Spontanous exposure and early bone loss: how to proceed?

I have had a complication with this case below. Patient had history of perio disease, now under control, but had a very bad dry docket in this UL6 area and has a history of severe dry sockets requiring hospitalization. No relevant medial history or bisphosphonates. The adjacent teeth have had bone loss in the past but are currently stable. A CBCT scan in this area showed enough bone for a short wide implant but bone deficiency palatially, she wasn’t keen on sinus augmentation.

The surgery went very well, no sign of sinus floor issues and I used small amount of GBR palatially. At the post surgery review we had specifically discussed spontaneous exposure and the patient was aware to contact us if she had any concerns in the healing period, the review showed no problems.

Unfortunately at today’s exposure appointment it had a small spontaneously exposure palataly. I attached a healing abutment and there was good integration. However, this is the post exposure Xray with obvious mesial bone deficiency. I informed the patient and discussed the history of dry socket and poor bone healing. I emphasized the need for excellent OH and review.

I am still relatively new to implants having placed about 75 and undergone rigorous training. Thankfully this is the first time I’ve had a significant issue like this. I feel I am a diligent and professional clinician but I feel terrible about this complication and accept perhaps I was over ambitious.

What are your thoughts on how I should proceed? What lessons should Learn from this?

![]Guide Pin](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/07/depth-guide-pin.jpg)Guide Pin
![]RX](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/07/RX.jpg)RX
![]RX1](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2015/07/RX1.jpg)RX1

10 Comments on Spontanous exposure and early bone loss: how to proceed?

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CRS

7/10/2015

If there was a history of acute alveolar osteitis the site may be sclerotic and not a good implant site. Tell me about the hospitalization for severe dry socket. Don't understand what you mean by a spontaneous exposure on the palate, exposed bone? Was there bleeding bone at placement?

mike shulman

7/14/2015

Hi, nice placement, on X Ray, supper. but small GBR and exposure, possibly small infection, i would clean up, remove healing cup, antibiotics and flagyl 10+days see if it will close, then back to healing cap. When it's all done you make a list of what you could, should and would. Let it heal first. One Big one though; we do miracles, lets do one at the time. cheers mike

DrT

7/14/2015

I think with hx of perio disease and multiple dry sockets, along with less than optimal implant site anatomy, placing an implant in this area was ill advised. And if the pt did not want a sinus lift I would have said No Go to an implant. As things currently appear I think you will be eventually lose this fixture.

Kadgil

7/14/2015

I can't honestly recall if there was much bone bleeding during surgery but I felt it went well at the time. She needed IV antibiotics for a dry socket in another site and the refering dentist was at a loss to explain the severity as it was a routine extraction. By spontaneous exposure I mean the cover screw was exposed through the mucosa when she presented for normal exposure. However it was small with no bone/implant exposure or inflammation.

Kadgil

7/14/2015

DrT, I agree you are right. Everything seemed fine at the time of assessment but I should have had broader consideration of those factors.

dr nitin sharma

7/15/2015

Correct me if I am wrong. 1. The osteotomy site have soft bone present and post implant placement 2. The parallel pin in directed palatobuccally. Meaning the position of implant as cervico-apically is Palatine buccal. May result in undue pressure on palatal cervical margins and the mesio apical margins of buccal plate where maxilla is in changing couture arch. Can we consider the following as a reasoning for about mentioned problems

Dr ATC

7/15/2015

I'm concerned with the distal aspect of the adjacent first premolar and the contour of the mesial aspect of the restoration on the second premolar . It looks like the first premolar has caries and together with the second premolar, that site could be a source of infection that is now causing inflammation around the implant site. Efforts to disinfect the implant site will not yield good results if the problems I have mentioned earlier haven't been addressed. We are encouraged to restore all caries and make sure the patient is periodontally healthy before we do dental implant treatments.

Kadgil

7/15/2015

Dear Dr ATC The first premolar has been restored with a non radio-opaque GI by the referring dentist, I think you can tell this by the angular shape of the area. I also think if you look carefully and compare all 3 x-rays the final x-ray has a clear dark streak running down the left side which crosses the mesial of the UL5 possible a processing error on the phosphor plate. What do you think? Thanks for the tip about restoring caries

Dr ATC

7/16/2015

Thanks a lot for the kind feedback Kadgil, sure the distal aspect of the first premolar seems like it has a tunnel restoration but my point is to try and exhaust local factors that will likely result in failure. Now we cannot easily tell if the site is healthy or not because of the radiolucent GIC. If you look at the implant site, you will notice that the bone is not well corticated but look a bit radiolucent especially if you compare the right and left side of the guide pin. Maybe a history of unresolved infection from an endodontic infection or treatment or following the extraction. The CBCT scan could also help but my point Doc is local factors are likely culprits.

drsk

7/21/2015

First let me say that the spirit of offering up our less than desirable results for comment by our colleagues is a brave and noble thing, and shows a real commitment to being better clinicians, and therefore helping our patients. I have limited experience with implants, so I have more of a question than a solution. It looks to me on the immediate post-op film that the threads of the implant are well engaged in bone on the distal, but not so on the mesial. The later x-ray shows bone loss in the same mesial area. I'm wondering if the problem was caused because the implant threads did not engage an adequate amount of bone. If that is possibly the case, I also wonder if a small amount of bone graft material between the mesial socket wall and the implant would have prevented this problem from arising.

Spontanous exposure and early bone loss: how to proceed?

10 Comments on Spontanous exposure and early bone loss: how to proceed?

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