Possible Reasons for Dental Implant Failure?
Dr. M asks:
Please see the case photos below.
I have a 62 yr. old male, nonsmoker, occasional drinker, who presented to my office for a consultation. He is an extreme dental phobic who I treated using IV Sedation.
His medical history revealed:
*Allergy to Penicillin.
*A stroke in 1983 leaving his left arm somewhat unusable.
*High BP which is controlled.
*A heart attack and stents placed in 2009.
*Type II Diabetes, controlled.
Clinically, he had generalized advanced periodontal bone loss, with bleeding and suppuration on probing. Full mouth extraction with a full upper denture and a mandibular overdenture was planned. I planned to place two mandibular implants in the area of #’22 and 27.
Initially, the patient was sedated and all of the molars in all four quadrants were removed uneventfully. He was given pain medication, clindamycin 300 mg qid and Peridex bid for a week. In one week the remaining teeth were removed and alveoloplasty performed. Unfortunately, the facial bone was lost during the removal of #6. I grafted this area with Bio-oss and covered with a resorbable collagen membrane.
Fortunately, I was able to preserve the facial bone when removing #’s 20-22, 27 and 29. All of these sockets were debrided of granulation tissue. I then grafted the mandibular canine areas (#’s 22 and 27) with Mineros mixed with autogenous bone.
He was treatment planned to only have these two sites grafted because they were to be the implant sites. I elected to graft the other sites because I had extra Mineros. In the socket of #29 my remaining Mineros was placed with Bio-oss layered on top and tamped down. Bio-oss alone was placed in the socket of 21. A resorbable collagen membrane was placed over all sockets and the areas closed with silk sutures. He was given another Rx for Clindamycin 300 mg qid, Peridex bid, and pain medication. He was asked not to wear his mandibular denture for two weeks. While the grafts integrated, he wore the mandibular denture minimally.
Four months after bone grafting, three Nobel Replace implants were placed. During implant placement, I decided to place an extra implant. When the osteotomies were drilled I felt that the bone felt comparable to when maxillary osteotomies we are drilled.
One month after implant placement, he came to the office with swelling on the buccal of the #22 implant. Visually, it appeared that all of the mandibular anterior area, from 22-27, was somewhat swollen. Clindomycin 300 mg was prescribed. The swelling subsided somewhat. When asked, he told me that he had not been wearing his mandibular denture.
Two months after implant placement, he returned with persistant swelling. Xrays revealed that all three implants had not integrated and needed to be removed. I have not removed the implants yet as the patient has time commitments. I placed him on antibiotics. I plan to remove the implants, degranulate the sockets, wait a month and regraft. I will also use PRP when bone grafting. I am considering placing a few mini implants to temporarily stabilize his mandibular denture and help relieve pressure.
When I consider the possible reasons for these implants to fail:
1. Bone grafting immediately after removal of periodontally involved teeth.
2. Using different bone material.
3. Not waiting long enough for the bone to mature adequately for implant placement.
4. An unknown medical/ systemic problem, ie. blood sugars that were not controlled.
5. The denture putting pressure in the area even though it was worn minimally.
What do you think? Thank you ahead of time for any criticism and/or advise. This case has been a disappointment so far .
After Bone Placement
Radiograph 3 Months after Bone Grafting
Photo of panorex just before implant placement
Photo of panorex at implant placement
Photo of PA x-rays one month after the implants were placed showing that they failed
69 Comments on Possible Reasons for Dental Implant Failure?
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John Kong, DDS
10/3/2011
Implants don't integrate 100% of the time...but when you have all 3 fail, something went wrong somewhere.
1)Bonegrafting after exo of perio involved teeth is a non-issue.
2)It isn't the bonegraft. Mineross with autogenous is fine.
3)Letting it heal for 4 months is fine.
Possibility:
4)It could be systemic (you say he's a controlled diabetic, but maybe his diabetes wasn't well controlled after implant placement)
5)Maybe you didn't relieve enough the area in the denture where the implants could be prematurely hitting with excessive force (yes, even if the implant's covered by gum).
6)Pressure necrosis.
7)Sterility issue during implant placement or operator error during implant placement (ie, was there irrigation during drilling?)
