All on Four #6 implant exposed

9 Rating(s).

Posted on By Rob Michienzi In Implants

This patient was treatment planned for fixed upper implant full arch restoration. He is a healthy 47 yo male, although he is a smoker, otherwise unremarkable med hx. Smoking cessation began 4 weeks prior to implant placement:

CT surgical guide was utilized, 4 nobel active implants placed in areas of #4,6,8 and 11, implants were placed 4mm subcrestal (all placed @ 65ncm) to achieve adequate buccal and palatal thickness of bone. After implants were placed through tissue punch w/ nobel guide protocol, bone mill utilized @ each implant (to allow room for bone reduction), then incision was created slightly palatal to crest, cover screws placed, bone reduction with carbide burs, and sutured with combination of horizontal mattress & interrupted using ptfe & pga 4-0. onlay graft was placed #4 position to bulk buccal plate in that region as extra safeguard. Pt presented 2 weeks po w/ open flap and exposed implant head #6 area. Hard to tell on photo but implant is placed at level of crest, it appears that the coronal portion of osteotomy has .5 mm gap from implant. Im thinking bone mill created this gap.

Please share your thoughts i will see him for 1 month PO on Thursday.
My thoughts are
1) remove 4.3 x 11.5 diameter active implant replace w/ larger implant ie 5.0 diameter active depending on health of site.
2) remove implant and possibly place immediate bone graft if adequate tissue for closure.
3) nurse implant back to health with coverscrew stabilized membrane using a osseo conductive/inductive small chunk particulate allograft. wait 4 mos new scan then place implant and bury.

Ct scan planning
Scan multi view #6

2 wk PO
2 wk PO

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Looks like necrotic bone possibly due to overheating at osteotomy or just previous heavy smoker creating poor blood supply
Did pt bleed well at procedure?
If no blood supply new implant will not work
Suggest remove and clean and let heal with good clot possibly prf/prgf


Thank you!
I agree with your comments.
I thought patient had reasonable bleeding during procedure, I used sterile saline w slow pumping motions
unless bone mill required more saline ...

Possibly that bone is not recovering because of flap opening combined w smoke hx. I do think it’s slowly recovering and looks better clinically. I will get periapical’s and new photography tomorrow and post.


A few things to note in denture cases transitioning to implants...especially with smokers, diabetics etc. Always place implants subcrestally, always achieve tight closure, remove denture for 1st 1-2 weeks to avoid pressure on wound during early edema.
This case looks like exposed or neurotic bone. I would ONLY monitor patient for several weeks and hope to achieve secondary intention wound healing. If none sequesters, remove and irrigate area. Keep us posted. Dr.. Salama


Thank you for posting Rob.
IMO something went wrong with the flap management in the area of #4 onlay graft. The way it looks on 2-week follow up, you might end up with about 5mm crestal bone missing around the implant as the best case scenario.
I am also not sure with the tx plan for a full upper fixed bridge, since all the upper implants positioned quite anteriorly.


That appears to bè necrotic bone. Is patient receiving biposphonate therapy?
In such a case you should remouve rapidly implant and necrotic bone, PRF Can bè useful and Need a very careful monitoring in follow up.
Keep posted.


Nobel Biocare