Implant Patient with Facial Gingival Dehiscence and Exposed Threads: Recomendations?
Dr. A. asks:
I am an oral surgeon and I was referred a young female patient with a high smile line, thin biotype, in whom I placed an implant more than 2 years ago. It was restored by a general dentist, using a Zirconium abutment. She came back to see the restoring doctor with a slight facial gingival dehiscence, and exposed threads. But instead of the restoring doctor referring her back to me, he placed composite on the exposed 2-3 threads. She now has more facial dehiscence, facial gingival recession, more bone loss. A CBVT scan shows loss of facial cortical bone only. Clinically the implant is still solid and is not mobile.
After viewing the CBVT scan and discussion with the patient, I decided to remove the implant, graft the area, with bone and soft tissue. What is the best sequence to treat this patient? I was planning on placing a bone graft using an allograft material. What allograft material would you recommend for a situation like this? I am planning on placing Alloderm over the bone graft to compensate for soft tissue loss. I am going to create a pouch for the Alloderm and graft underneath.
Is there another way that produce a more predictable result? Should a place a membrane over the Alloderm and if so which membrane would you recommend? As an oral surgeon, I am really looking for an advice from a periodontist who has had more experience with managing bone and soft tissue defects in the maxillary anterior aesthetic zone.
12 Comments on Implant Patient with Facial Gingival Dehiscence and Exposed Threads: Recomendations?
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Perio
6/12/2011
Dear colleague, First of all sorry to hear about this. This is a difficult situation even for a periodontist. What was the GP thinking? I think the most important thing is to bring your patient's expectations down. Do not guarantee success because it will most likely be a compromised result due to the high lip line and the thin biotype. When you graft you can consider harvesting autogenous bone and mixing with puros allograft. If you're going to use alloderm it is not necessary to use another membrane as it will act as a membrane itself. Biohorizon makes an alloderm variety that could be used as a membrane. Are you planning on redoing the implant? Is a bridge an option after you are done grafting? Are you familiar with th epediculated connective tissue graft? You can consider using it in this case. Anthony Sclar has published on it, look it up. It can give you a nice esthetic result. I also advise you to consult with a colleague periodontist. Good luck.
peter fairbairn
6/13/2011
Thought so, the GPs fault , same old story . But this generally is a issue from the placement , was it immediate , delayed was it host bone or a grafted site?
As to repair this is a very difficult senario especially with the high lip line and thin bio-type , a graft my lead to a worsenned senario with these factors so maybe removal is the answer.
If willing to try could use as above or try Mucograft but long term it is best to get some bone regenration in the site. I have restored a number of severe bone loss cases with synthetic graft materials but this may be a very difficult case , one to work with a periodontist.
Good luck
Peter
PCPerio
6/14/2011
Hello Dr. A.
You have already been given a couple of good recommendations. Without x-ray or photo it is tough to give specific advice, so just a couple of general comments.
The most important thing in these cases is don't make it worse and give the patient realistic expectations.
Implant removal is probably the best course. My main concern is the proximity of the implant to the adjacent teeth. If it is very close, you may damage the bone and tissue there, creating recession (by the very nature of the thin biotype, she is predisposed). Delivering it to the facial is probably the best approach.
Doing the removal, grafting and adding soft tissue allograft may be much more than a thin periodontium can tolerate at one time. Removing the implant and allowing some fill before attempting any grafting may be the most prudent approach. At that point you are essentially doing a ridge augmentation. Once you have some stable bone, it will be much easier to add soft tissue. In summary, in stages.
I think it was Denis Tarnow who said "one miracle at a time".
good luck,
PC
Dr. Dan
6/14/2011
This is a tough situation, but I believe that you are handling this situation very properly and I commend you for this.
First off, you should never place composite or anything over exposed threads..that's just plain lunacy.
As far as bone grafting material, I personally prefer to include something like Bio-oss cancellous bone or Nu-oss cancellous bone to the allograft (putty usually) just because it doesn't resorb that easily. Alloderm can be used as a soft tissue graft material and barrier so no additional barrier is needed.
Either way, with a thin biotype, blood supply is still at a shortage. Make sure you inform the patient that recession around his/her other teeth is very possible when laying that flap.
I wonder if there is another way to do this is a more minimally invasive way.
Good luck
Dr. Dan
Dr. Dorian Hatchuel Perio
6/14/2011
There is not enough information for specifics so my comments are general to try and help the MFOS.
