Hi there
I have a case where ext/sinus lift/implant and grafting was done at the same time. Extraction was pretty difficult too. 3 months later pt presents with some bone loss and bit of inflammation around the healing cap. Primary stability and torque test is good >50Ncm. What do you all think is the best course of action…? Does anyone have experience on managing this kind of case?
Thank you all for your time and and wisdom… 
Ideally a free gingival graft would be done to augment the attached gingiva ant to re-establish the vestibule that was lost when the flap was advanced. I prefer a free gingival graft though it is not always practical so I will use ZDerm from Osteogenics. I started using this material about 1.5 years ago as an alternative to a FGG and so far the initial results have been good. If you have any reservations about doing a FGG or you don’t want to refer the patient then I would suggest a partial thickness flap to extend the vestibule and secure the the ZDerm graft to the periostium vial gut sutures… Good Luck!!
from the BW. looks like your implant doesn’t have bone on the mesial surface.
looks like the graft in the socket was lost?
dr scotty, will FGG with native keratinized tissue or Zderm work w/o underlying bone?
unfortunately even if you restore the implant. most likely pt will suffer from periimplantitis due to exposed threads. even though the bone likes titanium. the gums doesn’t, specially if there’s biofilm on the exposed threads
I recommend next time, to keep the BG in the socket. u might consider using a cover screw to bury the implant. use a PTFE membrane to keep the graft.
I usually place the implant 1-2mm deeper, use a cover screw. after filling the socket with graft, i put a couple collagen plugs and use silk or PTFE sutures.
pt come back 1 month later. and i remove sutures. 95% i have BG retention in the socket. good luck.
Either of the materials, FGG or ZDerm, will just attached to the underlying periostium and ultimately follow the contours of the bone. No it will not attach to exposed threads…
Thank you for your time and reply… Do you think it would be better to remove and re place at the same time as FGG or Zderm?
In a perfect world yes but I am not going to be so quick to condemn this thing to failure because of some radiographic evidence of less than ideal bone level around the fixture. If it is stable and you can get some attached gingiva by either of the suggested methods then it will likely be fine because soft tissue is the issue as it protects the bone.
