Nobel Direct Loss of Buccal Gingiva: Prepare the Implant in the Mouth or Make PFM Instead?

dont grind the implant, ever. If I understand correctly your screw is showing? if so say good bye and take it out. after that graft or bridge. best of luck

If you have loss of gingiva, you should not even consider restoring the implant because it will fail. If the loss of gingiva is to the depth of the vestibule, and you are showing threads, then the implant needs to be removed immediately. Once healed with soft tissue, then the site can be built up with bone and then reimplanted, but only after the bone is built up.

You mean preparing the prosthetic abutment, not the implant itself, right :-)? It can be done, though it's not advisable (Misch talks about this method in his book). From what I understand your problem is not the prosthetic phase (yet) but 'the loss of buccal gingiva right up to vestibule', for which reason my advice is, firstly, to take care about the gingival defect (there are several graft procedures, though I'm not sure I fully understand your clinical situation) and even more than that make sure there isn't a bone loss as well (a gingival dehiscence in many cases may be the symptom of a bone loss). Good luck anyway!

Unless this question is meant to provoke intense reactions from readers and is not a real scenario there are serious concerns regarding your ability to assess situations and act sensibly. Its like a diabetic who is going to have his foot amputated asking whether to wear sneakers or formal shoes to the hospital.

Im also wondering about Mateit at this point as well. What forms of gingival loss to the vestibule exist without bone loss? Also, please tell us about the grafting procedure you would use in this case so that I can name my next child after you.

Nobel Direct is a one piece implant and therefore designed to be prepared in the mouth. The siuation you describe, however, is doomed to failure. That implant should be removed and the area grafted. I agree with DrAslanian as regards your question.

DrAslanian: What exactly are you wondering AbouT me? Not having enough details from our colleague who came up with this problem I could only assume what might have happened. As for the grafting procedure (again I emphasize that we do not have enough info to diagnose the problem and to make a treament plan) are you refering to my post or to Anon.'s one?

loss of gingiva invariably means loss of bone. the implant is doomed.However this situation demands a careful assessment of the patient's desires and the esthetic compromise.If esthetics is not a concern,which i beieve it won't be and the patient is completely made aware of the situation and adequately instructed on hygeine,you may restore with a pfm and wait and watch.explanting is not often a welcome suggestion to patients and in these situations explantingb and grafting may not always be predictable especially since, as iI understand from you post, there is no buccal bone.It amazes me the ease with which explantation seems to be the most popular response to compromised iplants.I wish to remind all that this could happen to the best of us.All the best with your patient

can we see a photo ??

A narrow implant has not a lot indications. Beginners often take narrower, not to have problem with surgery, but loss of bone later. Next time, if the bone width is not enough, build bone to use a correct implant diameter.

A litle bit offtopic: is there anyway we can post images in this forum? Thank you.

You can post images by registering for our case gallery: http://ddsgadget.com/implantcases/?page_id=5 Thanks.

You can get this from any implant, if the tension is too great on the bone or the bone is too thin on the facial.

"robin henderson January 13th, 2009 If you have loss of gingiva, you should not even consider restoring the implant because it will fail." WOW, what comic does that advice come from? - Certainly not the dental literature. It is all too easy to expound from our intuition, something a mentor has told us, or misinformation from "a book". Here is the answer from a colleague with an implant only practice for many years (placed and restored over 5000 implants), who is up to date with the literature, and with a master's degree (with distinction) in Implant Dentistry. The original question is a sensible one. For a 1-piece implant there is no issue in preparing in the mouth (Use a tungsten carbide bur and copious water spray). Even 2 piece implants can be lightly prepped in exceptional circumstances. Provided a reasonable thickness of material exists and there is sufficient implant still in bone, you can even polish off the threads if needbe - Shock horror! A one-piece implant is a solid rod of titanium or alloy, with an arbitary margin, prep it to suit your needs, not the manufacturer's. The implant won't care - believe me. Re lack of attached gingivae; this may make oral hygiene a little uncomfortable, but in no way relates to the ability of the implant to survive. Plenty of literature to back this up. Please don't be disheartened by comments from those who are giving opinion rather than fact. If you don't know ask, you did the right thing. good luck!

Right on John!

Finally a voice of reason in an angry mob. Thank you Dr. John

One can perform a poncho graft with alloderm, with or without a split thickness flap and turn this situation around. Then prep-then impress or perform a fixture level impresson then you are off to the races.

Dear Anon, There are a lot of experienced dentists putting in their comments to try to help you. However, when you seek advice, you must be forthcomng with the information at your disposal in order to get the best advice. You mentioned that at the onset, there was not adequate buccal-lingual width. Did you do an open or closed proceedure? If closed, you could not see if the implant buccal surface was within the bone. You might have been doomed from the beginning, by either not having a buccal wall present over the implant threads; and even if it was, the bone should have been grafted to enhance the thin buccal wall and keep it strong so that the gingival tissues would have been well supported. This being said, the best advice would be to remove the implant....being careful not to damage the mental nerve because of the precarious position of the implant. Graft the area,hope that you can build a solid platform to place a new implant....that is well covered by a new solid buccal cortical plate. Gerald Rudick dds Montreal,Canada

I find it interesting how easy some of our colleagues talk about removing an implant. I removed some (placed by me), and it was not easy. Also the bone destruction left behind is something to keep in mind. If it is doomed to fail (to a given statistic, like let's say 70%)I would try first to save it because you don't have what to loose. The first step would be to make a small flap to see how bad the bone loss is. Prep the implant smooth to the bone level - lots of water - decontaminat it with citric acid, and suture the flap back. Try to suture with coronally positioned sling sutures. Wait for the area to heal, and see where the gingival margin stabilizes. Prep againt the abutment at the gum level and take an impression for an pfg with hairline gold margins. I would not cement with temporary cement, as the abutment cannot come loose (it is an one piece implant), and any piece of temp cement left behind will kick you in the back later. Put the patient on 3 months recare schedule and give him/her Chlorhexidine before, during and after the surgery (to cover up to 1 month after you placed the crown). Of course everything depends on what you find when you raise the flap. If you really lost more than 2-3 implant threads of bone I don't think you have a significant chance to keep the implant in the mouth.

The implant was placed too buccal to start with. Now what to do: look for an ideal solution that means: remove it, place another implant more palatal and graft or cope with the situation, and prep whatever is above the gum level, (even if you prep the implant, that's fine as John mentioned) and make a longer and unaesthetic crown. That's your call....

I can no have a correct opinion since I don't have the clinical phot and don't know the conditions before implant placement, mainly the ammount of keratinized tissue. But the other know that that's why they have such a nice treatment plans. Can you send some photos? Place them on the gallery. Do you know any published article that refers an implant with few threads without bone in the bucal part that has less probability of sucess? I don't. Do you know any published article that says it's impossible to place a SOFT TISSUE graft over an implant with recession? I don't. Do you know any published article that says that grinding an implant in the mouth it's harmfull for the patient. I don't. But I know that titanium is a bad heat conductor. And I know that from the literature. Did you placed the implant flapless or with a flap. If you placed flapless without any keratinized tissue, this is why you have recession. But that hapens with any kind of dental implant. Without keratinized gingiva, flap or graft first, to get it. I placed more than 600 NobelDirect Implants, and I had no problems with them. Hope that helped