[Ivan]

Check these vids out: https://library.implantninjadojo.ue1.rapydapps.cloud/video/releasing-incisions-for-gbr/

[Ivan]

What Ivan said

– Move verticals so incisions are more remote from surgical site

– allograft so it turns over

[Ivan]

Your plan looks okay–with some minor modifications.

1) Grafting a 6.7mm site is good because you dont really need to gain much. Just a small win will be enough.

2) Especially if you are newer to this, I would probably want to move those vertical releasing incisions further away from the graft site. You can hop over to the next tooth. The idea is to keep your cuts away from your graft sites.

3) I typically use allograft for this. If you purchase a bone scraper you can even harvest some bone chips and layer them onto the cortical plate first and then put your graft material on top.

Lastly, have you taken David Wong’s GBR course? that would help. at least check out some of his vids in the video library in here

[Ivan]

Hey Anthony,

Thanks for the question.

4 months is usually a sufficient amount of time to wait before placing your implant–unless there is some underlying medical condition. For example, diabetes or smoking can alter healing.

I can definitely see the dimensional changes you mentioned, but the bone inside the socket looks how I would expect it to look.

What I do see that is missing though is a nice cortical shell formation at the top of the socket. If you wait longer, sure, you will get a better cortical plate formation for you to feel more comfortable placing your implant. But I think it is also totally possible to place an implant as is.

As far as size selection, I would be comfortable with a 4-4.5 mm width and a 8mm length. The position of your ruler over the site is not exactly on the bone (the lines extend out a little bit) so I would rather be a bit more conservative.

If you feel more comfortable and the patient is not in a rush, you could definitely wait a little–perhaps 2 or 3 more months before placing your implant. However you would not be wrong to place them now.

Your opinion on this @vorholtdds ?

[Ivan]

Here it is Jeremy. Your case was discussed at the 20 minute mark: https://library.implantninjadojo.ue1.rapydapps.cloud/video/coffee-and-case-review-with-steven-vorholt-episode-3/

[Ivan]

Hey Jeremy! Sorry for the delay in the post. We’ll be sure to post it up in the video library by tomorrow! 🙂 @erickimplantninja

[Ivan]

Hey Jeremy, thanks for popping this question on here. We actually discussed your case pretty thoroughly today in the latter half of our Coffee & Case Review session. We should be able to get that video up early next week.

However, I can definitely sympathize with your situation. Do you have any additional radiographs? Can you tell us a little bit about the bucco-lingual bone width?

[Ivan]

Hard to say without the original CBCT, it’s possible the crestal portion where the bone loss occured did not satisfy the biologic requirements of implants (1.5mm buccal 1.0mm lingual thickness) and the bone died from poor vascularization. If the gums are healthy and firm and no inflammation i would just watch and monitor and let patient know it appears some of the bone did not heal around the top of the implant but you will monitor

[Ivan]

I think they’re expecting the third molars and 15 and 31… I think pull the bad teeth and graft the second molar sites and re eval after Ortho which will likely be more than a year away, I don’t think there’s much treatment planning you can or should do until that is done and you can get a CT

[Ivan]

I would love to understand this case better. Can you tell me which teeth will be removed? Also where implants will be placed? Let’s discuss! @vorholtdds

[Ivan]

Great question. 4.5mm for a molar is okay.

However, it’s hard to give a cookie cutter answer. It comes down to the platform design, the titanium grade, and the occlusion.

So if you have a 4mm implant with a good emergence profile, and its made with titanium alloy and the walls of the platform are not thin, and occlusion is light or non-existant–it will likely be fine.

but conversely if you have grade 4 titanium implant, with thin walls (for example trilobe connection) and heavy oocclusion, you are in for trouble.

[Ivan]

That’s great to hear! I would definitely reinforce the the OHI and put the patient on a more frequent follow up schedule. Although the bone loss is controlled at this point, we do have to keep in mind that implants with exposed threads do have a higher risk for peri-implantitis in the future.

I’m glad to hear it didnt get worse!

[Ivan]

Hey Jeremy, how did ya end up dealing with this case?

[Ivan]

2. Why does the pinpoint exposure happen?

I cant say with 100% certainty. But I can guess at it.

Once possibility is that you had something that was harboring debris within your surgical site. I see this happen for example when a cover screw is lost early and the inner implant chamber becomes a plaque trap. Soft tissues don’t heal well when there is bacteria traped underneath.

Another possible factor is that the soft tissue was very thin. When it’s thin, it can sometimes not heal properly over the implants and these pinpoint exposures are very common in those scenarios.

[Ivan]

Great questions.

1. At what point do you intervene?

I intervene if this seems to be progressing and if the soft tissue around the implant seems unhealthy. If its red, oozing, irritated, then something has to change. However, if the tissue is pink and looks like has no issues, and the bone level seems to not be changing (assuming you have already checked for other things such as occlusion, patient health, etc) then it can be left alone.

However, if it does seem progressive or irritated, I would take action.

The thing is, those exposed threads are rough titanium and are likely to gather granulation tissue around it that is tough to get healthy. That’s why some people opt for something called “implantoplasty” for these types of situations.

However you must first remove the granulation tissue. My preferred tool to remove the granulation tissue is something called and i-brush or r-brush which goes on to an implant handpiece and can be used to pretty effectively remove it.