Did an immediate implant placement on tooth 26 with bone graft and cover with d-PTFE membrane (Permamem). 5 days later noted the sutures were loose but the membrane still in position. I re-fix the membrane. One week later, the membrane was partially dislodged. No sign of infection and there were epithelial growth under the membrane. I removed the membrane, irrigate with CHX copiously and instruct the patient to irrigate daily. But I noticed implant thread exposure at the crestal level. Will it help if I leave it be as long as there are no infection, and do a connective tissue graft when I place the healing abutment?
WolvesProstho comments:You probably have bacterial infection around the implant head. Remove and repeat - maybe tac your membrane in place or use one of the many grafting materials that do not need a membrane?
drshalash comments:Tacking a membrane in an immediate case?!! That's not needed at all as it means u need to raise a full thickness flap. leaving the tissues where they are, will help to preserve the blood supply to the buccal bone, avoid uncessary mrobidity for the patient in terms of pain and oedema and will just leave the KT where it belongs buccal to the implant.
Tim comments:Leave it alone as it will be fine. I have never been a fan of using PTFE around an immediate for this very reason. Since you placed the fixture immediately into the extraction site I am going to assume that you had adequate native bone to stabilize the fixture and so the graft was to just cover the implant within the contained 2-3 wall defect. You then advanced the buccal flap of thin mucosa to cover a lot of unnecessary and expensive material. Then when you saw it open up you used CHX which has been shown to inhibit fibroblast proliferation. In my experience placing immediate implants in such sites I will place a graft material only (I prefer RegenerOss Plus from Zimmer Biomet due to its putty form) and sometimes cover the exposed graft at the crest with a collagen plug or tape. This simple approach has worked well for me for the past 10-12 years.
JC comments:Thanks for the advice. There was enough interradicular bone to sit the implant in. I decided on this approach due to large bone gaps from the root sockets and I know I wouldn't able to achieve primary closure if I used resorbable membrane. I will look into your approach (graft in putty form and collagen plug) for the next case.:slightly_smiling_face:
guest comments:Seems like too many things are being attempted at the same time here. Remove the implant re-graft and close it primarily no membrane. The PFTE most likely as too much for the small space and unreleased tissue flap. What's your plan for the two failing root canal treated teeth with periapical issues?
drshalash comments:having done hundreds of successful immediate cases over the years, the need for primary closure over a socket or an immediate implant is rarely if ever needed. even if the plan is to remove the implant now, no need for primary closure to be attempted.
JC comments:I'm trying to avoid removing the implant unless there is signs of infection/failing. I might try to re-graft. Apical surgery has been done on those two RCT teeth and under close monitoring.
ALAN AMIN comments:Hi I agree with Tim on all his explanation on your case ,leave it alone , it will be fine.After immediate single implant procedure, I use bone graft, putty 4Alex from MIS with collagen plug,Irrigation with Normal Saline only,, it work.healing will be well,if at the end of maturation osteointegration if still you see implant thread bellow soft tissue level ,it will be accepted but if more than 2 thread exposed and above crestal bone level you can treat like peri-implantitis , you can clean and curettage around the implant thread add bone graft, I place implant for more than 26 years , and used most of systems .The only advice is to be familiar with indication&contraindication of membrane usage.Good luck . Alan Amin, Oral Surgeon&Implantologist
drshalash comments:As long as the implant has good primary stability i would leave it alone. the tissues will re-epithelialize and will heal like a normal socket. U can also change the cover screw to a wide healing collar for a transmucosal healing. next time plan to place the implant a couple of mm subcrestal when doing an immediate.
JC comments:Thank you for advice. Should I wait for the tissue to be fully epithelized and then change to healing abutment, or I can do it soon?