Implants Show Significant Bone Loss: Attempt Antibiotic Therapy?

Refer to your local periodontist to treat the peri-implantitis. Antibiotics will not fix the boneloss.

These are obviously Straumann Tissue type and the area above the threads is a polished collar so bone will not remain in this area , thus bone level is generally where it would be expected to be ( a bit more loss at the mesial of the distal Implant ). As the implants have been placed into a Xenograft sinus augmented site , probably best to leave well alone and yes treat with improved oral hygiene and maybe Abiotic gel. Sure this only deals with the symptoms but that should be fine for the next decade or so... Peter

Do avoid removal whilst may be easier with the NeoBiotech reverse torque technique , still a number of risks not least the peri-apical are of the pre-molar mesial to the implants . Refer if still worried ......... Strange these days as many Implants are now placed 1-3 mm sub-crestally so when a dentist sees a small amount of bone loss on a crestal or supra crestal system it is called dramatic loss. Peter

Peter is correct, also evaluate and treat the occlusion. No need for a periodontist , if you can flap, degranulate and graft. Learn this procedure it's very easy.

It’s a typical consequence of a unilateral mastication. Free standing crowns cannot withstand powerful occlusal forces from anthogonists Adjacent tooth (premolar) should be united with new implant-supported crowns in the future treatment plan.

To Don; There is no premolar mobility description here, and I would not say that premolar root is short. Moreover, I’ve seen tens of teeth with ½ bone atrophy and zero mobility, because of good collagen condition.

The antibiotics are for infections, not for bone loss, and will not solve the problem. The implant on the first molar site looks in healthy conditions. The other implant has problems: bone loss is not small and the shape of the loss is predictive of an aggressive peri-implant disease. Usually the patients don't accept the proposal for an implant removal, and the graf option sounds more acceptable. Check the occlusion. Overload is dangerous, especially if the implant is placed in a poor quality bone, like this seems to be.

Peter is correct as usual. These are straumann tissue level. The extent of bone loss has been reached. They will stay this way for many years. Keep on a close hyg recall to observe.

Are there any signs or symptoms of peri-implantitis or mucositis? Bleeding on probing, swollen gum, pocketing, discharge, sore to bite, increase in mobility? Hard to make a diagnosis purely on the appearance on the radiographs. Like Peter said, in Tissue level implant or any implant with a polished collar, bone loss to the first thread is the norm. Placing the polished collar subcrestally is a mistake! (15?) The good news is sinus graft resorbs very slowly and in the absence of clinical signs of active disease, I would leave it alone and concentrate on OHI. Antibiotics is not a long term solution and active disease if present, should be treated actively and appropriately. #15 is less than ideal and should be monitored closedly.

I agree with the consideration that the patient has to be clinically evaluated before diagnosing a peri-implant disease, but the shape of the defect on the mesial side of the second implant (see the first radiograph) suggests that something wrong is probably happening. Possibly the implant will last years without any treatments, but I would not be surprised to see a worsening of the defect in the long term.

It appears to me that the anterior implant is at least partially in the patients natural bone. The posterior implant is in a dead zone of some form of nonresorbable graft material. This is sclerotic bone with no osteoblasts and very little blood supply. You cannot successfully place graft material over sclerotic bone either with the implant in place or after the implant is removed. I do not think the etiology of this failure is periimplantitis but a failure of integration in sclerotic bone. In my opinion the infection is secondary to graft failure. I am hesitant to leave infection in this patient even if the implant survives. I would suggest the posterior implant be removed and remove the graft material and place a resorbable graft material. If and when the pateint wants then proceed with replacing the posterior implant. Greg Steiner Steiner Laboratories

Given the limited amount of information about the patient, two periapical radiographs without showing the lower arch and not knowing the occlusion, the health of the patient, the age of the patient,the habits of this patient; i suggest that any recommendations for future treatment with the information we have at hand, falls not under the guise of implant dentistry, but modern day witchcraft!!! Get the facts first, and then make the recomendations. Gerald Rudick Montreal

I agree. Perhaps we could agree on what might be a "suggested minimum standard of diagnostic information. Personally I think a pan really helps and properly angulated Intra oral films., Appropriate photos are also critical in my mind. It would just help to make things less speculative.