8)Sh*t happens.
On a final note, PRP does not enhance the healing of bone! So whether you use it or not doesn't make a big difference. It does seem to make the soft tissue heal better/faster and that could be your indication for using PRP. Good luck!
Dr.B
10/3/2011
The radiolucencies around all implants make me think of possible overheating during the drilling process. Other explanations given above also plausible.
peter fairbairn
10/4/2011
They keys to this issue are the episodes of swelling ( infection ) as although denture pressure could be a cause they were infrequently worn .
So residiual infection into which a xenograft was placed and then it possibly being infected .
Whenever there is an episode of pain and swelling a few weeks after placement the implants will be lost.
4 month placement is possibly a bit early into a xenograft site but I think the infective episodes led to the loss.
Peter
LANAP
10/4/2011
Could you post the pre op x-rays?
Dr b
10/4/2011
My gut, as mentioned above, that this is related to the systemic issues. You instructed him no denture wear, so not that. I can't imagine the heat generated bone death would occur so uniformly on all three implants simultaneously. Anymore I'm waiting six months on grafted sites. Just not seeing the bone density at 4. Remove, regraft and interface with m.d. on patients diabetes.
ClearChoice Doc
10/4/2011
piss poor protoplasm. It happens, although pretty rare, implants and some patient's bone just don't get along.
E. Abdo DDS oral surgery
10/4/2011
my remarks are:
-keys success in bone gafting you should not place removable denture over bone graft to avoid resorption.
- when you use xenograft you should wait at least 6 months before implant placement.
- causes of infection are possibly:
- systemic
- remaining infection
- over heating during drilling.
my advice is implants removal,well cleaning of sokets, wait for 3 weeks,bone grafting and then implant placement. good luck
Mike C.
10/4/2011
Cardiovascular dz + high Bp + diabetes + advanced perio dz. Not an immediate recepit for success but you did what you could to at least try to preserve bone with immediate implant placement. I agree with the temporary implants, might consider mini's and keep them long term.
Robert Wolanski
10/4/2011
I add 50% healing time to diabetic patients. this makes a diabetic patient with any graft 9 months. It does not matter where the bone comes from it is dead bone. The amount of angiogenesis has to be compromised in this patient. Poor blood supply equals infection. If your bone was red on the drill it is probably not overheating.
sag
10/4/2011
Dr. M:
You seem to have approached this case carefully and your analysis is very thoughtful.
Obviously, one can not always find a definitive cause for the failure of dental implants.
However, this patient certain has medical conditions which could compromise his overall healing and outcome. You did not reveal what medications he is taking as that may have an influence. But that would not have stopped me from treating the patient.
When looking at the xrays that you provided, and when reading your description that the bone felt like maxillary bone during the osteotomy preparations, one gets the impression that the implants were placed primarily into grafted rather than native bone.
In a situation that you described, I would not have bothered grafting at all. I would have extracted the teeth, vigorously curetted the wounds, reduced the height of the alveolar bone, then placed the implants immediately. I also usually place gingival healing cuffs, relieve then reline the prosthesis with a soft liner then let the patient wear the prosthesis (but not for eating hard foods).
I have performed well over 10,000 implants and this approach has worked well for me.
Dr. G
10/4/2011
The problems with Bio-Oss are for example:
Trigeminal neuralgias
Chronical sinus infections
Inflammations in the lungs, spleen, lymph notes etc
Swelling and pressure in the real human bone (the cow bone is unresorbable)
Infected Bio-Oss must be removed. Sometimes the nerves can be injured after that operation. Some patients need more than three operations. Nobody knows whether all Bio-Oss could be removed.
If the patient has an infected and thin mucosal and sinusitis please never use Bio-Oss for the augmentation.
The Bio-Oss will be infected.
One president of the ICOI told me that unresorbable Bio-Oss could get infected after more than ten years in the bone of patients.
He feels ashamed.
The Bio-Oss recircles from time to time. Also Bio-Oss could be in the maxillary sinus. The ENT doctors try to remove the unresorbable
Bio-Oss is unresorbable.
