Bone Loss and Pain with Failing Dental Implants: Best Treatment Plan?

I would do the same old story (only if implant causes no pain at percussion / is osteointegrated): eliminate threads, smooth surface (if you have laser go ahead and aply it after), remove granulation tissue, disinfect with ATB + saline + CHX + Saline + B-TCP / autograft + membrane + primary closure + 3 mths waiting + taking care of that pre-molar crown that is probably annoying you a lot + praying at night before going to sleep. Good luck

There is a wonderful book "Peri-Implant Infection" Authors Frank Schwarz, Jurgen Becker Thru Quintessence which has some helpful management protocols. I have found it helpful.

I know that this doesn't help answer your question but in a way it might. The canine next to the 2 failing implants is also approaching and is probably at the hopeless stage. What I am saying is that I suspect that there are a whole host of other dental issues in this patient's mouth, some of which may have a bearing on these 2 implants, eg occlusion. To attempt to treat the problems on the implants should firstly involve a correct diagnosis. I don't think this is possible by solely looking at a single PAX... DrT

refer back to original treating dentist. if you are the original treating dentist, take out the implants. There is zero reason for implants to cause pain. There are no nerves in bone! I think you are ignoring the radiolucent area between bone and the implant....the entire length of the implant, or so it appears on the web version. Curette and clean the residual sockets, properly graft, and try again another day. If you are having trouble being successful doing implants.....don't do them. Let someone else do the removal and re-treatment. But don't ponder what to do about such basics if you profess to know enough to do implants.

The implants are fused and the crowned natural tooth is failing. These are obvious findings. This patient lost these teeth because of neglect, they are loosing the implants most likely, for the same reason. Bvinci

rds although a bit harsh is correct. With the threads exposed as they are you are not going to be able to save these implants. The sooner you get them out and graft the sites the less bone you will loose. Cannot tell if there will be enough bone left to re implant until the grafting is healed and a proper CBCT is taken. I believe you have as DrT described, a number of issues risking the predictability of these implants. I can identify at least five. Re implanting a case caries with it even greater risk. Have this patient treated with experience and you will sleep better.

I agree with rds- not the sarcastic comments but with sentences 2 and 5. The postcrowned anterior tooth (LL3?)is failing and would probably be better in the bucket. The anterior implant (LL4?) appears to have a radiolucency around it and I suspect it is being held in by the posterior implant. It should be easy to remove once the crowns have gone. I would then back out the posterior fixture (LL5?) using a NeoBiotech implant remover. There is no need to faff about with the sockets; Mother Nature is kind and they will heal rapidly.Once everything has healed it would probably be simplest to place new implants at LL3,5 and a 3-unit bridge. But wait until the pain has gone (which hopefully will be immediately after the present implants have been binned)otherwise your patient will blame any continuing discomfort on the new bits and pieces.

In response to BVinci, in all fairness how can you make such a broad accusation and lay the problems that we are seeing on the patient? This individual has obviously invested a great deal of money just in the treatment of these 3 teeth(and we haven't seen the rest of the mouth). While I agree that ONE possible contributing etiology is poor patient compliance, there are multiple other possible explanations, including what we use to call when I was in school "iatrogenic dentistry". My suspicion, based on the PAX that we have been presented with is that the dentistry that this patient has received in the past was less than optimal. DrT

Dental nerves in the tooth socket can grow and make contact to implants. Check the literature. It's even documented in perio text (Lang and Lindhe, Clinical Periodontology and Implant Dentistry).

Since I do not know what other posterior function there is I will assume it is limited. The severe pain is not identified. There are strong signs this patient is a heavy bruxer like the distal abfraction on the adjacent tooth. Could the pain and implant deterioration be the result of MPD? Has a splint therapy been tried? Is there posterior function on the opposite side?Tooth wear and displacement of the remaining natural teeth can result in the excessive loading of the implants in question. I would attempt to save them and treat the other contributing factors.

Dr Richard Hughes seems to read a lot but does not give solutions, only advise on books.Remove the implants and the cuspid,plant some seeds from the tuberosity,suture with silk instead of reabsorbable(so you can follow the progress)and apply ultrasound waves to the bone.X-ray in 3 months and take it from there.

