Badly placed implants: suggestions for repair?

We are not given any pretreatment information in this case...… we do not know the condition of the tissues and bone prior to the treatment, or how the situation looked at the time of placing the implants, bar, prosthesis,etc…..from what can be determined from the information provided, this case is failing, and have to be removed.

She is only 63. Consider a complete revision since there is significant bone loss. Selective implant removal and use the "still good" implants for a provisional. Place additional smaller diameter implants in the failed sites. Remake the denture.

First of all, her hygiene is not good. For this type of bone loss to be present on all her anterior fixtures after less than 10 years implies poor hygiene, poor fit of the bar to the implants, implants that are too wide for the amount of bone she has remaining, implants that are placed to close together, and possible poor levels of vitamin D. Secondly, time must be spend educating the patient on her role in maintaining these implants, including presenting for recall on a regular basis. If she is unable to maintain recall appointments at an optimal frequency, then she needs to be transitioned to a removable prosthesis which may improve her home hygiene. If she is willing to commit to an optimal maintenance schedule, a full arch with fewer implants with machined soft tissue collars , or even full machined surface, should be contemplated, along with a highwater type design, fixed hybrid prosthesis with fully convex surfaces that are facing the gingiva. At 63, your solution needs to last more than 2 decades, otherwise, she will be worse off than she is now.

I agree with the above suggestions. Implants are failing. I'd remove them, let sites heal and replace with all on four concept with fixed hybrid or another overdenture.

Dr Flannigan is spot on. Also, hygiene needs to be improved.

I agree with Dr. Flanagan. After taking the bar off you can prepare the implants that are useful and make a cemented bar with ball abutment overdenture that is strong and very resistant to movement. You may not even need to place any additional implants. You will have plenty of vertical for fixture thickness strength. Make sure you have adequate attached tissue around the remaining implants.

It is over engineered with too many implants placed too close together. Considering what the opposing occlusion is (implant retained denture) just select 3-4 fixtures to retain the new prosthesis and sleep the others. No need to complicate things. You may have to use a bur to reduce the unused fixtures to the level of the crest.

consider overdenture with low profile locators. you don't need to use all the implants. just put cover screws on the unused ones.

Thank you very much for the awesome suggestions. Let me add on some more remarks. These implants were placed by a dentist who was sued for several malpractice cases and was behind bars etc. I also had patients coming to me treated by him - who were given implants made in a machine shop. Will you proceed with the same treatment plans? Does anyone figure out what company implants are these? Patient is looking for very good prognosis, with no more bone loss.

Remove the bar and all screws. Check the condition of the implants. Broken loose ones come out. Others are left for locators. Four or more "active" ( used with light retention caps ) locators and prosthesis is partially tissue born ( rest on the tissue minimally ). Two "active" locators ( with the other implants loaded with nonretentative locator caps ) and the prosthesis is fully tissue born ( lies completely against the tissue ). In both cases, the prosthesis is removable by the patient for daily home care maintenance ( super important ).

It appears w the radiograph that there is a bar misfit. Bar misfit, apposing implant reconstruction, the buccal tilt of implants, mentalis muscle pull & lack of keratinized tissue all contribute to the failures. Select the implants that have the most bone and vertical trajectory, remove the others and follow Froum's protocole to clean the remaining implants (that you are saving) during the implant removal surgery. Make a new bar and regenerate keratinized tissue, using fixtures that have adequate bone. With that bone density, regeneration of the lost ridge isn't predictable and it appears you'll have enough implants to work with from the data posted. Good Luck

Nobody has the guarantee that redoing the case will not result in failure after the same period of time or sooner. Perhaps removing the failing implant and remembering the rule of the distal extension to be no more than 1.5 AP will do the trick. A lesser dimension than 1.5 AP could be either better considering the density of the bone. Biological limitations are a fact of life and this should be taken into consideration not to mention the financial aspects.

