Bone Loss Around Implants: Recommended Treatment Plan?

I have done LANAP on cases like this with good success. Don't ignore the occlusal forces.

BTW LANAP is done with an ND:YAG.

I would not remove the prosthesis. Elevate a flap for adequate acces to the site to be treated. Debride and detoxify the bone and the contaminated implant surface. In my office we use the Waterlase but there are several machines in the market that can do this. If you do not have the appropriate laser, detoxify with rotary instruments, ultrasonics and tetracycline paste. Bone graft with beta tricalcium phosphate and cover graft with prf membrane. Warn the patient that some soft tissue recession is possible after the procedure. Good Luck!

I agree with Carlos on this one. Lay a small flap, look for the cause (maybe extra cement). Remove the cause of the bone loss if visible. Detoxify the threads with tetracyline or doxycycline (open up a capsule and put in sterile water). Bone grafting might not do much..it won't integrate to the implant..but it doesn't hurt to do. As far as lasers, some have shown that biostimulation can take place. However, I don't know which laser can do that and at what power it can be used to do this. The research on it is inconclusive. However, depending on that laser, if it matters, I'm assuming it can potentially get the light in the nooks and crannies within the implant and kill any bugs that might be hiding within it. I would double check whether your CO2 laser is appropriate for this. Good luck.

Would suggest remove the prosthesis place healing screws in both fixtures, use the laser to detox the site and then graft in the area covering the entire fixture place a long term resorbable membrane and suture closed. then place an essix temp and allow to heal 3 months before uncovering and restoring it again or placing the old bridge back on. I have found that isolating the graft it heals better in implant treatment with ailing implants then when the bacteria and plaque can work down the sulcus during healing.

i've done several cases with more advanced bone loss with the millenium laser (nd yag) and a modified lanap protocol with incredible results..... the occlusion is likely heavy in protrusion. expect some recession. good luck

Hey Dr. H; If both implants are failing, then trying to fix the problem just by treating the implants is not going to help you. First question: Why are they failing? excesive occlusal forces, poor placement, poor bone type, lack of support, excess cement,parafunctional habits. Answer the question and you will have your treatment plan. My suggestion: address them all, and the best way is to place more implants.

I agree with Dr. H . if the implants are failing there is a reason . Isolate the etiology first before trying to treat the implants . It is most likely overload . Remember you have two implants carrying 4 teeth .

I agree with most of the comments made already, and if you listen to Karl Misch he doesn't like implant supported bridges as a rule.I don't think that overloading is the cause of the problem in this case. The fact is that bridges are difficult to clean properly and herein is the most likely cause of the infection.The chance of rehabilitation is not good and is even more unlikely unless the bridge and abutments are removed. I have recently been using intra oral Ozone to debride and disinfect the implant surface in cases like this and have been experiencing increasing success. The Ozone is very effective and also stimulates the reparative process. The difficulty with most newer implants is the surface texture of the implants promotes bacterial growth and colonization when exposed and can be difficult to disinfect. Ozone appears to be the most effective in this regard.

I agree with the comments about being able to thoroughly clean the newer surfaces. My experience has been to take all the threads off and get a new metal surface that you know is totally clean otherwise failure is a major problem

I'm starting to sound like a broken record,but weren't implants invented as a means to replace teeth without using fpd's. If your going to place a compromised fixture then just prep his natural teeth. However, in my opinion even the best of scenarios, will show some bone loss in this area, after a year. This case is kinda of set up for oh problems. I have seen a lot of these cases do well with appropriate implant decontam. And bone grafting. I agree ,the best scenario and the most inconvenient would be to remove the prosth. And graft and completely cover with a suitable membrane. Surgery can sometimes be an inconvenience! Good luck! Bv

Sorry didn't see the purulent drainage part.NEVER MIND. Pus, late in the life of an implant does not bode well. This is data driven information. You never know,however. At least give it a go. You gotta let the pt. Know that the prognosis is grim. Bv

Mike, how do you remove the threads. Does this not cook the implant? Wow, I don't know about that. I guess that's why I'm on this web sight . Anybody else know anything about that. I'll refer that to the perio guys. Bv

Hey, First of all if you look at the implant platform and the restorative interface there looks like there is very little transmucosal element ie the implant probably had marginal bone loss at fit. So why-initial loss- premature exposure of cover screw / surgical reasons (lots of other reasons) Also is the fit of the restoration passive? Apply CIST protocils here; i would remove the prosthetics and torque healing abutments down and treat according to the CIST protocol purely to make cleaning very easy for the patient and make a prostehsis whilst prei-implantitis is controlled. Obviously the ideal would be new implants! but removing these babies will be difficult!

Next time use a different implant... Astra, Ankylos, and others like these.

