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Poor bone quality after site preservation: thoughts on this case?

Last Updated: Jan 22, 2020

71 yo female pt with a hx of osteomyelitis (lower extremity) and is concerned about implant failure due to another “bone infection”. I gave the pt the option of FPD vs. Implant and is still undecided at this moment. I had my periodontist review the scan and he recommended another scan in 6 mo. The ridge is thick with a healthy band of keratinized gingiva. There is no swelling, no abscess, no fistula, and no drainage at the site.

The bone in this case does not appear dense as compared to other cases that I eventually placed implants in. It appears that I have room for a 5-0 X 11.0 mm Astra implant, but I told the patient that I would get the scan reviewed prior to final tx plan. I’m concerned 1) failure of graft/persistent infection, or 2) slow resorption of graft (need to wait more like 6 mo or more vs. 4 mo). I™m including my operative note and dates for this case¦

(Operative notes from 08/27/2014)
Limited oral eval – medical history reviewed, pain scale 0/10. Exposed and reviewed Per XR – failed RCT w/ large osseous lesion spreading from furcation. Consent for procedure before initiating tx.
Dx: #30 has poor/hopeless prognosis. (Endodontic consult ) recommends ext of #30. Obtained verbal and written consent for ext #30 with bone graft in anticipation of future implant. Pre and post-op vitals WNL.
Tx: Ext #30 and bone graft with local anes. Bite block and throat packed placed to protect airway. Sulcular incisions carried buccal/lingual with minimal flap reflection. Atraumatic extraction #30. Curettage of socket with #4 Molt. Mineralized Can/Cort (allograft) bone graft placed into socket and covered with chorion membrane. Obtained good hemostasis. Discharged pt in comfortable-alert condition. Complications: None. Sutures: Silk 4-0 x 4 suture.

Pt was seen twice for POT™s, sutures were removed at 2 weeks. Healing was WNL. A limited field CBCT was taken on 01/08/2015.

pre-op pre-op
CBCT2

CBCTPANO

4 Comments on Poor bone quality after site preservation: thoughts on this case?

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CRS

1/22/2015

Provisional three unit bridge, this looks like either a chronic isolated osteo or slow healing. I would go back in clean it out and disinfect with the nd-yag. I would also culture the site send the bone for C&S. Note there is no buccal plate. There is most likely residual bacteria from the failed RCT which simple curettage did not resolve. This is not an implant site.

DrG

1/22/2015

I agree with CRS this is not a good site for an implant as is. The treating dentist did not completely degranulate the exo site and now the graft is poorly differentiated. Open it, remove the soft mass well, take your time. Then regraft and membrane. Also it will give you an opportunity to fix the Buccal defect in the ridge.

Miroslaw Woolwich

1/23/2015

re: 46 failed implant based restoration. Saddle area 46 is too wide for a single unit.Opposing 17 appears carious and a potential source of infection aswell as deficient occlusally. Failure has occurred from excessive occlusal forces from opposing crowned 16 which provided most of the posterior support on the right side and too much space for one implant restoration on the saddle area thus creating undesirable coronal torquing moments on the wide occlusal table. There is radiographic evidence of osteosclerosis in the bone 46 47 area providing further evidence of avascularity and excessive work. Is 48 vital?

Dean Licenblat

2/3/2015

I agree with re-entry of the site, thorough degranulation and decontamination as required. Without thorough degranulation and decontamination, given the history I think it was going to be of concern from the start. Given the nature of the infection, perhaps it would have been better to let the site heal for a few weeks prior to re-entry and grafting. The site could be ok for a single unit as a single unit filled the space prior, i think the implant choice (size, brand and length) is a very good option.

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