Rapid bone loss around maxillary anterior implants: advice?

My problem is not with how the implants look like on the x-ray, because they might be ok after all, and you may not need any treatment. I can't give a full opinion without a thorough clinical and radiographic examination. But here is where I see a big problem in your story: If the periodontist placed your implants without having sufficient pre-surgical x-rays in good diagnostic quality, and if a thorough clinical and radiographic exam is done by another independent board certified periodontist to get a second opinion, and if the second opinion results in diagnosing your implants with problems that could be the result of poor treatment planning due to the lack of good pre-surgical x-rays, and if the said problems require additional treatment such as grafting etc. then you may be able to pursue a malpractice complain in two separate avenues: 1) file a formal complaint with the dental board for a professional misconduct (substandard care), which may result in some kind of disciplinary action. 2) if you need additional procedures to correct the situation, then you may also file a law suit in the civil court for financial compensation to cover the needed procedures. Always look for specialists who are board certified by their American Specialty Board, and always look for independent practitioners in their own practices, and always read online reviews when they are available. Regards,

Hello. I'm sorry your stressed about your implants. Some more x-rays (include bwx) and photos would be helpful. What leads you to believe you have a fistula? Assuming you do not........ Going off the info we have now I have a few thoughts. The bone adjacent teeth will never be closer than 2mm from the cej. So we can't expect to see any bone until we measure at least 2mm apically from cej of #12. I can't tell for sure, but it looks like the restorative platform of the implant (#11) is about equal with the cej of #12. If so, a deeper placement would have been ideal. From this pa it also looks like #11 may be a little close to #12 . That could account for ( low blood supply)the vertical bony "re-modeling" distal #11. It would have been helpful to have seen the post-op x-ray too. If the metal showing through doesn't show when you smile and you are not getting more recession and or losing bone as time goes by, you might just try maintaining them. I'd recommend a Water Pik type irrigator and Super floss. I hope those were cogent thoughts cause it's late, too tired

This could be a case of pressure (avascular) necrosis, which is most unfortunate! This does need a surgical revision.

My qualifying question is Did you have any preoperative grafting prior to implant placement? The place where one can get burned with congenitally missing teeth is the lack of bone development due to the missing permanent teeth. It has not much to do with a board certified periodontist placing the teeth or avascular necrosis. It is about understanding the concept of congenitally missing teeth. Sounds like the person who placed the implants did not plan for this and now these implants need aggressive grafting, removal of the crowns and burying the implants and wearing an Essex to keep pressure off the grafts. This is a tough case to restore, chasing the bone. at three years I would consider these failing not due to perio but lack or site preparation which is key in these cases. Find a good surgeon, consider an OMFS ,to fix this who has experience with these scenarios sorry to be so harsh and bruise egos but I see this often in my practice. It is just the background and training and understanding the cause. It is not as easy as it looks. I don't have a clinical photo for soft tissue or a CT for buccal plate so please take my comments in moderation.Good luck!

I agree with CRS....however, I disagree that an OMFS is the only specialist who can help you. I am a periodontist and I often see implants which have problems that were placed by OMFS. It is not really the speciality certificate of the individual that is important here, but rather what is paramount is the experience and expertise of the individual practitioner. I think Dennis Tarnow is a periodontist, and I would trust my implants in his hands in a heartbeat. I also agree with the first few postings....it sounds to me that the standard of care protocol was grossly not followed when these implants were originally placed. I wish you all the best. DrT

Good post! Too often we see these results characterized as peri-implantitis. My experience is that bone loss in the absence of inflammation is often a sequela of stress to the bone's blood supply during implant placement. If the ridge is too narrow to accept the implant, it becomes thinned and the vascular network breaks down resulting in remodeling. I have received patients from very good oral surgeons, periodontists and general dentists with the same problem. There has been much recent discussion in implant/restorative groups about using narrower implants in the anterior maxilla because of these issues. If it is remodeling, then hopefully this is where the bone is happy and it stays put. Unfortunately, once the roughened surface is exposed, the bugs have a place to hide and inflammation is more likely to develop. An option is to seek more esthetic restoration and live with the loss. Surgical correction is really unpredictable. The disappointment is the lack of proper records from the parties involved. There really is no excuse for not having the minimum of a diagnostic pre-op image and a post-restoration image. Any attempts at diagnosis of future health or disease are limited without a baseline.

Hey 'board certified periodontist', I cannot help but to say shame on you to tell this nice lady to go complain to the dental board. I am sure you place perfect implants in your office at 100% successful rate, you may go to other website for that. She wants some answers and i would tell her to seek another dentist to get it treated instead of trying to talk bad about other dentist pal!