Bio-Oss is unresorabable in the softtissue and can cause bad reactions with scars.
Dr. G
10/4/2011
And in it could be possible proteins from cows inside which produce an immune response or a infection. Really bad. Dont´t use Bio-Oss. Build bone!
Dime
10/4/2011
I would not use xenogenic bone graft after extraction at a first place.
Les percentage of viable bone because resorption issue xenograft does not resorb.
If you decided to use it fine but I think you should have wait little bit longer at least 6 months.
Actinomycosis can be an issue if you have excluded all the others possibilities.
If this had happen to me definitely I would send a specimen on patohistological and microbiological examination you can get lot of answers from there.
I would remove all xenogenic material and leave mother nature to do the thing for you for at least 3 months. It is cheaper and more friendly to the patient, he is a dentofob wan`he. Then do the implants, place them subcrestaly and cover them with the xenogenic bone graft if necessary the use of membrane is questionable. I would use it only if I expect soft tissue dehiscence.
Goog luck.
S Robert Davidoff
10/4/2011
this is a surface contamination issue. Either at the time of placement or during manufacture....
Paulo Lenci
10/4/2011
Dear Dr. could you show to us the Rx before you have done the extrations?
The reason I would like to see the Rx is just to be sure there was not infections on the theeth that were removed, do you now what I mean?
Thank you.
Thomas O'Connor
10/4/2011
People that have allergies and other auto immune issues can be scary to work with whether placing bovine bone, human bone, membranes or any other foreign body into grafts. I think you may have done everything right and still had this catastrophe. Thanx for helping us learn by posting. I'd pull those implants out and try again next year. I'd also take a pre op CT before the next go round. Wait til the explants heal well and use a two stage technique with 6 mos before uncovery. Hope you and the patient are good friends. You should be by the time this case is done. Forge on! t
Michael W. Johnson DDS, M
10/4/2011
As a prosthodontist, I would rather not have my surgeons graft the mandibular extraction sites. I don't know why these implants failed, especially en masse since there are multiple reasons, all listed above. However, from a restorative point of view, the large buccal undercuts left behind, then accentuated with the bone graft will make denture fabrication very difficult. When planning an overdenture, please remove all buccal undercuts, and remove alveolar bone to nearly basal bone. This will make sure there is adequate space for the bar/clip or locators and adequate thickness of acrylic over the attachments for strength. This eliminates the variable of the grafting material in the surgical site and allows for nice primary closure over the extraction sockets for good healing. This also holds true for the maxilla.
Sammy Noumbissi
10/4/2011
Has any body though about titanium allergy?
Thomas Gibbs
10/4/2011
I'd be suspect about his smoking histroy. He may have been more than an occasional smoker. Typrically with smokers I'll flap back and bury the implants.
I'll usually also plce the dental implants two stage with history of tooth loss with periodontitis. They are more sensitive to bone loss in gereral and probably more prone to plaque issues.
Dr. Siegelman
10/4/2011
Dr. M
I don't believe anyone can tell you exactly why the 3 implants failed. I think there have been some good theories and ideas that have been suggested. Clearly you have had a cluster failure, which is a term used to describe multiple implant failures in one patient. In light of the care you have taken I don't think the failures have anything to do with the kind of bone you used or the amount of time you waited. The implants either become infected because you perforated the bone during the osteotomy on all three sites or the microflora associated with this particular patient was resistent to the antibiotics you used. If you and the patient are game to retreat this I would suggest you remove the fixtures and wait at least 12 weeks for some healing. Then start the patient on a different course of antibiotics at least one day prior to the surgical procedure, I would then continue that course for at least one week. There were some suggestions made in regard to plastying the ridge down and I think that is a good idea, although I don't think it will have any bearing on the fixtures integrating or failing. As a person who has been doing regenerative procedures for 25 years I would suggest you stick with human bone for your grafting. Lifenet is an excellent tissue bank. Good luck, please don't beat yourself up too much, these things do occur.
Dr. Omar Olalde
10/4/2011
Dear Dr. M, thank you for posting this case in wich many Doctors will learn about it. Because all of us will answer with our "theories" and self experience.
Because the infection appeared at the same time, two months after the surgery, I can think about contamination in your drills and burs.
