Top threads not filled in with bone: any solution?

On the x-ray if you look at the soft tissue there appears to be a deficiency . A spontaneous exposure which could be the main cause of the loss . Treatment would be to raise flap clean , prophy the implant and re-garft wit a fully bio-absorbable particulate and place a healing cay on closure , I know difficult for the patient ... Peter

Could you give a little history on how the tooth was lost? Was there good buccal plate, was it an immediate, or failed endo? The soft tissue gap could have also been caused by an infection and a fistula developing vs lack of tissue closure. What concerns me is the little spaces of black along the threads deeper along the implant. Sometimes non integration due to a peri implant infection can look like this in the early stages. Grafting is a more predictable option if an etiology is known. I would be sure to test for integration at grafting if not remove the implant graft the site and start again. The history is important to determine the best course. I'm sure you don't want to be chasing an "iffy" implant in the esthetic zone. Please advise.

Peter.Can you please explain how you can see soft tissue deficiency on this x -ray. Thanks Nico

Hi, it appears you may have placed the fixture on the midline suture? What are your plans for the upper right central (#11)? The bone in the 11 region appears resorbed/thin? Was the bone in the 21 region similar, if yes than that is probably the aetiology. If that was the case, I agree with CRS, remove, graft, re-enter after 6-9 months. Regards ST

HI there, I recognise this implant - MIS 7. I used that before. In the cases I have done before, I saw this sometimes. Some reasons why you can get a radiographic appearance like this 3 months post-insertion in my opinion are: 1) Peter eluded to an early spontaneous exposure of the gingivae over the cover screw (I have read studies which say the smaller the gingival exposure, the greater amount of crestal bone loss you can expect due to bacterial ingress and difficulty in cleaning the area - just like pericoronitis around an impacted 8 with an operculum). In your x-ray, I can see a soft tissue defect directly over the cover screw and there is most likely an exposed area of gum over the cover screw 2) If you placed an implant in a ridge with inadequate bone width surrounding the crest of the implant i.e. did not have 2mm of buccal bone - this in my experience causes crestal bone loss, usually around the micro-threads of the implant to the first large thread 3) Bone die-back from extreme compression of crestal bone due to high insertion torque but this is debatable from the studies I have read CRS eluded to the radiolucency along the walls of the implant on the x-rays. I have also seen this sometimes in my cases. It looks like you may have placed the implant in an area where the tooth was recently removed, and so the lamina dura of the socket has not completely remodelled yet and there may be a space between the implant wall and the space next to the lamina dura. You could do what Peter suggested, or if there is no clinical signs of any issues and you feel integration is adequate, I would go ahead and restore this. There have been cases where bone has actually grown back once it has been restored. Hope this helps a bit!

Hi good scenario to learn but tricky for the clinician involved. First things first. Do we know what bio type is the gingival tissue? and couldn't agree more with Peter. It appears this patient has combination of issues and in ideal terms it is a failure but does not necessarily mean patient would be unhappy if the results are satisfactory. In my experience doing a little bit of soft tissue advancement and augmentation may not help and can exaggerate ST deficiency as the uptake of graft material in a small area like the crest is very difficult to contain and am not sure if it wlll give you desired results. Closest I could suggest is bone augmentation and CT graft to bulk up soft tissue . I have used Alloderm which is useful as you avoid donor site. Eitherway I would warn the patient and I am sure you would have done it already. Removal and reinsertion seems a lot but in some occasions there isn't any option. Sorry for driving this critically.

I suggest what Peter advises. Expose, clean and detox, graft with a particulate and perhaps cover with an acellular dermal matrix membrane. There is no reason to remove the implant. A photograph or two from the site would be helpful.

What concerns me are two things, cupping dieback around the top of the implant and the little black triangles along the sides. If I had a history I could make a diagnosis instead of just guessing. This is not good after three months and prior to loading. Don't know what the implant looked like at placement and what the soft tissue looked like. Remember implants can be placed with a healing collar exposed and some patients require more time to heal. Without some kind of a history pre and surgical I can't honestly give adequate council. I would need to know if this implant is integrated clinically prior to advising grafting since it is early in the game and is not restored.

Thank you all. The implant has seems to be integrated, and I'm going to restore. I appreciate all of the input.