Implant Threads Exposed During Placement: How Do I Salvage this Situation?
I recently placed an implant in the maxillary first molar position.  I performed a conservative sinus lift at the time of implant installation. However, after placing a  bone graft in the sub-antral osteotomy site which was 8mm long, I installed a 10mm implant.  I was unable to submerge it under the bone, leaving about 2mm of the implant exposed. I am presuming this happened because I was unable to fracture the sinus floor and the bone graft got compacted laterally, narrowing the osteotomy channel. Also when I placed the implant, I was not able to get good primary stability and just achieved a passive fit.  I placed a cover screw and bone graft around the exposed threads. I was not able to achieve primary closure and left the cover screw exposed. I plan on leaving it there for 4 months and hope that it osseointegrates. How can I salvage this situation?  How can I avoid this in the future?
18 Comments on Implant Threads Exposed During Placement: How Do I Salvage this Situation?
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ASADI
4/18/2012
sorry.i think the implant will be fail because of two reason;
1.lack of primary stability
2.exposure of threads will be cause permanent gingiva inflamation and bone recession.
naswe
4/19/2012
either you drill to the 10mm for your implant or change implant to a shorter and wider one to get good primary stability and to ensure no threads are exposed do not panic or be in a hurry take it easy but accuratelly
peter fairbairn
4/19/2012
May be lucky and be OK , but next time use the DASK system to ensure safer internal lifting and then can get bi-cortical fixation . This is a time when a taper can be helpful in achieving a better primary stability .
Always think what you want to achieve and plan pushing the floor up forcefully can be dangerous and can lead to an implant in the sinus , which hopefully you could remove easily .
Simple ethos in Implant dentistry avoid things that you cannot rectify , so it was maybe better that you were too cautious and did not force it into the sinus.
Good luck
Peter
Peggy Archibald
4/19/2012
This is unfortunate situation, but as Peter said, better that you have a small problem to rectify than the larger problem of forcing the implant into the sinus. Naswe is also correct; do not panic or approach the solution hastily. Plan out what is best solution and than take it in steps so as not to make mistake. Good luck.
Peggy
Dr Chan
4/24/2012
I would take the implant out and replace it. Would you accept a compromised result yourself so early in the treatment process?
If you are not conversant with the tap up, get someone to show it to you. Or place a short and wide implant as mentioned by Naswe. Taking a periapical film with a guide pin is very helpful during the osteotomy and also before the infra-fracture of the floor. Take your time, keep calm, listen and Feel because you cannot SEE !! :)
I would recommend taking another periapical just before you push all the grafts up. Good luck!
Bruce GKnecht
4/24/2012
Look. You did not get stability and the cover screw is exposed and the implant is not fully seated. Get it out and infracture the sinus adn place another implant ,get stability and primary closure. If you want to babysit a failure and get the patient upset and leave your practice go ahead. Confront the situation and do what you would want in your mouth. The patient will appreciate your concern.
DrT
4/24/2012
I agree with the above posters....as the saying goes: "Three strikes and you are out"...this goes for batters in baseball and implants that have just been placed. With our current level of knowledge regarding the factors necessary to have a successful implant, if one has to resort to "hoping" that an implant integrates, then I would strongly suggest that you do the right thing and remove the fixture ASAP.
Dr sk
4/24/2012
I agree to last two comments,recall the patient remove the fixture clean the socket & go for a shorter implant,you'll achieve primary closure,in my experience any exposed threads of implants was always always a failure!best of luck
jon
4/24/2012
Best way to prevent this in the future would be for you to refer. Sounds as if you are not trained to do what you just did or you could have handled this basic procedure. I am so tired of seeing such things and questions. Why didn't you just remove the implant, osteotome to 9mm or even 10 if you were short 2mm originally, and then place a 10mm implant. This would have been simple to do at the time of surgery if you were not so hesitant and were sure of what you were doing but now you have an implant 2mm supracrestal. Good luck and I hope the patient is not the type that likes to sue.
