Crescent Bone Loss with Nobel Replace Select Implants: Feedback?

First pan looks like the the original tooth was extracted due to apical lesion. The site was not cleaned enough, granulation still present. Bone quality compromised - implant didn't integrate. Remove implant, aggressively scale the site. Immediate delayed or wait 6 months implant placement. Use a longer implant to gain additional apical stability.

the apical "lesion" is actually over preparation of the site when placing implant (i.e. I could have used a longer implant). original PAN shows healthy bone at site prior to implant placement.

Hi I think maybe his smoking status has something to do with it. In my experience very unpredictable the levels of healing and success rates in smoking Sav

It's a combination of: 1) using a non-platform switch implant 2) formation of biologic width beginning at microgap between healing cap and implant platform 3)smoking 4)peri-implantitis since the boneloss is more than the 1.2mm 'expected' boneloss within the 1st year on non-platform switch implants. Thats why when placing nobel replace implants, you should aim to place the implant with half the smooth collar supra-crestal when placing in posteriors; this would minimize the cratering. Or select an implant that allows for platform switch.

Hello Doc, 1. Did you achieve primary closure during implant placement? 2. was there a cover screw exposure during the healing phase? If I look at the first OPG I see that the implant top is almost at the soft tissue margin. Coverscrew exposure during healing phase can lead to peri-implantitis and crestal bone loss.

Can't be the diameter of implants is too wide in b-l sense?

I think given what you have said you did a good job . Nice position nice band of keratinized tissue. So the bone loss, i have experienced this with nb replace. Ti -unite surface is getting a poor rep. This type of bone loss is usually associated with unfavourable (ie non axial)loading-cant be as they've not been restored, or over torque when placing-but you didnt. The most likely cause is over prep and getting bone past its critical temperature. Hopefully that helps change the system to soemone liek astra which has all the core properties taht we require from an implant.

thank you everyone so far for the input, I appreciate it. I'd like to have your opinions on whether these implants could be restored as is with a good prognosis, or if one or both should be removed, sites grafted, healing and try again? Have any of you restored a case that looks like this and had success?

I have seen this before too often... I think the upper third of the ridge is most likely too narrow for the diameter of implants used. I very much doubt you had your minimum of 1mm bone surrounding the fixture.This does not look like the requisite 6-7mm hard tissue width...these look like 4mm+ diameter implants. Note the distal implant is worse which translates to the thin lingual in the clinical pic. On top of the thin bone you may have had over heating...but I am speculating on that. Although I am a proponent of platform switch ,I do not think it is an issue "at this stage" before the switched platform of the abutment is in place.Although I accept that many systems have a cover screw that is effectively platform switched..this is a lot of bone loss. The peri implant tissues look decent clinically so peri-implant mucositis/implantitis is not really the causative factor ...unless you have cleaned everything up? My advice here is to remove them...graft and re assess. .Consider 3 narrow implants (3mm diameter) well placed ??or indeed a more substantial graft...exactly what is guess work at this point. I agree that the placement is far from ideal on either one... for the proposed prosthesis which would compound the existing problem. Start again do it right this time..good luck.

It can't be because of smoking as the other impant is integrated. Hence all other systemic conditions, type of implants being used, etc, are ruled out. Further more the successful implant clearly shows your good surgical skills. Hence the only thing left is bone quality. I can see the socket lining on the original pan. Having a successful implant adjacent a failure (assuming everything being the same) - definitively show the bone quality is the reason for the failed impant. Remove the failed implant, curettage aggressively. Let it heal for 4-5 weeks. Re-evaluate. If enough bone, implant another at that point. If not, consider grafting.

Dr SenGupta is correct. Bone loss at this early stage before restoration, is most likely due to errors at the placement stage. These implants are Replace Select RP of 5 mm in diameter (Yellow neck). Removing the implant(s) is no easy task but may be the obvious choice. Because bone loss may get worse as soon as the implants are restored and in function. I suggest you should try to use one of those fixture removal kits (Neo Biotech). Referring the patient out to a colleague is another option. Good luck and thanks for sharing.

