Bone Loss Case with 6 Nobel Tapered Groovy Implants: Any Comments?

How thick was the bone crest, did it have atleast 6 mm wide to place implants with adequate bone on the buccal plate.

What about probing depths around the implants? If you have deep pocketing then you either need to position flap apically and smooth off grooves of implant or take out implants. IF you have deep pockets my advice would be to take out implants, prevent further bone loss and come back and try again. If you take off bar do any of the implants have any clinical mobility? Following Misch guidelines your patients implants are now Group III-compromised health-due to greater than 3 mm of bone loss in first year.

There was at least 6mm of bone with adequate buccal plate, implants are not mobile , and yes there is probing depth but no supperation and minimal bleeding. There is just alot of mobile tissue.

How deep were the probing depths??

Hi, sometimes this happens i would take out teh worst affected implanst because in reality its only goingto get worse and make a locator retained overdenture onwhat he has left. Re group after 6/12 then really you need x4 implanst for a rmeovable so replace as necessary. Also i dont liek teh ti-unit surface o dont think its that effective try astra they are way better implant. Cheers Tom

Groovy design may be the problem, I have been placing Branemark implants for years and never had a periimplantitis problem until I started with Groovy. I had 5 failiures with no explanation. Since then no more groovies and back to hapiness.

May not be the implants. Many people are lecturing cautiously about guided surgery now. Bone may heat up more than you know due to inadequate cooling of the burs/implants. In addition, with edentulous cases, If you are not careful to use a bite registration to seat guide, then you may be off with seating the guide, and this can throw off your implant placement. Guided surgery is NOT foolproof and many early errors can get magnified. I would recommend a CT scan to see where your implant are in relation to remaining buccal bone. My best guess, however, is that the crestal bone got overheated during preparation and implant placement, possible due to inadequate irrigation through the guide.

Been placing groovy forever. Never been a problem. You did guided (why??) surgery where you overheated bone and probably never got your implants down to the right depth to begin with. BTW, you DO NOT NEED 6MM of bone width to place an implant!

Having placed and restored implants for 32 yrs I have a hunch the dtr, though soft lined, and anterior occlusion only may be the culprit. Tremendous pneumatic pressure can be developed under an upper dtr. And it's compounded with no posterior support. Over the years I even had a normally placed post max implant forced into the sinus under a max dtr. I learned to totally relieve over implants, to the point of sometimes perfing the dtr. Over heating is a possiblility, but generally that happens at a deeper level and the implant is lost immediately.

Have you considered that this is not a surgical failure but a restorative failure? How long are the cantilevers? What was the occlusal scheme? Did you do a diagnostic wax up? Did you equilibrate the occlusion? When you saw the first signs of bone loss what did you do? Some implants fail spontaneously but in the absence of any systemic disease this has prosthetic failure written all over it.

Dr. Tabesh, A CT scan would probably reveal if they were placed bang in the center of the ridge or not. However, even if they were not, you would not see all-round bone loss, just buccally, exposing buccal threads. I'm not an expert, but I think it's a combination of overheating during placement (a disadvantage of using the guide), early or immediate loading, or maybe the guide software miscalculated the depth to which you were supposed to take them in, because of excess soft tissue which was not adequately detected in the scan. Or it could be that the cast bar superstructure is not passive, and is causing torque/eccentric forces during mastication, and the implants are adjusting to it. I know it happens with natural teeth, don't know if it applies to implants though. I see beautiful soft tissue integration though, something the Nobel gurus are proud of. I could be wrong everywhere, just my two cents.

Looks like we are getting closer to reality the farther down the possiblity list one looks. Dan, Richard and Andrews assessment looks to be plausible coupled with the similar effects of Combination Syndrome, ie lower natural teeth beating up implants in Type III bone, anterior maxilla. Whether teeth or implants, they loose. Particulary implants which do well with vertical loading and abysmally poorly with lateral loading, even if tied together. Also, hopefully the excess tissue was removed at the time of implant placement. Inflammation obviously contributes to the process.

