Implant Threads Exposed: What Should I Do?

Hi, if the implant does not show any movement,do not mess with it and just guide the patient to keep it very clean.The grafts might be an option but may also lead to further complications.You need to see why the threads got exposed. Was it an immediate placement after extraction or is the palate deep where the buccal crest would be higher than palatal.Is the occlusion causing any palatal forces.

Interesting that you have 3 threads exposed on the lingual and no esthetic issue on the buccal. Is there not a polished colar on the implant as well? Do you have a radiograph? or photo? I have a case that has threads out of bone but not out of tissue. One of the molar posished colars is showing just a bit. They are stable implants and the surgeon and I have opted to leave them alone and restore them as is. While I do not feel this is ideal radiographically, if it is stable over time and the patient is happy esthetically and functionally, it probably beats removing it or grafting it which could bring on other complications. I would suggest as I have done in my problem case to put the patient into provisionals and let them wear the provisionals for several months (at least 3-4 months) and then you can better judge stability over time.

Regarding the suggestion to graft the exposed threads on the palate- resorbable membranes are not magic and for regeneration to predictably occur, these membranes need to be covered, easier said than done on the palate. Why do you think this happened in the first place? My guess would be a high palatal vault with the creation of a dehiscence, perhaps undetected, at the time of implant placement or an unsuitably wide implant was used, or both. Either a CBCT or flap elevation to visualize the bony contours should have been done. Was this implant placed during a flapless procedure?

Questions: What are the patient's risk factors for peri-implantitis? What is the patient's medical history? What is the occlusion? Is the implant single or splinted? What are the adjacent tissue levels? Is the patient a periodontitis patient? What is the surface of the implant? Does the patient have the dexterity to keep the exposed, probably rough, surfaces clean? What did the 3D radiographs show preoperatively before implant placement? Volume of bone? Quality of bone? SO, in the absence of large-size studies, there is minimal predictability of bone "repair" around an implant, especially once it has been exposed to the oral environment. Robert Miller in Florida has done a lot of work with lasers on surface detoxification. BMP and/or other growth factors may prove of benefit, those studies have not yet been done. Even after that, we don't have human histology showing bone regeneration and osseointegration. Bottom line, you are left with a potential source of peri-implantitis and trouble. Bear with it as long as you and the patient can maintain the area free from inflammation.

I would think it is unusual that if threads were to be exposed on an implant, that this would occur on the palatal surface of the implant. I personally would have more confidence in the palatal aspect with better supported bone, with a better blood supply. When saucerization is taking place, there is usually a reason for it. Is it a question of hygiene, poor crown design,stressful occlusion, or something else. Rather than wait and see more destruction taking place over time, I would be inclined to open a flap and observe what is happening with the naked eye. If granulomatous fibrous tissue appears, it would be best to scrape it out, detoxify the implant surface and the bone with citric acid, or antibiotics, and then create bleeding by decorticating the bone and laying on a particulate graft with a membrane. As the problem is not on the buccal aspect, the esthetics would not be compromised, and the implant would have a better chance of surviving in a healthier environment. Gerald Rudick dds Montreal, Canada

R Horowitz is correct. It will be a plaque trap. To try tissue regeneration will not work if the surface has been exposed to the oral environment. It is very difficult to grow bone on a root surface, much less a dental implant that has been exposed.

The arbiter of success in repairing hard tissue defects around implants is the adjacent bone level. In a periodontal defect, infrabony defects are the most amenable to treatment. If the exposed part of the implant is above the highest adjacent horizontal bone, there is almost no chance of success in regenerating bone, much less the soft tissue. With regard to detoxification, ablative lasers are the new standard of care for both decontamination and removal of residual organic component as shown by our SEM studies. RJM

Yes I agree to the #1 comment by Natwar. If the exposed thread are above the tissue and exposed, it is benificial to smooth the roughened surface and thread of the implant body, to reduce plaque retention. If the crown has not been fabricated, you may extend the margin over the exposed implant body to eliminate the abutment - implant connection region, which may become a plaque reservoir in some implant design. If the exposed threads are below the tissue and the tissues remain healthy, the soft tissue "attachment" (really a dose approximation, since no connective tissue attachment is present)will allo the implant to remain helathy. Establish the cause of the bone loss so that it doesn't continue. If biomechanical stress is one of the factors, reduce the occlusion on the crown and consider a oncturnal occlusal guard.

I agree with Dr. Misch. This is a common sense approach to a problem that does come up now and then.

dr carl sir i have a question.can we perform a scaling of the exposed implant area with special titanium currettes and wait for the soft tissues to cover the area or perfom a soft tissue graft just for esthetic cover of such areas?

These would not happen to be implant direct implants?

Depends upon how much exposure. If little keep clean, smooth down the threads, evaluate and treat traumatic occlusion otherwise the usual. You can flap, clean and degranulate, graft and perform a ponchograft with alloderm etc.

I HAVE POSTED THE IMAGES IN POST ACASE SECTION.KINDLY ADVICE

Dear Dr. I would like to stress to a key point ,if you don't have any periodontal pocket it is good idea to smooth the exposed area and changed the area more cleanable than before,but presence of periodontal pocket may compromise implants during the time. so we should determine many factors like single or splinted implantto the another implant, location of implant ,and so on ... . but we should be honest to the our patient and aware them to clean this critical area