Thoughts On Surgical Irrigation And Topical Antibiotics for Treatment of Ailing Implants

If you are contemplating regeneration around this implant, also consider just replacing it. Unless you have prior experience with these ailing implants, attempting to repair the defect can lead to more problems. If you still believe that repair is better than replacement, here is what I do: 1 - Whether replacing or repairing the implant, first remove the crown and covert to screw retained. Inspect the crown margins to see if any excess cement were factors in the defect. 2 - Place cover screw and debride any obvious granulation tissue . 3 - Let the site heal for 3 weeks, instructing patient to avoid flossing or brushing the area, and dab chx on the site bid. The almost closed gingiva will allow you to minimize disrupting the mucogingival border when performing GBR. 4 - Anesthetize and disinfect surgical site w/ iodine 5 - Raise full thickness flap using a papilla sparing or Zucchelli approach to minimize formation of black triangles. 6 - Advance flap to determine volume limit of particulate 7 - Debride all granulation tissue using scalers. 8 - Disinfect residual bony defect and exposed implant surfaces with diluted iodine 9 - Mechanically debride bony defect w/ surgical electric handpiece and round diamond burs at low rpm until no soft tissue remnants are left 10 - Rinse cleaned site using sterile saline 11 - Place phosphoric acid gel onto exposed titanium for at least 20 seconds, avoiding direct contact with bone 12 - Rinse acid gel with sterile saline 13 - Trim and try in membrane (collagen for small defects, ptfe for larger defects) 14 - Place particulate graft (prefer anorganic bovine) under membrane 15 - Suture w/ horizontal mattress and interrupted monofilament sutures ensuring passive closure. 16 - Postop chx dab on sutures, and 2 wrc for suture removal. Dexamethasone regiment for larger flaps. 17 - Uncover in 3-4 months Hope this helps.

This looks like the infection spread from the RCT tooth with PARL. Unfortunately you may need to remove the tooth with root canal therapy and the implant. Don't waste your time trying to save the implant. Good luck

There is really not enough information provided to give a definite option as to what you should do. My comments are therefore these... From what you have presented it seems you placed some sort of graft into the socket when you implanted. I am suspicious this has not converted to bone and may be the source of the problem. If so, then I suggest you need to remove the implant and graft material and start again. Adding more graft and a membrane is likely to worsen the situation and is unlikely to solve the problem. You say the issue can be tracked to the apical third of the implant, but the PA shows it is more likely the middle third but possibly with platform height involvement. If this is the case, then removal of implant and graft material (if it was placed) would be wiser than attempted repair. Allow the site to heal and start again – but only after you deal with issues mentioned below. You might want to consider Ethoss as a graft material (for many reasons). It seems very likely that the adjacent tooth is a possible source of infection. Whether this is periodontal or endodontic in origin would need to be assessed. Again this is a strong indication that attempted repair around the implant is likely to be futile without at least sorting out the adjacent tooth issues. The bone levels around the implant do not look like there will be a realistic successful result. Again this is in part due to the issues with the adjacent tooth, but also I am suspicious about whether the apparent graft will survive (especially at platform height) or that the implant was placed deep enough. For a variety of reasons, I think it would be wise for you to refer this case to a specialist (probably periodontist would be best). If you want more opinions from readers then it would be better to provide the full history of the case (ie history of extracted tooth – was there infection involved - and surgical methodology). As an extra thought, does the other adjacent tooth have active caries? If so, this might be a possible source of infection at the surgical stage. While this is a more remote possibility, it might pay to keep it in mind.

The radiograph and picture you posted shows several areas of extreme concern. First the large radiolucent area on the mesial of the implant seems to extend from around the apical portion all the way to the platform area where you placed a graft that did not turn into bone ( probably anorganic bovine) ( dont' like it, not osteoinductive). Tracing the fistula with gutta-percha at this time is a futile exercise since you gain no useful information. A CBCT will tell you the extent of the lesion around the implant and if it is circumferential, it would be very difficult to access to be able to treat it. I prefer a slurry of tetracycline to treat the surface after cleaning it with the Waterlase, but I have to agree with the previous opinions that it might be better to remove, graft and redo implant at a later time. The CBCT will give you a good idea of what you will encounter during surgery one way or another. Good luck! Carlos Boudet DDS DICOI

Looks like the source of the infection is lateral incisor #7. If you don't take care of that it doesn't matter what you do to #8. Also caries noted on mesial #9. Rather than treating the peri-implantitis on dental implant #8 and infection on natural tooth #7, it may be simpler and more predictable to extract #7 AND #8 and place an immediate implant in area #7. You can cantilever #8 off of #7 in the final restoration.

As my colleagues have stated below, there is not enough information to formulate a definitive plan. You need CBCT slices to assess. The lateral is failing the canine is probably failing and this implant has massive bone loss and infection. I would take a step back and assess it thoroughly as a revision surgery may not be beneficial. Arestin is not for use in grafts. Revision protocols vary but involve decortication, degranulation, I use a laser to re-passivate and sterilize and titanium brushes along with acid to remove the smear layer, along with RAP and bone and membrane to fully cover. In this case you will probably need to remove at least the implant and lateral and assess the canine before proceeding. Best of luck. Richard Winter DDS, DABOI, DICOI, FAAID

A similar case: Soon after placement of the first implant in the canine position, I noticed a lesion on the distal aspect. I suspected that the culprit was the incomplete endo treatment on the premolar next to it. Following extraction of the premolar, the bone around the implant improved. Subsequently, I placed an implant in the premolar position. HINDSIGHT: Should-have, Could-have ? 1. I could have shaved off the mesial aspect of the molar to give me more room to get a better angulation of implant in the premolar position. 2. Taken care of the infected premolar first?    

hi, gently insert a yellow or suitable size of a gutta percha cone in sinus, to find out origin of sinus. (be careful not to break gp cone), , sorry if already suggested, did not read all comments, good luck