Implants done right but failing: what happened?

Great case for debate , it is always good to see cases from the past and assess them with modern technology . The central Implant is too big , but we all did that then and the 2 are way too close and finally splinting is not ideal especially in the aesthetic zone for aesthetic reasons and possible co-axial force issues. But the main point of interest in the residual graft material and why I feel strongly that graft materials around Implants should always be fully bio-absorbable . Bovine or Human HA merely confuses thematter biologically and radiologically. Sure they can make the soft tissue look better but I feel we mislead ourselves as to the true picture . My Treatment route is remove the central Implant and have a temporary cantilever of the lateral one whilst re-grafting central area ( I would replace a thinner Implant at the same time as graft , but is technique sensitive so beware , as akin to a Tiger Woods trick shot ) . A bit of sof tissue manipulation and re-load at 3 months . Can then if lateral Implant not ideal remove it and reverse procedure or leave with a permanent cantilever lateral for improved aesthetics if lip line high . Regards Peter

First off, sixteen years is a great run. Do you plan on treating the other failing implants and the periodontal disease of this patient? I would remove all the failing implants graft the sites allow healing, treat the full mouth for perio, (LANAP) and replace the implants with good balanced occlusion. I would provisionalize with crowns or Essex defending on how the sites look, full mouth periapicals, need pocket charting.Periimplantitis is a full mouth condition. Now what happened, possibly due to the initial trauma, poor blood supply poor grafting whatever not important now. The patient got 16years move on. Implants simply fail due to Periimplantitis they can't get caries. The beauty part is that after clean up, depending on howthe grafting goes and the patients oral hygiene you can place some fixed bridgework if the grafts are inadequate. Block grafts may be require depending on the defects, I prefer particulate with proper stabilization and growth factors. Three keys, occlusion, perio pathogens, proper site preparation with regenerated bone. Work with colleagues you trust, great case! As always thanks for reading!

This patient is doing something wrong (smoking, poor OH) etc. patients tell us all kinds of stories. I had a lawyer tell me that he did not smoke, there was a pack of cigarettes in his shirt pocket. All that aside, remove the failed implants, clean up the sites, graft if you think it looks feasible. Then restore with fixed partial dentures. You may need pink porcelain. If someone has had tis kind of loss, I strongly suggest that the Doc take a very conservative approach to treatment. Even removable may be in order for an observational period of time. Yes, the obvious, periodontal treatment and OH instruction is a must. If this patient cannot take care of the implants, then they are not a candidate for dental implants!

Hi CRS and Richard both of you have been involved for over 25 years I expect and I agree there may be some host issue to cause this situation . When you have 20 year plus cases to look back on some lost bone and then it has stayed the same say for the last 10 or 15 years . Few have a catastrophic loss without a host issue ( Smoking , bruxism poor auto immune response to bacteria etc . BUT there have been significant changes in Implantology since then , surfaces , graft materials , abutments , platform switching etc etc . So ignoring the lower issues at the moment I feel it could be worth another go . Over the last 10 years we have replaced implants where only two threads are in host bone and regenerated the severe bone loss areas ( some cases are now 9 years loaded with no issues . Again I feel the" gold standard" graft material is the Implant itself. Regards Peter

I agree, look at the other teeth, a lot of bone loss, need to repair. I feel it is a judgement call when the implants are removed / grafted depending on tissue quality etc. I do think it could be just as simple as long standing periodontitis. Worth a some medical testing due to "lifestyle?" Could get a simple medical clearance prior to treatment. Would need to know type of implant these are sixteen years old, newer surfaces etc. I think these would be tough to decontaminate and if they are mobile. Thanks Peter!

It is obvious from the maxillary graft site that the graft material is non resorbable and because it appears to be exactly as it was when it was placed it indicates that the graft material has produced sclerotic bone. This bone never remodels and is unable to adapt and as a result it breaks down over time. The site is surly infected but it is secondary to breakup of the graft material. The poster is correct. Everything was done correctly and the breakup of the graft material is a predictable result. The problem I have had with similar cases is the difficulty in getting bone to regenerate in the defects left by these failures. I understand that these graft materials have no osteoblasts but even when I remove all of the residual graft material the amount of regeneration I achieve is poor. The conclusion I have come to is that the antigenic bone graft not only affects the grafted site but also the surrounding bone. It is possible that allografts and xenografts may produce mineralized tissue here because the mineralization is not produced by osteoblasts but converted endothelial cells but then you are right back to what caused this failure in the first place. Greg Steiner Steiner Laboratories

Do we know what was used? Anyway the bone loss although most severe at the implants is whole mouth. Systemic problem? Poor oral hygiene or poor graft material?