To Dr, Hughes: how many of these "easy procedures" have you completed, and in how many of them were you successful in regenerating new alveolar bone? To be more specific, what is the protocol that you are following to sterilize the threads, and what regenerative materials are you using? Lastly, I would love to see some of these cases, both clinical as well as radiographs, posted. Thank you.

SG: I have treated well over 200 of these cases. I used citrate to detox the threads. I follow Meffert's protocol. I learned this from Dr. Meffert. One has to gain control of the occlusion and other habits, smoking for one. Sometimes I take the implant(s) out of function for several months. I have splinted a somewhat mobile implant/abutment to adjacent teeth with composite for several months to stabilize the implant and allow for regeneration of the bone. Again you have to degranulate and decorticate the site and graft with Osteogen and or corticocancellous bone. Autogenous bone is best Sometimes a membrane is in order. Also try to treat the adjacent teeth if they are mobile. I treated the bulk of these cases from referrals. SG, how would you treat? As I stated the techniques are easy to learn, for any motivated GP. It's not the same as neuromuscular surgery around the Circle of Willis or rocket science. It's about the same degree of difficulty as changing spark plugs and adjusting points on an older auto. New cars are way to high tech. Sorry to pop some bubbles, but it is what is is!

I stand corrected, not neuromuscular but neurovascular.

Dr. Hughes: I would love see some pre and post op radiographs, preferable PA's. I treat the exposed threads with tetracycline paste and I am currently grafting with allograft combinations of an osseous paste with cancellous bone chips eg Dynagraft. I have heard Dr. Froum speak several times on treating failing dental implants. Apparently you have been more successful than Dr. Froum...

Drs S Reiner and Rudick brought up good points. What graft material was used and what was the status prior to implant placement and grafting? The info is to limited. Refer to Dr Kong.

Dr Kong: let me back up on the splinting a mobile implant. Firstly, I am discussing a single stage implant. This can be splinted to teeth or other implants. I am not considering an extremely mobile implant for treatment. Also, one goes through the usual treatment of detox, degranulate, etc. For a two it's best to take out of function, if one can possibly do so. How would you treat the above case? Would you use Eye of Newt?

You remembered. Yes, Eye of Newt is like Crisco - so many uses.

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I believe this is the time to "keep it simple". I feel , from my experience the only way to truely graft a failing implant is to take it back to the cover screw and over graft. Assuming this case had that much bone loss. It had worked greater than 15 times with me and is hasn't worked 5 times. Real bone, citric acid, prp and gtr.. With respect, adjusting the occlusion, assuming the implant is integrated, makes little sense. This is coming from a guy that believes occlusal equilibration, has no effect on the temporal mandibular joint, as well. These beliefs come from sound scientific studies. I'll say it again bone loss, does not occur secondary to bruxism, with the healthy dentition. The most difficult extractions I do, are non impacted, canines and molars, in the bruxing patient . Bv

You haven't mentioned the clinical situation, is there suppuration? is there BOP? what is the probing depth? how mobile are these? what is the occlusion? is it unilateral occlusion? In the worst case scenario, I will remove the prosthesis, raise a full thickness flap, degranulate, detoxify with Chlorhexidine, Tetracycline , and Ca Hydroxide paste , irrigate with saline, place cover screws and close the flap, advise antibiotics for 10 days.Wait for 2 months for the residual infection to disappear.Then raise a flap, clean the area again, place particulate mineralised bone graft mixed with PRP, close , wait for 4 months.Then make a new restoration with crowns splinted together.