John Manuel, DDS
4/25/2012
Amazing to me that so little consideration is put to using one of the short implants. A Bicon of 5.0. 6.0, or 8.0 would work wonders near and into the sinus. Check out the Bicon Sinus Lift webcast replays on their site.
Also, the 5 or 6 mm long designs likely would not have needed any sinus intervention, even when submerged 2-3 mm.
The bone growth and success of these short implants is as good or better than the 11-14 mm cylinders so often mentioned here. The Bicons are finned, not threaded, so provide much more surface area in a shorter length.
John
DrT
4/25/2012
It is certainly advisable to have several choices whenever you are placing an implant. However, in this instance, I think that one of those "stubby" Bicon fixtures would have most definitely significantly compromised the buccal bone (which of course could have been dealt with with a bone graft). To me the main point of this case is that an internal sinus lift in this instance is a fairly routine procedure, provided that it is done correctly. I don't know about you, but in my mouth, I would prefer a "longer" fixture of average diameter, rather that a "shorter-wider" one. I understand Bicon implants are wonderful in many situations, but I do think that they are not this amazing panacea for every clinical situation that we encounter.
Dr Chan
4/25/2012
Early Bicon are not short and stubby. Through its evolution, it just keep getting shorter and fatter, like me! :D. In fact, even now, you can still get Bicon in 8 mm and 11 mm with a diameter as narrow as 3 mm in the Narrow range. see Bicon . c o m.
I do not consider internal lift as a fairly routine procedure. It should be carefully planned, taking into account of the health of the sinus, local anatomy, type of implant, bone quality, grafting material and acceptance by the patient.
John Manuel, DDS
4/25/2012
Name calling whether, "stubby" or "skinny" misses the point that an 8 mm long Bicon has more bone surface contact than many 11 to 14 mm cylinder implants. Most of the length of a cylindrical implant is dead space pertaining to bone loading.
The closer finned implants get to a sphere, the more a tipping force is directed down , across the bottom and back up the other side. We even have bone growing up over the abutments on these stubby models.
Of course Bicon makes 11 mm implants, but when the research is showing that their shorter implants are more likely to have bone growth on top for years AFTER the surgery, why would one choose the longer ones?
All I am saying is that there are clear options for avoiding sinus interventions in many cases such as this. Also, Bicon makes 3.0, 3.5, 4.0, 4.5, 5.0 and 6.0 mm wide models.
Dr. Samir Nayyar
4/26/2012
Hello
If you don't want to do the surgery now then just wait for 6 months and load it gradually if it everything goes fine, else wait for the failure to occur and then repeat the surgery.
Its always better to take multiple iopas at every step to avoid any problems like this future.
Best of luck dear
Baker vinci
4/30/2012
If you are going to go through the trouble of doing the traditional " sinus lift", then why would you place a 10 mm implant? I have to agree, your a bit " over your head", in this one. I would bet there was plenty of room, to position the implant, palatally. I have had a lot of successful implants that were not torque stable, but if it is dehisced buccally and you didn't graft and GTR at the time of placement , then the "crystal ball" doesn't look so good. I do not think this case would suit a short, wide body, if it's threads are too buccal. Bv
Dr. S
5/2/2012
Can you say oral surgeon?
Baker vinci
5/3/2012
I can! Bv
Baker vinci
5/8/2012
I'm sorry , I misunderstood what "conservative sinus lift" meant. So you did an "internal lift". This is a blind procedure and in my opinion, should be reserved for someone that can do a traditional sinus lift, with his or her eyes closed. That is, if they are experienced . You really have to engage the floor, if your gonna a place a short implant. It sounds as if, you maybe scared to go into the sinus and if you are, then don't . There is plenty of dentistry to be done. Please let someone else place the implant, next time and you can restore it. The economy is going to turn around!!! Bv
