Manage gingival and bony fenestration in 8-year old implant?
I am a periodontist and I did not place this implant. This patient presented with a gingival fenestration on the buccal of this 8 year old implant. I feel certain there is very little buccal bone on the coronal two-thirds of the implant. The patient is not experiencing any distress. She has a low lip line, so it is not a cosmetic problem. Obviously this is not a good long term situation. According to the patient, she has had 3 surgical interventions in this area. Extraction and bone graft, and a re-grafting of bone after the first implant failed. Then an additional flap and possible osseous grafting when or before this implant was placed. These procedures were all performed by a local oral surgeon with a good reputation. I did not take a CBCT because I think the burnout would obscure most of the buccal bone. I will take one before any actual treatment.
I think we all know where this implant went wrong. I think this group understands the importance of 2 mm of buccal bone on any implant as well as the necessity of several millimeters keratinized gingiva around all implants. I have been debating in my own mind the best course of treatment. I know what I think is best, but I’d like to hear your opinions.
12 Comments on Manage gingival and bony fenestration in 8-year old implant?
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Dennis Flanagan DDS MSc
11/25/2019
Take crown and abutment off debride and curet the gingival margins and fenestration. Make a subepithelial inverse-flap (the term escapes me right now ala-Anthony Sclar) and pull the subepithelial inverse flap over the implant (disinfect the implant platform) so that it covers the implant and facial defect and slips under the undermined facial mucosa. Suture and wait for healing and access the implant and place the abutment and restore appropriately.
John Manuel, DDS
11/25/2019
Yes, this may work. I’ve rescued several similar cases. Salvin has a”Peri-Implantitis” Bur Kit with brushes and burns to clean out the implant surfaces which works well.
John Manuel, DDS
11/25/2019
Yes, this may work. I’ve rescued several similar cases. Salvin has a”RotoBrush - Titanium” kit just for this purpose.
Sean Rayment
11/25/2019
You are deficient in both hard and soft tissue. While the coronally repositioned flap may cover the defect in the very short term, you need a better long term solutions, which I believe would start with hard tissue grafting (and membrane). Following that healing I would plan on doing a CT graft to improve the amount of keratinized tissue on the facial. Surgeries number 4 and 5 for this patient.
Carlos Boudet, DDS DICOI
11/25/2019
Many things to consider here. The case was restored very nicely, but maybe the implant should have been removed and replaced after the GBR to insure placement within the bone. The bone is not deficient, it is not there, and once you elevate a flap you will see that at least 1/4 of the facial circumference of the implant is outside the bone.
On a prominent root you can plasty the root to improve the success of a graft, but are you going to plasty those aggressive threads on the implant?
Also, to regenerate bone on the facial of the implant, do you expect that osteogenic cells will bridge the large dehiscence over the implant by migrating from the edges and the fenestrated flap?
I think the treating doctor is going to have to empty his bag of tricks and skills on this one, including incorporating human recombinant bone morphogenic protein with the allograft. I agree that the soft tissue needs improvement also.
I would love to see the post-op pics on this case.
Thanks, and good luck!
Dr Dale Gerke, BDS, BScDe
11/25/2019
I think most would agree that grafting over the existing implant is not likely to work long term. Also that more bone and attached gingiva is required before considering another implant. The difficulty is how to achieve this – remembering that it seems there have been numerous surgical interventions to date and probably a lot more in the future - so the local soft and hard tissue is likely to be compromised to a significant degree.
I suspect the real dilemma is the timing. It seems the patient is able to cope at present and apparently there are no symptoms. Previous treatments seem to have been carried out competently and as such it seems there might be a chance that further treatment might not generate any better result. So potentially you might swap bad for good BUT it might turn out to be bad for bad. So... when do you recommend re-treatment to the patient – now or when the implant fails (we have not been told what the patient desires).
