Salvage old external hex implants placed 13 years ago?

This case appears way too complex to diagnose without seeing the patient, CBCT and complete medical history. I can offer a basic approach that I use all the time in working with people who have been non-compliant with daily hygiene and followup professional care. First, we know this patient's case was poorly planned to begin with, but 30 years ago looked completely different, so don't blame the doctor. Look at systemic disease. The occlusion is a train wreck. So, let those 3 concepts guide you in totally rebuilding this case. Thinking full mouth rather than piece meal means you will remove most if not all of the remaining teeth and diseased implants. Replace the occlusion with well designed full arch fixed provisionals on 4-6 implants/arch, followed by the zirconia conversion in 6 months.

Obviously, historically, there was a lack of oral hygiene and periodontal maintenance. A new TP is needed in consultation with specialists for best results.

Dr Hacker is correct. That said I would remove all failing teeth and implants. that said I would provisionalize the patient with acrylic partials at the proper VDO. Then let the tissues settle and evaluate the patients oral hygiene , motivation and mental health. You may even want to refer. This case may be a time burner with little reward.

Remove the failing implants. Keep any good ones. Use two implants in each arch for an overdenture ( partials or full denture ) scenario. Put the rest you are keeping to sleep for the time being. Re-evaluate the entire case, systemically, functionally ( occlusal forces, etc. ) and from a preventative point of view ( home care habits, perio susceptibility, etc. ) then go slowly and conservatively according to the patients wishes and your own restorative experience.

I agree with all of the above postings plus: 1. Your 'pan' is reversed unless you are U.S. military. 2. Obtain excellent records if you planning to participate in this case in any capacity. 3. Refer out at the earliest opportunity. This case will drain you.

The answer is that it would seem some teeth and implants could be salvaged (albeit that as mentioned above – some considerable time needs to be spent on proper treatment planning). However a much better diagnostic work up needs to be done to be sure about this. To simplify a very complex situation let’s look at the basics of what you have. Ironically, despite all the problems, it seems superficially that some teeth have survived in better condition than some implants. Interestingly this adds emphasis to my philosophy that dentists should not be in too much of a rush to extract teeth that are functional. In my opinion retaining teeth is still a better option than placing an implant in most/many cases. Secondly there seems to be about 8 implants that still appear to have acceptable bone levels (this may not be the case and clinical evaluation and radiographic investigation need to be done). I have treated cases similar to this and I think it is reasonable to say that it is not prudent to be too radical too soon (at least until you give the body a chance to heal itself). Clearly the hopeless teeth and implants need to be removed ASAP. They have problems and will continue to perpetuate other problems in different sites if they remain. After doing this you should do the obvious in regards to cleaning and maintenance and oral hygiene instruction and restoration of all remaining teeth and implants. What I have found (after providing this service to similar patients) is that if they are compliant and willing to proceed, I can place an implant/locator retained denture on the remaining acceptable implants. This more easily allows you to provide acceptable function and aesthetics. However most importantly it allows the patient to quickly and very easily clean the implants 2-3 times a day by simply using a toothbrush and scrubbing the locator/implants. Of course regular maintenance needs to be provided by the dentist/hygienist. In almost all cases I have found such treatment has allowed the patient to finally clean properly and, even where implants have lost about 50% of bone level, the problems will stabilise and allow the implants to provide good long term service (possibly for a life time – depending on age and on going health of the patient). Such a treatment plan is less traumatic, cheaper and easier to provide. It is relatively conservative and “buys time” for the dentist to evaluate the out come before pursuing more radical options which to be honest I have not had to do to this point of time. It also allows the patient to evaluate their situation and consider their long term options which you will be able to advise them on as you assess what the healing and maintenance response has been. Having said all this, some of the advice above to seek specialist help (at least for some local advice) is very sensible.

The 2 implants in LR and the middle 2 in LL are not savable due to the amount of bone loss.

There may be a reason why the abutment/ crown are missing. From experience, bear in mind that sometimes the internal thread of a legacy implant is stripped or split and will not allow correct screw torque. Test with an appropriate screw before committing to using any legacy implant.

I agree with Dr Gerke, To many specialists and young dentists have not been exposed to seemingly hopeless teeth that respond to periodontal therapy. Older patients wish to save teeth as long as possible. Most dentists want to do large restorative cases. Take care of patients immediate problem by removing the bridge, identify the implant first (What implant is this), order new screws and torque screws properly with a sprig loaded torque driver. No latch type torque drivers,they are not accurate. After initial therapy is completed including removal of hopeless teeth, a fairer assessment can be made.