Compromised Implant Case: Design Options for to Avoid Failure?
I agreed to see a patient that another family was helping out. Patient fell on hard times and his mouth had many serious problems. I agreed to do comprehensive implant dentistry on the patient, used high quality lab for treatment planning, surgical guides and immediate temps. At the time, 72 yr. old male, had knee replacement in 2010, arthritis, HTN controlled with medications and NKDA. Upper was planned All-on-5, lower All-on-6. Patient first came to see me at the end of 2017. In March 2018, I extracted remaining teeth, performed guided bone reduction, guided implant placement and guided immediate PMMA reinforced with bar screw-retained temps for upper and lower. The lab representative was present at time of surgery and had my own lab technician refine the temps while I closed the case.
Surgery and immediate restoration went smoothly, no complications, all performed under local anesthesia only. Pt. started on Amoxicillin 2 days prior to appointment and took for 10 days total. I gave Decadron starting day of surgery for two days and Vicodin/Advil PRN. Pt. had no post-op complications in terms of infection and pain was controlled with Advil, and only took Vicodin day/night of surgery. Immediately discovered at surgical appointment, that patient was in an anterior open bite with his temps. Adjusted occlusion until pt. had group function, but he did not have anterior guidance. I gave pt. POI, soft food diet and normal follow-up appointments. (See photos below of pre-treatment and CBCT slices of immediately after placement and restoration with PMMA temps).
After weekly checks on occlusion, 2 months after surgery, the upper right side was painful to patient and it was noted that it was moving/loose. I removed the prosthesis and found that all implants were loose and needed to be removed. #30 was also lost. Made denture, removed implants and let area heal. In November of 2018, we performed surgery on the maxilla, placing 5 short implants in #4, 6, 9. 10 and 12 sites. (See x-rays included). I buried implants and had pt. continue to wear upper denture. 6 weeks later, took periapical x-rays and #8 failing implant and was removed.
Now, all implants were integrated and stable, we are ready to restore. Lower is easy, screw-retained hybrid or Zirconia bridge is planned. The upper is where I am having a little trouble treatment planning. My undergrad degree is biomedical engineering and I understand about stress/strain/force on implants and surrounding bone along with material properties. However, I am scared after the failing implant experience on the upper. So my options for the upper are as follows: Tissue supported, implant retained option of 4 Locator attachments and an upper horseshoe with metal palate denture. Or Implant supported, implant retained options of upper bar with Hader clips and Locators with hybrid horseshoe denture or upper Panthera bar and hybrid prosthesis or screw-retained hybrid prosthesis. I’m leaning towards the upper bar with Hader clips and Locators for best support during function, and splinting implants. I’m just nervous about #4. If that implant fails, pt. loses bar and then is converted to Locators and only on the left side. Anyone have any thoughts on what is best long-term solution to help #4 avoid failure?
![])](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2019/03/19682-24-8-failure-c9b72123c1da-e1553691843773.jpg)Failure
![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2019/03/19682-24-cbct-after-1st-srugery-upper-c9b72123c1da-e1553691908160.jpg)CBCT After 1st Surgery Upper
![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2019/03/19682-24-cbct-after-1st-surgery-lower-c9b72123c1da.jpg)CBCT After 1st Surgery Lower
![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2019/03/19682-24-cbct-after-1st-surgery-c9b72123c1da-e1553691964180.jpg)CBCT After 1st Surgery
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21 Comments on Compromised Implant Case: Design Options for to Avoid Failure?
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Richard
3/27/2019
Utilizing a bar over denture would improve access to hygiene and allow the patient to remove the denture at night thereby decreasing possible parafunctional stress.
It is hard to comment without also seeing PA's of each implant at parallel angles so threads are sharp and the case can be visualized better.
Dennis Flanagan DDS MSc
3/27/2019
Place another implant in the #3 site as a back-up since it looks like #4 is failing probably due to a previously infected tooth with residual vegetative bacteria.
Eric
3/27/2019
#4 not failing, fully integrated with good bone surrounding. #3 would need major sinus lift and patient does not want to go through that procedure. Question had to do with restoring what was there, not on how to add more implants. It is understood by just about everyone that another implant or two, especially distal to #4 implant would improve A-P spread and stabilize the situation for a implant supported and implant retained prosthesis. That is not the point of the post. Point is to open a discussion on stress/strain during function and to deal with that, do you splint with bar or use individual Locator attachments. My belief is that splinting with bar and fabrication a removable prosthesis would be best in this situation. I'm looking for others to either agree or disagree with my treatment plan and present ideas and/or thoughts outside the box that I may not have considered with the clinical situation presented. Thanks for your advice on adding another implant to improve the situation, do you have any constructive comments on restoring what is there?
