Implant-Supported Bridge with Bone Loss: How would you treat this?

I do not think you will be able to gain any vertical bone height with any procedure. The overhangs are likely resin cement. I would use a flame shaped finishing burr to remove the cement. I would also consider endodontic treatment of #3 and restoration with a crown.

These look like Nobel Active fixtures. Look closely at the collar. See the micro threads? These should be buried in the bone i.e. these are meant to be bone level fixtures. When they are exposed like this they are doomed to failure.

I'm more concerned with #3. What is her medical Hx ? Did you check her occlusion b

If there is no sign s of periimplantitis, IMHO no treatment necessary, just review in 6 monthly intervals. If the 47 implant fails due to physiological bone resorption, then redo treatment. Excess cement must be verified clinically. The overhangs might not be overhangs. They might be modeled porcelain on buccal side.

First get the immediate postop film and compare it to this film. Do not remove the bridge at this point. The peri-implantitis, if that is what it is, can be treated non-surgically with bleach, peroxide and Arestin weekly for 3 weeks with probable resolution. #3 needs treatment above all of this. Don't get yourself in trouble over the bridge.

If you are already planning to change the bridge anyway, it would be good to remove it by accessing and removing the abutment screws. The implants look rather parallel in this view, and that should not be too hard to do. It would be good to identify whether there is residual subgingival cement or not. The prognosis or retreatment would be better if you could identify the likely cause of the problem, cement or occlusion or something more sinister. Then I would raise a flap, assess the damage and then decide to graft or explant the posterior implant. Next time use an intra-oral cementation process that controls excess cement. Go to www.ReverseMargin.com for more information.

Good case!! These implants are bone level, and they were not placed at bone level, they are higher. Because of the roughness and porosity of the surface they are retaning plaque and that´s why the loss of the bone. We don't know if any implant is lost because they are ferulized with the bridge. I would take out the bridge, cutting it. Diagnose the stability of each implant and the deepth of the pocket. If everything is OK, then reshape with burs each implant, polish the surface and do an hygienic bridge.

Find out the history of the site. It appears to be grafted with cadaver bone due to the sclerosis. If the site was grafted with cadaver bone the bone is failing and it is not infection. It will not respond to regeneration. If the site was grafted with cadaver bone you will need to remove the implant and all of the sclerotic bone around the implant until you reach normal bleeding and then graft with a bio-compatible bone graft.

The implants are too superficial. I am not sure if you can change the course of destiny for the implants. Check the baseline radiographs and don’t touch the bridge otherwise it will be asking for trouble and ending up in disaster both for the patient and youself. Although the bridge is badly designed, there are, as I have understood, no symptoms and no clinical signs of infection. Clearly no reason for removing the bridge. The damage has already been done by badly placed implants and you can not improve the bone around the implants. With regards to suggested grafting by some of the colleagues, there is no indication for it and the site is not favourable for any grafting anyway. You can’t graft around 1/3 of the implants that sticking above the marginal bone. You need at least one bony wall for grafting. Finally, let’s not forget the age of the patient and life expectancy of the implants and the bridge that may exceed the patient’s! I would monitor the bridge every 6-12 months and focus on the upper right molar instead.

Please check the pockets around the implants if they are active or not. It seems that the bone pockets were produced by a post-implant insertion which is a physiological reaction to the treatment.