Failing Fixed Partial Denture: Wait or Take Action?

Good approach of thinking. I would not ruin it if the patient can use it asymptomatically. Mastication is mostly possible on the left side and frontally. When they fail you will have to rehabilitate both jaws.

Implants are great, until you see something like this....very messy to clean up. Take them out as you have 50% or more boneloss around all of those implants. There's no point in retaining them as he's going to have to deal with it sooner or later. He's only 54 and the sooner he deals with it, the easier it will be to rehab when he starts from scratch again b/c you will have more bone to work with along with less health issues. Also, I'm sure there's suppuration coming out of most of those implants; you don't leave untreatable infection in the mouth or wait for implants/teeth to abscess or boneloss to reach the apex. Don't be afraid to be aggressive in treating peri-implantitis cases when needed. If this case is over your head, refer to a specialist instead of covering your eyes and ear and *hoping* that it lasts longer without any symptoms.

If something goes wrong the patient may put the blame on you for a “pushy style of treatment”. Let it ride. This case is not supposed to be easy in the future.

Do you have a radiograph from the time of placement? I would be interested in how much bone loss has occurred before I start thinking about where I am going.

My question: Why did this patient come to see you? Is he aware of the failing case? If he is aware (now he is) either you treat or you defer; if not, your going to own the case (your liable). Just observing; is not an option. As per treatment; 1- establish which of the implants are good (half life) and which need to go! 2- Remove the failing and treatment plan for an overdenture on the remaining fixtures. Make sure you have good tissue support. 3- If the patient is happy then all is well. If not; plan for more implants. But, just looking at the case; all was done and it failed. So, a removable overdenture is your best bet. Good luck!

I agree with getting them out and saving bone and infection for the patient. Be right up front with what you see going on in this patients mouth with his implants. Tell him what you would recommend and let him decide the best course of action. Sixteen years is a long time but now they are failing and doing something now is better than waiting. I wonder if not restoring the lower teeth contributed to the overall failure of the implants. Presenting his options is easier for you if you didn't do the implants or restorative. If you did the implants or restorative it is a little tougher presenting perhaps how you would like to do it over. All in all this has lasted 16 years. That's a long time and dentistry has learned alot. We have learned that perfecting the bite and keeping it stable can reduce the risk of implants being lost. I hope sharing how I might present to the patient is helpful. Good Luck

More and more of these cases will be surfacing, and we can appreciate that implants have their own set of problems. Periimplantitis is caused by bacterial contamination of the implant surface, by the same bacteria that cause periodontitis. Of course, other factors are contributory. Periimplantitis can often be surgically treated. Dr. Stuart Froum has just published several case studies. These aren't simple surgeries, though. So far, there isn't any standardized treatment, but the goal is bacterial decontamination to the extent that osseous grafting will be clinically and radiographically successful: normal probing depths, without bleeding after probing and radiographic fill of the defects. This has the potential to be a real headache of a case

I totally agree with Dr Kong's suggestion.Be bold & tell the patient that they need to be removed.

First step is inform patient of conditions. We go to heroics at times but the patient may not want total treatment with bone grafts, transitionals, 2 years of treatment etc. Give an indepth plan with selected implant removal, extensive grafting, transitional denture, implant placement, transitionals fixed and final fixed. Give time and costs and let the patient modify (read, compromise) the treatment down to what he wants to afford. It may be a denture, it may be a 4 implant overdenture. Gauge his reaction to this to get an insight as to how the treatment will go with you. Leonard

More information is definitely needed. Did anyone notice the mass in the upper left posterior maxilla & sinus? What is the patient's medical condition? What is his history of care for the implants?

If the prosthesis is solid, I would first attempt to flap and decontaminate the implants, remove the failed ones (cut them from under the bridge) graft those areas; if the the patient is asymptomatic. It's funny that how we come back to traditional periodontal therapy/surgery with these cases. I would essentially do "pocket reduction" root amputation with antibiotic suppression, and place the patient on 3 months SPT with low dose Doxycyline for ever. I inherited a practice from a periodontist that had placed implants in the 80s and see a few of these type of cases. The above mentioned approached has served my patients well and stabilized them for a few years now. The other option is to remove them and start over again. Good thing with the old cases is that there were always over engineered and you have enough remaining implants ( Imagine if this was all-on-4!!!). With your case you probably only have to remove the 2 or 3 anterior implants and will have enough to maintain the prosthesis safely.