Dennis Flanagan DDS MSc
3/27/2019
I assume the maxilla is screw retained, if so you may be able to solder or weld a retainer to the frame to engage #3.
Dennis Flanagan DDS MSc
3/27/2019
Anterior guidance is preferable to group function since it can overload the implants since the posterior load capability can be 3X that of the anterior.
Joseph Kim, DDS, JD
3/27/2019
Once the implants are integrated, you should not have rampant failure like you did before. If you are worried that a fixed restoration may lead to failed implants, the same concern applies for the removable appliance.
Due to the limited AP distribution on the maxilla, I'd make a 10 unit roundhouse bridge, using metal reinforcement (PFM with 3 mm metal lingual collar and metal lingual cusp of posterior teeth) replacing 3,5,6,7,8,9,10,11,12,14. If you're worried about #4, then leave it 100-250 microns out of occlusion. Alternatively, you can place a metal bar or other stiff metal mesostructure on the implants and glue or screw a zirconia superstructure on top of that. The former option will be a lot less expensive (less than $2500), and most labs can fabricate it.
You may also wish to segment your lower prosthesis into 2 bridges (19-21, 22-30, or similar) in order to allow torsion/flexure of the mandible.
Richard Hughes DDS
3/27/2019
All due respect. The implant appears to be in failure.
Dok
3/27/2019
Palate-less all acrylic overdenture that is tissue supported keeping the tissue support to a minimum ( least amount of acrylic touching tissue in the horseshoe form ). If the patient losses 1 or 2 implants, no matter as it still funtions well, is retentive and is not to bulky or cumbersome. Of course the patient has to agree to an overdenture/removable scenario. The ability to remove and clean under a prosthetic piece cannot be overstated for maintenance especially if implants have failed in the past. Don't make the same mistakes twice.
Dr Dale Gerke, BDS, BScDe
3/27/2019
This was an excellent summary of the considerable effort you have gone to for your patient and the troubles you and the patient have encountered.
In my experience hybrid bridges are notoriously difficult for patients to maintain (unless there is a large crest to bridge gap which induces another set of problems). Furthermore if an implant fails, it is difficult to repair/modify the bridge if another implant needs to be placed. From your description it would seem likely that further implant failures may occur. (My experience indicates that for whatever reasons, some patients who have implant failures may continue to have repeated implant failures in the same area – despite the fact that they have other successful implants placed in their mouths and both successful and failed implants were the same brand, placed using the same method and operator. It seems to me that sometimes there may be a local bone quality issue that causes a problem in a particular area in a patient’s mouth – even though there is no obvious difference clinically or radiographically.) Therefore I suggest that using a bridge restoration would be unwise.
A bar retained over denture is a great option. They are retentive and durable (although I have noticed that in about 30% of cases the locators can wear over 3-8 years and therefore tedious and expensive repairs are required sometimes). There are now CADCAM designed bar and shoe dentures which can overcome this problem. However I have found many patients with a bar suffer from gingival hypertrophy which does not seem to be related to infection or poor oral hygiene. In these cases, maintaining the implants becomes difficult and therefore jeopardises the longevity of the implants.
For these reasons I often recommend implant/locator retained dentures (usually with a Cr/Co frame). I usually provide 4 implants but 3 will often suffice. Inevitably I only activate 2 on the initial denture insert appointment (leaving the other locator/s with neutral denture insert/s to maintain stability but not increase the retention). I do this because I have found it quite distressing for patients if they cannot easily withdraw their new denture because it is too retentive. I review every few weeks and after the patient is familiar with the path of insertion and can remove the denture relatively easily, I then activate the other locator insert/s (one at each extra visit). Quite often I do not have to activate all locator inserts because it is too difficult for the patient to remove their denture (they are very retentive).
So what I am getting at here (in a rather long way) is that firstly, locator retained dentures work well and are accepted and tolerated well by the patient. Secondly, you usually can get away with only 2-3 activated for retention (so in your case, even if 1 or 2 implants fail, you should not have to place any more implants). Thirdly it is extremely easy for patients to clean their implants (even the grubbiest patient can clean them quickly and well - just using a toothbrush).
Therefore I would recommend an implant/locator retained denture for your particular patient.
Eric
3/28/2019
Thanks for your reply. Probably the best scenario in terms of costs and function if patient agrees. Bar is expensive and if/when #4 fails, he is going to go into Locators anyway. Thanks again.
Ed Dergosits
3/28/2019
Image 4 shows both implants on the patient's right side likely having problems with bone levels surrounding the implants. A better image would be needed for me to provide any useful comment. I have restored a patient with a milled bar and a patient removable prosthesis made by Panthera and they do a fantastic job at providing the bar and suprastructure hollow bar that is retained with horizonatl moving pin retention. I would not proceed with the restorative aspect of this case looking at the radiographs provided. Both implants on the right appear to have most of the implant not integrated in bone.
