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The Original Dental Implant Community

Extraction Defects: What remedial treatment would you recommend?

Dr. F says:

This case is a continuation of our first post: Extraction Defects: Should they be repaired before placing Implants?.

What remedial treatment would you recommend for this patient?

Any suggestion as to what went wrong?

Patient: male, 58 (in 2006), good health, no major or chronic illness, no fractures, never hospitalised, smoker. Pt wearing upper partial chrome denture. General dentist referred pt for some posterior lower jaw implants. See Image 1: OPG 4 months before teeth extracted

The implant dentist (who provides implants, prosthesis and maintenance) said upper teeth more urgent. He extracted 6 firmly rooted anterior uppers and one third molar to enable All on 6.

January 2007: Roots broke during extraction. Sockets left to heal for 6 months.
See Image 2: Rendered CT scan for implant guide

12 July 2007: 6 implants placed.
UL1 4x13mm, UL2 4x15mm, UL3 4x15mm, UR1 4x15mm, UR2 4×11.5mm, UR3 4x13mm. Vicryl sutures. UR3 – 30 deg non-engaging abut – hand torqued to 15. Plastic healing caps multi-unit UR3 & UL3. 3x healing abut 05x5mm. 1x Healing abut 05x7mm. RFA readings recorded: UL1 ISQ 65, UL2 ISQ 66, UL3 ISQ 56, UR1 ISQ 63, UR2 ISQ 65, UR3 ISQ 45. Implants loaded within 24 hours of placement.
See Image 3: One week after implants placed

December 2007: Patient was advised that 3 or 4 implants had failed to integrate.

11 January 2008: RFA readings 13 days before implant removal:
UR1 ISQ 54, UR2 ISQ 66 & 64, UR3 ISQ 48, UL1 ISQ 59, UL2 ISQ 63, UL3 ISQ 46

24 January 2008: RFA readings on day of removal:
UL1 ISQ 58, UL2 ISQ 61, UL3 ISQ 56 & 57 No right-hand side readings were taken.
3 right side implants removed.
For over one year the patient wore a denture supported by remaining 3 left side implants. This caused stripping of buccal gingiva & bone due to movement.
See Image 4 OPG April 2008

15 January 2009: 2½ hours of sedated surgery booked. Plan to raise flap, test 3 remaining implants and if they could be removed, place new implants to bone level and bury to heal along with 3 replacement right side implants. This would allow for a less dramatic ridge height difference. If integrated, the plan was to accept the exposed threads and the loss of bone and tissue and use them as they were, compensating for height variance with the bridge, and perhaps making a splint to link them while the right side healed. Pt could not see how implants could be placed into a defect in a sharp, diminished ridge, so he did not proceed immediately.

2 March 2009: Implant UL1 removed because it was mobile and painful. CT scan showed UL2&3 in less than 50% bone occlusally. UL2&3 removed and patient informed there was insufficient bone remaining for further implant placement. The patient now wears a conventional upper denture but is finding it difficult to cope due to lack of retention. Image 5 shows the current status.
See Image 5 current status 2010

