Dental implant surgery with multiple systemic disorders and oral bisphosphonates?

This is a complex case that you have managed well over the years. It's unfortunate that this implant has fractured. While the baseline instinct might be to remove the apical portion that remains, this might be difficult and you are close to the nerve. Regenerating this region may also be complex, and might not result in an ideal site for a new implant. It might be worth considering leaving the apical portion of the implant in place , then placing a new implant more distally, where the pontic is at present, and then building a new bridge with a mesial cantilever in the first premolar region. Less invasive and perhaps more effective. Something to consider, good luck.

Skip the broken implant site and/or remove it and graft and place new implants in the first premolar and current pontic site for a 3 unit bridge. There is a reason the implant broke ... no more cantilevers here. I would tend to look whether the root tip is easy to remove and remove it Safely if possible.

Any further surgery should be avoided. Remake the bridge on the lower left by telescoping the canine and connecting t the implants

Hi, Other than the real issue at hand, the Patient is showing some calcification on Patient's left side (which is the right side of the picture) in 2018 Pano. Check that as well. Where are they? Carotid? Just thinking out loud.

This is obviously a very complex case. You have not indicated your expertise so advice is a little difficult to give except to say that you should consider a multi-specialist treatment plan approach. Although leaving the apical section of the broken implant would be a convenient option, as best I can see there is implantitis around to remaining section which I suspect will lead to an acute flare up at some stage soon and/or I suspect it will be unlikely that the bone infection/inflammation response will resolve if it is left. However it should be removed by a very competent oral surgeon. Clearly there are medical considerations but from a dental point of view I think you need to answer these questions before any proper advice can be given: 1 what are the CTx scores in regards to her bisphosphonate medication 2 how bad is her oral lupus 3 how bad is her Sjögren’s disease – especially how viable is her saliva flow You will understand that placing more implants is an elective option and I doubt you can justify doing this if her CTx score is below 400 (I understand some colleagues braver than me will push this to around 150 - but I repeat can you justify this professionally if she suffers consequent ONJ). Oral lupus can have negative implications on longevity of any restorative work due to the problem of maintaining viable gingival/mucosa health around teeth and implants. So this needs to be considered in regards to implants and also her remaining dentition. Similarly Sjögren’s disease can have an enormous impact on longevity of teeth. So your consideration is not just whether implant placement is wise/possible but also what is the reasonable expectation for longevity of her remaining dentition. Unfortunately I expect that if she requires dentures in future, both lupus and Sjögren’s disease will make it very difficult for her to comfortably wear dentures. With all this in mind, my suggestion would be to aim at getting her CTx score above 400 because that will give you many more options. I would go very slowly in regards to any treatment plan but I would emphasise to her the importance of getting her natural dentition into a state of good health. It may be that she is orally fit and healthy but as best I can see there are some problems in at least the upper arch that should be sorted out. Most importantly the patient should be informed of the difficulty of maintaining her long term oral health and the consequences if she is non compliant. Once a stable, disease free base line is established, further extensive treatment can be considered dependent on: her compliance, her health, her finances and her wishes. So you may gather that my advice would be to proceed slowly and with caution. If you consider the current situation, as long as the problem involving the residual fractured implant is solved, and the cantilever bridge issue and caries and perio is treated conservatively, is there any reason to be heroic in regards to elective surgery? It seems to me that she can eat adequately, I suspect she has reasonable aesthetics, so why push the envelop too quickly and un-necessarily?

As mentioned above, this is a complex case, and will become more complex if further surgeries are planned. By comparing the two panorexes over a three year span, it is obvious that this lady is a bruxer, and other implants are at risk to fracture. I would try to detoxify the fractured implant, place a collagen plug over it, and let the soft tissues close and keep it as is. I would remove the implant crowns on the existing lower implants and replace them with either ball attachments or locator type retainers, that would support a removable partial lower denture. Periodically, the lower partial denture teeth can be changed, and the occlusion opened to take the strain off the already worn down natural lower incisors...….with the type of medication that this patient is on, there is a risk of creating an osteoradionecrosis situation.

The patient has a colorful medical Hx. Dr Beckwith has the fight approach.

I think the apical part does not worth to harm periosteum with a full thickness flap, because restriction of blood supply increases the chance of onj. If the gingiva is healed over the implant, I would go for hybrid anchorage. I would not touch the left posterior abutments, literature showed that detachment of abutments leads more gingival demolition. I would splint the implants with the canine for one year, and control clinical and radiographic signs. please update your case next year!

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