The post says that the surgeon already decided to remove the implant. Dennis Tarnow summed it up by saying "Do one miracle at a time". In the anterior aesthetic zone there is no room for error. Dennis also said (I paraphrase) "sometimes you can get away with it, but the one time that you don't it will be a disaster".
In other words the sequence is to build the structures one at a time before inserting the implant in a thin biotype position of the aesthetic zone.
After removing the implant you will need to regenerate the bone. You may need to do a soft tissue graft before and or after that. Before - to create good tissue for coverage of the bone graft and after - to get bulk.
You can also consider placing a cover screw on the implant and burying it under a Connective Tissue Graft before having the restorative dentist bridge the site.
Part of your problem is the high smile, so consider "hiding" some of your incisions distal to canines.
Talk to your local friendly periodontist who has soft tissue grafting experience regarding the materials and techniques.
Best wishes for a successful outcome.
Steven
6/14/2011
I agree with most of the above. I would only add that I strongly think connective tissue is preferred over Alloderm for the following reason. Since esthetics is a major concern, you will not want to move the current mucogingival junction coronally, which you might have to do with Alloderm, since you do not want any Alloderm exposed. It is perfectly fine if some of the CT graft is exposed. As for the technic of harvesting the CT graft, as has been mentioned in an above post, a pediculated CT graft is probably ideal as opposed to one that is freely removed from the palate, since the pediculated graft retains much of its circulation at its base. Definitely a case for your periodontist.
gary weider
6/14/2011
I think blaming the GP's placement of composite for the further recession is not at all professional and is an assumption. Yes it is possible that the composite MAY have contributed the recession but that is all.
How do you know that the initial recession had reached its terminus? What caused the initial recession? It was not the composite. Possibly all of the recession was due to inadequate thickness of bone between the implant and the facial cortical plate. MAYBE BECAUSE THE IMPLANT WAS PLACED TOO FAR FACIALLY???? Maybe the recession was due to traumatic occlusion. To automatically blame the dentist is grossly unfair and UNPROFESSIONAL. I hope you did not tell the patient it was the gp's fault. That does no one any good.
Abg
6/15/2011
Thin tissue biotypes are the most difficult to work with as predictibility is not good . Problems added to already existing one is application of composite material on the exposed threads which is definitely going to cause further problems. Solution initially in this case would have been to go in for a soft tissue graft ( connective tissue graft)or a rotational pedicle graft.
right now it is a case of ailing implant. problem superadded is the loss of facial plate after implant removal.Here you need to go in for GBR procedure, get bone.Then retry
dr periodontist
6/15/2011
first of all, level of facial bony plate needs to be confirmed. if dehiscene is extended to facial 1/3 to 1/2 of implant length, i will give a try, doing GBR and submerging the implant by placing connective tissue graft over the implant. as mentioned pediculated connective tissue graft is best but you have to check the thickness of the palatal mucosa first. if its more than 1/2, implant removal may be necessary. since implant removal may lead deep facial defect, you may need to do repeated grafting to get the perfect result, so inform your patient accordingly. help of periodontist is must in this case. best of luck.
Dr. Samir Nayyar
6/20/2011
Best of luck, you got all the suggestions above.
Dr Ares
7/9/2011
The cause of this dehiscence could very well be not leaving enough bone margin bucally at implant placement stage (maybe implant was positioned too buccal, or angled incorrectly). The restoring dentist's decision to use composite over the exposed threads was way below standard of care. Nevertheless, why does the OS decide to explant right from the start? Is the implant malpositioned anyway?
I think explanting on a thin biotype, on the anterior region, with a high smile line may be disastrous even on experienced hands. How about detoxing the surface of the exposed threads with citric acid or tetracycline, and plain old GTR? I think if THAT doesn't work, THEN go all the way explant, graft bone, and place another implant. If esthetics are too compromised, do consider other restorative options, even without implants... Thanks for sharing.
Baker vinci
7/11/2011
I personally hate when the restorative guy doesn't send these complications back to the original surgeon. With that being said , I have treated a number of these with satisfactory resullts. Make sure first , that your scanner isn't "burning out" the possible thin layer of bone where this is no dehiscence . Your plan seems acceptable , however, I would use autogenous bone and use the alloderm as your membrane. Results seem more predictable if the restorative doctor will remove the crown, allowing you to treat it as a new implant. As you know , the exposure is likely to get worse. Best of luck. I might add this is when prp still has a fair application. The last two times I have treated these I put small holes I'm the alloderm on the buccal side. Bv