1 -4 months before teeth removed

2- Rendered CT scan for implant guide

3-One week after implant placement

4- OPG April 2008

5- Current Status

20 Comments on Extraction Defects: What remedial treatment would you recommend?

New comments are currently closed for this post.
Dr. Alex Zavyalov
1/27/2012
The latest (not current) status was in 2010, but now is 2012. Previous frontal implants were overloaded by excessive mastication function, because of absence a lower prosthesis. So, you need to think about prosthetic rehabilitation both jaws or you’ll fail again.
Fred Firth
1/29/2012
Dr Zavyalov: Thanks for advice. Pt has had 3 cone beam and 2 CT scans plus many OPGs & PAs – not so keen on having more. Do you think 2010 CB scan OK to rely on, or should he have another taken?
Richard Hughes, DDS, FAAI
1/28/2012
Treat the lower arch first fixed or removable, w or wo implants, remove the impacted bicuspid, level the curve of Spee. Proof to all this do a classic workup with articulator and face bow. Ifvyour goingbto use a denture for the upper, you may consider mucosal inserts.
Fred Firth
1/29/2012
Dr Hughes: Thanks for your input. Patient more concerned to fix uppers before moving to lowers. The thought was 3 or 4 short implants in anterior max to support a bar-retained denture. If that doesn’t work, would follow with referral to omfs for sinus lift and 4 zygomatics. Your thoughts on this would be appreciated. Mucosal implants sound interesting but not used in Australia to my knowledge.
Leal
1/29/2012
In my opinion, by viewing the current status (2010) you don't have enough height for implants neither on the anterior maxilla nor the posterior. And I don't think your problem was overloaded mastication forces as this patient apparently has a low mastication force by watching the incisal perfect contours of the mandibular teeth (may not mean anything anyway). Furthermore six implants are more than enough to support the mastical forces for this patient. Yes you have to rehabilitate the edentulous posterior mandibule, sure... but that is not why you lost all the implants on the maxilla (in my opinion). Also I don't know how the maxillary teeth were firmly rooted to the bone as you have more then 1/2 bone loss. I only see an endo on teeth nr 22 so probably that was the only tooth firmly rooted. My opinion is probably a lot of granulation tissue around the maxillary teeth was left after extraction in this perio patient and that probably resulted in implant loss. Did you make a nice good flap for the implant placement? Did ALL the implants stayed within buccal and palatal bone? Losing 6 implants at a time is a very hard pain in the ass; excuse my language. About the mucosal inserts DYNA implants sells Muchor in my country. Ask DYNA. That would be a reasonable provisional solution. Final solution for maxilla: Zygoma
Richard Hughes, DDS, FAAI
1/30/2012
Dr Firth, I would cut to the chase and perform the sinus lifts. You could place some short Bicon implants in the lower and restore.
John Manuel DDS
1/30/2012
Dr. Firth, This is a "high gonial angle" case. Most of them have massive forces on most posterior stops, dwindling as one goes forward thru the bi area and often, little or no anterior contact. The short, set back maxilla is reminiscent of a tongue thrust scenario. In any case, you need to at least wax up a base plate and teeth on the lower since the Maxillary Anteriors are going to have stretch out a whole lot to cover those lowers. There are keys to establishing occlusions and ignoring any one of them will get you into a less acceptable outcome than if you had covered all the obvious bases first. John
fred firth
1/31/2012
As explained in Part 1 of this case, I’m the tech guy who posted on behalf of the dentist. Dr M, who is the dentist, says: I can only tell you what’s in the pt notes. “Occlusion almost edge to edge anteriorly”. “Study models and face bow” (2 months prior to extraction). “Bone loss around most teeth but several very firm in position. Had to pick 21 & 22 (9 & 10) out in pieces as both roots fractured. Very little bone on buccal of 13 (6), decided to perforate socket cortical bone and allow to heal.” There is no record of socket grafting or alveolectomy. Was a flap raised? Notes say sutured so presumably, yes. There’s a lot of scarring and general tissue loss. There is no record of bone type, torque tests, perio etc. No record of any grafting, but there is a note made after implant removal: “Did not expect the pain level however a lot of bone cement was used”. Patient is distressed and now low on funds. I’m doing my best to pick up the pieces but could use some help.
Richard Hughes, DDS, FAAI
1/31/2012
Dr Manuel mentioned some excellent points.
David Sanchez, DDS
1/31/2012
What implant manufacturer and type was used for the all on 6
fred firth
2/1/2012
Pt notes say "Nobel Speedy Groovy Regular Platform".
David Sanchez, DDS
1/31/2012
Patient should be restored with upper and lower all on 4 . Not enough bone was removed to place the implants in the upper arch and a Nobel active implant should have been used . Too many implants were improperly placed.
David Sanchez, DDS
1/31/2012
If not enough bone do zygomatic implants
Baker vinci
2/3/2012
