Bone resorption and possible abscess: what to do?

I am a resident in surgery and I am the patient. I had lost 2 Molars because of dental carries many years ago. My dentist recommended that I replace my missing mandibular first molars #19 and 30 [mandibular left first molar, mandibular right first molar; 36, 46] with implants, as they are the best substitution for the natural lost teeth . He told me that he has a very good deep experience in this field.

On August 2013 he operated on me under local anesthesia. It was clear to me through the operation that he has zero experience in this field. His hands were shaking (tremor) , he had no idea about infection control. But, it was too late as I was already in the chair. At the end of the operation he closed the wounds but there was adaptation failure. Therefore, it took about 2 months until the flap around #30 healed. After the operation I had swelling bilaterally , but it disappeared in 10 days. I had taken 2 antibiotics prophylactically. I did not have fever.

Yesterday (7 months after the operation) I did a panoramic radiograph (see below) to check up before continuing. I saw 2 areas with bone resorption and one suspicious area that looks to me like an abscess. What should I do? Is that really an abscess? Clinically I have no complaints. Should I have the implants taken out? Should I proceed and have the abutments and the crowns? Thoughts on the bone resorption?


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21 Comments on Bone resorption and possible abscess: what to do?

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CRS
4/2/2014
Sorry to hear about your difficult experience. What you see on the panorex is bone dieback which could be from several factors based on the timing and your history. First off it is unusual for a flap to take two months to heal usually it is closed primarily and since these implants are so deep there should not have been an issue. Now I don't know what the edentulous sites looked like previously but the implants appear to be placed too deep which can cause bone die back usually they are placed at the crest and in relation to the adjacent teeth which sometimes requires some grafting. It is possible however that this is what existed prior to placement and some site preparation may have needed to be done, this is conjecture on my part since I don't have a preop film. This can also occur in the best of hands due to quite simply how you healed. But now there are crestal bone loss defects which need to be grafted by someone experienced in this prior to restoring the implants. Trying to remove these integrated implants is not advised they are deep and long and it would be difficult. So I would perhaps seek a referral to a more experienced dds who can manage this. It is also appropriate to ask your dentist about his training and experience perhaps show you his credentials and perhaps query him on what he thinks happened, that way you can make a more accurate assessment. I was not there so I don't really know what happened, only have your side of the story and a post op film to go on. But please don't lose heart I think these implants are very usable if the defects are grafted and restored in experienced hands. Good luck.
The Patient
4/3/2014
First of All thank you very much for your kind reply ... As I mentioned previously I'm a resident in General Surgery Department (Medicine) with no experience in dentistry , I moved to work in Germany ... and was operated before traveling in my Homeland and then I took the Xrays with me to Germany , at the moment I'm in a vacation in my Homeland and unfortunately I forgot the preop. films there in Germany ... but I can upload it in 3 weeks ... As I remember the Implants were almost at the level of bone crest level , and as I remember there was no bone loss before the treatment ... Flap healing took 2 months because of adaptation Failure (left side) , it was like a secondary intention healing , but the implant was never exposed , there was always granulation tissue above the surface of the Implant (left side). I was in my doctor clinic again before few days and he told me that he assumed that the cause of bone loss is the delay in proceeding ... he said that the abutments should implanted on the 3rd or maximum 4th post op months , and as waited for 7 months , I got the bone resorption ... He told me that the implants are long and stable ... and he thinks that we don't need to do anything , and we have to proceed normally ... He told me also that I have to do xray check in 6 months and when bone loss is progressive then he will do the bone graft ... he said that he can do bone graft through a lateral small incision and he will not have to take the abutment and the crown out !!! I don't know if this scientifically possible or not !!! At the moment the gingiva looks pink and healthy with no pain or redness ... he gave me an appointment for Caps Healing implantation in 2 days ...
CRS
4/3/2014
That's just not true, there is bone loss not due to delay in proceeding. I would fix it prior to loading it would be easier. Poor advice. At this point I am not going to comment further just reread my posts.
JB
4/2/2014
Position wise, the implants don't look too deep to me in comparison to the CEJ of the adjacent teeth and are nicely parallel. It would be helpful to see some preop images. Definitely have a fair amount of bone loss going on that will need to be addressed, but I don't think there is an abscess. As for the post op swelling, you are trying to be a surgeon and should know all about inflammation and such. When you say it took 2 months for the flap to heal do you mean it healed with the implant exposed and was repositioned? You do seem to have a lot of caries on other teeth and some other restorative problems. If it were me, I would focus on keeping my existing teeth healthy and present before worrying about replacing teeth that have been missing for many years. Just my opinion.