1) Please also post the X-rays of the other three implants placed by this periodontist and restored by your dentist that have no problems. 2) Placement appears to be perfectly placed, sinus floor expertly engaged by one of the implants, both appear to have 'platform switching' built-in. 3) Crowns appear to be cemented type. Correct me if I am wrong. 4) Bone loss was only noticed in the third year and that too accidentally. Are you not going for regular recare/follow-up appointments with your dentist/periodontist? As a dental hygiene student, you probably understand the importance of re-care more than anyone else? I'm sure you did not assume that implants do not need maintenance? 5) Horizontal bone loss after the first year around an integrated implant is either due to incorrect occlusal load or large gobs of cement overhangs (not always seen on X-rays) or very poor periodontal hygiene. Definitely not a failure of osseointegration. 5a) An implant does not integrate fully first and then start to lose bone because of avascular necrosis from incorrect placement torque. If that were the case, it would simply not integrate in the first place. No question of the restoring dentist proceeding for a crown. 6) It does appear that the periodontist's record-keeping is inadequate, from your story. 7) yes, usually congenitally missing teeth areas typically do not have a lot of vertical bone loss, but horizontally, bone is always less than if a tooth had erupted there. This morning, I placed an implant in a 1.3 location (upper right canine) where an over retained primary canine was removed 2 years ago by her previous dentist. X-rays showed beautiful bone, and we planned a 3.75 diameter (No, we don't always insist on a CBCT), but guess what? Raised a flap and saw a very thin ridge bucco-lingually. Barely could place a 3.3 mm Narrow Platform with bone grafting to bulk up volume. Will see how it goes in next 3 months. 8) Have you learned about 'probing depths'? Can you post some numbers along with the other information? Also mention if you (or your classmate) finds pus in the pocket around the "failing" implants. 9) Have faith in the profession and those who will eventually be employing you. Your summary in your post "Since my teeth were congenitally missing and not missing because of infection the bone would be at its normal level. I am almost positive that I do not have peri-implantitis, and this is due to inadequate surgical preparation, incorrect installation, fracture of the fixture, or inappropriate prosthesis design...." shows half knowledge of the subject and your hurry to rush to a diagnosis when you obviously are not trained for it and your need to blame it on someone other than yourself (and I'm not saying this is your fault either) tells me you have not even gone to see your restoring dentist or any dentist for that matter for your current concern. Have you?

Quick questions 1. How often do you get a routine prophylaxis? 2. Do you get any food impaction around these implants? 3. Do you smoke cigarettes? 4. Any medical Issues? Ie diabetes, overweight?

Encouraging a lawsuit and a board complaint right out of the shoot?! Most people are pretty reasonable, talk more with the periodontist. Problem solve with him, maybe show him this discussion. Without more info, photos and x-rays, it's hard to give much more advice, but it may be worth considering smoothing the threads making trans-mucosal segments, then redoing the crowns for esthetics. I have a feeling that the bone will stabilize.

i think the best person who can help you is your own peridontist , he knows what he has done and i am sure can solve the problem in a better way

CRS is right , congenitally missing teeth cases are a lot more complicated due the lack of development on the cortical bone and as a result you have a deficiency bucco lingually with a concavity . Maybe this case was treated with expansion and the Implant placement closer to the adjacent teeth would suggest that the surgeon placed where the bone was the thickest .... But grafting is critical in these cases , particulates at the time of expansion and placement or else this can happen.... A challenging case to correct ... As they say the only "failures " are other Dentists Implants.. Peter

I like to see this interest in this problem case. In my experience, 25 plus years, the labial-lingual dimension is often very thin with congenitally missing incisors. Since most of the remaining bone is cortical rather than cancellous the repair potential is compromised. Often a ridge split procedure can gain the necessary bone dimension. There is always the risk of losing vertical bone height with any procedure in that area. Of course any well done grafting technique can increase horizontal bone, but many patients are strongly opposed to grafting, so it doesn't always get done. Vince Kokich had several cases where he moved incisors into congenitally missing spaces to sort of force the increase in bone dimension, then he would move the tooth back to where he needed it and an implant was placed in the widened space with good long term success before the site could narrow or relapse to former dimension. These implants appear to be placed by an experienced surgeon.

Yes sorry meant cancelllllous bone ......... speed typing between patients ..

I agree that there are some anatomical limitations in this case. I also agree wholeheartedly that in spite of our best efforts, thing don't always end up the way we had hoped. I think that a critical issue in this instance is whether standard of care protocol was followed both during the diagnostic phase of treatment as well as in the post operative phase. Based on the information that we have been given by the poster, it seems to me that the answer to both of these questions is No. If this was a close relative of mine I would advise her to request copies of all clinical notes relative to these implants including all x-rays and digital images from both the surgeon who placed the implant fixtures as well as the general dentist who restored them. I would also recommend getting copies of all of the maintenance appointments that have occurred since the implants were placed.

Good to see that Board Certified Periodontist Megalomaniac has never encountered a loss. The young lady did not ask how best to attack her periodontist and inflaming the situation with such blatant comments is not warranted. The problem may be that the crestal bone was very narrow and there was not enough bone for proper blood supply to the system. The bone has resorbed possibly to a stable position where there is enough bone to help maintain the blood supply. Taking off the crowns and placing cover screws and then grafting over the implants and defect is a very risky proposition. Very difficult to get vertical bone height over the threads. There is no research that shows that bone actually will grow to the implant after this sort of repair.and realistically there is probably a fibrous connection and not bone. The system may be stable now because of the potentially greater amount of bone around the implants than in the beginning of implant placement. I would recommend to wait and see if there is more bone recession over time and make sure that the area is irrigated well with chlorine solution with a water pic device. If the bone loss progresses then remove the implants and graft.

