to place a second implant later.

If I were you I would make a triangular flap in this case. After observing the problem the flap can be extended if needed. Clean bone, implant and fistula. Then make the place bleed, don't leave it dry. Place back​ the flap. Don't bother if blood comes out through the fistula. I suppose that the problem is in the marginal part of the implant. The implant is quite long so integration is enough.

If a cover screw is not completely seated into the implant body at the placement surgery a fistula can appear after some time passes. It could take weeks or a few months before it is seen. The cover screw may seem to be seated and tight if a little tissue is trapped under it. Open a flap as if you had a defect on the facial aspect of the implant that needed repair. Start from the junction of the gingival attachment on the adjacent teeth and the facial over the implant. You will be able to see what the problem is and correct it. Is the fistula blind? It may just be a short healed tract lined with epithelium similar to an ear ring hole. Is there any drainage?

I see the main question you are really asking is in regard to flap design. Let me clear that up for you. Without a CBCT it is impossible to tell you what flap design would work best. If this is a small Apical perforation and the implant ends in soft tissue then no flap will help. If this is a long buccal fenestration then a semi lunar flap will miss the coronal portion that needs to be detoxification and grafting. Get a good 3D image for us and we should be able to help you know what to do. If you don't have access to a CBCT then anticipate a full buccal and palatal flap, grafting, gtr and burying the implant. Or just take it out wait for healing and start again.

Dear We would like to find out what is the main cause of the problem. I think this is one of disadvantage of immediate implant placement.

First step- place 35 size gutta percha into the fistula and push it until resistance is felt. Take radiograph to trace the infection origin. The source may not be the implant? If it is the implant, you can now plan appropriately. Plan your flap design based upon the amount of buccal bone present. Determine your goal (therapy) based upon the size of the lesion as well. Your diagnosis determines all of this. Good luck.

without a cbct its all speculation talk. How do you know if this implant is in bone this area seems relatively easy but it does have a palatal angulation most of the times and this is a very long implant, you don't see fistulas that often with implants if you place them into bone.

Do a vertical releasing flap posterior and anterior to the implant. Keep the base wide of course. Include the teeth if u want be careful of the papilla if u decide to include a tooth. Raise the flap into nonkeratinize or just enough to see full defect. Currette the heck out of the cystic lesion that you will fine. Curaterize it if u have one. There should be no soft tissue left in the defect. Clean implant with citric acid scrub. Perforate the bone with 557 bur regraft with collagen membrane and graft materials Add Metronidazole to graft. Undermine flap of course to get primary closure. Resuture; don't worry about a scar. You are a surgeon save the implant. If u find that the implant torques out then just remove it...and still remove lesion...and follow above info...Get an Ellman cautuery machine 4Mhz and use versah burs.... I graft with a Calcium Hydroxide, DFDB xenograft,and Metronidazole Mix BTW. Hope this helps...#weAREall brothers&sisters#BlessGOD

Given the new information regarding when the fistula appeared, here is how I would manage: 1. Take the crown and abutment off, torgue test the implant. If it is stable at 35nCm, put cover screw back on and be certain that cover screw is firmly seated. Proceed to step 2. 2. Place Atridox in the sulcus around the marginal aspect of the implant. Discontinue systemic antibiotics. They have no role here. Place the patient on Peridex per Atridox protocol. 3. Re-eval in 2 weeks. Fistula most likely will be gone. Start back over with seating of abutment. Note: If implant is mobile when you torque test it, proceed to open flap procedure, replace implant and graft accordingly.

Yes late to party , but my 2 cents , could be non indexed abutment fit ... hence bacteria .. depends on system .... or a chip of root or bone in the site ... happened to me last weeks ... Peter

I have just reviewed this. The fistula appears to be at the level of the apex of the endo treated tooth. There is probably a bony deflect of the labial plate. It is also possible that the curettage at the time of extraction left bacterial contaminated material in the osteotomy site. The Implant is compromised. Clindamycin is not the panacea that we once thought it was. Check with the íD service in your city. In my city 70% of all Oral infections have resistance to it. Most of the organisms in a fistula are mixed and in most environments there will be some resistance. Torque test the Implant. If it is stable, then it is reasonable to try to do a salvage procedure. Put on a cover screw. Then design your flap in such a way that your flap margins will be on intact bone. You need to have a wide base to your flap. Wash out the deflect with 500 to 1000 cc of Bacitracin solution. Make sure that you remove all necrotic soft tissue and bone. Pack the deflect with your bone of choice and use a membrane. I use Snoasis in this case. Use a fine - 5-0 or 6-0 non resorbaable suture - Proline. Cover with antibiotics for 7 days and offer a 50 50 chance for survival. You should not image this preop to see where the bony margins are.

As long as you get primary fixation , GRAFT and close it up.

Hey Bob, it's Mikey. Good direction. Is this case still being discussed or has it been determined what was done and what should be done. We all know the obvious but what was the end treatment here.

Hey Mikey; no indication it's been treated already. I've opened many of these cases through the years. Virtually all of them were fenestration defects and just needed to be grafted. The toughest part of the procedure, however, is complete debridment of the implant surface, especially if the soft tissue defect has expanded to the palatial side. This is where ablative lasers, with side firing tips, really shine through.

As a follow up here's what went down. Flapped and found a buccal fenestration , explanted the implant and bone grafted. So far the patient is doing well. Thank you all for you input.