Ed Dergosits
3/28/2019
How did the initial immediate restoration result with an anterior open bite? No one can determine if this was a cause of the implants on the right side to fail. SOmething went "south" in the digital planning. These types of cases are very complicated. Extracting all remaining teeth and performing alveolar bone reduction and then expecting the subsequent surgical guide to fit well enough to position the implants in the correct position that will enable an immediate provisional restoration is something I avoid because I have done it and the stress is great. You must have lots of experience with extensive extractions,alveolar bone reduction,
immediate implant placement, and immediate full arch provisional restorations. What do you think caused the open bite and the failure of the right side implants?
Eric
3/28/2019
This was my first case with this lab. They use Panadent articulators when planning. I took all records after deprogramming and verifying a repeatable joint position. Facebow and leaf gauge bite records taken. I did not verify the case when I received it from the lab on my Panadent before surgery. Unfortunately, I assumed (you know what that means) that everything was planned perfectly. After surgery and adjusting the anterior open bite, I put the lab models on my articulator and discovered that exactly what I found in the mouth was exactly what I found on the articulator, unfortunately, it was after the fact. I talked to the lab and the head technician and they did not have a reasonable explaination. I said I couldn't be the only DDS with this problem, only thoughts we came up with was the tolerance levels when dealing with engineering principles which if off could have caused this to happen. Fast forward another three months for my second case with the lab. I check the models this time on my articulator and low and behold, another anterior open bite. I then sent my articulator to them so they could see if something was wrong on my end. Nope, they had the same open bite on their articulator as on mine....mmmm??? So for my second case with this lab, I buried the upper implants and gave the patient a full upper denture and a screw-retained PMMA lower immediate. He is doing well, just put him in his new PMMA screw-retained temps on upper and lower 4 weeks ago which will be removed in two weeks, then send back to lab for final bridge fabrication based upon PMMA's So long story short (not really), I don't know what caused the open bite and neither does the lab. I love digital technology, but I still do my own wax-ups for comprehensive cases and I think I'm going to have to go back to analog models, guides and temps until my hard work on treatment planning, gnathology, deprogramming, finding a repeatable joint position, facebows, bite registrations and envelope of function can be repeated in the digital world within a tolerable range.
Eric
3/28/2019
Maybe you misunderstood the posting. The periapical is of the failing implant in #7/8 area. It has been removed. The other implant shown in the periapical is of implant in #4/5 position. This implant is fully integrated and stable. Therefore, there is only one implant on the patient's R side and three on his left side. Sorry for any confusion.
Eric
3/28/2019
Also, I do think the failure of all upper implants and the lower right posterior implant was due to overload stress from having a posterior only occlusion without anterior guidance. As you can see, the CBCT from the first surgery shows implants in perfect position in the alveolar ridge, not like the implant were place in thin buccal bone or at incorrect angles. It has been a very frustrating case.
Greg Kammeyer, DDS, MS, D
3/28/2019
Eric,
I am impressed by your thoroughness, esp in presenting this case as well as tx execution. I think it's a nice example for others that post cases. I personally won't do surgery for a maxillary "tissue supported" locator cases. If you really want to do it, label it an iterum solution and know the single on the one side WILL fail. I've seen too many problems because the bone resorbs and it still becomes an implant supported prosthesis. In grad school I saw too many cases where the dentist didn't want to face backing up the tx plan to get appropriate support for the occlusion.
I like the CAD/CAM bar overdentures in the maxilla yet "all on four" with this prosth configuration/support distribution adds more risk. I have to remind myself regularly (after 35 years of placing implants) of 2 concepts:
1) Force factors: You have a male (strike one) and apposing implant/support(strike 2)-I wonder if the patient has any parafunction. I have seen so few implants fail, even without anterior guidence when they are staged,...I'll bet he has parafunction/
2) Anything we do for patients says" This is acceptable, predictable treatment". The reason that you are hesitant is normal and is because you are pushing the envelop wanting to finish the case as is. The price of failure of a case like this is chair time, lab fees, more implant costs, practice momentum, staff morale, heart muscle and stomach lining for you AND ESP for your patient.....Remember that this is a big deal to do once for the patient even tho you know what you are doing. I would suggest that you reconsider how many implants you want in a case like this for your mom. For me 6 integrated implants would be minimal given the 2 above force factors that you have.
