Fistula after implant placement

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Posted on By Cristian Rotaru In Failures

Hi, i want to share with you a case for discussion.
Male, 36 yo, treated with implant in 24 area and sinus lift with simultaneous implant placement in 26,27 area. The bone was a D4.
After 3 months patient came for implants uncovery and all was ok and stable , but 1 month later patient came with fistula in the 24 area, no pain, no disconfort.

What do you think is the best approach here ?
1. Wait, make antibiotic lavage through fistula and hope for a recovery ?
2. Explantation and
a) if walls missing,GBR performed in the same surgery
b) wait to heal and perform GBR after site is healed.

Thank you !

fistula

initial situation
D4 bone


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15 Comments

Cristian, I vote for 2b: explantation, wait to heal and perform GBR after site is healed.
Best regards
Snjezana


Reply

Hi, Snjezana !
Thank you for your opinion, always valuable .
Any way you would give this implant a chance in this situation ?


Reply

I have edited my initial post.
It was late here and by mistake, i left out some details in the evoluion of the case that i think are important for choosing the treatment plan .


Reply

Cristian, I´m afraid Snjezana is right...But the question is what happend?
It has been an extraction recently in this area? The surgery was done flapless?
Jorge


Reply

Hi, dr Campos !
That is what i am asking myself also, what went wrong here . I personaly do not believe that this is a case of bone compression due to agressive thread. Maybe some remnant epitelial cells was there in situ from previous dental infection and the implant stimulated this cells and made them active( same as cyst growing pattern maybe)
The extraction was done a long time ago, not by me.
The surgery was not flapless, a papilla spearing flap was created. The acces was good .


Reply

It is not common to develop a peri-apical infection on an implant.
Check if this fistula is not draining from the 25 that has inadequate RCT. Stick a GP -point in the fistula, take x-ray and see where it goes.


Reply

Hi,
yes, implant periapical lessions are not common and the literature on this subject is not enough. A general consensus is not reached as to why this happens .
Using a gp to see if the fistula is from the tooth or implant is a good idea.
Thank you for your comment.


Reply

Christian. A possible etiology relates to the use of an aggressive thread pattern to compensate for compromised bone. I would remove the implant place particulate allograft and replace with an implant having a less aggressive thread patern using principles of Osseodensification. Thank you for sharing. Best regards. Chuck

Infection of aggressive thread implant in soft bone
After removal another implant with less aggressive thread placed with Osseodensification


Reply

Hi, dr Scwimmer !
Thank you for your comment.
Do you think that by using agressive threads in a maxillary poor bone quality will lead to overcompression and bone ischemia ? The insertion torque was around 50-55, i dont think that this torque in a D4 bone could lead to overcompression. Have you experienced this issue in a site like this ?
Using osseodensification is a great ideea, but unfortunately i dont have acces to this burs yet. I am now trying to get them from US, hope i will receive them this summer :)
Thank you for your comment.


Reply

Christian. Just to be clear I wasn't implying the failure was caused by osseocompression. Merely suggesting this thread design may have a negative impact on bone and soft tissue remodeling. I have noticed this phenomena multiple times under similar circumstances since I started using Megagen Any Ridge implants. In addition, the issue is most predominant for 5.5's. I now avoid using the 5.0 and 5.5 AnyRidge implants and failures are significantly less. Unfortunately, I have no explanation of the exact mechanism as to why. Good luck with other fixtures. Best regards. Chuck


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Dr Schwimer,
Your advice and expertise are always welcomed.
Thank you for sharing your thoughts on this.
I dont have that much experience using these big diameter implants, i dont usually utilise them. I will be more careful in using them.


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I would remove implant , and graft site


Reply

Thank you, dr Albani !
A fair and never loosing solution . Probably the best here


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Cristian pressure necrosis in maxilla is highly unlikely and it would lead to early failure. You said that at uncovery everything was stable. I would start with stability evaluation of the implant. If it is stable then antibiotics and saline irrigarion through fistula. If this does not work then flap and see. It could be a graft particle, or fenestration of the implant...if major grafting necessary only then I would replace it.

Yiannis


Reply

Hello, dr Yiannis Vergoullis !
Thank you for your suggestions !
I also think that pressure necrosis in this case is very unlikely .
The implant was stable at uncovery and no signs of inflamation on the mucosa.
I opted for a conservative approach here and the explantation was last on my list.
I will post my treatment tomorrow .
Thanks again !


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