Usually a post-op infection appears after 5 days, but you had your treatment with a good antibiotic.
It would be less probable that you or your assistant contaminated the implants or even less probable that the implants where with a not good sterilization.
Or it could be an Allergy to Titanium with a rate of 0.6%
Good luck
sandy
10/4/2011
i am not very much into implants but wanted to share few possibilities;
1;xenograft not taken well or st ingrowth during healing due to membrane issue or local sites infected at time of placement.or denture trauma to grft sites
2;placed implant into same failing sites.
3;systemic issues as discussed.
4;should have felt the intial stability and quality of bone at time of placement before restoring with denture.
5;advise to plan a guided surgery incl a cbct,preferably change sites into natural bone if doing again after all the precuations discussed.
good luck
Baker vinci
10/4/2011
NUMBER ONE CONTRAINDICATION for implants is active perio disease . You said his nidm was controlled . Certainly you did a complete exam on this patient before proceeding ,correct. Two scenarios up, everyone is trying to engage two cortices, so why not now? It appears that you left the anterior alveolus significantly higher than the posterior ridge. This disallows you from engaging the inferior cortex and your implants are in soft bone. I would bet the patient wore the denture on the graft and or implants. I would have made patient have a thorough cleaning before the extractions and graft. Regardless of what abx you have the patient taking, upon extraction and grafting , the purulence and plaque is falling into the graft site .Now your site is innoculated, so when you place the foreign body in the area it's done. Again we can be sloppy are we can use evidenced based medicine. Have you ever heard of a general surgeon closing a belly with puss spilling into it? Bv
pisitroj
10/4/2011
Dear Dr. M. I had the same case like you 5 years ago.
residual infected--well removed infected bone socket topical metronidazole, tetracyclin ir with A LOT OF nss Wait for 2 months. Do not do any bone graft in the socket.
implant-- in sound bone if you can not in bonegraft. If you decide to implant in socket let it sink in natueral bone 2-3 mm.. fill socket with auto genous bone.
Denture--I always can not sleep because of intermediate denture.
Baker vinci
10/4/2011
Take the implants out and do an adequate alveoloplasty. Mill the bone that you harvest from the alveoloplasty and graft with that. 2-3 implants work much better on an even ridge. You may not even need to graft. Implants get much better initial stabilization in cortical bone. Make the pt leave the dentures at your office. If he's not smoking, he's wearing the denture! He is not a good mini implant candidate. For heavens sake three real implants failed. It's rare to have more than one fail , unless you are placing implants in everyone that ask for them. Bv
dr. bob
10/5/2011
You wrote that you were going to use temp mini implants to stabilize the denture while healing. Why not place these mini implants in positions so that long term function with them would be an option? This may be a soluton to the problem. Be sure that no infection remains. If the mini implants also fail please have your patient tested for titanium allergy. It is rare but does happen.
Keith VanBenthuysen, D.M.
10/5/2011
Does your surgical handpiece use internal or external irrigation? If internally irrigated, assistants need to insure no debris is left within the irrigation channel between patients. It might have been possible that some debris from a previous patient contaminated your surgical site and led to premature failure.
John Kong, DDS
10/5/2011
Bv, I think the NUMBER ONE contraindication for implants is iv bis-phos or radiation tx in the jaw where implants to be place b/c of high risk for osteonecrosis. I agree that active perio should be treated prior to implants (with exceptions for sequencing in treatment plan), but you are treating the perio by extracting it. Have you placed an immediate implant on a hopeless tooth with a periapical pathology? You simply exo the tooth, degranulate/irrigate or drill out the pathology dring implant preparation and place your implant. Its the same thing with perio involved teeth; if the tooth has heavy accumulation of plaque, you can certainly clean that tooth spick&span prior to exoi you wish, but i dont think it's a big deal if you just exo it with all the crut attached. You just have to degranulate and irrigate the socket well prior to bonegrafting anyways...if you cant do this well, you are always going to get subpar results with grafting no matter what.
Also studies CLEARLY show that history of perio disease is not a contraindication for implants.