This type of bone loss on TiUnite surfaced implants is a routine finding. The classic crestal bone loss around this type of architecture is the single reason that I abandoned this system several years ago. Since we started blogging about our findings, clinicians around the world have confirmed that there is an inherent problem with this implant's parameters and with Nobel's implants generally (especially with Speedy). This is the reason that, for a second time, they purchased another company's system (now known as Nobel Active). The fact that so many clinicans worldwide still use these implants, despite their shortcomings, is astounding to me. Call it lazy, call it uninformed, or just flat out uncaring, there is no excuse for accepting this type of bone loss after good surgical execution. Don't beat yourself up over this; beat a retreat from this type of architecture. RJM

If any of you get ICOI implant Dentistry publication ...check out the recent article by Ziv Mazor et al on replacing molars with 2 narrow diameter..(3mm)implants..with 10mm mesio distal space..I think they did 60 or so molars...it makes a lot of sense...I have acheived similar results with this as I do with wider implants.You have a reduced occlusal table which if designed well looks pretty good,and has not been an issue ...hygiene is also manageable with a properly designed crown. Back to this case.... I am certain that the implants here are too wide for the ridge ...this problem is expected. 1mm of bone is the MINIMUM not the IDEAL .If you dont have it... then graft before or at the time of placement.....The inevitable removal of at least the distal implant will compromise what was a good site. I also think that the mesial implant will come back to haunt you in the future. The purists will probably have insisted on widening the ridge in the first place.I can't disagree with that, as an option.However collective circumstances dictate options. Another point to note. You realise that you have made 2 implant placements designed for 2 "small" molar crowns right? I disagree with previous comments about "great placement"....The mesial implant could only be a molar with the placement you have done.. Although it matches the other side I dont think it is the correct design as the 2nd molar will be small..almost a premolar...not good. What was your intention for the prosthetic result? Did you "begin with the end in mind"? Even if integration was perfect with no bone loss...your mesial implant is poorly placed for a premolar...its too distal.. Your study model and wax up should have shown you that..which would have then been used for a surgical guide for placement particularly as this is your first case. In the absence of a 3D scan your first measurement with calipers would have dictated that the widest implant here should have been 3.5mm diameter. Dont take this personally ,I admire your courage to throw yourself to the wolves..if you keep your cool you will learn a lot from your implant debut!

Did you say you placed these implants as part of a course? So this was didactically planned and executed? Find another course that teaches implant dentistry from the fundamentals.Hang in there, we learn from mistakes much more than successes. "Implant dentistry is a prosthetic discipline with a surgical component"

The person has/had periodontitis. There was no mention if it was treated. Prognosis for implants will be reduced if there are bad bacteria doing the backstroke in the saliva. It is protocol to treat perio dx before doing implant surgery.

Looks normal for a non platform switch implant.

I appreciate all of the positive comments on this thread. Also, it is especially valuable that the original poster has been involved in the back and forth comments.

Please don't be discouraged! Thread loss can happen. Your 2 choices are: 1) leave alone, possibly do laser or Periowave or flap surg and try to add bone graft material such as GEM 21S or Dynagraft around the site. Check for osseointegration and stability and restore. 2) Remove, fill site with bone material and try again. I have had a worse bone resorption than this in the upper left premolar site. There was only 1/3 implant integrated. It was stable and seen by an oral surgeon. We chose to leave it and restore with the crown covering some of the exposure because removal was not the best choice. It worked! As said before, this is part of the learning process and cudos to you for trying!

I think this has a lot to do with smoking. I have placed thousands of implants and some of my largest failures have been in heavy smokers. If they smoke more than half a pack a day they are at significantly higher risk. Two packs a day and they are very high risk. Interestingly, it is not all sites in the mouth that are affected equally. Posterior mandible seems to have a predilection. It also depends on their smoking method - where do they pass the smoke over? How long and where does it sit in the mouth. Smoking in my clinical practice and according to the literature has a porter prognosis. Smokers have to accept this. If they want their implants to survive they have to quit. I am not a big fan of the nobel replace select. I used them many years ago and have seen greater incidence of failure and peri-implantitis than on other implants. SOme has to do with the surface and some has to do with the mature of the connection and that all of the stress load is transferred to the platform area. I like Strauman, ASTRA AND BIOHORIZONS CONNECTIONS MUCH BETTER.

I advise my implant patients that smoking accelerates perio & implantitis. It's part of my consent form. Don't be discouraged....they call it practice.

The implants used were Nobel Replace Tapered Groovy, textured collar, RP 4.3X10mm.

I strongly disagree with perio 1's comment and to put it as politely as possible, it is way out of line.

