Bone Loss Around Implant Case: Is this Periimplantitis?

Dr. M asks:

This 64 year-old patient (image below) came to us from another practice. He recently presented with pain in his maxillary left posterior in the region of implants placed in the #12 and 13 sites [maxillary left first and second premolar; 24, 25]. The patient had implants placed in this area approx 5yrs ago by another practitioner. I do not have that much of experience in the field of implants having done 60 cases so far. My x-ray shows some bone loss around one of the fixtures [Please see radiograph]. Could it be peri-implantitis? Soft tissue is dramatically lost along the implants. I would be grateful for any comments. Thanks.

Case Image:

18 thoughts on “Bone Loss Around Implant Case: Is this Periimplantitis?

  1. Dr M.
    There are many possible explanations for dramatic bone loss around those implants.
    One possible explanation is if the ridge was not wide enough at the time of placement and after a few years the implant lost that thin bone plate resulting in both bone and soft tissue loss around the implants.
    I cannot see the radiograph very well in my screen.
    If there is no suppuration from the tissues or inflamation around the implant it may not be active periimplantitis but the case may still be a failure cosmetically.
    Try to identify the source of the pain and develop your treatment plan accordingly.
    Good luck.

  2. Dear Dr. M,

    Generally speaking, peri-implantitis (PI) may be primary or secondary to another cause, although I agree with Dr. Boudet that increased probing depth (PPD), bleeding on probing (BoP) and / or suppuration are pre-requisites for a PI diagnosis. Loss of soft tissue (recession) may also be due to resorption of buccal wall (Again as Dr. Boudet suggested).

    I can add that the radiographic picture is not really the classical picture of PI (saucer-shaped defects all around). It is rathar towards the distal aspect and it seems like it is reaching the level of the internal screw.
    Could there be a fracture? Did you check the PPD?
    Is there a one point deepening or is it deep all around? Is there any mobility?
    Did the patient mention anything about a recent “crack” or “tick” when chewing on something?
    And finally, is it possible to obtain any previous radiographs to compare?

    I hope at least some of these questions may be useful.

    Wishing you the best of luck!

  3. What is the patients home care like? Is he able to adequately clean under the pontic ?pontic shape/design or had something lodged under the pontic for a period of time. I agree the defect seems more localized (on this x-ray)to the distal aspect of the
    proximal implant.It is always problematic to treat these cases with bone loss.
    Good luck

  4. Bottom line is if there is probing and inflammation and or suppuration offending implant(s) must be removed asap. I would see if you can remove the prosthesis. Looks possible to save the 2 distal implants from the radiograph. Take the mesial one out. A long tip on the Biolase is great for getting these out – I have done it many times. Absolut minimal trauma or collateral damage. Takes a litle patience or time. You can drill or trephine it out, but that is messy an has higher collateral damage Remove atraumatically. Let it heal a few weeks and then graft to rebuild lost height and width

  5. Dear Dr. M,

    I do believe that the data included in the question is not enough to give a reasonable and scientific judgment. The pain duration, when it started, is it intermittent or continuous, stimulated or spontaneous? Beside,the x-ray shows bone loss, but other data is needed such as, presence of puss, probing depth, and edema, because this is the data that will confirm perimplantitis diagnosis.
    Pain is not one of the approved criteria in perimplantitis diagnosis. It could be radiated pain from opposing or neighboring teeth, unless it was identified as related to pain on chewing.
    I do hope that you will find this comment helpful in solving your dilemma in this case.

  6. Dear Dr M,
    I agree with all the above comments except the presumption that the implant has failed and the notion of explantation.( its too early to talk about failure/explantation) Please carefully read and understand the clinical significance of each of the above comments and things to look out for……
    I would-
    1- take good dental history, history of symptoms, possible accidents/ trauma etc that may have caused a crack etc etc
    2- do a good clinical assessment – probing all around, noting bleeding/ pus etc, check out the bridge for any signs of fracture/ cracks that may indicate unreasonable forces on the mesial, check bite etc……… this should start giving a reasonably good idea of whether this bone loss is resulting from inflammation or rather a product of other factors at play eg failed prosthesis, cracked implant, buccal bone resorption. Also check if the bridge is removable ( screw or cemented)
    3- do a detailed radiographic assessment- (1) take a good PA view to see the whole length of implants…….. see how far down the implant has bone been lost etc (2) I would also take a 3D scan to get a more realistic appreciation of the bone loss pattern around the implant and do a quantitative assessment of the defect size
    4-If all else is inconclusive, I would not hesitate to raise a flap and check, clean out granulation tissue, treat the implant surface and close up….. then review
    5- By now you should have a reasonably good idea on possible cause of the bone loss around the implant. I would address this and treat the resorptive process aggressively to try and achieve stability…..
    6- After stability, I would see if the prosthesis could be removed and the defect repaired surgically., bury the implant/s…… leave implants unloaded for 6-9 months and then re-restore……..

    Periimplantitis doesn’t have to be the cause of the bone loss. Other bio-mechanical or physiological factors may predispose / cause the bone loss which could end up being the precursor to peri implantitis.

