Implant Failure: How To Handle the Situation?

Difficult situation to treat. I have done ridge/pontic site development utilizing connective tissue grafts with various success. There are many technique out there. There is a paper by Orth that uses a combo CT/FGG graft that works nicely. This is also a nice Paper by Toscano on the Bio-Derm technique which uses bio-oss and dermis allograft to build up the ridge. It is in this months issue of the Journal of implant and Advanced clinical dentist, JIACD. It nice because you dont need a secondary surgical site. Langer uses strictly CT graft, but shrinkage can be an issue. Allen uses HA. As far as charging, I think you have to be paid for your time. Implants fail no matter what you do sometimes, You can give the patient a deep discount off the pontic development surgery but wouldnt loss sleep if you didnt. Plastic surgeons get paid for failures, its called revisions.

I agree with dr brogo, having recently experienced the same on an 8, we opted for Dynagraft, and got a tremendous result. In terms of money..... mmmm discount at your own judgement but dr brogo is right on the money sort of speak.

For a deep defect you could perhaps use some Xeno or HA to act as more of a bone filler. If you think a CT graft will fill in sufficiently, fine. Discounting to a patient because of a failure hmmmmmm some people might see that as an admission of guilt?? Sometimes no good deed goes unpunished! Ultimately you'll decide. If it keeps everyone happy ,positive, and out of lawyer's offices it might be the best money you ever lost. It's kind of a double edged sword.

As far as patients are concerned they see medical procedures like any other contract. You instilled a sense of trust with your patient to perform a service. If YOU can't fulfill your part for any reason YOU need to find someone why can and either refund the money or YOU pay to get it done correctly. YOU are putting to much of the burden on the patient, they have already fulfilled their part of the contract in advance. This is how all professions are expected to meet their obligations on a mutual agreement. I don't understand why you would think ethics and morals are not required in dentistry. And if plastic surgeons can justify their screw-ups then add them to your friends list. In most cases lawyers are used as a last resort and you give a patient the brushoff routine.

Anon, Gosh. You are right if our brother can own exactly what went wrong. However, we are not mechanics working from a procedural manual on a 99.999999% perfectly engineered machine that has near universality in parts across the same make and model. So many confounding factors are at play. Perhaps this patient has had other orthopedic surgeries that have failed, smokes, drinks Crown from the bottle while playing hockey...... So if Dr. S cannot identify the cause of the failure- no refund. We set our fees at a reasonable level not at a level that includes insurance, that would be unethical (billing for planned failure). Sorry to disagree. You have shared many brilliant insights. MP

One of the selling points, for implants, in some offices is: The success rate is so good, the office will redo failures at no additional charge. The major problem with this concept is: the patient may be a major contributing factor in the failures, through habits, i.e. smoking, not following specific instructions, or underlying health problems you don't know about (possible illicit drug use or ?). Whatever the office policy, the patient needs to know that implants can fail and that they have a significant responsibility in their success or failure. A reduced price may be in order, but be careful not to assume too much of the responsibility. Your generosity can lead you directly into a lawsuit against you. Best of luck

I think that the biggest problem of implant failure is handling the patient. My policy in case of failed implant that the patient have 2 choices: either to have a new implant after few month with no extra charge. Or to deduct what is paid for implant (if we change the plan) to make a bridge. Considering the original cost of fixture,I think it is fair enough. Not all insurance companies pay for implant and what is paying for implant will not pay for failure. Best of luck

I agree with the above comments. Discount at your will a plastic surgeon wouldnt discount a revision. I did read online the Toscano Bio Derm article in October's JIACD. I agree with his assumption that you need both bone and soft tissue to rebuild the pontic to present shrinkage. Very well done article, with a great photo documentation. Interesting use of dermis and bio oss, avoids a second surgical site. I myself have seen shrinkage using soft tissue alone.

The fact that an implant failed twice in the same site is disturbing. Implant failures are very expensive for both patient and doctor. In my office, this patient would owe me nothing. This is not an admission of guilt. Your records will be proof enough that you did not malpractice. But the patient paid you for an implant, and after two attempts, still has nothing, and now needs more treatment. I would offer a full refund and consider referral. That's just my opinion. Yes, pontic sites are easier to augment vertically and horizontally. Xeno graft for slow resorption, and CT / dermis. This is well documented. Back to the implant failures, why twice in one site?? What protocol did you use after the first failure. Was it a post load failure? Was there a flipper? Was there immediate temporization? The patient cannot be blamed for implant failure. I guess what I'm getting at, is, did you learn something from these failures. This patient now has no faith in dental implants and these folks have big mouths. We must learn from these failures. Implants fail for very specific reasons. We should be able to diagnose the cause.