Both of the implants should be removed, as they are beyond any reasonable hope of salvage. To pretend otherwise is wishful thinking. There are many protocols for regenerating bone around infected implants, but they seem to be designed for implants that are within the form of the arch, that is, the threads don't protrude past the buccal or lingual outline of the ridge. So, a space making osseous defect. Dr. Stuart Froum just published a textbook about implant repair and Dr. Myron Nevins, along with some Japanese compadres, is presenting cases of bone regeneration around implants, using a laser, at the current AAP meeting in Los Angeles. Again, the common theme seems to be that the implants are within space making defects. From the description, one or both of the implants are beyond the confines of the ridge. The canine is hopelessly involved also. If this section of the dentition is any indication, the patient may have other problems, and deserves a thorough workup. As for severe pain, if the lingual threads are exposed, then the patient may have a large traumatic ulcer on the ventro-lateral surface of the tongue. Grasp the tongue with gauze and lift it up to see. These ulcers are quite painful, especially upon swallowing. The pain radiates to the ear and throat. You have to get rid of the cause, whether it be an osseous sequestrum, sharp edge on a tooth or restoration, or exposed implant threads.

I think Richard has been very forthcoming on solutions over the years , alas we are interested in the golf at the moment. Anyway , my 2 cents as they say and using only this x-ray it possibly may be that the mesial ( the wider Implant ) has failed ( the dark area aaround it , again subject to these x-rays ) and due to the splinting is retained , hence the issues. So remove the splinted crowns if screw retained or separate if not and the mesial will be removed easily . Cause , well if appear that the ridge is thin ( use of thinner implant distally ) and the buccal plate has been lost on the wider implant. Again due to low input data , just my thought. Peter

As to Splinting although Carl is a fan , I am not and rarely splint due to possible co-axial force issues and this situation occuring where failing Implants are retained due to it. Peter

Joe Jaws, yes I do read, I also do practice implant dentistry 85%! of my practice is implant dentistry. So it is not a hobby with me. Because of this I do not fool around with things that do not work, so when I give advice, it's based on experience both good and bad. One can learn from reading, also one has to think in a critical manner.

This Case is failing. Remove the splinted retainer and evaluate the implants. If they are salvageable try to save them. If not then remove and evaluate the patients ability to maintain, also evaluate the occlusion.

Thank you Peter. Keep it in the short stuff.

I bet if you removed the implant crowns the mesial implant would fall out. I'd plan removal of the cuspid (I know I have that as an implant site especially if the RCT is over 15years old remove the implants and graft over the ridge with prgf and bone teflon reinforced membrane or a strip of allograft to help hold the graft. Primary closure remember you only need a few mm of height and place a 3unit implant bridge depending on the opposing occlusion. Ct scan would be a good idea prior to implant placement. The patients overall perio condition must be addressed or the same thing may happen. Very good discussion!

Peter, hownare you enjoying the Ryder Cup! Both sides are displaying outstanding golf. My second cousin, Ed Oliver, played for the US in the way past.

I'm not trying to one up you Richard , but our course record holder and member played in it as well. D. Toms.

Baker, I did not take it that way. I think it's great that you enjoy golf and have had exposure to such talent. Keep up the good work on this blog and keep it in the short stuff.

Crs, your thought process is on the money! The patients OH should also be evaluated. Note the decay on the distal of # 22. There may be more decay elsewhere. Remember, grafted bone is not the same as original bone. That said, I would do the same as you suggested.

1. Remove implants. 2. do the augmentation, then place implants.( best option ) OR 1. remove the crowns. 2. detoxify the implants 3.Place the titanium mesh with bone graft ( with risk of dehiscence )

Peter, Intake my hat off to the European Team! They pulled out a nice victory.

Hi Yes it was a great Cup , real nervy close competition. Peter

Doesn't seem like bad dentistry. The adjacent tooth has decay or a severe abrasion, it could indicate poor patient compliance. One of the most underrated phrases in implant dentistry: "Case selection". The patient might have not been a good candidate for implants. Anything could have happened in 3 years. People that post here really need to be aware of the fact that patients and attorneys check this website and might get polluted by poorly-worded or poorly thought out opinions, thus relating ANY bone loss to "bad dentistry".

Didn't the US Choke? I thought they blew a big lead Oh well the weather was beautiful.