1) Your buccal place was probably less than 1.5 mm thick from the facial aspect of the implant. 2) The implants are probably angulated more than 20 degrees. 3) Your frame is not completely passive, as evidenced by the discrepancies at the platform. The first PA shows frame margin is too far to the right on the left and middle fixtures, and the margin is too far left on the right implant. 2nd PA shows both margins are slightly left of the platform. 3rd PA shows slightly open margin on right implant. 4) Cross arch connector appears thin. Remember, cross sectional thickness should increase exponentially in the coronal-apical dimension as distance increases, or a stiffer material should be used, to assure rigid cross arch stability. I would section the bar until it appears perfect radiographically, relute with a thick amount of GC Pattern Resin, and return it to the lab for soldering or welding, if possible. The metal housing on the inside of the denture should be reset in the lab as well. We need more full arch cases, both successes and failures to be documented if we are going to have more patients benefit from this wonderful modality. Kind Regards, Joseph Kim, DDS

I am concerned with the draining fistula at 1 week this I think is a clue that something is going on. Do you have an PA of the implants at placement so we can see where the bone was at the start on the implant? How much bone was on the crest on both the buccal and palatal after implant placement based on measurements on the CT when planned? Was the denture after relining relieved over each implant healing abutment so that upon maximum occlusion there was zero pressure on the healing abutments? Since this is a case with natural teeth sitting in the densest bone apposing implant placed and healing in the softest bone the implants may have been inadvertedly loaded during healing causing the bone loss. In cases like this may be better to set the implants flush with the crestal bone and use a two stage approach so that you eliminate any loading during healing.

With regard to the Locator attachments on the bar, you dont need more then 4 on an arch or the patient may have difficulty removing it. IMHO we have to be more aggressive in treating these cases when bone loss starts to be apparent. Spirochetes may be the cause of the bone loss and will continue till they are lost unless you intervenne Suggest reading this book on the topic. http://lymebook.com/silent-saboteurs-nordquist-krutchkoff

Good day I am with Dr. Richard Seberg. All signs indicate denture damage. Try to avoid tissue supported temp dentures.They are the major reason for early implant bone loss and implantitis. It looks to me safer having healing cap with the denture seating on it with soft reline. The denture gingival margins,around the implant should be free

Dear Dr T, I would agree with Dr Richard Seberg. Bone loss is due to irritation by micro-organisms and foreign substances. In this case, the loose flappy tissue will increase these possibilities. Bone loss is also due to persistent mechanical irritation especially if the implants are subject to lateral forces. The implants look quite angulated and therefore are subject to lots of lateral forces which will exacerbate the bone loss. Loose flappy tissue especially around the implants should be removed. The best way to remove the adverse biomechanical forces due to the angulated implants will be to remove and redo them perpendicular to the occlusal plane. If you are to do that, remove all loose flappy soft tissue first. You may even want to try mini-implants with O-rings and housings for a removable full denture. They are more user friendly and having flappy tissue may not be so critical as they make a smaller hole in the gums and they serve mainly to stabilize the denture while a large part of the load is still taken up by the mucosa.

I think this is a matter of devascularization of the bone. I' ve had the same problem in edentulous maxilla. Now I put in only 4, only 6 with a sinus lift and +/-10 mm interimplant space so more remaining blood vessels in between. If premature loading was the problem, I think the most extreme (anterior or posterior) implants would have had the most resorption instead of the middle, probably even no integration. I now use narrow diameter implants (3,5 mm) in edentulous maxilla with less early failures so far.

Dr. T I agree with the previous comments as to why this case is failing. The comments are from knowledgeable and experienced implantologists. But I think the problem stems from ignoring normal form and function and just placing implants wherever you can find bone. If sinus lifts were performed and the implants were spread throughout the arch and allowed to integrate I think this would have been avoided. I do commend you on having the courage to post a failure for all of us to learn from. Greg Steiner

Thank you for all your comments, Nobel Guide stent was used only as a surgical stent, flap was elevated and implants were placed according to the prosthetic plan. Bar was placed recently, and it has a passive fit. However there is alot of flappy tissue and perhaps implants were overloaded via hydrolyic pressure of the denture. Just wondering if any body else has had the same experience!

Dear Dr T., To begin with, during implant placement, conditions of #21 is highly compromised by an undermined, defective restoration, a large cervical lesion, and a periapical radiolucency exhibiting a sinus tract that is draining through the pdl space. Conditions of which were/are not fully addressed; a steady source of infection. As many colleagues had pointed out, implants are more laterally inclined which could magnify and render occlusal loads, destructive. Just as important, loose and flabby tissues are likely to be displaced during masticatory functions, which would contribute to the instability of the prosthesis, leading to enhancement of bone resorption. Moreover, this situation will cause the complete denture to fully to rely on the implants for support and retention compounding this degenerative condition. I'm a novice,I could be wrong, but as I see it, it is simply a matter of time before this structure will collapse under progressive bone lose and intensifying occlusal loads. My two cents...

My apologies ... Dr T. I didn't see your post before I posted mine.

Implants were placed at an disadvantageous positions.

