All on Four #6 implant exposed
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.