Baker vinci
10/5/2011
Dr kong, I didn't say a history of perio dz. Is the contraindication. Obviously bronj , radiation and active cancer even are contraindications. Just as a fresh jaw fracture would be a contraindication, but the strong adage , is one that will continue to apply in my office. Just because you have cleaned the area during surgery doesn't mean that these microscopic little buggers aren't falling into your sight. This is exactly why our general surgery colleques don't close a dirty belly. They will wash it out for an hour with abx/saline and still leave it open. Again, you can be sloppy or you can be a surgeon. Your choice. Bv
Baker vinci
10/5/2011
Dr kong , do you not agree that bleeding is less , the mucosa holds a suture better in non inflamed tissue? Plus you can instill in the patient the importance of good hygiene , before they spend this money. You will never convince me that operating In a filthy environment is better than operating in a clean one. This why we prep , by the way, on sterile cases. It's an imperfect world, every little thing helps. This is just my opinion. Bv
John Kong, DDS
10/5/2011
Bv, are you sure your an oral surgeon? You sound like a periodontist. ;)
rsdds
10/5/2011
we need better xrays ,that doesn't even look like a mandible, it looks like minimum invasive surgery was performed. you can always get in trouble for that
Francois
10/5/2011
We usually do a lot of ridge reduction after extractin the lower anteriors so that the implants are placed in basal bone, not alveolar bone, which is not very resistant.
The lack of initial stability might have prompted to anchor the implants bicortically. The upper cortical was already weak due to reduction.
I would hesitate to graft again. I would get a scan and asses bone density and implant length.
Put the longest implant and go bicortical.
Best of luck
Baker vinci
10/5/2011
Dr. Kong , I have been called worse things. Some days I wish I were a periodontist. I've seen a huge transformation in two decades. I went to university of tenn. Dental school , that has a strong perio program, and I never once saw them place an implant, but they did instill some pretty important concepts into my philosophy. Today some perio guys tend to overlook the obvious and go straight to implants( I said some ). I truly believe in the concept by which that specialty evolved and apply a lot of it to maxillofacial surgery. Sometimes I feel like I shouldn't have to preach to the quire . I do send a lot of my surgery patients to the periodontist, especially before orthognthic cases . I am, as most of us, a touch OCD. Bv
SG
10/5/2011
I am one of "those" periodontists, so perhaps my opinion is not to be as highly values as a OMS...still, here are my 2 cents. The clinical picture above labelled 3 months after grafting show severe concavities of the alveolar ridge across the entire mandibular area. In addition, the graft, at least from what the picture shows, looks far from resembling mature bone. If implants were placed into this situation, I would have to suspect that at a minimum there would be apical fenestrations everywhere. Whether this accounted for the implant failures, I think probably not. However, this situation should certainly be dealt with if other implants are to be placed in the future.
These are my 2 cents offered from one of those periodontists...no change requested :)
Baker vinci
10/5/2011
Dr kong, yes the europian surgeons have proven prp is not what Marx said it was. There are, as you say some decent studies that prove it is helpful for soft tissue repairs and improves bone graft in slightly infected areas. By golly, however, I'm still using my expensive harvest machine regardless. I do believe it allows you to handle your grafts with more precision. Dr. Sg. , I have said it before ,there are some perio guys and restorative guys in my town that do a damn good job at placing implants. My only little greif, is that they can't tx all the complications. I enjoy treating complications, so really don't mind it. Just wondering if the patients know this. I personally have found your advice quite helpful. Now ,how is that, for playing nice? Bv
Baker vinci
10/5/2011
Did you say 3 percent of pt's have titanium allergies? I'm sorry , I'd like to see a good clinical trial that supports this. Do you know how many people that suggest they are allergic to penicillin really are? Ten percent . This is a data supported statement . I'm calling a big B.S.. Bv
Baker vinci
10/6/2011
Dr. Wolanski, the treating doctor told us his diabetes was well controlled. If I am treating a diabetic( for a big case) , I will obtain an a1c. Assuming this treating surgeon was thorough and the patient' s dz is under control, then what you suggest has no validity, as far as integration time or healing. Now in your defense , if the diabetes has been long standing and he has subsequently suffered peripheral vascular disease( he has had cad),from poor control in the past , then you may be correct. The Amreican association of diabetes and more importantly the JDRF( it's juvy) counterpart, have come a long way in making the dz very manageable , and believe it or not , they are on the "cusp" of a cure to this dreadful dz. . You really can't make a broad generalization , however, on every diabetic. If their dz is well controlled,they generally are at no more increased risk of any of these things. This is one reason we as doctors of dental surgery, need to look at the entire patient. Bv
Dr Joe
10/6/2011
I would also suggest to try and figure out how many uses you had out of the burs. Were the new , did they have a lot of use , a dull bur will burn the bone with good irrigation every time. Good Luck
Mark nartey
10/6/2011
I was wondering why cipro was not added to the clindamycin for a more comprehensive coverage
Robert Wolanski
10/6/2011
Dr Vinci
Thank you for your excellent insight
For me it is about risk factors and the unknown
Most of my older patients with diabetes admit they do not know when their diabetes started. Some patients have co diagnosis that leave me suspect. Many of them share reports of delayed healing. This is why I error on the side of caution. My patients seem to appreciate it. Thanks again
Dr. J.O.