Hi Greg and CRS , I had a long lunch last summer with an older Swiss Professor ( ITI founder ) where we discussed graft partictulates whilst drimking fine wine , as only dentists can sadly . I was speaking about newer materials and his response was to send him a core to analyse for the presence of Osteocytes . This he said was the key to long term sucessful grafting and here possibly is the counter showing the possible effects of sclerotic regenerated "bone" . We agreed material must be fully turned over for true bone formation. True there is a generalised bone issue but nothing too out of the ordinary on most scans we see . I agree Greg re-grafting sites where previous graft failure has occured can be problematic . I have a great case where 6 years ago after 2 graft failures and 1 implant failure I replaced and grafted at the same time without membrane or autogenous . I saw the case 3 months ago and it was great bone to top thread and great buccal profile restored showing again you do not need HA to help in this area. Good Luck with the case Marc. Peter

There are many issues to consider in this case......and many good observations have been stated above. If one looks at the scans, there seems to be a generalized periodontal condition, there are lower anterior implants that are experiencing bone loss as well.....IS OCCLUSION A FACTOR ? Years ago when placing implans in the anterior maxillary area, we tried to follow the position of the natural tooth when drilling an osteotomy.......today, we realize that the buccal plate is very thin, may have limited blood supply, and hence the angulation of the drillling is directed to the palate where the bone is more dense and the blood supply is better. Every week we read about a new particulate graft material ...... but regardless of where they arederived from, they are all osteoconductive.......they do not have the ability of producing osteoblasts....... we never know if they are going to be completely resorbed and if the site turns into natural bone with good circulation..........this case is a perfect example of the grafting material not turning into natural bone. Recently, I watched a Dental XP presentation on grafting by Dr. Zev Mazur of Ranana Israel........he showed cases where grafting was required in an immediate implant site following extraction,and rather than mix PRP with a commercially available graftling material or even cadaver bone, he placed only Platelet Rich Fibrin, with no additives.........just placed it directly next to the implant. in the vacant space....months later he went into the grafted site and took a core sample and found mature bone with good vascularization.....all in direct contact with the implant......this technique requires some serious consideration....is inexpensive and should be considered for preserving bone at the time of doing extractions....aside from some simple armamentarium and owning a centrifuge......it is very inexpensive and the rewards down the road could be tremendous........no costly materials.....because the PRF acts as a grafting material and as a membrane at the same time. The old school of thought for those of us who have been doing implant for more than 30 years, were of the belief that the larger the surface area of the implant, the better chance it had to succesfully osseointegrate....so we used implants that were in many cases larger than what the natural roots would be......but today, with surface treatments, that enhance the area of the implant that would be in contact with the bone through nano technology.......we are using smaller implants....best example of this are the mini implants which are smaller than the natural roots. In years to come, when non of us reading this terrific internet site will be around, dental implantology will be a function of cellular biology to regrow and replace teeth as nature installed our first two sets of teeth. Gerald Rudick Montreal, Canada

PERIO!!!!!!!!!!!!!!!!!!!!!!!!!

Fairbairn comment # 1 most accurate in describing what happened. Judging by the bone resorption pattern the Implants are too large and too close together. Implants placed labial to apical bone and the bony plate was too thin to begin with especially if a labial flap was raised. Too many implants placed. Not stated if bones expansion case at time implants placed not stated if a membrane was used and whether the implants had HA coating, bare metal or plasma sprayed surface. In retrospect, a cbct was in order but not readily available 16 years ago. Optimum treatment now would be 1. implant removal and bone grafting, temporize then cbct to judge implant size and placement after bone heals. Screw retained stiff resorptive membrane best and graft with osteoblasts potential. or, 2. Partial with labial flange.

All very good perspectives on causes of failure for these implants. I do believe this patient is a bruxer as evidenced by the flat appearance of the occlusal surfaces of the cuspids and bis. I expect the natural dentition may attrite at a more rapid rate than the porcelain and the implants without a pdl will certainly receive greater forces. I believe that implants restored in this manner need close attention to adjust for hyperfunction as it may occur over time due to the uneven wear of differing materials.

I find it interesting that you suggest the implants were done correctly. Why were they splinted? I briefed some of the responses and it is obvious that hygiene is an issue. It is far more difficult to clean around splinted fixtures. If you are going to splint something, just cut a fixed partial. Bvinci

Also, based on the 3-d scan,it appears that the maxillary implants are too big and too close. I'm not sure if I recall any text suggesting placement of implants larger than their original tooth roots. The philosophy of larger and wider still applies in certain instances, but not at the incisor region. Bvinci

Were these delayed implants or immediate. What were the aesthetic like?( a photo would be useful. The implants appear too large and close together. What was the dimension of the available bone proximally? What was the graft material? Was he receiving regular maintenance (perio etc) over the sixteen years and were any concerns expressed during that period......that would give you at least a starting point for when potential complications were starting.

On 18 July 2013 Dr Ralph Roberts and I testified before the U.S. Food and Drug Administration's Dental Products Panel of the Medical Devices Advisory Committee, Docket No.: FDA-2012-N-0677 Blade Form Endosseous Dental Implants. Dr Roberts pushed for this hearing. The Blade Form Dental Implant has been reclassified from a Class III to a Class II medical device. Now the Blade Form is in the same class as Root Form dental implant. The Blade Form dental implant can be used in the same bone as root form dental implants and is ideal in atrophic bone where bone grafting is needed.