Any and/or all of these issues can factor in. I do not feel this is too narrow a ridge, these are 4.3mm diam. (gold), the 5.0 are blue. Smoking may have a bigger impact than you think. A lot of heat on the implants during the woven bone/composite bone phases through 4-6wks. One can be affected more than another, it just happens. This is now an old implant design and the implant is tapped and has square threads and a questionable reputation. In a long implant career, you are going to see a lot of interesting results, this case is just starting your education. What we are looking for is predictable results. All implants will work most of the time. It is the failures that make us scratch our heads. Good Luck

Just a suggestion and just my opinion...remove these implants ...they are in the process of failing...due to smoking and peri-implantitis...clean out sockets and replace with short implants (Bicon)...placed below the alveolar crest...I know I lot of my collegues still do not believe in short implants...8,6 and 5 mm...with wider diameter...5-6mm... ..it is my experience, esp. with smokers that using short implants placed below the crest (1-2mm)gives enough healing to get them past the initial healing stage (3-4 months...maybe sometimes longer)...we have had a lot of suceess with this technique...with and without grafting...In my opinion the days of longer implants (above 8-11mm) are over ...and the sooner we realize that , the better results we will have.

If there is a question of adequate ridge width how will it be advantageous to place short WIDE fixtures??

If there is a question of adequate ridge width, why would you want to place short WIDE fixtures??

Robert Miller's comment on the surface coating TiUnite comes from a professional with a strong research background...in the early years we were very excited about HA coating, as it was thought to attract osteoblasts....we later found out, that bacteria had a great affinity for it as well and caused perimplantitis, and eventual failures. From what I can see in the radiographs, saucerization around the implants ( especially the distal one) was there from the very beginning; and as well we do not have a report on why the natural teeth were lost in the first place....what pathogens were left behind to later act up? Even with the amount of bone loss exhibited, these implants may be well integrated and next to impossible to remove......debriding the area, washing witch citric acid, applying antibiotic to the infected area, and a bone graft with PRP, PRF....may possibly improve the situation....but the patient must absolutely stop smoking forever......not even a puff....good luck, we all have our failures, and this is how we learn. Gerald Rudick dds Montreal

Dear Jimmy, I read most of the first twenty comments and than It was late so this is what I would do if I were you. First off the size and placement of the implants seems reasonable ; Nice Job! Second I have placed quite a few of this type of implant and have rarely seen this issue. However I do believe if the buccal and lingual bone is wide enough than the issue must have been the quality of bone and perhaps some granulation type tissue that remained. So here is what you do: 1DONT REMOVE THE IMPLANTS, THAT WOULD BE NEEDLESS BACK PEDALING AND DELAY YOUR TREATMENT INDEFINITELY Do the following: 1. percuss both implants with a mirror handle end , they should sound solid 2. torque test to be sure they truly are integrated and resist 32 -35 ncm's 3. than lay a full thickness flap around the crest of bone and facial to explore and check out the exposed threads 4. clean away all connective tissue in defective area 5. use curretes and make sure that you have removed all soft tissues 6. treat the implant titanium surfaces with a slurry of Tetracycline Hcl ( just break open the tetracycline in a dappen dish and mix with sterile saline into a medium thick slurry, use this with micro brushes to scrub the implant surface for 60 to 90 seconds at least. 7. rinse thoroughly with water and than sterile nacl 8. dry lighly and if you own a diode laser from discuss dental ( only costs $3500) use the laser to complete sterelization of the implant surfaces. 9. mix mineralized allograft like lifenet,or mineross with a 40% bio-oss (for stability and slow resorption and add some clindamycin powder all with sterile saline for injection. place/pack the bone graft over the defects that you are repairing and them place a bioguide membrane , or a conform membrane from ace surgical. 10. Suture closed with Vicryl or other fourteen to 18 day suture and leave your healing caps in place. 11. Instruct the patient to keep it clean by using peridex and cue tips to swab the site and sutures after meals and at bed time. 12. observe and remove the sutures in 14 days and the implants will continue to integrate over the next four months. Take a post op radiograph and another in 4 months. I have done this more than once and it works Please let me know how you do. Sincerley, David Furnari DDS D David Furnari DDS Suite 211, 14 Harwood Court Scarsdale, NY 10583 phone 914-723-4707

Jimmy jam, there seems to many opinions as to why you're having the boneloss on these implants, but no one can say for sure exactly b/c they weren't there at surgery to watch you and it could be a combination of things. But now that it's occured what do you do? I would leave implant #29 as is - its FINE. #30 implant, I would remove and redo. Nobel replace implant has stood the test of time and it 'works'; it's just that there are better designed implants now (which you actually have complete control of in choosing), so why use an older generation of implants which tend to get more crestal boneloss? Just something to think about for your future implants.