10/6/2011
I agree with some of the doctors above, there is no need for bone augmentation/ridge preservation in this case. Trim the alveolar bone, reduce the ridge height to a 6mm broad base. I very often do this, from premolar to premolar area. No bone grafting. It would be nice to see a full view panoramic x-ray. Then I wouldn't use Nobel Biocare implants. They are very unforgiving. Did you use Groovy or Tapered TiUnite? I have had problems with those. The patient can wear the soft relined denture immediately.
Baker vinci
10/8/2011
To clear choice doc, tell me what I'm hearing isn't true. Implants advertised at 700 dollars. This looks like the same BS that the optho guys went through some time ago when lasix became voque. You know , there was one absolute in that scenario; almost all of the undercutting docs were not board certified. I was told that the advertising is gross misadvertisement. Please tell me I was Misinformed. Bv
Baker vinci
10/9/2011
I investigated , and all the clear choice guys seem to be pretty credentialed. Oh , well no need to respond . Bv
Bend Family Dentist
10/18/2011
Chronic hyperglycaemia affects different tissue structures, produces an inflammatory effect and, in vitro, has been shown to be a stimulus for bone resorption. Bone loss in diabetes does not seem to depend so much on an increase in osteoclastogenesis as in the reduction in bone formation. Hyperglycaemia inhibits osteoblastic differentiation and alters the response of the parathyroid hormone that regulates the metabolism of phosphorus and calcium. In addition, it produces a deleterious effect on the bone matrix and its components and also affects adherence, growth and accumulation of extra-cellular matrix. Mineral homeostasis, production of osteoid and, in short, bone formation has been shown to be clearly diminished in various experimental models of diabetes. I generally like the HgbA1C at 7 or less for at least a year before considering an implant but obviously this cant always be the case. DM patients are truly at a higher risk for failure
Baker vinci
10/20/2011
Dr. Bend, nice med search. You are exactly right! Poorly controlled DM is a nightmare from every perspective. Well controlled diabetes however, allows the patient to live a relatively normal life . My oldest of four had had insulin dependent diabetes since she was 14 months old. Now she is a 14 year old freshman, playing v-ball,making good grades at the toughest school in baton rouge, and has not been hospitalized since diagnosis! We are on the cusp of a cure! If you ever have a chance to donate to an organization , their is none more worthy than the juvenile diabetes research foundation. Bv
Baker vinci
10/20/2011
So dr. Bend it is our respnsibility to see that these patients are managing their dz. , just as you suggest. If we are placing impants in poorly controlled diabetics ,we are doing the industry and the patient a disservice . When I place Implants in a diabetic there is no increased risk of failure, aside from the vascular damage that may have occurred previosly. Data driven studies prove, that tightly controlled diabetics are at no increased risk of surgical complications. If you look at the original question , you will see the treating doctor stated , the patient has well controlled type 2 diabetes. This is an absolutely different "beast". Your comment caries with it, volumes of truth and should be something we are all aware of. If not , I encourage everyone to read your blog again. Bv
drais
10/21/2011
I totally agree with Dr.Baker vinci ... i am impresses u r very much confident.
drais
10/21/2011
that was impressed
Baker vinci
10/21/2011
Drais, I read a lot and call colleques and old professors all the time. I seek assistance from other surgeons and advice from any knowledgeable surgeon or dentist. I measure twice and remeasure, on every case. I get the assistance of LSU residents every chance I can and learn, even from them. I am very confident, but I treat every case like it's my last. To suggest any of us knows it all is laughable. Hope some of my opinions are helpful. Thanks bv.