As per the failure(s), I try to treat the patient the way I want to be treated. All said, when a patient dies in the hospital etc., that relatives /estate receive a bill from the hospital and doctors. We cannot assume that all failures are our fault. There is bad biology and poor compliance. I address this as a matter of fact and charge the patient when the situation is proper to do so. It's just like recurrent decay. If you placed an excellent restoration etc. and the patient does not take care of it, then what do you do? Likewise if we miss something then it is on us.

Everyone seems focused on the implant failure and refund. Thats a small part of this question. I think what the person wants to know is how to do pontic site development. So far we laid out 3 techniques: Allen HA technique 1985 JPerio Langer CTG technique 1982 IJPRD Toscano BioDerm Technique 2009 JIACD I agree with Dr Xavier about the assumptions of the BioDerm technique is that there is less shrinkage. What are others doing for Pontic development?

Site development - VIP-CT flap I would apply the cost of the implant to the bridge. If the patient already paid for the implant and implant crown, I'd do the bridge for free.

Paul the vip CT graft is a awesome technique. I think you can really plump up a ridge utilizing that. It is technique sensitive and you have to go to a second surgical site. The dentium website has a nice case example by Dr Lee. I still think the Bio Derm technique may be the way to go as you dont need a second surgical site. You can see the case examples published online in the October issue of JIACD. A nonsurgical option maybe just doing the pontic with pink porc. It is a option.

I read the Bio Derm Technique in JIACD. Very well done, I do have my issues with Dermis. I think Alloderm works a little better. But good overall technique. I tend to prefer pontic development with a thick connective tissue graft. Works well. As far as a discount, do what you think is best for the patient.

"What is the best way to handle this situation from either a surgical or prosthetic solution for pontic site development?" "I think what the person wants to know is how to do pontic site development." The skill and experience of the surgeon is a significant facture in implant success. I have to say it's disturbing from a patients point of view (peer review and practitioner experiences aside) that professionals performing surgery would be asking for instructions on a web forum on how to choose or perform a surgical procedure to deal with complications or corrective operations. A patient expects that a professional considering operating on his skull/jaw (or any other part of him) when at all unsure or inexperienced would refer him to someone who has extensive training and experience in a given procedure. Especially where there have already been failures or complications. Failure can be due to patient non compliance, individual physiology but out right rejection of the implant from what I understand occurs in only about 5% of cases. Other risk factors can and should be evaluated pre op and patient expectations set accordingly. Except in those 5% of cases it's not a mystery why it failed and not only should this evaluation have been at attempted pre op the repeat failure may well be inevitable if you don't understand what happened the first time. As to patient expectations if your patient knew you were searching online for instruction on how to correct what has already been experienced by him as multiple failures (even if not your fault as you did everything\evaluation any highly experienced knowledgeable oral surgeon would have done ) do you think he would actually want you performing the procedure or prefer to go to some one more experienced in this particular procedure ? Would I want to have a procedure with even a minimal chance of premalignant nerve damage such as an implant by anyone but a professional that is highly experienced specifically with all aspects and possible issues related to that procedure? Harsh as they sound these are the patient’s expectations and even if the requirements to perform these procedures are not in line with those expectations you owe it to your patients to either acquire that expertise (not on them unless they are informed they are getting “med school surgery” and an educational discount, though even then the dental school supervises these don’t they ?) or know when to refer them and how to inform them so they have correct expectations. If you are not experienced to a high enough degree to be comfortable in this operation refer him elsewhere. It's if you have trouble this time and your patient goes to someone like "eric-sb oms" who starts identifying likely causes for failure or ends up advising that the patient was not a good candidate for the implant in that specific location due to bone density to begin with that the patient is going to look at legal action. If they realize other practitioners have better equipment or have extensive training and experience and would have affected the result that they will feel wronged. It’s when the patient expected a certain level of competence that may have been available elsewhere then finds they could have chosen another practitioner with much higher chance of success even if their physiology presents a challenge but were not informed or had false expectations of the surgeons skill that they feel wronged and this is justified in my opinion. Is your patient aware your are not entirely comfortable in how to proceed? As a patient I would pay you simply to give me the option of referral to someone specializing in this operation just to avoid any possibility of further problems at this point. The fact he is still willing to allow you to operate on him shows he does not blame for the past failures understands this was not your fault and has a high confidence in your skills still. It is if he later feels mislead and mis-informed that he is likely to decide he was harmed not because of the implant failures themselves. Unlike auto mechanics people only care about cost as a secondary concern. They entrusted the much more difficult repair of the living human body to an experienced professional educated and trained to a high degree of standard in a particular specialization. Patients can't be more like predictable cars and this is not an across the board excuse it is an important factor that mandates that surgeons are far more skilled, experienced and informed in handling and minimizing risk and involve patients in informed desicion making regarding these risks and thier own areas of expertise. Doctors and surgeons are only human but I feel should hold themselves to the highest standards of education and discipline to insure they come as close as possible to deserving the high degree of trust patients put in them or should correct false patient expectations before hand. Monetary concerns are secondary and this goes a long way to preventing malpractice suits. I don’t think most people are out to sue but do have high expectations when it comes to their bodies and health and they are willing to pay a lot more than what they would for their car or the raw materials that go into medical services only because they expect this high standard is where that money goes. It's just like the way a an airline pilot gets paid more than a taxi driver. Seeing surgeons asking how to do procedures online is to patients about as comforting as it would be to you if you were flying on a plane and mid flight and heard the pilot radioing ground to ask if anyone knew the best way to land in a snow storm.

