Monday, May 6, 2013

Implant Troubleshooting Advice by Dr. Sam Jain-Failed Immediate Implant: Feedback on this case?


Failed Immediate Implant: Feedback on this case?

The case you see below is a failed immediate implant tooth # 21. I placed the implant after atraumatic extraction in the palatal wall and left sufficient space between the implant and the labial wall and there was no pre-existing infection, rather a split tooth situation.
Everything looked radiographically and clinically fine until the patient returned after having the screw retained temporary in place for 6 weeks (9 months of osseointegration). At this point the lesion you see on the labial appeared. I then had another CT scan done and it appears as though there is little to no labial plate. My plan is to flap and graft the labial area. I think retrieval of the implant would be difficult as it is well integrated elsewhere.
I am not sure with such a graft if I can leave the temporary in place or if I should place a cover screw and let the site close over for optimal graft results? Any feedback on this case would be greatly appreciated.
(click images below for enlarged photos)
Healing Collar 7 Months
Temporary crown 9 month’s
Healing Collar 7 months
healing-collar-7-months
Implant Troubleshooting Advice by Dr. Sam Jain
Sam Jain says:
Remove the temp and look with 6x loupes, may be some debri or open margin, over hang , crack in provisional etc. clean with pgd… I scrub with cotton pallet soaked in clinda and replace the temp and then wait.
Sam

Implant Troubleshooting Advice by Dr. Sam Jain-Calcium sulfate instead of bone graft materials for Summers Lift?


Calcium sulfate instead of bone graft materials for Summers Lift?

I am going to be doing a Summers lift to install implants that will extend into the maxillary sinus.  What I plan on doing is fracturing the sinus floor with an osteotome and pushing the segments up and then placing a bone graft.  I was wondering if I could used calcium sulfate instead of bone graft materials.  Is this an FDA approved use for calcium sulfate?  Is this a   procedure that will have predictable success?  What do you recommend?
Implant Troubleshooting Advice by Dr. Sam Jain
Sam Jain DMD says:
Use mfdba mixed with clinda encef
use prf chunks for cushion
Caso4 why!!!! It dissolves in no time.
Sam Jain, DMD
Center for Implant Dentistry
Fremont, CA

Implant Troubleshooting Advice by Dr. Sam Jain-Small sinus tract on 3 yr old implant: any input?


Small sinus tract on 3 yr old implant: any input?

implant with fistula
I placed this implant in #9 site [maxillary left cental incisor; 21] 3 years ago in a 32 year old healthy male.  I did  an onlay graft prior to the surgical installation of the implant.  The patient returned for stage 2 uncovery. Radiographically everything looks fine as you can see.  I noticed a small sinus tract on the labial aspect of the cortical plate in the attached gingiva a few millimeters below the occlusal aspect.  He has had no symptoms and did not notice this. I did milk a small amount of exudate from the sinus tract.   My initial thought is to send this off to my periodontist and cover any costs to have this managed whatever that may be.  Any input as to why this would be occuring and what I may be able to do? Any advice would be greatly appreciated.
Implant Troubleshooting Advice by Dr. Sam Jain
Sam Jain DMD says:
You gotta have an in house CT scan.
Primary closure over implants is very often accompanied with fistula like the one mentioned in this case. If you say 3 yrs and then fistula with it, then it is loose screw or food in the hex of cover screw. The fistula would have cause some bone loss of the facial crestal bone.
That’s why I hate primary closures. In this case after the implant placement, the temporary crown should have been placed and if needed some sectg from tubrosity, hugging g the temporary crown.
And a flipper or Essex ……none of that. The temporary has to arise from the fixture. Provide px with good quality of life by putting a temp crown….especially in the front. Cosmetics is excellent, no uncovery surgery, no fistulas, and progressive loading.
Well in this case uncover the implant right away, clean and scrub with IV metro / clinda soaked gauge, make a nice screw retained temp and to avoid the nightmare of recession, place a thick sectg from the tuberosity and let it mature for 6 months. Remember sectg at the uncovery stage is paramount.
CT scan evaluation is must to have a feel of the buccal bone level and thickness.

