Exposure of cover screw during initial healing: suggestions?
I am a beginner in implantology.  I placed an implant along with GBR with Ladec/Memlock in #4 site [maxillary right second premolar; 15]. On recall appointment in following implant placement I found out that the sutures have pulled through and the flap opened over the crest of ridge.  I tried resuturing, but could not manage primary closure, probably because I did not do enough periosteal release of the flap in the first place. I left the implant to heal by secondary intention knowing that I may have to do GBR again on the exposure stage. Today I did a followup to find out that secondary healing was progressing well but the cover screw was exposed. Any suggestions about this case? Shall I replace the cover screw with transmucosal healing abutment and if so at what stage?
15 Comments on Exposure of cover screw during initial healing: suggestions?
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Peter Fairbairn
12/19/2012
You have a spontanoues exposure which can happen , but now is the 64 million $ question do you removed with reverse torque at a critical time and place a healing cap or leave.
Again this is case dependant we always forget the most improtant thing the patient and their metabolism and oral hygiene . Most exposures are no issue but some where these patient factors are poor you will see bone loss of a mm or 2 often associated with a small amount of pus.
So assess the case and place a healing cap if you have any doubts.
Peter
CRSAa
12/20/2012
Leave it alone let the tissue mature before placing a healing head or abutment . I have the patient dab it gently daily with Peridex. It should be fine if the screw is not loose. Don't try to resuture a failed flap. It should be fine.
bülent zeytinoğlu
12/25/2012
Ä°f there is no sign of inflamation leave the case as it is but tell the patient to keep oral hygene very carefully by using oral medicaments ( clorhexedine rises) and advise him to keep up the exposed cover screw as clean as possible .Ä°f there is inflamation you can add antibiotic therapy.Please do not forget to control the case every week and olso do the x - ray check up every two months.
DL
12/25/2012
All the above answers are right on the money. I've had this a few times and pt hygiene is a big factor, having said that all cases went fine despite a little acceptable bone loss. I've changed my protocols a little and now use 2 different implant systems depending on the requirement, I use collagen, Teflon/ptfe or combination of both over a graft and I use page, silk or vicryl sutures again case dependent. I also find ozone gas and curasept per and post op have reduced my infection rate to virtually zero
jerry
12/25/2012
It is fine. It is like a single stage implant. There is evidence in the periodontal literature that if you have a partial screw and not a complete screw exposure it might be a good idea to trim the excess tissue over the screw. If you leave the lip of tissue, this creates an area when bacteria are less accessable and can multiply. It is also a good idea to apply CHX two times daily on the exposed screw with a cue tip.
DR JLD
8/29/2013
Wonderful response. There was a recent posting regarding trying to back out a healing cap that resulted in the implant spinning in the osteotomy. Do not mess with the cap! Do exactly as Jerry suggested in the above post.
Alex
12/25/2012
I would not worry about it as long as the patient keeps it clean. Have them rinse with listenine or natural dentist mouth rinse.
TOBooth
12/26/2012
Hi if you had good primary stability change to healing abutment and rinse with saline and Chlorhexidine. Small exposures cause more bone loss than large ones.
Dr. Gerald Rudick
12/26/2012
Having a cover screw exposed during the healing period is not a problem at all......in fact after the 4 month healing period, just place a little topical anaesthetic around the gingival tissues, and change this screw for a healing collar...no anaesthetic necessary.
Leave the healing collar in place a few weeks, and watch to see how the gingival tissues develop, which will give you an idea how to plan the final restoration.......for ideal aesthetics in the #4 area, the margin of the crown might have to be built to cover a portion of the implant body, in order for the crown to be subgingival.
Gerald Rudick dds Montreal, canada
drshalash
12/27/2012
never attempt to re-suture a flap..the exposed cover screw should not be of any concern as long as the patient keeps good oral hygiene..topical irrigation with chlorohexidine is something to consider..Early exposure is not a good predictor for the outcome of your regeneration process..good luck!
Baker k. Vinci
12/27/2012
I'm not so sure that the exposure of the screw is any indication at all. This doctor has not placed many implants. Some of my referrals encourage me to have the cover screw exposed. 20 years ago, we would fret if this occurred . This is no different than the one stage implant. Bv
Edward Dergosits
12/28/2012
Like others have said it is probably not something to worry about but if you performed GBR at the time of placement it may be a problem. What kind of membrane did you use? I assume it is exposed somewhat on the buccal. Watch it closely and make sure the patient is using Chlorhexidine twice a day. I would have the patient use a 2% gel applied directly and gently with a cotton swab. If there was no grafting done at the time of placement I wouldn't worry about it at all.
Gregori M. Kurtzman, DDS,
4/30/2013
Cover screw exposure is not an issue and is common in implant placement when extraction is done at placement. Key to avoid this in the future is to place your sutures 10mm from the margin so that muscle pull can not pull the sutures out and use a criss-cross suture. When doing GBR always best to place a resorbable membrane over the graft/implant and under the flap so should a small opening happen the tissue will quickly migrate over the membrane to close it.
emlan
11/19/2013
nothing to be panic except safeguarding that only the cover-screw is exposed.its often a post scenario in single triangulated or vertical marked bone loss sites in molar. often dense grade-2 with narrow width molar area is of similar problem so selection of implant in that area is important and bio-absorbabale memebrane aids in making tissue contour to avoid wedge area denudation.if graft is not on load time then its not of much worrisome ,but selecting abutment angulation is important.
Mike
12/18/2013
Things happened, probably for a reason, make sure he keeps i clean, see him once in a wile. Clean and (peridex) watch if closes. If it get infected, membrane is or will get exposed, don't miss it, may need to remove some of it. But hopefully it will pass.
I use peridex, but there are suggestions not to. Any take on that?
