Exposed threads and perimplantitis: Treatment recommendations?

Doc There are no legitimate published studies on the success rate of implants placed in allografts or Bio-Oss. No one never considers bone as a possible reason for implant loss. Look at the three case of marginal bone loss currently posted on the front page of osseonews. I don't even have to ask if the implants were placed in cadaver bone because it is so predictable. But ask them and find out for yourself.

Steiner sells synthetic grafts thru his company Steiner Biotechnology. He should post that as a disclaimer, as he is clearly quite biased. I think Steiner's products are made from bTCP. But, I don't remember off-hand. Nothing wrong with bTCP, of course, but nothing wrong with allograft either. Last I checked, there is study after study in related medical disciplines, including orthopedics (where the studies are much more rigorous then in dentistry) showing successful use of allografts.

Dr. A Orthopedic studies can be just as fake as dental studies but there is one very big difference. They never put implants in cadaver bone. Also dental bone graft are more advanced than orthopedic grafts at this point because or our ability to evaluate graft performance every time we place an implant. You can not do this in orthopedics.

DrAZ One case? How about finding our what the other two cases that are being discussed were grafted with and you will find that it is 3 out of 3. What amazes me is the it is the bone that is failing and no one ever considers that the bone could be the problem. Truly amazing.

I have placed 2500 implants in the last two years, 50% in cadaver grafted sites. The failure rate has been 4-6%. I don't see how you can say that it leads to failure in all cases. According to Moy at UCLA, you can use just about anything to graft as long as you give the bone adequete healing time.

Yes, I placed transmucosal healing collars at time of surgery. There was no bone graft placed at time of implant placement and the implant was torqued better than 35ncm. In retrospect, I believe a covered healing cap (cover screw) should have been placed. Had I known that patient was leaving for 3 months I would have done so. But that brings up a good question....healing collars or covered healing caps? I think it depends on the situation. I have placed many transmucosal healing collars with success. But I have monitored these patients carefully....once a week for 4 weeks then every two weeks. Several times I found a loose collar. ...with inflammation, irrigated and tightened it and it resolved well. From articles I have read, if there is good primary stability, no bone graft, good tissue approximation and good OH, a TM healing collar works. (A lot of if's) Thoughts?

no cadaver bone in this case?. need to look at each aspects of grafting. Lack of gold standards lead to confusion. personal comments are good to learn from each others experience but to claim that one treatment is better than the other i think should be evidence based, I use diff options and cannot see much difference. although no audit has been done.

With a torque of 35 ncm at time of placement and no need for a graft, this should've been clear sailing. Based on everything you've stated, instinct and logic both tell me that it's OH related, specially if one of the healing caps came off. The patient herself also may not have stellar OH. I find that many patients just don't keep up with it in the beginning, even after they've been thoroughly instructed. They just don't develop that discipline until later, after they've been "bugged" or "scolded" a few times and the importance of it sinks in. I think that you should not give up on these implants just yet. Open, debride, add bone-filler, preferably do not do implantoplasty at this time, and close completely, with the implants completely submerged. I never -- repeat, never -- place transmuccosal healing caps at time of initial implant placement, no matter how straightforward the procedure is. I always cover the implant with its cover screw and bury it under the tissue. It saves a lot of headaches, and eliminates a lot of unwanted variables, specially since not all patients are compliant enough to come in for checks as often as I would like. As it is, we have many more variables to deal with, above and beyond what's been mentioned here, not the least of which is host response, which I find is not talked about enough. But it's very doubtful host response is the problem here. That said, I think these implants still have a good chance of success, that is unless there are other missing details. As for that retained root, I would love to see a CBCT of it, because I've never left a root in deliberately no matter what. It's a point I've always insisted on, and I've been closer to the mental foramen (or other critical anatomy) than this x-ray looks.

Dr Mick, I place healing collars almost every time I place an implant. Even with concomitant particulate grafting. Just remember to torque it down well. Research supports this technique, and patients love that there is no Uncovery surgery.

Dr. Vipul, you call a small incision to uncover an implant to place a healing cap "uncovery surgery"? Oh please, let's be serious. If that's surgery, then what's a a sinus lift? A flight to Mars in the USS Enterprise in warp drive? Thanks for the good laugh. Humor aside, I think your technique is asking for trouble and not keeping the patient's best interests at heart. Read Dr. Robert Wolanski's last sentence in his post right below yours: "If it were your mouth, what would you prefer?" What is it with all you guys in such a hurry? You never heard that haste makes waste? Keep doing it Vipul and one day you'll post here with the same problem, asking us for advice. Then again, maybe you won't, since you think you're so "smart".

Sounds like a plan. Its interesting to get different perspectives on a case. My final take.....Bone loss was due to hygiene issues. When pt returned, there was food, not bone in the site...I'm talking lettuce particles. Placing a cover screw and burying would have prevented this problem in this case, I believe. I should have done that. Im going to do flap, bone graft, cover if possible, and wait. Will do implantoplasty if needed as you recommended. I'll send to guys some cbct shots when I get back to the office. Thanks for your help. Im going to be doing more 2 stage implants from now on!

Lettuce particles? WOW! Just as I thought! You do know what that means! This patient chewed over the freshly implanted site with absolute and total disregard! She didn't pay attention to your post-op instructions, didn't think, didn't care. One of those nasty variables -- the unfortunate slob. Always happens. Now do you see why I always do 2-stage? After all, what does it set me back time-wise? Nothing practically! But the potential problems can set you back a lot more, like in this case. We have advanced so much, and implantology has become so painless, that patients just take it for granted that it's "minor" and they don't appreciate the importance of guarding the post-surgical area. This is also a point of patient management: I always make a big deal out of it, so they understand. I agree with Robert Wolanski completely. You can do implantoplasty if and when you end up with exposed threads again. No rush now. You would prefer to have threads that the graft material can catch, if there's a chance, and I think that there might be a decent chance. This is definitely not peri-implantitis and, since the crestal bone loss looks minimal (note that the x-rays have slightly different angulations), I would bet you won't have to even add that much grafting material. In fact, I think that once you raise the flap you'll find the crestal bone loss to be quite localized, and certainly less than what you expect. Graft into sound, bleeding bone and if you have any doubts you can even add a small piece of resorbable membrane over it before you suture. It'll be fine. Good luck and please keep us posted. And teach -- better yet, firmly scold -- that woman to pay attention and to maintain OH and not eat on that side at all for 3-4 months.

Excellent comment Robert. Ditto! I never leave any threads uncovered if I can help it. It's one of those details that I insist on.

Dr. Bryson- Very well said, everyone should really take note of this post. I too, have been placing implants for more than 20 years. What works for me may not work for someone else and vice versa. That being said, this is not the place for egos.

My apologies in my post: Where I write 2-stage, it should be 1-stage. Typing quickly in between patients here...