Necrosis of Gum with Bone Exposure: How to Manage?

Failed. by infection, by failure of tension of flap. Remove all implants and let it heal by itself. Considering his systemic condition, I prefer not to add any other grafting material in the postexplantation site. Maybe collagen tape at most? Sorry to say but there are lot of things you should have done better. First of all, there are too much distance between two implants, it could be your pain in the ass even if it succeeds to osseointegrate. Constant mechanical problems could have occured later on. Seconds, in order to achieve proper flap management, you gotta make sure the tension free flap. I can clearly see the flap got ripped off by the harmony of sutures and heavy tension. Never ever try to tighten a flap using suture material. For bone graft surgery, you gotta make heavy tension releasing of flap by using internal tension releasing incision on buccal, and brushing of lingual flap. Maybe existance of mental nerve hindered your gut to cut periosteal layer of buccal flap. You gotta make sure the flap overlaps 2 mm at least to the counterpart flap in neutral position. The suture material should just 'assist,' not tighten. Thirds, severe and prolonged post op pain starting after 3~4 days is somewhat scary omen you gotta be serious. Not to mention of early exposure of primary closure site. If the pain goes severe as time goes by, it could mean infection spreads all over the medullary bone. Judging by drilled amount of #26, the bone could be heated up due to poor irrigation. It happens a lot to posterior drilling, since there are some obstacles such as flap or mouth corner that hinders copious irrigation from handpiece tip and you cannot see the handpiece properly at that area. At last, poor blood supply from peripheral soft tissue as well as hard tissue could have hindered primary granulation tissue formation. You should drill cortical bone in order to achieve better bone graft results. Poor vascularization means poor bone conduction. Also, lack of blood from soft tissue might have attributed to poor initial healing reaction. Merciless releasing and wide elevation of flap might give patient quite amount of postop pain, but it also gives operator peace of mind. There might be problems at implant loading stage for patients with systemic problems, but I personally think patient management part has (relatively) little thing to do with immediate postop result, unless physical tampering.

Could there be some other systemic conditions that are overlooked, such as antiresorptive medcation? Long-term Prednisone? Do you know what the HBA1c level is? This could be from flap tension but I also would consider that medical history and not having overlooked anything. Smoking and Diabetes will affect healing. When I see a medical hisotry such as this, I often stage the treatment: GBR followed by staged implants. The GBR will allow me to assess healing before I consider placement of the implants. As to the implant placement - not sure I agree on the location or angulation but you didn't ask about this, I will keep my post specific to your concerns.

Sincerely I don't think this is necrosis and infection. This seems to be that the flap was opened because: 1. Local inflamation 2. Tension on the flap because of the bone augmentation 3. Not good microcirculation because of smoking So, what you are watching is healing by granulation over the membrane. Stop clorhexidine. This process Is painful, but I'm sure that in 2 weeks It will be pink. Extend antibiotic. Be sure there is no suppuration. Take x Ray in 2 months. Please write to follow the case.

Hi, I didn t agree with that comment to remove the implants. Wait. I don t know what was the main fact, caused the necrosis or that s a multifactorial. But i had a very bad experience with the hialuron acid, Gengigel. Some of my pt had healing process problem, gum dehiscence and necrosis. From that time, after the oral surgical procedure i suggest just the warm salt water rinsing without chlorhexidine and hialurone acid.

If the patient is an ideal candidate I MAY graft simultaneously with implant placement. When one has a patient with medical red flags I always do one step at a time, meaning grafting THEN implants. In this case you diagnosed the need for grafting, so even if the implants survive, the graft will not and you're starting with a less than ideal situation, not to mention the spacing considerations. "One miracle at a time".

Try wounding the exposed bone with a large round bur to stimulate bleeding then using the back of a Pritchard elevator release the lingual and passively suture with a more tissue friendly material like PTFE or nylon (I use 4-0 chromic gut). Avoid CHX as it inhibits fibroblast proliferation.

Place PRF membrane and tension fee closure, exposure the PRF membrane could be fine, and work most of my time.