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Justin posted an update
Hello Everyone,
I have a patient I recently saw for an impression for an implant crown. I completed a two stage implant surgery. I didn’t note any complications at time of implant placement or uncovering.
The patient returned after three weeks for her impression. I noticed some inflammation surrounding the buccal of the healing abutment. There was also mild bleeding when I removed the healing abutment. I was able to pull out some debris/loose tissue that was between the implant and healing abutment. Patient said she noticed the inflmmation anout a week after the healing abutment was placed.
I took a new PA to compare and it appeared there could be some slight bone loss. I also took a CT at this appointment and have attached those photos.
Today I irrigated with peridex and prescribed her peridex for two weeks. She is scheduled to return for follow up in two weeks.
Do you think the inflammation was caused by debris or could the implant be failing? Any other suggestions for management?
Jedediah, Ingus and Ivan11 Comments-
Was the healing abutment down all the way? Typically nothing should get between the healing abutment and implant if that connection is snug. I’ve seen ones where stuff gets in there with it not being down all the way.
Oral hygiene? This absolutely makes a difference when you have a fresh surgical site (even just for an uncovery) and can cause some PI mucositis.
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@jostanger it looked all the way down to me in the radiograph. Overall her oral hygiene is great. I’ll instruct her to brush the healing abutment for the next two weeks.
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Hey Justin,
Thank you for sharing this case with us.
Let’s rule out some possibilities.
1. Was the healing abutment brand new? If it was brand new, was it sterile? Some docs sterilize old used healing abutments and re-use them on other patients. Unfortunately, that sometimes results in transfering debris from one patient to another, which is not great. Although its an additional expense, I always use a brand new healing abutment.
2. What is your tightening protocol for healing abutments? Do you hand tighten gently? Do you make it as tight as you can with your hand? Do you torque it? From the way you described it, it sounded like tissue was impinged between the healing abutment and the implant platform. When there healing abutment is not firmly on the implant, it causes a pretty significant bacterial trap. Similar to when the healing abutments fall out during healing. This bacterial trap leads to inflammation and bone loss.
This can still be a successful case. @jostanger how do you manage these once the bone and inflammation has stabilized? Leave it alone? Any grafting?
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@ivan-chicchon thanks for the reply Ivan!
1. Yes the healing abutment was brand new.
2. I created an “X” incision over the implant and hand tightened the abutment. Based on your response I’m guessing I did not retract the tissue enough and some was stuck between the abutment and implant. Would you recommend a mid crestal incision next time to get better exposure of the implant?-
@jmsdds that might be where the complication is coming from. I used to do what you described, (slicing a little x and then placing the healing abutment) but that sometimes results in exactly this scenario. It traps some tissue and results in a loose healing abutment as well.
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@ivan-chicchon Would you recommend an antibiotic?
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@jmsdds I think that simply by removing that debris, and cleaning that area out well, it will resolve the issue
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@ivan-chicchon when it’s so minimal I honestly just leave it. Sometimes I find at this stage you can do more damage by trying to fix it than letting it be when it’s so minor.
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No suggestions here, just a question. What was the size of the implant and what was the available size of the site? I think a longer implant might have been better plus placing it subcrestally too. Was there any work done on the soft tissue during the implantation?
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@javohiros it was a 3.5 x 8. Ideally I would have placed a longer implant but there was a radiolucent area on the pre-op CT that I didn’t want to drill into. It was subcrestal at placement but I believe I lost some bone due to the inflammation.
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Might be ok and just had some food of forgeign body irritating tissue. However, there is definitely buccal bone loss around the crest as implant is placed very buccally. In the future you want that implant more straight up and down buccal lingual as to not put as much pressure on buccal plate and overall more lingual to use more of that lingual bone and maximize buccal wall thickness
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