Bone Loss of About 4mm Six Months After Implant Placement: Suggestions?

Dr. JC, an oral surgeon, asks:
I recently performed extraction and immediate implant placement in the #11 [maxillary left canine] socket with a Nobel Biocare Replace Select implant, 4.3×16 mm. I placed Puros bone graft material [Zimmer] in the space between the socket walls and the implant, advanced a flap for primary closure, and let it heal for 6 months. At Stage II uncovering today, circumferential bone loss of about 4 mm extended from the crest. No soft tissue inflammation was noted. The implant, however, tested solid with a reverse torque test at 40Ncm. I elected to debride the soft tissue around the exposed threads, packed Bio-Oss [Osteohealth], and will re-evaluate in a few weeks. I am thinking of letting the restorative dentist place a temporary crown and just monitor the bone levels for 6 months to 1 year, before finishing the case. Anyone have any thoughts on this case? Other suggestions?

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13 thoughts on “Bone Loss of About 4mm Six Months After Implant Placement: Suggestions?

  1. 30% of the alveolus towards the crest is bundle bone. Bundle bone belongs to the tooth. The tooth goes the Bundle bone goes. You havent written about the soft tissue situation. Your definitive crown delivery depends on the level of the soft tissue. Often inspite of boneloss soft tissue levels remain high without peri implantitis.

    You are an Oral Surgeon, you obviously know more than us.

  2. You have used a mineralized allograft and a mineralized xenograft. Neither are resorbable and both have proteins that will cause an inflammatory reaction. Neither of these graft material will result in implant integraftion in the site of the graft because they do not alter the healing process. If you want implant integration in the graft site google “Socket Graft”. I am sure you are thinking Bio-Oss is anorganic but sorry it is not.

  3. Dear JC and collegues, I made a lot of cases like this extraction and inmediate implant placement and provisional restoration, but In my practice and experience using Bicon dental implants and Synthograft (pure phase Beta-tricalciun phosphate) and I never had any boneloss, If you need to see my case I can send to you picture’s case and talk more abouth this technique.

  4. The Bio-Oss could work, but it is only a scaffold to grow bone. If that was your route I would decorticate with a round bur, place the Bio-Oss then a resorbable membrane. For faster results GEM 21s would be a good choice. For socket grafting I like Pepgin P15 flow. I know there are alot of strong opinions on P-15, but I like flow because the particles are far enough apart so they don’t inhibit bone formation.

  5. Dear Dr

    hello,i think your labial bone in socket after exteraction was less than 1.5mm,and when u use selleced noble ,u have 2mm machine surface in collar region ,unfortunatly when un instal sub cresteal u will have bone loss untile first tread.

  6. Have you submerged again the implant at uncovering? An incomlpete closure of the flap creating a small communication with the oral environment at imlant placement is a possible reason for bone loss.

  7. Horizontal bone loss is expected after extraction regardless of placing an implant and/or bone graft material. The facial wall just resorbs. This is why immediate implants can be problematic in the esthetic zone where the bone can resorb down to the implant surface, leaving an esthetic challenge.

  8. To have bone loss there is inflammation. The question is, “where is the inflammation and what is the cause?”
    May I suggest the following articles.
    Loss of Crestal Bone Around Dental Implants: A Retrospective Study. Implant Dent, 7:258-266, 1998.
    Maintaining Cosmetics and Marginal Bone with a Dental Implant. Implant Dent 2000; 9:154-161.
    DNA Probe Identification of Bacteria Colonizing Internal Surfaces of the Implant-Abutment Interface: A Preliminary Study; J Periodontol, Jan. 2005.
    Superior Esthetics Without Micro-leakage of Bacteria and Bone Loss. Implant News & Views, May/June 2006, Vol. 8 No. 3 (6-11).
    Excess Cement and Peri-implant Disease. JIACD September 2009, Vol. 1, No. 6, (61-68)

  9. Dear Dr JC
    First of all, you probably did a lot of things right – Chose the right Implant diameter and length, placed it optimally , grafted around the implant, with one of the best materials around today , waited the right amount of time before exposing for the second stage…. and yet your’e wondering why you had about 4mm of bone loss!

    Well, some thoughts –
    1) What was the indication for the extraction of the tooth?

    2)Was the relationship of the Canine with the Lower teeth in dynamic , lateral excursive movement assessed prior to extraction?

    3)Was there a pre-existing pathology that may have caused the Labial plate to have thinned out or even depreciated considerably (which the soft-tissue would have masked significantly at the time of extraction)?

    4)Was the implant placed Sub-crestal with respect to the adjacent Gingival zenith or with respect to the extraction socket wall ?

    Often, the allusion that the implant is sub-crestal comes from an inadvertent relationship of the implant to the inter-dental bone or the adjacent tooth’s gingival zenith .
    In which case, when the initial osteoclastic activity ceases and osseintegration is achieved at the end of the stipulated period, the labial plate (which is the most vulnerable to loss)would have migrated more apically than it was at the time of extraction.
    The other reason that one could expect to lead to this kind of bone loss would be violation of the labial bone during the preparation of the osteotomy which would exaggerate the bone loss on the labial plate.

    Just as a suggestion, an implant with no collar (threads all the way to the top) or a Platform Switched design would minimize the possibility of such bone loss further.
    Cheers and good luck

  10. if you extract a tooth 60%of the bloodsupply to the buccal bone is gone,periodontal ligaments blood supply which consists of a third and if you do a flap procedure the periosteums bloodsupply is diminished ,whatever else follows makes matters worse like buccalbone engagement placing implants oo dep etc

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