Case 5
“Where do we go from here?”
Neal Lehrman, DDS, MS
[email protected]
A 53 year old female, presented with a failing dental implant site #9. Medical history was non-contributory, but the patient had already suffered a failed implant/ and implant restoration 3 years prior to this visit. Clinical and radiographic examination revealed suppuration, bleeding upon probing and significant concomitant bone-loss peri-implant. There was no mobility noted at that time. To increase the degree of difficulty in terms of treatment options, the patient had a very high smile-line, making the loss of this implant even more troubling from an esthetic perspective.
When discussing the options of treatment with her, It was imperative to advise her that there are no great options/outcomes. Should she lose the implant, multiple surgeries would be indicated so as not leave her with an un-esthetic emergence profile, if even from a pontic standpoint. Full thickness flap-elevation would most likely result in significant recession, so that benefits of retention of the implant might be lost due to the disfiguring outcome. Patient management in these situations is almost as important as technical skill.
We opted for LAPIP. Ideally, removal of the prosthesis and replacement with an abutment is indicated for at least 6-9 months, but in this situation that was not feasible.
Under local anesthesia, the peri-implant probings were 12mm on the mesial and 11mm on the distal aspects of the fixture. A far as energetics , 83 joules were used in total ( falling within the range of approximately 4j per mm of probing depth ) for both passes. Excellent hemostasis was achieved.
The patient returned in 4 months and looked well, and then at 8 months she presented for emergency with advice from a third DDS( not the referrer ) that the case was failing. New peri-apical revealed excellent healing and there was still no probing. The patient returned at 16 months with virtually no probing on the mesial and only 7mm on the distal. She elected not to retreat but was stable enough to have an esthetic and hygienic crown re-fabricated. It is important to note that over 10mm of probing depth at the outset of any case might very well require a second procedure down the line. This falls under the category of managing patient expectations.
Is this a perfect result? That depends on your perspective. From a patient standpoint, it is excellent because she didn’t need to undergo more surgery which would have had greater morbidity than LAPIP, and as an added benefit the bone buttressing the adjacent teeth has been stabilized. It is important to bear in mind that these procedures might best be seen as “maintenance “ rather than definitive treatment. We do not have long term data as to how they will hold up over time. Perhaps patients will best be served to be treated multiple times rather than just once and to move in another direction if a ‘perfect” result isn’t achieved. Food for thought, anyway.
Fig 1.
Initial presentation. Bleeding and suppuration upon probing.
Fig 2.
intial pre-op periapical. N.b the loss of 2/3 of the osseous support due to peri-implant disease.
Fig 3.
4 month post-op n.b bone fill on mesial .For reference note the height of bone relative to the polished collar of the implant fixture.
Fig 4.
8 month post-op. bone now reaching past the junction of threads and the polished collar. Distal filling in but not at same rate.
Fig 5.
16 month post-op. Bone on mesial to level of original height pre-defect #8. Distal probing 7mm but patient elected not to re treat.
Fig 6.
Final photo. Free of disease, patient can now have new, more – hygienic restoration fabricated.