Implant Troubleshooting Advice by Dr. Sam Jain-Loss of gum due to laser: does this case need a gingival graft?


Loss of gum due to laser: does this case need a gingival graft?

anterior
I have exposed an implant with a laser in an anterior case where keratinised gingiva seemed abundant. When I placed the healing collar, the buccal gingiva was very thin and now it is gone. I had put the cover screw on and the patient is under observation. Do you think now that the healing screw is off the tissue will grow back or does this case need a gingival graft?
Implant Troubleshooting Advice by Dr. Sam Jain
Sam Jain DMD says:
I think it would be better to bury the implant instead of removing the implant. Put cover screw, deepithelial the soft tissue. Take molt and scrape off epith from max tub crestal tissue and then take out the entire thickness of tissue and put it like a wedge in the cleft.
And then crown and bridge at NO CHARGE. Inform px of YOUR mistake/irresponsible behavior.
And life moves on.
Sam Jain, DMD
Fremont implant dentist



Implant Troubleshooting Advice by Dr. Sam Jain-Can this site be made suitable for an implant?


Can this site be made suitable for an implant?

A 26 year old white female patient in excellent health presents with a missing #30 [mandibular right first molar; 46] and a large radiopaque area.  The mandible does not show any expansion and the area is asymptomatic.  The mandibular canal appears to traverse through the apical extent of the radiopacity.  What do you think this is? I have received opinions of condensing osteitis and odontoma. I thought odontoma, but I am not an oral surgeon.  Should this lesion be removed or should I just proceed with the implant installation?  Should I expect that the bone in this area will have an increased density like Type I bone?
iCat Vision

Implant Troubleshooting Advice by Dr. Sam Jain

Sam Jain DMD says:
Many times we make osteotomies with trephine…in this case use a new sharp trephine with a steady hand and you get normal and abnormal bone in one cyclinder and you would be able to see and touch and look under 20x if you have Global microscope, the kind of stuff we keep wondering about just like we are doing right now. You are gonna send it to the pathology lab. If you feel it feels like hard bone, put the implant but if feels like enamel (very unlikely), do not place implant and send to the dental school omf dept and write a paper, we would all like to read. A very good learning opportunity.
If u are in bay area, bring the px to my office and we write paper together. Give me a call.
Good learning opportunity. Enjoy
Sam Jain, DMD (UCONN 2000)

Implant Troubleshooting Advice by Dr. Sam Jain-Does #10 implant need to be replaced?


Does #10 implant need to be replaced?

Implant at site #10 [maxillary left lateral incisor; 22] was placed in 2007. In March 2013, the implant became infected and was treated with amoxillin.   The  implant was also infected in 2008, about one week before crowns were placed. Pain is currently still present at implant site despite treatment with antibiotic. Any thoughts on whether implant needs to be done again?
implant-image-1
implant-image-3
implant-image-4


Implant Troubleshooting Advice by Dr. Sam Jain
Sam Jain says:

A Picture of the site is needed and a good pa is needed to assess the interproximal bone
Facial bone is present at the crest where it is the most important. So if prox bone is good the infection is not at the neck of the implant.
So if the apical buccal is infected and red, make a horizontal incision just apical to MG junction, expose the threads and grind them away with a diamond bur all the way to body of implant , this will remove infected titanium, scub with metro clinda tetracycline until your heart's content, and make taco salad of bmp soaked collagen with mfdba +autogen bone from max tubrosity and graft ( one xxs bmp bottle would be enough)
I also add prf liquid and prf membrane over the graft and close gently with vicryl or gut.
Crestal buccal bone is the best thing going on for u.
Call me if you need help. Enjoy
510 574 0496
Center for implant dentistry