Baker vinci
10/24/2011
Dr bend, are you from Sweden? You look familiar. I lived there in 1985. Just wondering! Bvinci
Baker vinci
10/29/2011
Dr. M , why did you extract his teeth in stages? Do you not think perfuming this procedure with light iv sedation and monitoring would be the best, for your patient. I'm afraid you have " pushed the envelope" a bit too far. One surgery,with immediate implants, that engage cortical bone ,is the standard of care in my area. This patient should not wear anything at the mandible ,for at least two months and since he has failed once already, three months. This is a short period of time , relatively speaking. The cost of this service just tripled and now the guy is edentulous for half a year. This is when short cuts bite us in the rear. Remember you are not the person that neglected his teeth, and " good care" sometimes is inconvenient. Certainly, we can learn a lot from a case like this. Thanks for having the " guts" to show it! Bv
Richard Hughes, DDS, FAAI
10/29/2011
There are several possible reasons for failure! The implants possibly failed under load and should of been placed deeper. You may not of had proper fixation. There could be an IL1- alpha or other interluken factor. The BioOss and mineross do not turn over and make bone, they resorb very slowly, if at all. You should of used something like Osteogen, which does turn over and is bacteriostatic. You should of checked the HbA1c.
Baker vinci
10/29/2011
Dr. Hughes, why wouldn't you use bone morselized from alveoloplasty . If the bone reduction was appropriate , he could have done the case without grafting at all, most likely. Bv
Richard Hughes, DDS, FAAI
10/30/2011
That can de done. I do not like to use bone from periodontally involved teeth, due to the high chance of said bone being contaminated.
Baker vinci
10/30/2011
This is the exact reason active perio dz. Is the number one contraindication( or one of the reasons) to placing implants. This is the reason I mandate a thorough cleaning and followup before I proceed with extractions . One perio guy suggested that the dz is treated when the teeth are removed. You have made my point. So, if what you suggest is true , why not clean them up, provide some oh education and use gold standard bone? You can also provide your patient with more efficient care, buy operating just a single time. Time is money , for both us and our patients! This is just one way ,we as doctors can reduce the burden of waisted healthcare dollars, and reduce the risk to patients. Bv
Richard Hughes, DDS, FAAI
10/31/2011
The Italians have been placing implants in smokers and people with perio for years and with decent results. So it is not always perio that causes the failures.
Baker vinci
10/31/2011
Dr Hughes , decent results don't cut in " the states". The reason only 1 percent of all applicants matched to accredited oral surgery resedencies in the late eighties was because our forefathers never settled for fair results. It is still considered substandard care to place implants in heavy smokers or patients with active perio disease. Are you a periodontist? Do you not see why some surgeons might consider it a conflict of interest for the endodonist and periodontist to place implants without making every effort to save the tooth or eradicate active perio disease , first. If you are not a periodontist and you don't mandate erradication of active disease first, then you are just plain sloppy. Sorry if this offends you, but it is our responsibilty to see that these patients are "tuned up", before doing any elective or medically necesssary surgery. I've presented this math before ,but if your success rates are 84 percent, then 16 out of one hundred implants fail and 160 out of 1000 fall out. I'm not boasting ,when I tell you I have lost 7 implants in 18 years, but I guess what I'm suggesting is ,our patients deserve more than myopic medicine. Some are seeing an empty space or missing teeth, where some are seeing a patient in need of comprehensive dental care. By forcing patients to discontinue smoking of eradicate active chronic infections , we are actually saving lives or at least improving peoples quality of life. Sure you have gotten away with practicing the way you do, but are you not interested in " upping your game"? If not what are you doing on this site. Certainly , some of those letters behind your name mean that you have at least attempted to go the "extra mile". I hope you don't take this personally, but we know way too much to not consider the obvious. I'm going to suggest you read the "china study". Hypocraties said "food is medicine". What he meant by that, was ,we are responsible for the toxins that go into our bodies, and if we don't direct our patients, who will? Yes , I'm probably going to place fewer implants than you, but I am willing to wager a wad on the success of mine vs yours. One opinion, from one omfs. Bv
Richard Hughes, DDS, FAAI
11/1/2011
Vinci, get off your high horse. I was just noting what is done in Italy. I do not subscribe to the Italians.
