Dr. M asks:
Please see the case photos below.
I have a 62 yr. old male, nonsmoker, occasional drinker, who presented to my office for a consultation. He is an extreme dental phobic who I treated using IV Sedation.
His medical history revealed:
*Allergy to Penicillin.
*A stroke in 1983 leaving his left arm somewhat unusable.
*High BP which is controlled.
*A heart attack and stents placed in 2009.
*Type II Diabetes, controlled.
Clinically, he had generalized advanced periodontal bone loss, with bleeding and suppuration on probing. Full mouth extraction with a full upper denture and a mandibular overdenture was planned. I planned to place two mandibular implants in the area of #’22 and 27.
Initially, the patient was sedated and all of the molars in all four quadrants were removed uneventfully. He was given pain medication, clindamycin 300 mg qid and Peridex bid for a week. In one week the remaining teeth were removed and alveoloplasty performed. Unfortunately, the facial bone was lost during the removal of #6. I grafted this area with Bio-oss and covered with a resorbable collagen membrane.
Fortunately, I was able to preserve the facial bone when removing #’s 20-22, 27 and 29. All of these sockets were debrided of granulation tissue. I then grafted the mandibular canine areas (#’s 22 and 27) with Mineros mixed with autogenous bone.
He was treatment planned to only have these two sites grafted because they were to be the implant sites. I elected to graft the other sites because I had extra Mineros. In the socket of #29 my remaining Mineros was placed with Bio-oss layered on top and tamped down. Bio-oss alone was placed in the socket of 21. A resorbable collagen membrane was placed over all sockets and the areas closed with silk sutures. He was given another Rx for Clindamycin 300 mg qid, Peridex bid, and pain medication. He was asked not to wear his mandibular denture for two weeks. While the grafts integrated, he wore the mandibular denture minimally.
Four months after bone grafting, three Nobel Replace implants were placed. During implant placement, I decided to place an extra implant. When the osteotomies were drilled I felt that the bone felt comparable to when maxillary osteotomies we are drilled.
One month after implant placement, he came to the office with swelling on the buccal of the #22 implant. Visually, it appeared that all of the mandibular anterior area, from 22-27, was somewhat swollen. Clindomycin 300 mg was prescribed. The swelling subsided somewhat. When asked, he told me that he had not been wearing his mandibular denture.
Two months after implant placement, he returned with persistant swelling. Xrays revealed that all three implants had not integrated and needed to be removed. I have not removed the implants yet as the patient has time commitments. I placed him on antibiotics. I plan to remove the implants, degranulate the sockets, wait a month and regraft. I will also use PRP when bone grafting. I am considering placing a few mini implants to temporarily stabilize his mandibular denture and help relieve pressure.
When I consider the possible reasons for these implants to fail:
1. Bone grafting immediately after removal of periodontally involved teeth.
2. Using different bone material.
3. Not waiting long enough for the bone to mature adequately for implant placement.
4. An unknown medical/ systemic problem, ie. blood sugars that were not controlled.
5. The denture putting pressure in the area even though it was worn minimally.
What do you think? Thank you ahead of time for any criticism and/or advise. This case has been a disappointment so far .
After Bone Placement
Radiograph 3 Months after Bone Grafting
Photo of panorex just before implant placement
Photo of panorex at implant placement
Photo of PA x-rays one month after the implants were placed showing that they failed