Rocking crown or implant ?

A little more info about the case: Patient has paresthesia in right mandible and slight pain and swelling palatally associated with maxillary implants. How should I assess the prognosis of these implants and what is the best treatment I can give her. Thanks in advance.

This is a very tough case you are basically trying to correct poor technique. The lower implant should have been removed or backed off immediately it is impinging on the nerve and is too long. Doubtful at this late stage that it is reversible. The maxillary splinted implants were most likely a hygiene issue and need to be removed and the area grafted. The short answer on whether it is the implant or crown that is loose is often pain. Painful is usually the implant is loose. A flap will need to be raised and the abutment interface inspected. It is a no win situation since the crowns will need to be sectioned off and the implants removed if mobile. Check for retained cement. This patient has significant full mouth periodontal bone loss which needs to be treated. Be very careful on correcting this minefield. Patient needs to be well informed and consented. I would also if possible to get the former records all information is helpful and to get both sides of the story before 20:20 hind site and judging based on current films. I have gotten cases like this very important to get the patient informed and establish trust.

There is a distinctly different feel in the looseness ....... it has a metallic rattle .....but generally if painful then Implant failing .....this is only a screw issue I think

It may at first be difficult to evaluate which is loose. Remove the crowns. If the implants are firm, then flap, detox the implant surfaces and graft with a particulate graft material. Do not load till the graft has matured. Follow the concepts the occlusal concepts by Misch. If the implants are lose one may screw the implant in deeper then detox and graft and load after graft maturation. If not then remove, degranulate, detox, graft and reinsert the implant later. Make sure there is sufficient bone on the buccal. Evaluate the LDL cholesterol, Thyroid levels and Vit D2 levels. One must have control over occlusion and bruxing. Hygiene is also a consideration.

With the uncontrolled active periodontal disease in this patient's mouth, along with the extensive bone loss around the UL implants, I think the prognosis for bone regeneration around these 2 fixtures is slim to poor. I suggest remove these fixtures and treat the active periodontal disease, and then consider new implants for the UL.

"If the implants are lose one may screw the implant in deeper then detox and graft and load after graft maturation. If not then remove, degranulate, detox, graft and reinsert the implant later. " Could you elaborate on this advice in more detail. Please.

I think I might not want to be screwing the implants in any deeper. At least one of the maxillary implants appears to be in the sinus and the other is right at the membrane and the mandibular implant is already impinging on the nerve. Rather than screwing them in deeper, maybe it is time to remove them, treat the periodontal disease and at some future time, if all is healthy in the mouth, consider implants. Sometimes you gotta back up and take a look at the full picture.

Thank you everyone for your suggestions regarding the case. It has definitely helped me clear all my doubts and made me think about the larger picture. Its indeed a great platform to discuss and learn. Good work osseonews!