Clinical Observation

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Not being the right one to do these types of procedures I was asked to try and reduce the significant bleeding and inflammation in the area of these implants. I treated them with Tetracycline, Perioderm and closed them up. I reentered today approximately 1 year later to remove the muscle pull from the area. Clinical observations were minimal probing and 0 bleeding. What appears to be connective tissue over the threads which were previously exposed. Clinically the area looks very stable. My question is what else should I have done at the time as I did have a pow wow with Rick Rasmussen on conservative ways to treat this area?

Open for suggestions and I appreciate any help!

Thanks,

Danny

[photographs redacted]

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Danny, I just wanted to let the group know that I didn’t place these implants.

Richard

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For sure Rick you didn’t or you would have been the guy treating them. I am sure no one even mildly thinks you did!

Danny

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🙂

Richard

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Danny –

Check out the IJPRD article by Froum, Froum and Rosen. I think it was sent around (maybe even by me) after Stu’s meeting 2 weeks ago. That shows their “cocktail” for treating peri-implantitis, or getting new bone and dense, non-probeable tissue near an implant. Doing what you did eliminated inflammation and should stop bone loss where it is. That should be enough to keep the implants in situ and healthy for many years.

Bob

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I see nothing wrong with what did nor is results.

Chuck

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Thanks Chuck and Bob for your responses. I could use all the help when dealing with implants as I am virtually brain dead!

Danny

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The outcome achieved by the 3 authers is notable. Material costs/surgery would be about 700.00/ procedure. It was noted in the article that a number of the infected implants required 3 repeat txs.

Mark

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Danny,

I am surprised no one has made any remarks regarding the level of misfit the restorations seem to have.
I would suggest changing those crowns.

Best

Ricardo

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Thanks Ricardo,

Odd case as everyone wanted to stir clear of it. The Implant Doc said no mobility no problem That is how I got it. Right now she is happy because the tissue is not bleeding. I know I did not change the support at all so I will pass along your suggestions to her Restorative doctor. Any thoughts on the use of Emdogain as some have suggested?

Thanks,

Danny

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Hi Danny,
Your’e Tx w Perioderm is very innovative & seems to be working. I’ve never seen this tried before. If we knew how to Tx. periimplantitis, there wouldn’t be so many choices out there: Tetracycline, saline,CHX, rough surface removal, Prophyjet (Froum), water lase, YAG laser, bone graft, or no bone,barrier or not, osseous&/or soft tissue reduction, Peek Cavitron tip, etc.,etc. However, changing the crowns doesn”t seem indicated by your photos. The implants seem to be Straumann tissue-levels with well-fitted crowns on beautiful, well-contoured abutments with excellent emergence profiles. The platform of the center one could have been more level to it’s two neighbors, but these implants may well have been placed within the bony housing & a thin buccal plate may have resorbed, especially if flapped,`which is usually done. 1-2mm of buccal plate resorption is the norm w flaps over thin bone. My mother used to say “Don’t critasize another man until youv’e walked a mile in his shoes, even if your’e a mile away & he can’t catch you since youve got his shoes. Seriously, WE WERE NOT THERE WHEN THESE IMPLANTS WERE PLACED. Nice job. Keep on trucking.

Ted

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Treatment options for periimplant problems are about as straight forward as the treatment options for periodontal disease. There seem to be plenty of ways to gain health and we claim to “know” how to treat periodontitis…

Great result! Nothing wrong with stable and healthy.

