Bone density less than expected: what complications may one encounter?

Were you able to get primary stability and why is the implant buried so deep? Is there no lingual plate? I 'm suspicious that there may be retrograde peri-implantitis based on the endodontic history is there a preop film? Personally I find that dynagraft does not give a great result I like cortico-cancellous bone with a Teflon membrane over the top to regenerate the lingual plate. A lot of factors here in six months should have been plenty of time. I think it would be wise to remove the implant and regraft the socket as above into decent bone I've had this happen and always felt better correcting it early on vs rolling the dice and hoping for osteointegration I just don' t like the look of the bone on the radiograph not much density.

The implant seems to be very deep below the crest of bone. If possible try to remove ,place closer to the crest and pack some graft apically because trying to restore will be very difficult in current position.

It is deep, but it looks like an ankylos, and this looks normal subcrestal placement for ankylos.

CRS This is the new fashion 8mm implants placed 5 mm subcrestally We will see .

The most common reason for socket graft failure is retained foreign bodies such as root tips and gutta percha but in those cases you get granulation tissue rather than poor mineralization. You have placed number of foreign materials in this socket in form of demineralized freeze dried bone and mineralized freeze dried bone in a medium to make it into a putty. I suspect that your patient produced an immune response to one or more of these potential l antigenic agents which interfered with mineralization. Graft failure aside, no graft material is perfect and you will experience failures and in the case the best course of action would to have increased the length and width of the implant so that the majority of the grafted area would be removed during the osteotomy and you would then be placing your implant in normal bone. When you are ready to expose this implant if it is not integrated be ready with that bigger implant and place it at the time this implant is removed. Greg Steiner Steiner Laboratories

If I were you, I would proceed with a temporary crown fabrication at your own expense and monitor the case. I think it’s immoral to ask the patient to pay when the outcome of the treatment is uncertain.

This will be fine. You had less dense bone than you were expecting and you've buried this implant as a two-stage procedure. A nice safe approach. It will be fine. As for too deep - this isn't an implant that has to be placed at the crest, nor is it an implant that will lose bone if placed below the bone. Peter thinks it's been placed 5mm below the level of the bone - but his eyes clearly aren't what they used to be ;-) This implant appears to have been placed 2-3mm below the level of the bone AND FOR THIS SYSTEM that is a perfectly restorable position and one in which you would not expect to lose crestal bone. It's a nice placement - though for clinicians not familiar with the system it may look strange. Kind Regards, Bill Schaeffer

Thanks for the clarification it did look strange to me!

a longer and wider implant should have been placed engaging the normal apical and axial bone , here your implant is floating in the graft material only .

For this situation, I would perform the typical socket graft procedure (degranulate, detoxify and decorticate then place a slurry of OsteoGen or whatever you want to use). Then place the implant. This will increase the BIC at this site. In the maxilla I would do the same with a socket. A virgin site in the maxilla, where the bone is soft D3 or D4, Use osteotomes to improve bone density and OsteoGen. Under prepping the osteotomy by width is an option. These are basic procedures that have proved to be most reliable.

I think Greg Steiner is right! Soft bone in a mandible socket 6 months after extraction? It must be related to the bone remodelling of the demineralized bone.I checked Keystone Dental, and the indications they give for the use of Dynablast. I don`t think you should use similar materials for bone grafting at all .Here is why: First-the demineralized part of the material will trigger fast resorbtion (predominantly osteoclastic activity),resulting in soft bone. Second-each graft material should have porosities, to alow fast vascularisation of the grafted site (within 3-4 days), otherwise oxigen tissue level in the grafted site will be reduced, resulting (again) in osteoblastic activity.In a material with a putty shape, or gel-no porosities! Remember- osteoblasts (the "good guys",around our implants, which produce new mineralized bone) come at the end, when there is enough oxygen in the grafted area. Otherwise only soft tissue and soft bone will result. Excellent planning and perfect implant placement for a bone level implant (Ankylos). My advice-after 5 months uncover the implant, measure its stability (with Osstell, Periotest, whatever), if values are acceptable, place a healing abutment, then-provisional crown with moderate to light occlusal contacts (train the bone), after 1-2 months re-measure the stability and complete the case. Keep us informed, Yassen Dimitrov

It’s a molar mastication area, and the apex-implant-bone void will cause the implant sagging after loading.

Every one is talking about grafting the socket for six months. I can never see the point of this because if you leave the socket alone then after 6 months you will have the most beautiful natural bone to place an implant into, what could be better. It also gives the body time to get rid of all the problems that were associated with the old apical area, that has been described in the comments above as having a detrimental affect on any grafting material. When you come to place the implant, if you have any deficiencies around the implant you can then simply graft these regions, which will be on the outside of the implant where as the main body of the implant, where we want all the strength and stability to be, will be into natural bone, which surely is what we want. Having said all of this I would actually be back into a socket, radiographic evidence permitting, in three months so as to reduce the amount of crestal buccal bone loss and I can guarantee you at 3 months there is normally good bone to work with.

i would remove this implant asap 3 to 4 mm subcrestally is unacceptable follow dr. hughes advice.. good luck

I have had a few cases like this . One was on a friend that I caused a paresthesia on and she would not let me place a smaller fixture back in it's place. 13 years later she has severe osteoporosis. That is my only permanent paresthesia case, with implants. Other cases, I have filled the osteotomy with a mixture of dfdb and autogenous bone, or autogenous only and half had no failures, that I can recall, with this type of case. Today, I would use mineralized and autogenous. Bvinci

Addendum : I place the fixture on top of the grafted bone, in the soft site. Sometimes with less than 35ncm. Certain cases I have placed membrane, even though the grafted bone was not exposed. Bvinci

Bill has years of amazing cases with this protocol , which is correct for this system so as to the depth of placement , there is no issue . Anyone who has been to a Ankylos meeting will understand . And yes Bill the "5mm " was a figurative statement , and yes I do place sub-crestally in cases where it warrants it The surrounding graft material may have some issues , but best to leave the body will heal and this will work. Peter

You have got to image your pilot drill and final position,even on the "simplest" cases. Bvinci

I have used Ankylos implants before. They are supposed to be inserted until flush with the crestal bone or a little below. Initially, they left the collar polished where it is next to the cortical plate. Logic was a rough surface is susceptible to germs attaching and causing an infection. Thus they left the collar polished just in case part of it ended up above bone. Later, they gave all the collars a rough surface. My experience is even if the implant is slightly above bone, the bone rises to the same level and sometimes even cover up the whole implant in which case, I had to remove bone to uncover and use the implant. All things considered, we should respect the body's natural tendency to want to heal and recover itself with minimal help from humans. Please study this link: http://smalldentalimplants.blogspot.com/2012/12/bone-climbing-up-mini-dental-implant.html. In this case, it would be better to have inserted the implant until it is flush with the crestal level though part of the implant may be exposed. However, this particular implant can still be completed satisfactorily and no attempt should be made to improve things.