If I was involved, I would present the facts and options to the patient and let her decide what path to take. The age and health of the patient has not been mentioned and these variables might influence what should be done and when. Like others, I would be very interested in the final result of this case.
Dr A
11/25/2019
Thanks all for your input. Dr Gerke, you and I think alike! Dr. Flanagan, thanks for reminding me of that sclar flap. I need to pull out his book and review it. Personally I think that there is too much bone loss and too many potential pitfalls,
Sorry I did not include other factors. This is a 45 yo female in excellent health. She is a non-smoker and she is not a diabetic and she has no periodontitis. If you can believe it, she was considering ortho and the orthodontist made this referral.
I decided to bring this case to the forum because my treatment plans changed multiple times during the course of my 1 hour consultation. The patient is open to ideas. She considers herself functional. She has a high dental IQ and she knows she has a long term problem.
Here is my opinion on how to manage this case:
I cannot offer this patient any treatment that has great predictability other than explantation. She would have to have multiple surgeries, most if not all would fall into the heroic category. The risk of implant failure would be great. The costs would be great. This patient is functional and not in discomfort, so why explant now. My advise is to maintain this implant as is for as long as she can. I would be monitoring it clinically and radiographically, because we cannot afford a bony blowout. At some point in the future, we will remove the implant and start all the repairs. Even with the compromised blood supply, I think the situation would be better and more predictable. She will have 2 implant failures in this site and as I understand it, that gives her about a 60% chance of success with another implant in today's world. Maybe the future will hold something better for her.
For me, this was a reminder that planning is so important in implant success. Let's not rush in, let's think it through. Thanks again for your thoughts and ideas. I'm still open to hear more.
Ernesto Bruschi
11/26/2019
Personally I believe it can be successfully treated with debridement and remodelling of the titanium surface in combination with palatal CTG and Coronally Repositioned Flap. Best wishes.
mark simpson
11/26/2019
It is possible that the best solution at this point may be a bridge. I realize that I will probably get kicked out of the group but if you were the patient and had been through all of that and had this result? Leaving this alone it will most likely get worse. I just like to make sure the patient has all there options.
Frank Serio
12/2/2019
Mark,
Make room in the boat. By all accounts this is a very challenging implant case with no great predictability. Sometimes a bridge, even with virgin abutments, is the treatment of choice. Here, with a SCTG, the final ovate pontic and bridge can give many years of fine service.
Greg Kammeyer, DDS, MS, D
12/5/2019
I agree there are alot of choices here: Why did the other implants fail is a key question? Long standing failed root canal with residual toxins in the bone? Inadequate site width....highly likely. Thin labial mucosa? I would recommend dividing your options into;
1) Explanting and bridge
2) Explant and replace w implant
3) attempt a rotated vascular palatal flap over the implant body
4) attempt to grow bone/soft tissue w growth factors ( L-PRF + BMP w GBR)
Explain to the patient your best guess of prognosis of each and what you would recommend and why.
If you know what matters to the patient, how much risk they want to take, how much concern they have about time, number of visits, pain, cost etc then it is alot easier to treatment plan options that suit their wants. Without that, you are going on what you'd want which is best for you yet may miss the mark of what she wants.
Good luck....tough case. Good thing her lip line is low!!
Dr A
12/5/2019
Very well said Dr. Kammeyer. I will be speaking with the patient over the weekend. I will let you all know her thoughts. I have already shared all of these short of a fixed bridge with the patient during our consult. I think a fixed bridge is a good plan b, but I would prefer explant, gingival graft, ridge augmentation with biologics, scan and place a guided implant. I would have healing between each step and only move forward if I am satisfied with the tissue response. She reported an endo failure and no apical surgery. I don't know any more, but I am always wary when I hear failed endo. In this case, I cannot blame it all on endo, because the ridge width is seriously deficient and the tissue quality is so poor. Its remarkable that the implant has lasted this long especially when I think of some of my failures that looked so great, even as I was explanting.