I to agree with the probability of denture overload. In a case with soft bone and a denture that is not stable, the decision to place long healing abutments left the patient open to lateral force transfer from the denture during healing. That bone loss WILL NOT EVER come back with today's technology. If you want a chance to stop it, you need to remove the restorations, debride the sites, treat the implant surfaces with the voodoo method of your choice, graft, bury the entire batch of implants and pray fervently and often. There is also a chance that the bar is not passively fitting and can be putting additional torque on the implants. BE AWARE that you have Grade 1 titanium implants and as the bone level lowers, you have a chance of fracture on top of the progressive peri-implantitis. Good luck.

1- would remove cantilever on the bar. 2- reline the dtr to have good tissue support, all the way back to the tuberosities. 3- thread design on this implant is not ideal for type III bone, from a biomechanical point of view. Think about "metal screw" design Vs "wood screw" design. No need to be a rocket scientist; just go to Home Depot!... 4- Implant surface lacks nanoprofile features....

I think your problem is a bad position of the implants Bad oclusion Very bad cantilever Of course you can have a perioimplantite but with the things i told you upper....

Good theories mentioned and some interesting ones that I feel are off the mark. If it's any consolation I have had several similar cases, walk into my office, with the same groovy implants that exhibit the same amount of bone loss. In these cases the tissue has receded and there were no pockets to worry about. The cases are several years out and the bone loss has not become worse. Keep the patient on a strict perio regiment, most likely will be fine.

bone resorption do not occur immediately loaded implants in addition, the antagonist teeth to implants are thus requires a contact surface to distribute the load in all implants at no contact and have a prosthesis on implants are resorbed bone tissue of the buccal plate, and the position of the implants is not ideal load should go in the direction of the axis of the implants Dr. Ricardo Nuñez

There is a lot of Monday morning quarterbacks here. There are a lot of theories and ideas. Some may be true others may not. It just goes to show where we are in the state of implantology science. To be accurate, the operator followed a commonly accepted protocol with competence. We may not actually have a perfect answer. THere may be an idiopathic element. That being said, I had a lot of problems with nobel implant failures and have been happy with ASTRA for the last couple of years. I think the more implants the better when the angulation is compromised. Consider reducing your case fee so you can throw in some extra implants as insurance

I had a case like this an year ago. It might be due to all of the above, but take a moment to think: 1. Have you achieved a final torque superior to 60-70 N/cm? 2. Did you use higher revs during osteotomy prep.?Keeping the drill at the bottom of the guide for more than 3-5 sec? 3. Did you place any of the implants closer than 3 mm next to each other? 4.Was the denture relined and occlusion corrected just once? I think that if you answered YES to more than 2 of the mentioned above, your patient might have developed compressive osteitis. I think that is the cause for the periimplant bone loss. I aggree with Dr Horowitz: unscrew, decontaminate, try to regraft around the implants (removing the exposed threads with a carbide bur, until you obtain a shiny surface of the implant body) Best of luck, Dr Dimitrov

So sorry this is happening to you and your patient. So often we look to implants as the 'final' solution only to have it be not so 'final'. These kinds of cases are very frustrating and the kind of thing that lead laypeople to think/say that implants don't work. (we know they do!) Lots of comments - it probably is a combination of a bunch of those things. I am not sure that even 20/20 hindsight can really figure it out for sure. I have always explained to patients that disease can sometimes be like doing a high-jump. There may be no one thing that gets you over the bar but when you add them together, you can go from healthy to unhealthy. IMO - I sadly think this case ultimately will come apart. I would sit down with the patient and make a decision - there really is only one BIG decision to make. You could debride, smooth, alter the case and wait and see and pray and patch. If or when you suspect active disease or infection brewing around any of the fixtures, it will need to be addressed before more bone is lost. I have seen some research on using the hard-tissue laser to debride the collars followed by citric acid treatment and grafting/gbr any walled defects you find - never tried it myself. You will never get back that vertical height though with our current technology. The other road is to de-install everything, graft and start over. I think it's really up to the patient and what they will go through. Lastly, just my 2cents, most of my friends - even the most die-hard nobel fans, have given up on the groovy for these types of cases in the maxilla - especially in type III bone. I would be leaning more towards a parallel walled implant with coarser threads like Straumann and place after only partially tapping. I also might convert the denture into an immediate fixed to avoid the whole pressure issue if I was to redo. Best of luck, Ryan

Just remove the bar, detox and bone graft w/ membrane. Also place dense HA on the top of the graft to assist the retention of the soft tissue. Things happen with human biology. This is not a come to Jesus Moment.

forget guided ,theres nothing like visualizing the exact location of placement. maybe you placed the implants into cortical bone and thats why all the bone loss..