Peri-implant complication Diagnosis

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Posted on By George Kotsakis In Failures

50yo Male non-smoker patient with an implant-supported anterior FPD presents complaining of "dull" pain associated with #11 implant that is the distal abutment for the implant-supported FPD and a "bump" in the area of the implant that is sore during brushing. Upon probing, probing depths were 1-3mm around the implants with no bleeding on probing. As part of the clinical exam the restoration was removed to access the site and a sinus tract stoma was found ~4mm below the mucosal margin. Upon palpation there was serous exudate coming out of the sinus tract. Tough diagnostic case. Dental history included placement of the implants several years ago to replace a failing tooth-borne bridge. The #11 area underwent ridge preservation followed by implant placement and contour augmentation. Ideas on possible diagnosis and diagnostic workflow?
Case treated by Drs. Chiu & Kotsakis, Seattle WA

Diagnostic exam

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In the magnified image you can see that the peri-implant tissue is very healthy and can even see the vascular network through the healthy mucosa in the peri-implant sulcus after removal of the restoration. The peri-implant seal was so tight that the probe could barely fit in the sulcus.


Can you provide us with x-ray?
My first guess is a xenograft particle, encapsulated in soft tissue, about to exfoliate.
But knowing you, I expect some titanium nanoparticles lol
It is good to meet you on this forum, dear Georgious and get some stuff to think about.
best regards


Dear Snjezana, as expected that's spot on input. I will have to see if I can find the radiograph on the server but nothing specific except for 3mm distal radiolucency. How do you proceed to diagnose?


I prefer to see this x-ray:)
CBCT often does not contribute essentially to the diagnosis, due to artifacts (but Chuck`s CBCT shows everything).
I would open the site, avoiding marginal gingiva elevation, in order to visualize the site and find - cementum? xenograft? Was restoration screw-retained or cemented? Although with cementum one would aspect more probing depths and bleeding.
Best regards


Spot on! Let's wait to hear more comments and I will post exploratory surgery images, even better than the x-ray :)


I must agree with Snjezana, without radiograph difficult to assess but the radiograph and CBCT may be limited. Need to find source of infection.....loose graft particles or tooth remnants is a typical finding. Regards Dr. S


Great points and all seem to agree that loose particles are not an uncommon finding. This was also the case here where you can observe in the surgical re-entry image the particles standing out trapped in soft tissue. Tracking back the chart notes for the case, at the time of placement contour grafting was done with xenograft without the use of a membrane. Having followed up several cases since, I have observed similar situations with contour grafting without a membrane. Haven't encountered one yet when a membrane was used, which could be associated with the slow turnover of this type of graft and the need for more time to protect hard tissue integration from competition by soft tissue that will encapsulate the rough particles. You can observe the image post-debridement show the extent of residual particles in soft tissue after their removal. The diagnostic workflow and treatment of the hard tissue defect will be shown in the upcoming webinar. Hope to catch you all there:



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