Abscess ToothAbscess Tooth These images are from a new patient in my practice. A periodontist referred her to me for a restorative evaluation of the implant-retained crowns.  There is a resolving abscess on the facial of #7. What do you speculate might be the cause of the abscess? I’ll post the radiographs of the implants in a few days to give us some time to talk about the case. What else do you see that might give you some clues to the implant position or what is going on below the bone?

Implant


Comments

Commenter's Profile Image Jay Stockdale
December 8th, 2010
Patient obviously has a very deep bite, and is probably exerting a strong anterior force on the upper anteriors. I am thinking that the patient is a male, based on the morphology of the teeth/crowns. From the position of the abcess, it could be a fracture of the facial aspect of the implant itself. That's my guess, based on what I see thus far.
Commenter's Profile Image Pierre Morin
December 8th, 2010
Did you look for cement under the gums? Very tricky when cemented fixed protho on implants !
Commenter's Profile Image Barry Polansky
December 8th, 2010
wouldn't venture a guess at the cause without radiographs, but the "abscess" on #7 isn't the only place to look. Number 8 toward the mesial has a fistula as well. I am also not in love with the tissue around 9 and 10. Besides radiographs I would like an assessment of the tissue.. Is there pain...on percussion?
Commenter's Profile Image Pierre Morin
December 14th, 2010
open margins in the biologic width. What kind of implant is this? What is this overlaping abutment? Looks like good traps for bacterias ! Is this a buid-up on tooth 8 ? If so it wont last long.
Commenter's Profile Image Bruno Pereira
December 14th, 2010
The implant is too far way from the adjacent CEJ,is too deep, there's a deep sulcus which is imposible to clean. Moreover the abtument design is questionable, with expanded platform which trap a lot of anaerobius. There's also no slhoulder on the abtument which requires an overcountered crown which is not the best for tissue health. I would like to know the sulcus depth and if it bleeds on probe. Number 11(#8) has an open margin...
Commenter's Profile Image Bruno Pereira
December 14th, 2010
This is a cemented crown we also can have some cement under there
Commenter's Profile Image Steve Ratcliff
December 14th, 2010
Well done gang. The choice of an implant restricts the available restorative options. A wide platform in this case makes developing emergence profile very difficult. The abutment appears to be a stock zirconia abutment that wasn't or couldn't be recontoured. Since this is a tissue level implant rather than a bone level there will be some die back of bone, add to that the proximity to the adjacent teeth and this restoration was doomed from the beginning. When the periodontist probed the area it bleed and there was an exudate that could be expressed through the fistula. The area was debrided and the hygienist pulled what appeared to be a small seed from under the implant platform. So what do we do now?
Commenter's Profile Image Pierre Morin
December 14th, 2010
What I would do is refer the patient to you Steve !....
Commenter's Profile Image Pierre Morin
December 14th, 2010
remove the implant, bone graft, let heal properly for months and observe what will happen with tooth 8. I just don't like the open margins of the crown of tooth 8 on the X-ray.
Commenter's Profile Image Brad Blair
December 14th, 2010
In retrospect we're all geniuses, but this might a case where a good, old fashioned fixed bridge would be the better way to go. There is such a large vertical defect that to expect that large a volume of unsupported soft tissue is to expect a miracle. Actually, I would have expected recession and a very long tooth. Ideal-extract, bone graft, soft tissue augmentation CT graft. Or....weird idea coming up....ortho extrude adjacent to bring down bone.....
Commenter's Profile Image Vivek Mehta
December 16th, 2010
How about letting the implant be - "bank" the implant - dismantle the crowns # 7,10. Design new crowns # 8,9 with cantilever pontic #7,10 off the central incisor crowns. Get ideal tissue in the pontic area with CT graft.
Commenter's Profile Image Bruno Pereira
December 17th, 2010
The height of the crest on 11(#8) seems too far down, so it would be difficult to get any papilla even changing the abutment design. Getting height with bone graft seems to me very unpredictable, the bone crest height on # 8 would be the limit. Forced eruption of 11 would be a choice to consider althoug the root is quite short,submerging the implant and CTG with FPD with a good pontic design seems the better choice
Commenter's Profile Image Chul Oh
December 17th, 2010
remake crown using smaller abutment!
Commenter's Profile Image Mike Weisbrod
December 17th, 2010
What does the patient want? Ideal esthetics from #6-11? or only fix the problem created by the implant?
Commenter's Profile Image Pierre Morin
December 20th, 2010
if it is only the abutment that is too large, then I agree with Chul Oh, simply change the abutment for a more friendly for the tissus , and crown on implant.
Commenter's Profile Image Steve Ratcliff
December 20th, 2010
All great options. Here is the challenge, if you look at the implant, you'll notice that the platform is a wide platform. The abutment can change but that platform will still influence tissue contour.
Commenter's Profile Image Pierre Morin
December 21st, 2010
It seems like there is plenty of gum tissu. If it's the case I like what Vivek wrote and banking the implant would be a great idea. If we have a proper ferrule effect on 8 then a cantilever on 7 would be very nice. I opt for this suggestion. If we don't have enough tissu then banking would still probably be a good idea with grafting tissu and cantilever. If we don't have that ferrule then we're in big trouble, Have a great Hollyday season folks ! I won't be there anymore, maybe in the future due to financial restrictions, nothing major just bugging.Life is a journey! It was a great pleasure to be in contact with all of you. Keep up the fantastic work, best wishes, Pierre
Commenter's Profile Image Fernando Llorente
March 19th, 2011
I have another case like this in my oficce , I m dying to know what to do, please give me the answer pleasssse