Dr. Z asks:
I placed Straumann ITI bone level implant 4.1/14mm in the #9 area [maxillary left central incisor; 21] 8 weeks ago (see attached case photos). There was very limited bone volume, good primary stability, but almost 80% of the buccal bone had to be grafted with Bio-Oss [Osteohealth] mixed with autogenous bone collected from a bone trap. A Bio-Gide membrane [Osteohealth]was used.
Following the implant placement and bone graft, the patient failed to return for 8 weeks. Patient now presents with a dehiscence in the crestal region where the cover screw can be seen. Some of the Bio-Oss graft has been lost, compromising the buccal alveolar crest area. There is also a sinus tract on the buccal of the graft site which is actively draining. Patient has also complained of feeling ill. I have prescribed 500mg of amoxicillin and 400mg of metronidazole.
She will be returning in 2 weeks when I will attempt to cover the dehiscence. I will use a split-thickness flap which I will rotate from the palate over the dehiscence and attempt to submerge the implant. But, should I just be cutting my losses here, and would it be better for me to just remove the implant, graft and place another implant later? Or, should I proceed with my protocol? I really would appreciate advice.
Probable solution >>>>
1.
While your pictures of placement look appropriate, infected grafts need removal. Your graft is infected.
I would cut my losses here.
Do not do any more surgery on this site. It is infected and until the graft is removed, it will remain that way. Surgery to repair a soft tissue deficiency here is not going to help when the underlying implant – graft is infected.
If I were you I would remove everything and send to a specialist. I do not question your ability, but at this point you have a compromised anterior site. Anterior sites will be your greatest successes and greatest failures. Just learn and move on!!!
2.
would suggest a full thickness flap and extend it making the base wider then the crestal and up past the mucogingival line. then with scoring the periosteum you can stretch the tissue to cover the site totally. After flapping you can eval if the implant has any mobility if it does remove graft and wait 3 months to reimplant. if it doesnt then treat like an ailign implant and remove any granulation tissue, place Doxy in a paste on the implant exposed threads only rinse after 1 min and repeat then treat the entire area with citric acid rinse and repeat. I would use Regenform or similar moldable graft product and cover all of the implant including the cover screw. place a peice of Ossix or other resorbable long term membrane and get primary closure and allow to heal for 3-4 months. in the mean time keep them on the antibiotics for 2 weeks post surgery.
