4 to 5 Threads Exposed on Position D and E: Suggestions?

This is trouble! If your implants have only been in for two months and you have this kind of situation the best thing you can do is refer to s specialist. Here is why: 1. You probably had no buccal bone to begin with, or you placed them too far buccally. You may have had a bit of pressure necrosis (are your implants tapered??) Was this a flap surgery? Did you see the bone and it dissappeared or was it never there to begin with. The fact that your implants do not exhibit mobility doesn't really mean much. They are still doomed. 2. The anterior mandible is tricky. I'm not sure what you mean by D and E but I'm assuming that you replaced two incisor teeth and may have placed the implants very close together. This could also be a reason why they are not working. 3. You cannot really call this peri-implantiitis. The implants haven't been there long enough to even establish a biologic width. 4. Do not try and graft around these fixtures. This would be a pointless endeavor and put your patient through unnecessary surgical morbidity. Anyone who attempts salvage of these fixtures is really practicing below the standard of care. The biology here is working against you, Trust me, I've been there. We just don't know enough about GBR around implants. Everyone seems to have their answer, but I have had limited success. I 5.Do you have a flipper on these fixtures? This may be making things worse. Are there healing abutments? Were they immediate? PLease provide more info. 6. In my hands with the limited amount of info that you have supplied, I would back the implants out (may require a bit of muscle but if they are only two months old and have some bone loss it shouldn't be too difficult. ) I would graft the site. I would have the restorative dds place a fixed temp if possible, or at least something with clasps so your temp is not moving a lot on the surgical site. I would wait about 16 weeks, scan, and plan accordingly. 7. I'm just not sure how this happened. Is there anything unique about your patient? Meds, Smoking, med hx?? 8. Im my opinion you have lost control of this situation. Your treatment may have been within the standard of care, but your result isn't. Refer, take your medicine, and sleep well.

I think that you have to try to make a determination as to why these implants are failing, or you will not take advantage of a bad experience by turning it around and making it a learning opportunity. The previous comment posted a lot of great questions that could give you insight as to some of the causes. If you would expose the implants, you could determine the type of defect around the implants. The greater the number of walls around the defect, the more potential for bone producing cells and vasculature to infiltrate your graft, and the greater the chances of regeneration of some of the lost bone. Detoxifying and disinfecting the site and implant surface with a Waterlase or similar laser would be better than using just chemical means. Just some extra food for thought. Good Luck!

Dr NG : could you please ellaborate on what do you mean by placing implants at the ABDE positions? Both previous comments are right on the money and I think you should follow their advice. Good luck

MEU A B D and E refers to the position of the implants in the intraforaminal region that are used most commonly to support a bar on four implants, with positions A and E being closest to the mental foramen and positions B and D being more medial. The letter C position is at the midline if you place five implants.

It surprises me when people ask what is ABCDE position on this platform!!!. That is something a specialist performing implant dentistry should be knowing... It seems there was a problem in treatment planning in this case. guess the implants were not positioned appropriately otherwise this wouldn't had happened. can some one please provide the CT images of the case. it is good opportunity to learn.

Thanks Dr Boudet for your clear and concise explanation of the ABCDE system to identify implant location on the anterior mandible. Quite frankly and after many years involved in the placement and restoration of dental implants it is the first time I see this system. It really makes a lot of sense. I always thought thast this was a blog for dentists to ask questions without having to worry about how stupid the question may appear to some. I have been looking for the source of this numbering system but I have not been able to find it . Perhaps Dr Juneja with his vast Knowledge can enlighten me on this

Dear MEU, Please Check Carl Misch,third edition, page 300 (chapter 14 The edentulous Mandible: An organized approach to implant-supported overdentures)for ABCDE system. Good luck

Thanks Dr Juneja for the information. Rest assured that I'll check on Dr Misch's book so that I can learn a bit more.

only misch uses the abcde system. i have never heard of it outside his book. its for placing either a hybrid type prosthesis or a overdentures.

Do you have ample bone adjacent to the failing implants? If so, I would remove the failing implants (a torque wrench should do it), and place 2 more implants. If there's not enough bone, graft the defect (mfdb and collagen) and come back in 3 months. Make sure not to seat the implants at more than 35Ncm and use lots of irrigation, sharp burs and a pumping action when drilling in the anterior mandible. If the crest is narrow, you may have to reduce the ridge height a few mm (making the crest wider) before placing the implants. Consider a 2-stage approach. A cbct or lateral ceph would be helpful in evaluating bony width and angulation.

Check the occlusion!

Check for parafunction. You would of known at the time of placement if it were a bone thickness issue, bone compression/necrosis issue.

Please take a scan & check. If you have enough bone apically and if you are happy with the present location & angle remove the old implants and place them deeper with confidence. I think you hesitated while going deeper while making the receptor site. Inform patient what happened and he/she will be happy to learn that you like perfection :-) I have been involved in implantology, surgical / prosthodontics since 1985.

if you want to do less, you could just make a provisioanl fixed prostheses on the implants and monitor. in case that you lose more bone then you could go back take the failing implants out and put some new. if you have bone deeper now you will still have in a year. in the case that you have new implants placed you will still have a fixed provisional which willl not put pressure on the new implants. it seems that this is a common problem. iam placing xive implants wich are tapereed and i found many cases of loosing the buccal bone. i tried to tap all the lower sites even if itis not in the original protocol but still the same. in some other cases however i dont lose bone. seems to be a combination of over-pressure necrosis, denture presure, smoking , placing them baccully, and maybe unknown reasons

After 25 years of working with implants and 20 years of placing them, I too am not familiar with Misch's ABCDE system of naming implant position. However it does seem easier than approximate tooth numbers and makes a lot of sense for this region and situation.

Your fixture diameter may be too much in such an edentulous patient , with reduced bone width . Simple GBR could not remove problem . If you have this problem and alsoo good stability and lenghth of implant ,and also overdenture with ball , you can cut off threads by highspeed and ampul water to make them smooth so then ,get rid of food contamination and continue with ball attachments and overdenture .

Misch information as Jerry Niznik would say. Problems do Occur.Remove the implants, graft the site wait 12 weeks(depending on the graft).Then start again.

Dear DR. NG Exposed 4-5 threads with such short ımplants will be an invitation for an unsuccesfull treatment.What ever the reason is I humbly advise you to remove the implants graft and augment the area waıt for atleast six months and try the case again. Anterior mandible is usually composed of very hard and dense bone you may have heated this part during osteotomy although you have got ınıtial fixation at the periapex of the implant.May be anteroposterior width of the bone was less thah the diameter of the implant you may have mıssed this point if the flap was not large enough.Again sturing of the soft tissue with traction may cause dehiscence which inturn causes necrosis and resorption of the bone exposing the threads.

in case that you lose more bone then you could go back take the failing implants out and put some new. if you have bone deeper now you will still have in a year.