So if we compile the causes, following could be the reasons: 1. Insufficient bucco-lingual width (in this case it was minimum) 2. Smoking (if yes then why the other implant is good) 3. Overheating during the surgical placement (possible) 4. Implant Design (? some would agree to that) 5. peri-implantitis (? no bleeding, the gingival tissue looks good, dont know about the probing depth)

Hi Jimmy , my two cents worth , SMOKING is the issues , do I treat smokers of course they are my business , can you stop them , no you can only try , they will be economical with the truth. In a smoker it is best to not use healing caps but cover screws to allow for sub-gingival healing and only if there is a spontaneous exposure revert to healing caps. As to replace a lot of people like them , yes the concensus of the Opinion leaders ( Lang , Mombelli etc ) is that there may be an issue with Ti-Unite but NB has their research to refute that . I am still asked to place them by some refering Dentists who swear by them . As to your treatment plan , it was fine things happen and the key to this job is problem solving of which you will have a lot more in the future so relish it. Crestal loss like this is also patient physiology dependant , not merely the smoking and Diabetes story there are other factors at play down bacterial flora etc. What to do , well strangely there is a strong possiblity with smoking cessation and improved oral hygiene the loss may stay at that level for years and not deterioate , I have seen it in cases over a 20 year period. So discuss it with your patient and I would graft the distal implant maybe attempt to cover it for a period and load the anterior one. And Jimmy we are all still learning even my mentor says that and he hasplaced since 1964 . Regards Peter

Dr. j.Miller mentioned that this is due to Ti-unite surface implant type ,also most of publications state that it enhance oseointegration ,plz if you have any publications confirm your statement and the explanation.

It's hard to tell, but it looks like radiographic calculus on the roots of 26,27,5,6 mesials. When was this patient's last cleaning? Has he been required to do a 3 month recall? It is an obvious periodontal case, so if he has been compliant prior to and following treatment and there is radiographic calculus, it might be time for a new hygienist. Periodontal status is of course a major factor in the success of implants. Please have a look at the xrays. If I am right this pt needs scrp asap and did need that before treatment. I definitely agree with the suggestion to avoid the healing cap and use cover screws and bury it to heal. Dentist just remember your work is only as good as the patient's home care and your dental hygienist's abilities. Your dental hygienist is your best friend for the lasting results of your work and the prevention of future problems/ failures.

The presence of calculus on a few teeth on a panorex does not mean this patient has active periodontal disease. The bone level appears to be excellent around all of the teeth so I would conclude from this that active periodontal disease is NOT a contributing etiology to the problem around the implants.

bone levels are not normal. furcation 5mesial, max ant bone loss, calculas. Most smokers will have periodontitis That is by definition consistant with perio Dx. Was there a perio ex prior to surgery? If so, did it include full probing? BoP, Plaque levels, furcations assessment using a furcation probe. Implant protocol involves treating perio Dx to stability prior. Mark

I am astonished about the comments on everything else as possible reason, like the patients smoking, oral hygiene, perio, mean implant system etc, rather than on the placement itself.Well, I ask my self questions....Are implants usually (and especially nobels replace) not for bone level placement? What is the pano showing? 5mm above the bone is the implant shoulder, right at soft tissue level!!! you can see it exactly on the pano, question is what for?? is soft tissue not designed to cover hard tissue? if so, and if soft tissue is beeing held up by the implants 5mm above hard tissue (bone) like a tent, then what happens underneath in the space created if not paradise for anaerobia?wondering about bone loss??really?? astonishing, really!!my congrats on the above comments and wise conlusions!!!!

Dear Jim, Well done for a first case. Mine was worse. Nobody mentioned screwing in the implant too fast (thereby causing overheating at the cortical bone) as a possible cause. Perhaps having a brief pause when turning your torque wrench would help. I agree with the others on smoking. Dr Tomo, mind sharing some of your mess-up with me? I like to learn from mistakes, mine or other's.

How wide was the ridge at the crest and what diam were the implants? This frequently occurs when the crestal bone on buccal an lingual of the implant is too thin at placement

Would someone comment, as to wether we are looking at implants with healing abutements, or did I misunderstand the initial post? These implants were initially at bone level. They aren't now because of the bone loss. Not sure why I'm letting this bother me so much, but we are all learning on a daily basis. Bv Baton Rouge, La., Vinci Oral and Facial Surgery inc.

yes those are 5mm healing abutments, implants were initially at bone level.