Everytime a flap is raised, and you expose some alveolar bone, there will be some loss of bone. I don't understand your rationale for doing TWO surgical procedures, and exposing the bone TWICE.

You know, sometimes I think some of us are practicing witchcraft, in stead of medicine/dentistry. Keep the pot hot. Bv

Sg, I only suggest that treatment for the integrated implant, with significant bone loss, that is on the cusp of removal. Everyone knows, that when you lift the periosteum from the bone, subsequent bone loss occurs and if they don't , they shouldn't be placing implants. This is why I use real bone, overgraft and guided regeneration. Bv

I still don't understand why you flap the area TWICE. In addition, if you are dealing with any acute inflammation, we know from the periodontal literature that there is more healing potential in an acutely inflamed area than in a chronic one. So why not take advantage of this added healing potential around the failing acutely involved implant and graft at the initial flap rather than doing two procedures, exposing the bone twice, and doing your final graft in a slower healing, chronically inflamed area?

I didn't see anything about acute vs chronic inflammation, in the initial quiery . Albiet, my suggestion maynot apply in this scenario, my suggested procedure, is a one step surgery. I don't consider the incision directly on top of the cover screw( sans sparring any tissue ), with exposure, a second surgery. Most of the time, despite the overgrafting, the cover screw is already exposed, thus obviating any incisions. Bv

As I reread the post on Feb 25th, I read the word FLAP twice. Sounds to me like you are doing TWO flap procedures??

Baker I'm with you on this case- When you've done it a thousand times, these things just make sense. When I read the above posts I just can't believe them. If I did some of the things that these guys do in my small town with 8 oral surgeons and 7 periodontists and some good GP implant guys, I'd be hangin from the gallows pole in no time. Bring the zep! And yes this is the same sboms who usually disagrees with you.

Dr. Kong, would you share with us how would you treat this peri-implantitis. Thx

I think what makos was talking about is a situation with a very bad infection. I would do this as a one shot procedure. The best way, for several reasons, is to remove the prosthesis and unload, if you can (some modalities one cannot). Open the site withna broad flap, irrigate, degranulate, irrigate, detox with citrate (some authors advocate other agents) decorticate, place the resorbable graft material, place a membrane, suture. Evaluate and treat the occlusion. Evaluate the patients habits and hygiene. Place the patient on peridex. The new literature is also suggesting flagyl po. I have heard of some docs using fluoride. There have been some Japanese studies with the use of fluoride with ailing and failing implants.

Sg, I know this is a leap year, but I'm not seeing anything in my entry( feb. 25) that says "flap twice". I don't use the term flap, unless I'm making pancakes. The "term", is redundant and antiquated. My suggestion only calls for one surgical exposure, with the exception of when the grafted bone, ends up on top of the cover screw . I slap myself on the back, everytime this happens. SB, we are not that, over the hill are far away, on the way we think. We are just hard headed!! Bv

SG, Good One. Dimachki, i will treat this differently based on whether #15 is a screw retained or cement retained prosthesis and what cement was used (ie can I take the crown off without destroying it). We all know functional mastication is at around 85% so long as you have your 1st molar, so how aggressively do i want to treat peri-implantitis on #15 when the boneloss it seems is apical to the 1st thread and possibly to the 2nd and it offers 'just' 10-15% additonal chewing function (assuming this pt has opposing dentition with good prognosis. Is the possibility of getting a few mm of BONEFILL worth it to the patient to pay for the expense of surgery with membrane & bonegraft (I would place a coverscrew & use autogenous only for bone around the threads of the implant and if you choose, allograft for the outer layer) and a new crown with abutment? Because of the SLA surf of the implant, I would also pray that tetracycine can detoxify all the tiny crevices being grafted and if I see radiographic bonefill at 6 months, great! If no bonefill, the patient just threw the money for the surgery, new crowns, time and aggravation down the drain. Another option would be to smooth out the exposed rough surface and thread as best I can to a polish, detoxify with tetracycline and laser (optional), osteoplasty, apically position the FLAP to reduce the Pocket Depth for hygiene. Then place the pt on a 3 month cleanings and maintain the implant. Maybe it will prevent the implant from fail-LIN, but treating peri-implantitis is one of the least definitive and the most unpredictable procedure I do. EASY to treat? Hell to the Naw! But then again, I'm not Mr. 200+ peri-implantitis.

