Infected Implant

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I have seen a patient for the removal of a failed implant. The radiograph revealed loss of bone down the side of the implant, the implant was class III mobile and exudate was viewed on initial examination.

I suspect this implant was originally placed with little or no buccal bone. The patient reports he bit into a cookie, felt a pop, and about a week later developed a fistula on the buccal of the site. Unfortunately, questions about the original placement need to be handled carefully, as the referring doctor’s father placed this implant.

I have removed the implant and debrided the site. I will re open the site in a few weeks to graft the site.

I am having doubts – should I have grafted the site at the time of removal of the implant?

Also, how likely are we to get enough bone to replace the implant? What is reasonable to expect in this challenging case?

Pt is a 64 year old male, non smoker. No major health issues, no allergies. Pt takes statin drugs but nothing else.

The referring doctor sent me a printed x-ray that unfortunately is not the best of quality. My scanner is not working this morning! When the site heals I will take my own radiograph and can include it if anyone feels they need to see it.

James

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Jim,

My preference would have been grafting at the time of extraction, as over the years, I found “abscess healing” to be exceptional.
It appears from your photo, that there is enough bone present to stabilize an implant. Of course you wouldn’t place it in the same position and angle as the previous attempt (probably why it failed).
So long as you skew the placement toward the Palatal and angle the implant parallel with maxilla you should OK.
If there is sufficient keratinized tissue present, I would place the the implant and graft in about 10-12 weeks. Perhaps you may even be able to mechanically split the ridge a little as you place the implant. I do this by under preparing the site and torquing the implant in by hand.

[photograph redacted]

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When I remove something I pretty much always graft the socket at the time of removal.

Yesterday, I did something interesting (and video’d the procedure).
A bridge from 12/13-15 was failing due to caries under #13. The #14 pontic site had very little bone height as the sinus had pneumatized. After sectioning the bridge, I reflected flaps and removed #13 root, then opened the crest in the #14 site, lifted the sinus, and grafted #13 socket and intralifted the #14 site.

After healing we will place 2 implants for #13,14. #14 site may require some additional intralift.

All the best,

John

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Jim,

I apologize for posting a repeat case, but this is a 3 year follow up on a case that demonstrates the importance of implant position and keratinized tissue.

Chuck

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I’ve attached a series of pics of a case like that, but it started with a periodontally hopeless #8 tooth
rather than a failed implant… but same idea. no buccal bone but favorable perio bio-type. take a
look at the series. this is why i love implant surgery: you could have done this case 6 or more
different ways!!

BTW, I did a frenectomy after the last pic was taken.

Best,

Andrew

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Hi Jim,

Infuse as performed by Craig Misch may have been a good consideration. Still had support of both adjacent root prominences.

Mark

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Jim,

I reviewed the case on and enlarged the photos of the insertion and a lot of times a stent is utilized in the pre-prosthetic planning number one. Secondly, I find that the implant was placed too far buccal as I viewed from the second photo..
Thirdly when I have thin <2mm of buccal bone I will enhance the buccal with Bio-Oss or a Bio-Oss type(ala Danny Buser) of cancellous material and then sandwich a mixture of cortical cancellous graft underneath.and cover it with a Bio-Exclude membrane just for graft containment. Basically, we need expansion of the bone(buccal-palatal) prior to implant insertion. I like to do this at the time of implant removal or at least put a collagen wound dressing in at time of explanation.

Was the patient covered with antibiotics????

Yes we will see more of this as we go on. Just the tip of the iceberg to come.

Gail

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Andy,

I was unable to open your attachment.

Chuck

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Chuck

Here is a PDF version of the case I sent earlier, for anyone
who could not open the original.

Andy

[document redacted]

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The lateral has significant loss of bone- I believe it’s a matter of the location of the tooth, not some pathology.

I was thinking this might be an opportunity to use Osteocel. I’ve never used Infuse before, but have heard that its expensive. Can anyone tell me what it would cost to use Infuse in a case like this? About 5 years ago I tried to get some information from the people who sell Infuse and was greatly underwhelmed by their non-response to my questions.

I appreciate the feedback on this. I’ve gotten a bit too conservative. I have a nice track record for success, but today I think I’ve paid a price in saying “no” more than necessary.

Jim

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Andy,

That isn’t a Straumann implant. Looks like a machined screw. I would certainly want to make sure it was a rough surfaced because bone regeneration to machined implants does not produce a very high BIC. I suspect that is why lots of people had mediocre results with older generation immediate placement cases.

Conceptually, I think you can’t argue that the best regenerative healing occurs in a submerged, closed environment. While I might violate that principle frequently, I do it with the full knowledge that we might not be getting optimal results and pick the cases that can tolerate imperfect results. That means that in my mind, one of the worst times to do bone augmentation procedures is when you remove an infected implant or tooth. When you do that, you have to deal with a hole in the flap (socket) and bacterial leakage from open healing. Best cases to do this are where the site is not critically esthetic, thick biotype, etc.

If getting contours, esthetics and bone augmentation are really important, then allowing socket closure to occur at ~6 weeks makes the most sense to me. Then I can control the environment better and usually do both augmentation and implant placement simultaneously with plenty of tissue to close.

Jeffrey

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You would need one vial of the smallest dose. + a .5cc vial of your particulate of choice. The cost for the Infuse is 876.00. Maturation until implant placement takes 6 months. I place this at extraction.

Mark

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Jeff,

I apologize if my pics didn’t come across crystal clear.
It is indeed a Straumann 4.1mm diam bone level implant.
In my 12 years, all I’ve done is Straumann…

Andy

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