This is yet another case where a clinical examination and medical information is required. However there also seems to be a conflict of opinions on the most basic issue – oral hygiene. The operator says it is good and most comments say it is bad – so what exactly is the answer (it obviously needs clinical evaluation and 3-4 reviews to determine the real situation). However in my experience, while I think bars are fantastic for stability and retention, there is no doubt a bar makes it hard for the patient to clean perfectly. For this reason, I have been advocating implant retained dentures to patients in exactly this type of situation for about 10 years. By removing hybrid bridges or bars and having only simple locator/ball retainers, the patient can easily clean the implants and in the majority of cases, implantitis is arrested (albeit that sometimes minor surgery to remove inflamed/infected tissue is required also). However when pocketing is too deep, implants need to be removed. So if we now consider this specific case, it seems that the implants might not be genuine parts made by a proper implant company. The presentation is also not great with the radiographs not telling a consistent story (some indicate gross bone loss and others suggest bone loss is not too bad). It also seems that some “smoothing” of the supra-gingival implant surface has happened on the buccal side but not on the lingual side. The operator tells us the implants are firm but almost all comments suggest the implants should be removed (which I would normally support). The operator tells us that removal would cause too much bone loss. It seems to be that the bar is not fitting well and probably can be considered an active not passive fit. So what are the practical solutions? I would suggest the operator tries unscrewing each implant and removing those that can be reversed out. If that can be achieved then firstly the damage to bone is minimal (or none at all). Secondly it would indicate there is not enough osseointegration for the implants to be viable for the long term. I would not recommend immediate implant replacement – it would be very prudent to let the tissues heal (and probably place some allograft material to assist bone regeneration). If 3 to 4 implants do not easily reverse out, then you could consider retaining them. Hopefully you would be able to retain at least 3 well spaced implants. However then you need to consider how to restore the implants. If the implants have been manufactured as a one off, then this could be tricky. You would need to find an engineering manufacturer who would work with you. Hopefully the existing bar will provide some sort of accurate fixture impression surface detail which you could ask the manufacturer to duplicate and also construct a locator abutment. Alternatively a manufacturing engineer might be able to cannibalise the existing bar and mill locators from the bar. If not, the operator will have to be inventive and I would suggest consulting a prosthodontist who will have experience in these types of situations. However it is obvious that there is no easy solution here. This needs to be explained to the patient. Unfortunately there can be no guarantee of success. At best, any attempt to retain the existing implants will be a patch up job. At 63, the patient could expect to live another 20+ years. So a patch up job could be a poor solution.

Cut implants you desire to a parallel plane that is sustainable periodonticaly that you want to use. Cement equator abutments or equivalent that are parallel. Make new denture.

easy peasy

I was the first person to reply to this scenario...…. I stand my ground and say that this case is failing...however, I will add to this in the sense, that the patient has to function somehow in order to be rehabilitated... and so I will add.... remove the bar, see which of the implants can be kept on a temporary basis, and used as stabilizers for a removable full denture.... placing cover screws on those implants that can be left without causing any infection, and using the few implants to retain the over denture by relieving the tissue surface of the denture and applying a temporary soft reline material, so that the implants will stabilize the denture and give the patient comfort.

I started my having my implants about 8 months ago. I was told that the upper teeth would be extracted and the implants would be placed and I would go home, with my temporary false teeth. He said the pills that he gave me would put me to sleep, I had been told that I was going to have general anesthesia and at my last meeting before my surgery I was told that they do not put people to sleep at their office ! The 2 office girl are sneaky and continue to lie even now. The pills did not put me to sleep and I was in terrible pain. The pulling of the teeth were horrible, I have a small mouth, and I'm sure that added to the nightmare of pulling, which I was I was petrified and in pain the entire procedure. I closed my eyes, which is how I handle anything that I am nervous about. There were 2 girls assisting him, and I kept holding my arm up to tell them that he needed to stop because it hurt so much. The pulling and yanking me around was probably the worse!!! I had 5 implants in and he called my husband in, and told him that he didn't think I should receive the last one on my right side, because I had already been in there for 5 hrs. My husband looked at me, and agreed, believing he knew what he was saying was true. If I been able to speak, I would have definitely Told him to finish, after all I had been through. He told my husband that even if he put last implant in, there was no guarantee that he could finish, by putting my false teeth in! The dentist to old him that I had lost a lot of blood, and needed to take a pain pill and ice frequently. He gave me upper false teeth, to wear a little each day. During the extractions, in the end I heard them talking about going to Los Vegas that night, and how this was taking so long! The girls were having a conversation about how much fun it would be, and one said, this is not how I planned my afternoon, I am planing to go to the Mall to buy some shoes! It has been nothing but problems since then, with telling me lies, to the point of having 3 people all giving me a different answer, to my questions! I am allergic to a couple meds and wrote it down in the paper work, My pharmacy called to tell me it couldn't be filled, due to allergic reactions. When I spoke to my Dr about it, he said, that I was in so much pain, he thought it was worth trying!