CRS
4/3/2014
You know these are some interesting points, caries on impacted wisdom teeth with distal pathology #17, recurrent decay and a few open margins. I was taught in dental school it is the dentists responsibility to proceed with caries control first and/ or periodontal treatment if needed. I don't know how the decision to place the implants were made but I feel it is squarely in the control of the treating dentist to determine the treatment plan. I see this a lot in my speciality practice so I can't judge how the decision was made with the "implant goggles" on. All I can go on are the points mentioned above and two deeply placed implants with early bone loss and quite a surgical story. Unfortunately I have seen the rush to place implants by inexperienced dentists then defense of the complications and /or unexpected outcome. I find that if implants are placed in sites well prepared, at the crestal level with a good emergence profile and good follow up and oral hygiene success is more likely. The implants are well below the CEJs of the adjacent teeth which is usually not preferable in the molar areas. I don't think it is fair to assume that this patient only wanted implant replacement since the treating dentist should have control of the treatment protocol even if the patient insists on a particular treatment. Just MY opinion Thanks for reading.
The Patient
4/3/2014
Thanks a lot for commenting and your interest to help me ... I'm a resident in a general surgery department (medicine) not dentistry and I don't have experience in dentistry ... so I apologize if I described something wrong or not precisely ... Flap healing took 2 months because the wound was not properly closed (thread was too loose or not good knotted) , I was operated in my homeland and after 3 days I had to travel to Germany were I work , therefore I couldn't do check up with my doctor ... I noticed that the wound is open (left side) but there was always granulation tissue above the implant (the implant were never exposed) ... I was also with a dentist in Germany but she advised me to let the wound for secondary intention healing as I had no inflammation ... Regarding the other problems , my Dentist told me that I have caries in Molar #18 and I was treated , otherwise he didn't told me anything !!! so if you please tell me where the other problems are , so I can treat it ... Thank you very very much for your Help ...
Richard Hughes, DDS, FAAI
4/3/2014
I would like to see pre op radiographs of the sites. That said, consider flapping mad degranulate on, detox and grafting with a particulate material such as OsteoGen. Close with tension free primary closure. Difficult to say with a pre op film. CRS makes valid points.
rsdds
4/3/2014
#30 needs grafting something happened there but it should be very simple to fix with a little experience in bone grafting.. In reference to # 19 it shows some sauceration which to me is normal bone remoldeling that happens when you place an Implant in an edentulous space between 2 natural teeth if the soft tissue looks pink and no significant pockets I would restore it.. I agree with CRS it looks like #19 was placed a little too deep but its hard to tell without pre op xray
The Patient
4/3/2014
My Dentist told me that he prefers not to do bone graft directly , he said that the implants are long enough and stable and I should do xray again in 6 months , when the bone resorption is progressive then he will do bone graft through small lateral incision !!! Is it possible to do bone grafting through lateral incision without taking the abutments and the crowns out ??? Thanks a lot for replying ...
Pynadath George
4/3/2014
I believe we should not be basing our opinions on the little information that is being given here. We cannot say there is bone loss unless we have access to pre op X-rays of the areas to assess bone levels previously. However there are a number of facts that can be said. It is unusual for healing to take 2 months for the soft tissues. It is also unusual to have implants placed in this mouth when other issues need addressing, such as the radiolucencies in the other teeth. It is also unusual to not have implants upto the crestal bone. However does this all mean the implant need replacement? We need further info. If they are integrated and solid I would not take them out. If you have lost confidence in this surgeon, find another.
Anton Andrews
4/6/2014
Your treatment plan has serious flows; Among those are: 1.the sequence of the dental procedures: caries control to establish prognosis of the remaining teeth. 2. Wrong choice of the implant diameter on the lower right side - to narrow to support 10 mm+ wide crown. This will eventually cause the one or combination of the following complications ; screw loosening, abutment fracture, implant fracture, further bone loss at the neck of the implant , food trapping due to poor emergence profile from such narrow implant table etc. Possible causes of the existing bone loss are : buccal bone atrophy occurred PRIOR to implant placement and not addressed during the surgery; Bone overheating; excessive compression during final torquing of the implant etc.
CRS
4/7/2014
