Problems with Bone Level Implant: Any ideas?

All these patients medical classification are either ASA I OR II so I don't see any issues there. I neglected to mention I would also appreciate any constructive advice re. treating cases 1 and 3. Thanks

PSS.: BOTH case 1 and 2 involved internal sinus lifts.

maybe case #1 on the tissue level implant but the bone level implants i don't believe that is the issue.

Cases 1&2 have the transmucosal collars buried at bone level, the bone won't adhere to it so you get this type of dieback. I would call these Straumann knock offs not Zimmer. Case three shows Periimplantitis which I would have treated earlier with LAPIP or an open flap procedure. First two cases are iatrogenic.

crs.....Appreciate the thoughts...so how would u handle situations 1 and 2? Do u believe the bone is stable around the implants in case 1? The tissues are pink pocketing WNL the occlusion is centric with no laterl forces and she wears a nightguard. 2 is recently placed. Can i back itout? And that still leaves the question of why the zimmer generic had early bone loss.? If i recall correctly 6 weeks is when the implant is still not integrated ( unless a roxsolid). Thanks.

I sense some confusion here, a tissue level implant is placed with the collar above the bone the polished surface will not have bone adhere to it. Case one is already integrated and the die back should be stable. Case two can be backed off to where it is supposed to be placed. The thread pattern is a Staumann knock off unless this is an Zimmer Advent knock off. I think you need to understand where to place a tissue level, perhaps looking at a Straumann manual online. Six weeks is when osteointegration starts and the implant is most vulnerable, regardless of it being a roxsolid. Implants are designed to be placed according to the surface specs and emergence profiles the first two cases were placed incorrectly hence the dieback. Case two did not integrate, and case three is not early bone loss but progressive periimplantitis over three years.

Re. case 3 I should add that for me the question is not what happened in case 3 but why the zimmer style developed peri implantitis and the straumann did not? For me I am a little spooked because since I have been using the zimmer type for the past 3-4 years I have had more problems than the iti bone levels I have placed in the past. I don't see any explanation for the problems with the zimmers placed in case 2 and 3.

Whew I'm relieved! For the primary closure issue on a transmucosal implant just undermine the flap or use a bone level. It is daunting to remember the surgical protocol for all the various implants. I had a similar problem twenty five years ago placing implants too deep and watching the dieback to the first thread which was deemed acceptable back then. We have better implants and better understanding of the abutment interfaces. The third case would be amenable to a grafting procedure with laser disenfection. What did the original site look like?

Its the issue with biological width and soft tissue attachment. Where there is poor keratinised or thin tissue we have seen bone remodel to establish biological width of 3 mm or so. case 1 & 2 fall into this category. As tissue level placed deep at bone level has helped to establish biological width. Also where poor keratinised tissue is present tissue level implant works better as healing color is not disturbed after placement in restorative stages. Case 3 is different. Probably u know what is the cause of peri implantitis. Many be thin biotype made u place a bone level implant to start with. What was the bone volume like? I use straumann regularly. At times i plan tissue level but end up placing bone level in mandible when observe thin tissue or have buccal resorption and tissue level implant be too lingually placed. Oral hygiene is also easier to matain in tissue level implant.Also less chances of tissue irritation with cement.considering age of ur patients these could be relevant aswell. In otherwords tissue level implant is less forgiving so we place these in more ideal situation. Hope make sense.

Hello friend, my opinion: If implants are zimmer, the problem may be the surface treatment MTX (containing HA, the inflammatory cells that recognize a noxa). and thus a prolonged inflammatory process that prevents a complete osseointegration at that level. Second distribution of adjacent implants. An internal hex connection implant should be placed at 3 mm distal to the next implant. By "physiological" cratering process around the neck. if the distance is less, the collapse will be higher. This is due to micro-movements occurring in the joint (connection) implant pillar, on voltage generated at the cortical level (es stresses are greatest in connection hexagonal cylindrical implants), which causes high resorption. The level platforms implants also plays an important role in bone loss, since this discrepancy generates generates tension because the levels of force moment are distant. causing reabsorption. And finally, the height of the abutment trasmucosa. when a abutement has the least 2mm transmucosal height, it is likely that bone remodeling cortical level is higher. when it is greater than 2mm. I hope you were able to help, best regards

Hi Gary, I agree that the issues in case 1 stem from the initial placement of the tissue level. In case 2 the first three thoughts that come to mind are; was the healing screw exposed, what was the initial torque, and was the patient wearing a partial/flipper while healing. It looks like the implant may be a bit supracrestal leaving the possibility of exposure to premature forces, ie partial/flipper. In the third case it looks like the bone level had it's micro-threads supracrestal early on, maybe when placed, but certainly when restored, leading to bone loss.

I think that in case #1 there could have been some pressure exerted by the tissue level implant at the crest of the ridge from the flare of the fixture that may have led to the dieback of the inter proximal bone there. Pressuer Necrosis? If the torque values were excessive for the insertion it would seem more likely to have occurred from this. The dieback from this alone would not be expected to progress IMHO.

Case #1 and 2 are bone graft failures. You can see the outline of the bone graft and that is where the lesions developed. In case #1 the broken up graft is floating in granulation tissue and when you remove it you will have a large defect on the distal of the anterior implant. I have never been able to repair bone graft failures. Greg Steiner Steiner Biotechnology