    I hope my comments are of some value and logic to set you off in the right direction………

  7. Thank you very much for all the comments. There is no suppuration or any swelling associated with the implant. However, the patient reported that the bridge “fell out” and she somehow “pushed it back in”. I assume that perhaps she has felt a “tick” or “click” at a time. I referred the patient back to the practioner who placed the implants. Pt reported back to me saying that the dentist reassured her and adviced that no treatment is required and there was no reason for concern…

  8. Peri-implantitis defo:
    bop with over 5mm bone loss in England we call this peri-implantitis! bop/suppuration no boen loss peri-mucositis. Typically bone loss is circu,ferential in this instance, the more dramatic bone loss is one teh distal of the more mesial implant. I think there well be an occlsual element? non axial load, or overheating/over-compression of the implant on placement.
    my advice
    -get in and have a look possible to debride and using bio-oss and bio-gide in teh defect
    -or remove implant debride wait 2 montsh bio-oss .
    biogide again to augment teh ridge heaight and width.
    Wait 6 months and place anothe rimplant-allows time for angiogenesis into augmentation material.
    I would remove all implant prosthetcis from the start and place healing abutments and make a dentyure which doesnt touch teh soft tissue.
    When refelecting flaps use curvilinear approach.

  9. This saucering of the bone around the implant is classic for an occlusal disharmony and I suspect that there is a premature “heavy” contact. (Please refer to Misch latest text for explanation of the biomechanics and microstrain that contributes to bone loss with occlusal prematurities)After reading all of the comments I noticed that the bridge had come off and the patient had “pushed it back on”? If this is the case I suspect that the prosthesis may have micromovement that is being transmitted to the implant bodies…………A lot of good ideas. These cases are difficult to graft around the implant body with predictable success. If you try I would take the prosthesis off and replace with a provisional on the remaining implants and leave the space “open”. As a side note it is very difficult to get a good blood supply to feed the graph at the most crestal portion of the graph. Good luck, Duke Aldridge, MAGD, MICOI, DICOI, FMISCH

  10. Dear Dr M,
    It is peri-implantitis. An inflammatory process that occurred around the implant that resulted in bone loss.

    Inflammation is due to a response of the immune system to resist an infection that has been introduced due to the microgap at the crown-abutment margin or the abutment-fixture margin or remnants of excess cement or a foreign body or accidental or deliberate probing with a toothpick or fishbone etc.

    Lastly, as Carl always obsessively emphasises, is due to poor biomechanics i.e. occlusal disharmony or high bite of that particular implant that traumatises the surrounding bone and makes it susceptible to the microorganisms that are perpectually present in the mouth and in the iatrogenic pocket that is around all dental implants.

    Go in quick and debride and close back up with antibiotic cover and adjustment of any occlusal disharmony.

    Good Luck…though luck has nothing to do with it.

  11. When you’ll raise a flap, there is a 90% chance that you find out that you have lost the buccal bone, because your implant has been placed too buccal.
    Should have been placed more palatal or have used a smaller diameter implant.
    If that is the case, remove it….
    Keep us posted after you have raised the flap.

  12. The 3 implants are splinted together, and there is no bone loss on the 2 distal implants, therefore the bone loss has to be from infection. The fact that the bone loss appears to be on the distal where there is a pontic to me indicates poor oral hygiene under the pontic is the most likely cause of the problem. If traumatic occlusion was the problem, then one would expect to see bone loss around the other implants which are splinted to this one.

  13. Part of the clue in this case is the original statement of a dramatic loss of soft tissue around the implants. The primary cause of tissue loss in implants in the maxillary bicuspid area is a pronounced frenum pull. There is apical migration of the tissue margins with crestal bone remodeling until the roughened body is exposed, resulting in the classic diagnosis of peri-implantitis. Best treated with a frenectomy at the time the implants are placed.
    RJM

  14. To me it looks like perimplantitis. The PA it is not very clear on my screen but it looks like there is a light bone loss also on the mesial side. We all know that bone loss is much faster around implant than around teeth. Furtermore, also the implant in the middle is losing bone, if you do not take out the lateral implant ( and you can be sure that the difect is going to be much worst with the flap open ) you will have a nice flat defect beetwen the 2 implants. Note that the resorption on the middle implant is already at third thread. Get ride off that implant ASAP and treat the one in the middle.
    Keep us updated.
    BR

  15. Need history which if possible will include past radiographs from the prior practitioner. Then you can see if the bone loss was present long term or its acute. Also need a PA seeing the apical of the implant to see the extent of bone loss. Looks like the bone loss is very extensive and I dont think treatment will do anything as its possible if the bridge were removed this fixture may have mobility.

  16. There are many causes of bone loss at the crest.

    One of them as already stated is occlusal disharmony.Plz also check for para-function, for eg. bruxism or clenching.

  17. Another consideration which may merit attention…

    If one were to look at the IMPLANT LEVELS closely, one would notice that #10 is sligthly deeper than #12 and #13. This discrepancy in implant levels can cause the prothesis to tilt or rock to a certain degree enough to effect cellular disturbances at the BIC. As usual, it is the area of least resistance that is bound to suffer.

    The defense mechanism/reparative ability of the body is unable to cope up with the constant torquing w/in
    the area, leading to the degenerative transformations.

    The fact that the patient had reported history of prosthetic detachment supports the concept of prosthetic instability, as the culprit.

    A healthy and prosperous 2011 to all!!!

  18. can we talk about microbial in periimplanttitis?after healing and osteointegrate that one problem is dental periimplanttitis.how about the progressive of microbial?prevention?and treatment?

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