Implant recession treatment options

Dr. Stuart Froum published a paper recently on his protocol for treating peri-implantitis cases much like the one you have displayed above. After gross debridement of the implant surfaces using implant specific (graphite) curettes/scalers, Dr. Froum employs a 6-step surface decontamination technique including in order: air-abrasion of the accessible implant surface with a prophy-jet, a saline rinse, tetracycline application to the accessible implant surface, repeat prophy jet utilization, chlorhexidine 0.12% rinse, finished up with another saline rinse. After surface decontamination, he applies enamel matrix protein derivative, DFDBA, and either a collagen membrane or subepithelial connective tissue graft(s) with primary closure via periosteal releasing incisions. I've never done this technique nor treated a peri-implantitis case like this one so in no way am I an expert in the management of a case like this, but his results are impressive with this protocol. I understand other experts and clinicians in this aspect of implant dentistry utilize different protocols including laser decontamination and/or different bone/membrane combinations. As long as the implant is not symptomatic or mobile, and the patient does not want it removed, I'd try it. Good luck.

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Jonathan; I like your answer and Dr. Froum's suggestions are excellent but 2 more issues I would like to ask.
1. Would you remove the threads and roughened texture to reduce plaque accumulation by preparing the exposed implant surface?
2. Would you add a FGG or CTG to address the lack of dense functional keratinized tissue to prevent further recession and/or downward migration of plaque and bacteria?
We are seeing more of these cases all around the world as more implants are being placed in areas of inadequate bone and soft tissue environments or in patients with high perio risk.
Dr. Salama

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The implants are out of the bony housing and they are showing us a typical natural root's hard and soft tissue deficiency situation(even though they are NOT roots).
Lack of keratinized gingiva promoted the recession and the weakness of the soft tissues around the implants.
Is important to classify between peri-implantitis lesion(Dr Froum's article) and osseous defect around an implant because of continuous trauma.
The oral hygiene looks excellent so this case probably was worsened because of many factors:
Ridge deficiency at the time of implant placement(not overbuilding procedure was performed) and lack of attached gingiva.
I would strongly recommend to remove the implants and rebuild the area in terms of hard and soft tissues. I consider that, the most predictable treatment for this specific situation.
Good luck!

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The right diagnosis is the key to proper management of any implant case. The recession in this case is more likely due to an early peri-implant bone loss rather than peri-implantitis process. This early bone loss results from a physiological remodeling process because of the thin peri-implant hard and soft tissue. The thickness of buccal bone after osteotomy is a critical factor in predicting bone loss around implant and subsequent recession.
The good news is that the patient has no esthetic concern, which means no treatment is needed. The bone will keep remodeling at fast pace until it reaches an area of thick buccal bone, and then it will slow down. In this case thickness of peri-implant tissue is more important than the occlusal factor. Adjusting the occlusion to remove lateral excursives is not a bad thing.

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Great comments. Question to all.
Would THICK tissue have prevented this even if the buccal bone was THIN?
Dr. Salama

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Would you remove exposed threads with burs or would attempt to detoxify surface and cover exposed threads with tissue graft?

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Thick soft tissue (typically bound down tissue in Myron Nevins words )would've slowed down the loss but not prevented it. This loss could only be prevented by adequate thickness of bone bth buccal and palatal.

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yes, I believe thick tissue would have considerably reduced amount of recession.

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Thick tissue with thin bone will minimize the recession, but it will not prevent it especially in multiple implant cases.
Thick tissue with thin bone may not recede in single implant cases between natural teeth especially with good level of interproximal bone.
Question : Will grafting increase the longivity of these implants?

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Thickening the tissue and preparing the exposed roughened surface and threads would increase the longevity of the prosthetics if the patient performs adequate oral hygiene.

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Great responses. Thank you to all. I have tentatively planned to place a "thick" CTG in order to minimize the likelihood of further recession. As for "correction", I am not optimistic that any treatment is predictable enough to warrant trying/charging for. Agree?
Dr Salama, what protocol do you advocate when "preparing the surface of the implant"?

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I am affraid these are going to fail no matter what you do. The occlusal stress is overwhelming the supporting bone and soft tissue. My guess is that this is the same reason their natural teeth failed. Removing excursive contacts aside, these implants are holding up the occlusion. If you were to do a sinus lift and add a third implant and attach them together it may add more resistance to occlusal loading. Was a nightguard perscribed? What is the occlusion on the opposited side? Are these teeth splinted?

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follow up of orthodontic cases taught us you don't violate the realm of neutral zone without impunity translated into dehiscence and fenestrations.
I see those implants placed at the level of the B roots of the lost teeth.
I wonder whether an inert type graft vs a bioactive one would've prevented this?

Sameh

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