The cause of the bone loss in the first place is likely due to the microgap/microorganisms at the first critical margin between the abutment and the fixture. Antibiotics will not be able to eliminate the microorganisms hidden in the microgap. Since everyone seem to agree that peri-implantitis is not easy to treat and any debridement and bone grafts are quite unpredictable, I would suggest the implants be removed, and the wound allowed to epithelialise. Then, go back in and reimplant with bone grafts if necessary. But this time use platform switching abutments, ideally with morse-taper connections and keep the crown abutment margin near the emergent margin of the implant so that all excess cement can be removed. This will solve the cause of the bone loss in the first place and give quite an assured end result.

Dr Kong I like your answer. The cases as I stated were mostly refered to me by another Doc that had a long and established implant practice. As I stated before, the procedures are easy to learn. As you mentioned the results are sometimes questionable, which I agree with you.

I still say that this is easy, the results are not always what we want. It's not as complex as many other dental procedures.

I agree with Richard here , yes the treatment of "peri-Implantitis " cases is relatively straight forward and yes the results can unfortunately be varied mainly due to patient issues such as Bruxism , smoking , and their physiology . But ove rthe last 9 years or so I have had many fantastic results . I only Prophy jet blast the Implant surface clean and sometimes use citric acid but never use anti-biotics as this will pollute the newly cleaned Implant surface. I then graft with Bacterio-static synthetic graft materials and let the body do the rest , and more often than not am supprised with the outcome . I took on an Internet case which had lost the bone to the last thread and was suppurating , so a bad case . This was mainly to prove to sceptics , the case is restored back to near the top thread and symptom free 18 months on . This was all done showing the stages on-line , so had to put faith in the materials Anyway after all that , this is not the case to do due to the polihed collar , and its position . Just clean and watch .... Peter

Thank you Peter!

My mentioned treatment results are inclusive of subs, ramus frames, blades and root forms. If one segregates the root forms, the success rate would be a little higher. The treatment of subs pulls the results down. My initial exposure and training was with subs, so the frame of reference is different from one that only has experience with root forms.

Sg, what's the chance of you taking the personal out of the mix ? Maybe Richard has had this much experience and if he has, then pay attention. When I was in dental school, I perforated a crown with a pin, so the perio residents, had a grand rounds, on how to address this. They performed a "flap surgery"!! Everyone was watching the senior resident, raise the flap and 40 minutes later , she trimmed the overprotected pin, level with the tooth. Everyone was on the edge of their seats. You would have thought, they were doing a multy organ transplant . You might do yourself some good by reading all the post. Bv

"You know, sometimes I think some of us are practicing witchcraft, in stead of medicine/dentistry. Keep the pot hot. Bv" Exactly! Thankfully the body is very forgiving, to some extent.

dear Dr Hughes:first with flap opening region and cleaning with hand Perio Scalers,and than cleaning region ,w chlorohexidine,tetracyclin,giving antibiotic oral for 5 day,if healing not occure in 3 months after these operations.we must be removing implantes ,and after 3 months we, can replace new implants w CBCT and others important consideration for example smoking,osteoprosis,etc .... It,s suggested Better diagnose with the pathologic cause bone radiolocencey untill don,t repeat mistake before replace new implants.......

Dr. Kazemi, you should consider citrate over tetracycline. You may want to check the literature on this issue. Occlusion may be an issue in these cases.

Dear Dr Hughes: thanks for your attention,,Occulusion is very important For This Case I Agree