Dear king, what does the implant have to do with it? In general, as long as some basic principles are met, a screw is a screw. There are ten other variables that effect the outcome of implants placed like this. What company makes an implant that doesn't have to be cleaned? Bv

I've had the most bizzare case with a patient that was referred to me. He lost his lower left 36 after an endo perio history 3 yrs by another dentist. When he was referred to me the 36 had been missing 3 yrs, and he started having problems with his 46 (aggressive bone loss, very uneven). The odd thing is that he is a healthy male in his early 40's; overdue for hygiene but otherwise his entire dentition is perfectly healthy. I placed an implant at 36 and extracted / socket grafted the 46 over a year ago. Over a year later at stage 2 surgery of 36 I opened the implant (it was originially left submerged) and noticed about 4-5mm bone loss around the implant. In this case the bone loss could not be due to prosthetics or excess cement as the bone loss occurred prior to restorative phase and it was a screw retained crown. At crown placement appointment I scaled and washed with chlorhexidine (not flap approached). Upon taking pockets I noticed the discharge and the bone loss comes from the buccal aspect only. My treatment plan is to open a flap, debride the implant and graft just in case some graft material takes. I usually used Bioss and have had great results for years. If I could suspect the reason: I think when his tooth was extracted the buccal bone must have either been broken or was resorbed from the perio that tooth suffered. Any ideas if that is a viable reason for this otherwise bizzare bone loss? I've been doing implants for years with great success, I play it safe and wait a long time for integration. Should I used Bios and human bone mix to graft? What about a resorbable soft tissue graft to contain the bone? I usually lay over some sugicel to avoid soft tissue from invading but this time I think I may need something more sturdy. Any advise in this particular case would be greatly appreciated. Thanks, LEO.

I would recommend doing a blood test for Vitamin D. I am a periodontist, and I have been seeing more and more of my patients who are deficient in Vitamin D. Also, I would recommend a DNA pathogen test. If you aren't familiar with either of these tests, then you might want to consider referring pt to a periodontist. As with many of the comments above, the key to treating problems is to identify the etiology, In this case, I recommend that you look for possible systemic factors in addition to local ones.

Absolutely, if one of our patients has rickets, malabsorption phenomena or isn't getting enough sun ,they should first see a periodontist. Vit. D deficiencies lead to type 2 diabetes and heart dz,so run right over to your perio guy for that to. Look, I'm all about having a broad base of knowledge but if our patients are suffering from a nutritional defecit go see your pcp. All of us tend to become a little full of it,but let's keep it real. Bv

I doubt lanap would help....I do have perio laser..but... i think it's been over-rated..... Nd:YAg laser from millenium dental will help..but it will not save the case.. there are so many believers in lanap..... something happen...then ....periolaser it......that is sick..

How do you remove the threads from the implants?does that really work? Any studies? Very curious! Bv

someone suggested cleaning up with rotaries and unltrasonics; I'm assuming you would not want to touch the implant; where would the rotaries be used? just touchup on the adjacent bone?

Need to clear up some misconceptions about treatment of peri-implantitis. First, biomechanical bone loss is generally not associated with purulent drainage. It is simply an inflammatory reaction from excessive bone microfracture and turnover. The presentation of purulent activity indicates a significant pathogen load. This implant appears to be a Nobel Replace Select, generally with a TiUnite surface. The literature shows increased incidence of bone loss with this particular surface. While a 1064 nanometer wavelength laser(either Nd:Yag or InGaAsP) has a bacteriocidal effect and reduces the inflammatory component, you are still left with a considerable osseous defect. This implant remains in "ailing" mode with a high recurrence of pathology and return to "failing" mode. The area should be flapped, debrided with an Erbium laser (Er,Cr:YSGG or Er:YAG)or CO2 laser to not only decontaminate, but also to surgically debride the surface. All organic debris must be removed to allow this portion of the implant to reintegrate. This surgically "clean" surface will look identical to the original manufacturers surface when originally placed. We published the SEM studies in Implant Dentistry back in 2004 to support our findings. Following debridement, the area MUST be grafted to prevent re-epithelialization of the exposed threads. We can regrow bone that is stable in function and our oldest cases are now past 10 years. While it is preferable to remove the prosthesis, replace the cover screw and cover with a membrane, we have great success leaving the prosthesis in place. But you must have excellent closure of flap margins and an atraumatic healing phase. In our hands, through 20 years of trying all previous protocols (mechanical, tetracycline hydrochloride, citric acid, EDTA, prophyjet, and soft tissue laser alone), only this protocol gives us consistant, predicatable results. RJM

Klee why do you find it "sick" to use the periolase?

IMO I think it is "sick" not to use the Periolase.