Joe, I agree with your comments wholeheartedly. The problem we have in dentistry which is stemming from dental school themselves is lack of education and lack of team work and I am a general dentist. First lack of education. There are kids graduating dental school today and they do one root canal or 3 crowns to graduate. Yet these are the same people that start doing sinus lifts after a weekender. Dental education is weak today due to lack of faculty support, no specialist, everything being taught by general dentists. When I went to dentist school we learned the value of team dentistry and the referral. If you couldnt do a procedure your referred it. Remember do no harm. Now its about keep as much money in your pocket and dont refer. Very sad, Perio, endo, OS and even ortho are starting to be hurt by the lack of team dentistry and the referral. When does it end. Joe your post while long was more elequent then mine, I think we are saying the same thing. To get back on topic, I did read today you can build up a pontic using HA alone.

Sorry, Joe, we are all, always learning and that's the point in life. Science, and dentistry, is constantly changing and it's impossible for a practicing dentist to keep up with everything given the short time anyone has in their day. The only shame is on those who are too afraid to ask and learn, because they are afraid of disparaging comments like yours. The Internet only makes learning and education that much more accessible, which is why online forums like this are incredible resources, even for the most educated people. Oh and by the way, many pilots, unlike dentists, surf the Internet while in the cockpit (see this link), so maybe you really shouldn't fly anymore.

Joe, I am haveing a quite difficult time following you in your comment. I think it is your sentence structure that is giveing me the the problem. Could you please rewrite your comment, I would like to understand your point with better clarity. Regards, Scott K. Kareth

joe, I don't know if you are a patient ,dentist, or surgeon. One thing you SHOULD consider is we all are human. I've been doing most of oral surgiccal procedures for many years. Had extensive training in it. To this date, from time to time, I still have to go back and read some of the books that I bought in early years to refresh. This forum is no different. Have you checked the title of this forum? It's really for dentist who are into implant procedures so tghat we can ask each other for better ways of doing it. Some of dentists here might be a little informed on the topic than others but the bottom line is we are all trying to do better jobs. And Xavier, only dentists who complain about team work not being done correctly are the ones who just want to fillings and crowns all day long. Many endodontists, periodontists are now doing implants. Was that their specialty from the begining? Ask yourself that. As far as I know, lines between specialties are getting vague when it comes to implant. Sure, os get more extensive trainig in it depending on where they do the residency since some programs in US still don't put too much emphasis on that. We should know when to back off and think second about doing a case but at the same time, I am getting sick and tired of comments about general dentist should be doing 'general stuff'.

Enough with the Specialist VS GP stuff. If GP's knew how to manage there practice effectively they wouldnt need to being squeezing every dollar they can out of the practice just to get by. And if specialist had better interaction skills and showed dentist the value of why to refer they wouldnt be crying about GP's doing surgery. The topic has nothing to do with this anyway. The topic is managing a implant failure with a bridge and discounts. My answer to the question is: While I read the bioderm technique in JIACD and it has value, you should have multiple tricks in the bag. Root submergence by Dr Salama and Garber works well. Read Int J Periodontics Restorative Dent. 2007 Dec;27(6):521-7.

As a OMFS I tend to favor connective tissue, for pontic build up. My practice actually has been increased by many people taking the weekend course. I get to clean up alot of garbage and alot of mistakes of people not knowing what they are doing. Mentoring helps, so now my local dentist's refer the more complicated stuff and they stick with the slam dunk cases.