Richard Hughes, DDS, FAAI
11/1/2011
Baker Vinci, relax! You may pop a blood vessel.
gautam peswani
11/1/2011
dr baker, strong words eh! hold both u and dr hughes in high regard and like the sparring that goes on.for neophytes like me this is a site where learning is the order of the day.
Dr. M
11/1/2011
Would it be helpful to post pictures of the surgical removal of these implants? I could then continue to provide pictures as the case progresses.
Baker vinci
11/4/2011
Dr Hughes , certainly you understand that we need to have a genetic predisposition for cerebral annuerism. I would also have to have a congenital pseudo-annuerism ,hypertension and or hypercholesterolemia . I promise you,that corresponding on this site does not raise my baseline blood pressure one mm of mercury. My diet is based on moderation and I have exercised daily for the last 35 years. Am I "riding a high horse", when I suggest that the science of placing foreign bodies in human bone requires certain parameters,and those that don't except them ,shine a poor light on the industry? I prefer not being compared to the Europeans ,in that every time I cross over the great ponds,despite the beautiful people and views,I come back and hit my knees and thank God, I'm from the USA. Don't worry, my circle of Willis is fine. You have good weekend now. Bv
Baker vinci
11/4/2011
Gautam, if you start to get involved,just remember ,none of this is personal. I agree with you, there is a lot for us to learn. Short cuts are just that. Bv
Baker vinci
11/5/2011
Dr. Hughes, certainly you know that greater than 87percent of cerebrovascular accidents are "dry" , so I'm more likely to stroke by "lobbing a thrombus". This is one of the reasons I was do hesitant to suggest doing anything to the 90 plus year old that wasn't necessary. As I tighten up my laces on my golf shoes, I will only play with 14 clubs, I will not improve my lie, I will not ground my club in a hazard. These all seem trivial to the weekend golfer, but could you imagine if tiger woods did this at the British open, On live tv.? Well ,he is in the "big show", so it really matters, even the minutia. We are on the " big stage " , daily. I'm trying to shoot 58 everytime I tee it up. Usually when I here someone say relax, twice , they should be looking into a mirror. Let's not take that route. This part of the business is fun. I do not take any of this personally. Sorry for suggesting you operated like the Italians . I thought you were from Italy. Fore!! Bv
Richard Hughes, DDS, FAAI
11/6/2011
BV, like you, I am cautious and take my patients well being into account. I was making the comment because the Italians are getting decent results. They also have some good surgeons, just a side thought. Keep on playing golf by the rules. It is a great game.
Baker vinci
11/6/2011
Yeh , shot 74 yesterday and 84 today, by the rules. You know what the difference was in the two rounds? Today I didn't pay attention to the details , just on a couple of shots, and the bottom fell out. Also some of the guys I was playing with, wanted to play the course 7000 yards. This is out of my envelope, so my results were no where near par. Think there is any correlative? That question was rhetorical. Have a good week! Bv
Baker vinci
11/7/2011
To dr. Keith vanb., are you not sterilizing your handpieces? Regardless of wether there is bone or not in the irrigation port, if it is sterilized it's not going to cause an infection . Not only does the sterilization process kill spores , bugs, and funguses, it also renders the DNA helix, untranscibable. Where are you practicing? Certainly that was just an oversight. Are you letting your office manager get into your emails? Bv
fawaz
11/10/2011
i think that the above case is not indicated for the implant from the begining ... and all the above method of tretment should not be done