I agree with the treatment sequencing, but we were not there during the treatment planning discussion. I think one has to be careful when jumping to the quick fix in extra wide implants fixing everything. There has to be adequate live bone supporting the implant to maintain it if all the surrounding bone is removed to support an inert implant it will fail. Also the multiple problems cited are related to several factors, occlusion, depth of placement, emergence profile and restoration. The timing on when these things happen aids in the diagnosis. For example pressure necrosis at placement usually rears it's ugly head very early on within the first few weeks, these implants are appropriate size but I feel were placed too deep or that the crest was not grafted at surgery. I was not there but can only speculate. There seems to be a consensus on placing implants deep, and using wider implants to prevent problems with restoration and fracture but this is not accurate. One needs to understand the surgical parameters, occlusion and biology vs just placing a wider implant which is looking at it from a technicians or mechanical viewpoint. And by the way based on this panorex only this case should have been a slam dunk in experienced hands, but I understand that healing cannot be controlled.
DENTOLOGY
4/11/2014
CRS I think that now, after you visited my website and saw results of Russian AAA technique in combination with 7+mm implants , you might be not so confident, opposing wide diameter implants :).
CRS
4/12/2014
I can't make any evaluation on a triple A technique since no one seems to know what it is and it appears you may have a sales agenda and are using this blog to promote some technique that you invented and plan to market a course on. I can tell you that my advice is confidently given based on education, experience, and humility. And by the way my credentials are superior to yours but I have the grace not to compete with you.Your website does not post any three dimensional films to evaluate the buccal plate, nor how these implants fare with time. I would advise not posting other's failures I feel it is unethical advertising. Perhaps you may consider more conventional avenues such as submitting your technique to a peer reviewed journal vs leading everyone on this blog as a dentist looking for a solution to a clinical case vs someone with a promotional agenda with a case already treated and asking questions that you already have answers to. No one enjoys being mislead.
Gregori Kurtzman, DDS, MA
4/8/2014
I do see the crestal angular bone loss and IMHO this should be addressed prior to restoring these implants. My recommendation would be to have the site flapped, clean out any granulation tissue, treat the exposed threads of the implant with citric acid to detox the surface, then place an osseous graft completely covering the implant to the height of the cover screw, place a resorbable membrane and get primary closure and allow it to heal two months. the renter and place a healing abutment and suture the tissue around that wait 2 weeks and you are ready to take impressions. Regarding the apical area cant really eval that on a PAN and a CBCT would be needed to see what it is, most likely not abcess but area over drilled and didnt form bone after implant placement or they had slight lingual perf on placement of the implant. When the implant is exposed i would suggest a gentle counterrotation test to see if it is integrated
DrT
4/8/2014
Does anyone have any explanations why there has not been any crestal bone loss on the distal aspect of the LR fixture with the fixture head placed right at the crest??
Gregori Kurtzman, DDS, MA
4/8/2014
Cant tell where the bone really is as its a 2D image and although you can see even in the mesial the level of the palatal bone, you cant tell where the buccal bone is and on the distal there may be bone loss but its overshadowed by the palatal bone.
Dr. Gerald Rudick
4/8/2014
It is possible that the dentist who placed these implants may be new at this procedure, but I do not think they are badly done. The "dieback" of the bone can be repaired easily using the suggested methods mentioned above. The real issue is that the patient himself is guilty of negligence for not maintaining his dental health...there are many carious lesions that need to be tended to, that are equally important. Following all the suggestions that have been offered, we invite the patient to present photos and radiographs of the finished case six months after the grafting and crowns are installed. Gerald Rudick dds Montreal, Canada
The Patient
4/10/2014
Thank you very much for commenting ... I do wash my teeth 2 - 3 times daily , also with teeth floss . I visit my dentist every 6 months and in the last year I did multiple Panorama and Periapical xrays , but no one except for the last time has mentioned that I have carious problems .... I was also with another dentist and he told me that I have caries problem in Molar number 18 and he treated it ... Would you please tell me where are the other caries problems so I can treat them ? And o fcourse I will upload the post treatment panorama and photos ... Thanks again ...
Dr. Gerald Rudick
4/10/2014
Dear "Patient" A panorex xray does not have very good resolution....but here are some of the problems that I see on what you have provided : Upper Left :- #24 D (11) ; #25 M&D (12) ; #26 D (14) ; #28 M deep (16) Extract it Lower right :- #42 D (26) ; #45 M (29) ; #47 Deep Abcess? (31) Lower left :- #37 D(18) ; #38 M ( 17) Extract it Periapical xrays should be taken for better definition....there may be more problems than I have listed Good luck Gerald Rudick DDS Montreal, Canada
dr Zoran Milankov DDS
10/5/2016
Hi there, I think there is too many different metals and galvanic current is main reason for decay and bone loss, because of osteoclastic activation. If you have a capatibility to measure galvanic current between the metals, do it.

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