Eric
3/28/2019
Thanks Greg. I appreciate the thoughtful response. Only problem I am facing is there is no bone left on R side and patient does not want a sinus lift. I will usually make patients with parafunctional habits some type of night time prosthesis to wear if they can grind on the attachments/bar, etc. I usually have to make these when using a bar or the Syncone system, but not with Locators. I think I'm leaning towards Locators, but my usual protocol is to inform the patient of the R, B, A's of all options which was also done before treatment started in the first place. Thanks again for your thoughts.
Matt Helm DDS
3/29/2019
Eric, do locators and tissue-suported denture. Your nerves (and your pocket) will thank you for it. Please see my comment below and congrats again for the fantastic, well-thought out effort you've put into this case. It's indeed an example all can learn from.
Riyaz K Gangji DDS AFAAID
3/28/2019
I think you have a good knowledge of implantology, biomechanics , (occlusal scheme) and you followed all the priciples and procedural protocols.well prepared case.
In my early cases , my failures were always in the maxilla and I still get them once in a while.
Failure mainly occurred in maxilla ,not mandible . I used to encounter moments like this , and always in the maxilla,frustrating, embarrassing and upsetting for Me. .
Maxilla - never had to worry about vital nerves, but Poor Poor bone quality, especially grafted bone , so in poorer bone quality we are now pushing the envelope of further risk by loading immediately, which can be successful , but everything has to fall in place properly. My concern was that some of your fixtures could have been taller , also main concern , what were your ISQ for upper fixtures prior to loading. That in my opinion is critical with maxilla, I always under prep my osteotomy , now I’m using Versah protocols to compact bone but if ISQ numbers are low ( that Implant has to be rock solid ) failure will will occur.on loading, even with splinting fixtures unless you are lucky and you have good quality bone, pt has mild forces on occlusion, females I’ve gotten away with low ISQ ). Also not a big fan of steroids as yes it lowers inflammatory phase issues ( which is only a few days 3 or so ) but can increase infections as pt immune respose is lowered. I like ice and nsaids and “ you will swell” approach.
I would have used the guide as a pilot type approach and then freehanded so I could feel the bone quality. Our hands should not be like stone, you should be able to feel floor of nose, even cortical bone above the inf aIv nerve or if you perf in the submandibular regions , you should not go deep when you drop suddenly ,it’s a feel , and that comes with time. I think that implant on upper right is gone, graft site and pick taller fixtures and bump into sinus if you have to .
After telling you all this , I still encounter issues and get occasional failures, it’s the nature of the treatment as so many factors are involved from biomechanics, biology, to the patient ! Patients will never always eat soft foods for 4/5 weeks, they cheat as well!,,
Good luck and great case to post and we all learn from these cases. By the way never a bad idea to consult with you perio / oral surgeon , they may be able to help. I always have a couple of experts locally to hold my hand in some cases especially with surgical advice.
By the way I found an easy way sometimes to treat a case like this is to extract all upper and lower teeth, graft bone and make dentures so he gets used to a bite scheme with traditional dentures
Then conversion to a fixed with same dentures or new ones .
Eric
3/28/2019
Thanks for the feedback and advice moving forward. I used to do all surgeries free-handed 15 years ago. Since purchasing a cone beam 10 years ago, I do 95% guided. I have noticed that while placement is ideal, my failure rate has increased slightly. I think your suggestion of using guide for pilot, then free hand rest of the way is an excellent idea. I'm glad I posted this case, I hope everyone is learning something which is what this is supposed to be about. Thanks.
Matt Helm DDS
3/29/2019
All good suggestions above, but IMHO, considering the poor maxillary bone quality (as well as the previous implant failures) your safest bet by far is a full upper denture that is implant-retained but TISSUE-SUPPORTED. However, contrary to other suggestions that it be only on the alveolar crest (i.e. completely palate-less) I would make it with at least half a palate for additional stability and tissue support. This is what I would do if this were my case! I feel that, in light of the whole history here, any fixed restoration is completely out of the question and, even the bar is risky long-term, for the same reasons mentioned by the others above. Individual locators ad tissue support, however, will not only allow you flexibility in case one or two implants should fail, not only give you predictability but, above all, a much greater chance of implant survival in the long term. And isn't that the idea? Hygiene will be easier for the patient and almost ensured, and the implants won't be stressed by masticatory forces. Furthermore, if a critically-positioned implant should fail and need removal, you can always fall back on placing a mini-implant (3M 2.4mm max-thread, or 2.9mm, same locator system) right next to the failed implant, making installation of the locator in the denture easier. You've made a valiant, superb effort with this case thus far (nice planning and execution) but with all the effort you've put into this case, I think it's time to face the reality of the poor maxillary bone quality you're dealing with which, quite frankly, is fairly evident radiographically . Good luck.
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