Dr. “Smiles in McKinney” a graduate of our LIVE patient implant training courses, asks: “Dear Dr. L, an implant and vertical sinus lift was performed about a year ago by another doctor. The patient lost the healing abutment awhile ago and now there is soft tissue ingrowth and resorption…. “donuting” on the implant. No infection or exudate is present. What would you suggest on how to treat this case ? When and how would I know if it is still possible to restore it?”
Dr. “Smiles in Mckinney” or Master Clinicians are on the case! Indeed without the presence of a healing abutment soft tissue invasion of the screw access channel and implant platform transition zone is quite rapid. Even though it appears that the biologic width had been established surgically as taught in our implant courses for dentists (by the thickness of the tissue apparent on the radiograph) the now tissue occupied space becomes a non-cleansable defect. Here gram negative bacteria such as A.A., Staph Sanguis, P. Gingivalis etc will fester. In response to the byproducts of these bacteria the crestal bone around the implant platform will begin to resorb. If the bacteria should colonize any exposed threads/micro etched surface of the implant this could potentially cause further bone destruction, infection, and or eventual de-integration of the implant.
One suggestion to treat this is to go ahead and expose the implant; curettage and remove any granulation tissue present. Of course being careful not to damage the internal screw channel or implant surface. Once the granulation tissue is removed, careful inspection of the implant and the bone response or peri-implant defect can be visualized. Prior to this one can also take a 3-D CBCT small FOV periapical as seen in units such as the Genoray Papaya 3D Plus; to create a specific surgical plan. Once the implant is exposed and granulation tissue removed, copiously irrigating the site with sterile 0.9% NaCl which is isotonic will help cleanse the area. Should exudate be present and the implant be truly infected one would have to treat and cleanse the implant surface.
If a peri-implant defect is present, one suggestion is to regraph the site with a 50/50 FDBA cortical cancellous powder mix such as OsteOss, and then covered by a type II cross linked bovine or porcine resorbable membrane such as Cytoplast. Generally, given this case a “poncho technique” can be performed as a new healing abutment can be placed through the membrane and proper suturing performed. Due to the regrafting of the peri-implant defect (with close post opt followup) one should wait approximately 3-4 months prior to finalizing the case.
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