Retrospectvely, this is a wonderful lesson in why we should do everything we can to save as many natural teeth as possible. Had this case been treated as per ,initial suggestion and referral, it would have been an excellent implant case. This case went from a rather simple one, to a very complicated one. Now, your patient needs bilateral sinus lifts, a nasal lift and hopefully, simultaneous implant placement, at all sights, assuming there is adequate alveolar bone. Yes, you absolutely need an updated, higher quality ct scan. I would start by explaining to the patient, that they are not a good fixed candidate and that ther are limitations to everything we do, when teeth have been lost and bone has atrophied . He is not a good candidate for zygomatic implants, in my opinion. Good luck. Bvinci
dr. bob
2/3/2012
Can not only restore the maxilla. The upper and lower jaws must work with each other in a non destructive fashion. I would start with removing or treating the mandibular teeth with problems. Well made removable prosthetics to establish proper vertical and centric relation. After function and aesthetics are established the need for bone grafts and implant placement can realisticly be evaluated.
K. F. Chow BDS., FDSRCS
2/5/2012
Frankly, this is a horrendous disaster. Six good teeth extracted to do an “All on Six” and ended up with “All on None”, a fear expressed by none other than Carl Misch. They must have been good strong teeth because the roots were broken during extraction. The patient is distressed and low on funds. The priority now has to be how to salvage this and rescue this oral wreck. I have to say this before I proceed further…… this should never have happened if proper treatment planning had been done. It does look like a lost cause but not a total loss yet. I would suggest removing the sleeping lower right premolar and restoring the lowers first to give immediate stability to the upper full denture and subsequent implant supported prosthesis if the patient is still game. Restoring the upper with implants especially with the patient low on funds is going to be tough if the usual conventional route is taken. Zygomatic implants are out especially as it is very costly and success is uncertain. I restored a patient who has lost all his upper teeth with a similar lack of bone height in the posterior and with only a few remaining lower front teeth. Due to similar constraints I used a very unconventional approach which might help this patient under discussion. G’day and good luck mate !!
fred firth
2/6/2012
Thanks for comments and ideas. Dr Chow, thanks especially for your very useful and supportive comments and suggestion. I viewed the case on your website and recommend to other posters that they might want to take a look. It shows brilliant lateral thinking and may well be practicable for this case. I'll contact you direct for more info. I'm interested if anyone else can comment on the feasibility of this potential solution. Would also appreciate comments on cluster failure. Is this more common than we realise?
Hoang
2/7/2012
In my opinion, patient lost of implants due to several reasons, and patient at this stage complain that the upper denture is not retentive. My suggestion is to make a lower chrome casting partial with proper impression technique and make the upper denture as retentive implant denture fully balance. In this way it will be cost effective and patient also have a proper funtional dentures. Then we have to wait for future to see how is the patient cope, and plan a treatment if patient can affort a fix prosthetic.
Hoang
2/7/2012
My bad, I didn't see image 5. Patient no longer have any implants. We have to make a full conventional maxilla denture with compress impression technique. In this way, we will know if patient will know if the denture have retension or not. I have made many dentures in the past, and the problem I find about retention is all about doing the right thing 1st. If the current denture is not done correctly and it doesn't have retention, why we thinking another implant treatment, since we noticed that patient have lost 5 implant in the past.
K. F. Chow BDS., FDSRCS
2/7/2012
Thanks Fred for the kind words. Only too glad to be of help in whatever way to your unfortunate patient. I would not be too worried about repairing the bony defects if you are using narrow diameters. My experience is that the bone in most cases regenerate back around the minis. Amazing!!, but we cannot take the credit for it because I suspect it is just our wonderful bodies' propensity to repair itself especially if we do not over-challenge them with unnecessarily big foreign objects. And if we address head-on the perennial problem of the ubiquitous periodontal pocket that comes with every dental implant ever placed..period... The overall philosophy should be to minimize everything we can, the surgery, the implant, our intervention etc. and allow nature as much room as possible to work. Now that I have stirred things a bit..... 'Nuff said.
extraction followed by immediate implant placement what does de epithelialize the extraction socket meanextraction defects should they be repaired before placing implants

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