Bone Loss and Pain with Failing Dental Implants: Best Treatment Plan?

This patient presented to me with severe pain. Implants (OSSTEM) placed 3 years ago. Radiograph is attached, and shows considerable amount of bone loss. Current situation is that the gingiva on the lingual side is of a thin biotype and is rubbing against the threads of the implant, hence causing the pain. Patient also has an issue of BMS on the same side of the tongue and this situation aggravates it.

I have looked for causes of the bone loss, I have corrected the occlusion, and have got a periodontal consultation done, the periodontist suggested some LASER treatment to disinfect the pocket and improve the condition, which I have also tried. The patient is not completely relieved. I do understand that the line of treatment would involve smoothening the implant surface, but is that what is suggested and the best treatment plan? How should I proceed with this situation?

Periapical radiograph of the Implants
Periapical radiograph of the Implants

36 thoughts on “Bone Loss and Pain with Failing Dental Implants: Best Treatment Plan?

  1. I would do the same old story (only if implant causes no pain at percussion / is osteointegrated): eliminate threads, smooth surface (if you have laser go ahead and aply it after), remove granulation tissue, disinfect with ATB + saline + CHX + Saline + B-TCP / autograft + membrane + primary closure + 3 mths waiting + taking care of that pre-molar crown that is probably annoying you a lot + praying at night before going to sleep.
    Good luck

  2. There is a wonderful book “Peri-Implant Infection” Authors Frank Schwarz, Jurgen Becker Thru Quintessence which has some helpful management protocols. I have found it helpful.

  3. I know that this doesn’t help answer your question but in a way it might. The canine next to the 2 failing implants is also approaching and is probably at the hopeless stage. What I am saying is that I suspect that there are a whole host of other dental issues in this patient’s mouth, some of which may have a bearing on these 2 implants, eg occlusion. To attempt to treat the problems on the implants should firstly involve a correct diagnosis. I don’t think this is possible by solely looking at a single PAX…
    DrT

  4. refer back to original treating dentist. if you are the original treating dentist, take out the implants. There is zero reason for implants to cause pain. There are no nerves in bone! I think you are ignoring the radiolucent area between bone and the implant….the entire length of the implant, or so it appears on the web version. Curette and clean the residual sockets, properly graft, and try again another day. If you are having trouble being successful doing implants…..don’t do them. Let someone else do the removal and re-treatment. But don’t ponder what to do about such basics if you profess to know enough to do implants.

  5. The implants are fused and the crowned natural tooth is failing. These are obvious findings. This patient lost these teeth because of neglect, they are loosing the implants most likely, for the same reason. Bvinci

  6. rds although a bit harsh is correct. With the threads exposed as they are you are not going to be able to save these implants. The sooner you get them out and graft the sites the less bone you will loose. Cannot tell if there will be enough bone left to re implant until the grafting is healed and a proper CBCT is taken. I believe you have as DrT described, a number of issues risking the predictability of these implants. I can identify at least five. Re implanting a case caries with it even greater risk. Have this patient treated with experience and you will sleep better.

  7. I agree with rds- not the sarcastic comments but with sentences 2 and 5. The postcrowned anterior tooth (LL3?)is failing and would probably be better in the bucket. The anterior implant (LL4?) appears to have a radiolucency around it and I suspect it is being held in by the posterior implant. It should be easy to remove once the crowns have gone. I would then back out the posterior fixture (LL5?) using a NeoBiotech implant remover. There is no need to faff about with the sockets; Mother Nature is kind and they will heal rapidly.Once everything has healed it would probably be simplest to place new implants at LL3,5 and a 3-unit bridge. But wait until the pain has gone (which hopefully will be immediately after the present implants have been binned)otherwise your patient will blame any continuing discomfort on the new bits and pieces.

  8. In response to BVinci, in all fairness how can you make such a broad accusation and lay the problems that we are seeing on the patient? This individual has obviously invested a great deal of money just in the treatment of these 3 teeth(and we haven’t seen the rest of the mouth). While I agree that ONE possible contributing etiology is poor patient compliance, there are multiple other possible explanations, including what we use to call when I was in school “iatrogenic dentistry”. My suspicion, based on the PAX that we have been presented with is that the dentistry that this patient has received in the past was less than optimal.
    DrT

    • Dr. T, what is the #1 cause for loss of teeth? People’s habits do change, but in my experience, not without a lot of education and persuasion. If this patient lost these teeth secondary to trauma, I apologize. Trust me I see bad dentistry all the time. I am 1 of 6 boarded surgeons in a town with 400 dentist. We are looking at bad dentistry right here. Bvinci

      • We don’t know if it is bad dentistry, we really couldn’t state that as a fact. It is an opinion. Yes, it could be that the patient is non-compliant. Look at a plaque index, look at the overall perio health, etc. Then, there’s more info. Plus, science does not deal in absolutes, it works by ruling out possibilities and reaching the most likely conclusion.

        Patients lie, lie and lie again. “Yes, I floss. Yes, I use the Waterpik. Yes…(insert lie here)”. Good treatment can go bad, especially in 3 years, and look like it was done by Edward Scissorhands.