These are cemented crowns with marginal openings and most likely excess cement. The abutments are more than likely over contoured given current thinking. Rather than rushing to litigation, remove crowns, place ideal contour provisionals, see what the soft tissue response is and make decisions form there. Any surgical decisions at the moment are clouded by possible prosthodontic problems.

Here is my treatment plan flap open site graft hard and soft tissue may need to remove crowns and leave buried. Then in four-six months evaluate if continued bone loss remove the implants and start over that will minimize the amount of total bone loss. I don't have a clinical photo to evaluate clinical placement or soft tissue but based on the film they are failing. Usually the placing doctor fixes this vs allowing the continued bone loss or they need to refer appropriately all this speculation won't solve much. That is how these cases are managed.

I think you need some comparative readiographs to compare bone levels to, purhaps one taken after restoration of the implants. there are two schools of thought on bone loss on implants 1. watch and wait and 2. intervene early to limit further bone loss, in this case I would intervene flap the area and do an ailing implant treatment of the implant surface that is exposed (after granulation tissue removal, condition the implant surface with doxy paste then bone and implant surface with citric acid then place graft material and a membrane and close it up and let it heal

Agree with Gregori, however since you did not place the implants there is a considerable fee. If the initial surgery dies not work then remove before the loss is worse, with the remover kits available we don't have to wait. Also may I mention ruling out occlusal factors!! The key to this bone loss is usually multifactoral. Since the original "surgeon" is not helping I am suspect on the follow up maintenance perhaps they don't want to fix this appropriately. I thought this was part of managing peri implantitis. We don't know how an implant will fare until we restore it, but I would intervene here. It would be interesting to see a photo or study casts to see labial-lingually if the implants are in the alveolar housing also a ct to view the labial plate!

@CRS- Your ideas are ALWAYS on point. Here are my thoughts - Tough case to repair. Ideal course of action is remove crowns, untorque abutments, place cover screws. Thorough curretage of affected areas. Flush affected areas (I use hydrogen peroxide on sterile gauze). Place bone graft. Lay over PRF membrane( autogenous fibrin membrane from blood centrifuge), then cover tightly w/sutures (preferably PTFE) - Congenitally missing teeth area always problematic. When teeth fail to come in, bone shrinks (or perhaps never grows in). Bone growth follows teeth growth. - I DISAGREE W/CRS regarding bone graft pre-implant placements. In my experience, you can often skip this step. SPLIT RIDGE+ SPREADERS are a godsend. Very important for these borderline cases to flap it very wide so you have good buccal/lingual visibility. 2 buccal releasing and lingual envelope flap--- If you do indeed perforate, you can visibly see it. At that case, remove implant and place bone graft. - Less aggressive option- It looks like you have 3-4mm of bone-loss on a 11.5mm implant. While this isn't ideal, it often can work for a good amount of time. I would get have them flap the area, curettage, and flush w/antibacterial solution (hydrogen peroxide or CHX), the suture up. Maintain hygiene and regular check-ups/Xray. Treat it like as if you were a perio patient w/6mm pockets. As long conditions doesn't worsen, do nothing.

Having 35 years of implant placement and restorative experience, I would suggest you take full arch impressions, facebow transfer, cr bite, and mount the case on a semi-ajustable articulator to evaluate your occlusion. As we know, anterior guidance and the excursion pathways if not properly worked out with the physiological harmony of the patient can destroy bone around implants or natural teeth. I personally would have splinted #10-11 and require an essix type nightguard in your case. Improper occlusion or excessive loads can make bring any of us to our knees.

What I see here is 2 implants placed adjacent to each other in the maxillary anterior which never works out cosmetically except for central incisors because there's no contra lateral papilla for the eye to compare to. You just can't maintain interproximal bone between implants to support papilla well. Everybody is trying to do it. Even with crestal bone preserving implants (platform switching, Astra). Granted there's more bone loss than the norm here but so much we don't know. 1) what was the bone levels at the time of healing abutment placement? And prior to final abutment placement? 2) what's the buccal-lingual inclination of the implants? 3) retained cement??? Implant the cuspid and cantilever the lateral is always my first plan.

I agree with Barry and others, "So much we don't know." Full work up needed first for more accurate determination of current status and remediation, hopefully minimal. But great commentary on potential scenarios.

I'm sure we all know a 3d evaluation would be the first thing to have done. Everything else is conjecture at this point. 2d imaging tells us nothing except if we missed the neighboring roots. Occlusion , cement, buccal placement with no facial protection, angulation ,explant or graft ? -- Personally, I think Post op conebeams should be the standard of care, especially if you are going to restore or "fix" an implant placed by someone else. I would want to know it is in bone and how much buccal bone is there. The fact that she can see the abutments through the gingiva could mean too far buccally . If outside the boney housing- particularly # 11- you can't graft and gain anything over the implants due to the lack of neighboring horizontal support in the arch since the cuspid is the most prominent of the teeth.