All the best,

John

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I avoid at all costs criticizing others work especially implants. I am truly clueless and at 63 am not about to try to catch up to those that know what they are doing. With that said I tend to get cases of implants that may have inflammation and probing and am asked to treat these cases. I would like to know what I should be doing vs. treating only with limited clinical experience with implants. I try to remove infection and add connective tissue but if there is something else I should be doing I am open for suggestions.
Thanks,

Danny

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Danny –

As many have said, there are 3 issues with treating peri-implantitis, similar to treating periodontitis:
1. Surgical access – thorough debridement, surface treatment are key. Yes, I do all with microscope, but it is not always easy even with a conventional scope to visualize everything.
2. “Cocktails” – what is the ideal mixture for root/implant surface treatment, defect fill, barrier for covering the site.
3. Predictability – histologic regeneration of bone, reattachment of bone to implants, cementum/PDL and new bone formation around teeth. Those are our gold standards, but we will be happy with no bleeding and seeing more of the periodontal probe out of the gum line on a recare visit.
With and around teeth, Emdogain seems to have the most literature and best results according to people who have tried both EMD and PDGF.
Around implants – still a crap shoot. I am now doing what Paul Rosen shows – iodine then tet on the roots followed with PDGF. A mineralized allograft soaked in PDGF for 15 minutes and then EMD mixed in to fill the defects or cover the exposed areas. I then cover with a bioactive barrier – BioExclude from Snoasis, coronally position the hell out of the site and go for primary closure with PTFE sutures. I then treat with a laser for LLLT, pray and tell the patient to not eat there nor brush it. I let them rinse gently with H2O2 or salt water and clean it myself 2 – 3 times a week.
After all of that – I have 100% success on my first case out 3 months.
The problems are magnified with a case like Danny’s – in the aesthetic zone where there may be thin bone to start with and lots of lateral, excursive forces, the patients may not only need 2mm of facial bone as Grunder and Buser say, but may require a nightguard to protect the site from parafunctional forces.

Bob

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Bob

Are you sure you didn’t forget anything?

Danny

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More than enough to learn from Bob,

Thanks,

Danny

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Danny,

Let me comment on what you’ve said and done and as importantly comment on the value of this venue that Alan has put together.

Firstly, thanks for sharing your patient’s problem and how you addressed it. Thanks even more for asking for help. Because as a result, the answers from those who were kind enough to share their clinical knowledge and knowledge of the literature came forward. As a result, I learned a lot.

In fact, this has been a great week with the new information that Greg and Jeff shared in their clinical research on restoring the facial plate.

This is why I read the comments on this list. It is helping me and helping my patients.

Lee

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Hi Lee,

Thank you so much for your book. I will get to read it on the plane to NY tomorrow. I am sure it will be very helpful for our patients. Happy Holidays to everyone!

Kenny

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Danny,

After being a passive member in this extraordinary group for quite sometime, I decided to contribute with my 5 cents worth whenever I felt that they could be meaningful.

Since I was the one suggesting to repeat the crowns, I am happy to share my following thoughts to the group. I cannot agree more with the fact that clinical dentistry should not be criticized just for “being criticized”, but I believe that a core value of this group is the quest for excellence in clinicalinterdisciplinary dentistry, and my prosthodontic background forces me to speak up whenever I feel a contribution may be useful.I have learned quite a lot from everybody in this group, and I feel very proud to be included in the list, particularly as I realize that a vast majority here is involved in education. (many here are WorldClass educators).I read your post yesterday with mi iPhone and reviewed the images on its small screen, but now as I double check your images with a a big screen there is no doubt in my mind that the fit of the restorationsis poor. This may or may not be related to the loss of buccal plate. In a time where the more we know about implant dentistry seems to be “the less we really know ” I believe that we need to take a step back and be as analytical as possible regarding issues that we “can” control,and I certainly believe that prosthetic accuracy is one of this issues.I see a definitive gap between the crowns and the abutment finish line, and if I was treating this patient ( either if I had done those restorations or anyone else did), I would certainly do anything I possibly could to redo them.

Respectfully,

Ricardo

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Ricardo,

Your opinion was well taken! I think another view was given about the fit of the corwns but it does not mean anything less about yours. The case is a little more bizarre then discussed. The patient had full maxillary implants and both sides were identical. There was very little buccal plate remaining on any of the implants. I will try to post the left side tomorrow. The case is only a couple of years old and the Implantologist simply washed his hands of the case saying no mobility no problem. As I said originally there was significant inflammation. The goal was to remove the inflammation and that was my only interest.

Have a great evening,

Danny

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