  9. Since I do not know what other posterior function there is I will assume it is limited. The severe pain is not identified. There are strong signs this patient is a heavy bruxer like the distal abfraction on the adjacent tooth. Could the pain and implant deterioration be the result of MPD? Has a splint therapy been tried? Is there posterior function on the opposite side?Tooth wear and displacement of the remaining natural teeth can result in the excessive loading of the implants in question. I would attempt to save them and treat the other contributing factors.

  10. Dr Richard Hughes seems to read a lot but does not give solutions, only advise on books.Remove the implants and the cuspid,plant some seeds from the tuberosity,suture with silk instead of reabsorbable(so you can follow the progress)and apply ultrasound waves to the bone.X-ray in 3 months and take it from there.

    • Please explain to me the ultrasound technique. I know it’s been used in bone fractures but how do you apply it and have you seen any results?

  11. Both of the implants should be removed, as they are beyond any reasonable hope of salvage. To pretend otherwise is wishful thinking. There are many protocols for regenerating bone around infected implants, but they seem to be designed for implants that are within the form of the arch, that is, the threads don’t protrude past the buccal or lingual outline of the ridge. So, a space making osseous defect. Dr. Stuart Froum just published a textbook about implant repair and Dr. Myron Nevins, along with some Japanese compadres, is presenting cases of bone regeneration around implants, using a laser, at the current AAP meeting in Los Angeles. Again, the common theme seems to be that the implants are within space making defects. From the description, one or both of the implants are beyond the confines of the ridge. The canine is hopelessly involved also. If this section of the dentition is any indication, the patient may have other problems, and deserves a thorough workup. As for severe pain, if the lingual threads are exposed, then the patient may have a large traumatic ulcer on the ventro-lateral surface of the tongue. Grasp the tongue with gauze and lift it up to see. These ulcers are quite painful, especially upon swallowing. The pain radiates to the ear and throat. You have to get rid of the cause, whether it be an osseous sequestrum, sharp edge on a tooth or restoration, or exposed implant threads.

    • You don’t think this doctor examined his patient? He took the time to post the case, certainly he examined the patients tongue and lingual aspect of the mandible . The natural tooth, is most likely salveagabe, unless you are one of those guys that uses his “hammer for every procedure”. Keep the natural tooth please. No one likes to place implants more than myself, but nothing replaces a natural tooth better than a natural tooth . I’m tired of saying it ! Bvinci

      • I appreciate your desire to save natural teeth Bv…however, it all comes down to diagnosis. In this instance, if you consider crown to root ratio post crown lengthening as well as the ferrule rule, not to mention what you will have to do to the bone on the adjacent teeth and implants, I would have to say that in this instance, retaining the canine is an unwise choice.
        DrT

      • Unfavorable crown/length ratio; insufficient ferrule, remove it. I don’t know whether the dentist examined the patient thoroughly. I merely suggested a possible source of the pain, if it please you.

  12. I think Richard has been very forthcoming on solutions over the years , alas we are interested in the golf at the moment.
    Anyway , my 2 cents as they say and using only this x-ray it possibly may be that the mesial ( the wider Implant ) has failed ( the dark area aaround it , again subject to these x-rays ) and due to the splinting is retained , hence the issues.
    So remove the splinted crowns if screw retained or separate if not and the mesial will be removed easily .
    Cause , well if appear that the ridge is thin ( use of thinner implant distally ) and the buccal plate has been lost on the wider implant.
    Again due to low input data , just my thought.
    Peter

  13. As to Splinting although Carl is a fan , I am not and rarely splint due to possible co-axial force issues and this situation occuring where failing Implants are retained due to it.
    Peter

  14. Joe Jaws, yes I do read, I also do practice implant dentistry 85%! of my practice is implant dentistry. So it is not a hobby with me. Because of this I do not fool around with things that do not work, so when I give advice, it’s based on experience both good and bad. One can learn from reading, also one has to think in a critical manner.

  15. I bet if you removed the implant crowns the mesial implant would fall out. I’d plan removal of the cuspid (I know I have that as an implant site especially if the RCT is over 15years old remove the implants and graft over the ridge with prgf and bone teflon reinforced membrane or a strip of allograft to help hold the graft. Primary closure remember you only need a few mm of height and place a 3unit implant bridge depending on the opposing occlusion. Ct scan would be a good idea prior to implant placement. The patients overall perio condition must be addressed or the same thing may happen. Very good discussion!

  16. I’m not trying to one up you Richard , but our course record holder and member played in it as well. D. Toms.

  17. 1. Remove implants.
    2. do the augmentation, then place implants.( best option )

    OR

    1. remove the crowns.
    2. detoxify the implants
    3.Place the titanium mesh with bone graft ( with risk of dehiscence )

  18. Doesn’t seem like bad dentistry. The adjacent tooth has decay or a severe abrasion, it could indicate poor patient compliance.

    One of the most underrated phrases in implant dentistry:

    “Case selection”. The patient might have not been a good candidate for implants. Anything could have happened in 3 years.

    People that post here really need to be aware of the fact that patients and attorneys check this website and might get polluted by poorly-worded or poorly thought out opinions, thus relating ANY bone loss to “bad dentistry”.

  19. This is something the orthopedic doctors used to do. There is nothing in the current literature to support this type of treatment in implant dentistry. Bvinci

  20. You also have to consider that the original post placed in the natural tooth was too short, in the first place; assuming the poor radiograph is not fore shortened. We are dentist first!!! Bv

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