Best thing to do is to inform the patient of the condition. Give the option of full rehab with grafting and new implants , just removable prosthesis construction, or leave it till it blows up with swelling and pain. After that, it's upto the patient. Ah.... We used to say implants are permanent. I 've just seen a similar case that's failing. It was all on 6 type of a roundhouse bridge. The patient paid $23000 to get it done 9 years ago. When I told the patient what's going on with the bridge, he really looked lost. That was saddening to me as a dentist. Like my friend who's a marriage counseller, nothing lasts forever..

You do not continue to observe without advising the patient of the existing bone loss and infection around the implants. Next you would explain the options to the patient. Treat the peri-implantitis and determine postoperatively your ability or inability to improve or eliminate the periimplantitis after determining what is hopeless and what is not. Where the case is over-engineered, the prosthesis will continue to function, and where it is not, it will need to be modified.

Hello First of all treat the peri-implantitis. Its better to refer the patient to a periodontist for the same. Periodontist can suggest you better as diagnosing through x-rays is not appropriate as you need to co-relate it clinically also. Definitely the severed implants need to be removed and the new prosthesis ( removable much better for the patient ) has to be fabricated. His age is 54 now & he got implants 16 years back. This means at the age of 38 years only he might had some trauma or severe periodontitis. Do find the cause of getting Implants and procede accordingly. Best of luck.

Let's look at the beautiful amount of alveolar bone that is around the lower teeth. And these teeth are more than 40 years old.

From prosthetic point of view the case was perfectly done. If the bridge had been sectioned (not splinted), it wouldn’t have lasted for 16 years. Once it is removed, it’s impossible to predict a real clinical picture. Therefore, some “detailed” options now don’t make sense.

Flap, degranulate, detox, graft. Evaluate the occlusion, adjust and give the patient a NG. You will be able to give the patient more service with the bridge.

ssargent says: "What is his history of care for the implants?" This is the key question. If he isn't taking care of the implants, remove them, graft the sites, and give him a traditional full upper denture. In a year, you may consider him for implant placement again, but if home care doesn't improve, they will fail also. The patient MUST take some responsibility for this. Don't be a hero (or a fool). Remove them and tell him a conventional denture (or no treatment) is the only option at this time.

This looks like a screw retained prosthesis with the accompanying problems of microgaps that allow microorganisms to proliferate and cause an ongoing chronic peri-implantitis. A 0.5 to 1mm bone level loss per year was deemed acceptable in the early years of implant dentistry before the problem was solved via platform switching. If this is screw retained with microgaps present, the solution is to unscrew it , scale the implants as best as possible and eliminate the microgaps by screwing back the abutments and prosthesis with some temporary cement in the microgaps. Tempbond may work, but try to put in just enough. Have to repeat the whole process every 6 months though. The alternative is like what has been suggested, remove everything, temporize with a upper full denture and then reimplant, this time with platform switching abutments.

you can not judge on dynamic situation just from 2D picture, as mentioned above what is the patient complain and bridge mobility 2nd and it is number one is the condition of occlusion of course with that long time there changes in occlusion which is the first guide in treatment planning and may be the cause of bone loss so listen first to your patient check occlusion tell the x ray condition adjust any traumatic occlusion (functional and if there is para-functional) treatment of perimplantitis +(occlusion and oral hygiene)

When a patient comes to our office for an assessment of the entire oral and maxillofacial region, it is quite obvious that this patient is expecting from us an accurate assessment and account of the present condition. The case was done many years ago. Now, we are going to tell this patient that we can treat the case with newer evidence and technology. With the bad news this patient just received, will the patient believe us? Probably not!

I'd be willing to bet the farm that this patient is or was a smoker. The disease is only affecting his maxillary arch. I'd try to do a more thorough diagnosis before contInuing on with this case. I'd hate to make the same mistake twice. He's probably a denture patient. Let's be realistic.

Periodrill, I wouldn't be so hasty in betting the farm because you will probably loose it. I have a patient referred to me showing similar loss of bone around similar implants.... I think they are nobel biocare. The patient is a non-smoker and has meticulous oral hygiene. I maintain that the bone loss is due to the microgaps present in all the implants because it is carrying a screw-on partial denture. The microgaps full of micro-organisms act as a toxic pump each time the patient bites and let go. Let us ask Dr C..... Is this 54 year old patient with no medical complications a smoker or non-smoker ? Dr C. Please tell us. My friend, get ready the title deed of your family farm!

nothing pushy treat here..............1st-to read the whole clinically from a 2d pic is not suffice.......................2nd------we need to be honest n bold to tell the patient to wear off the load.........3rd-very important is occlusion....................................4th..where the excess load is arising to cause ''ARC'' patern of boneloss n in such a grade..........................................5th --retreat is almost a definite yes in such case.....................................my take is to TEMPORARISE with a full denture for atleast 4-6months till we r ready for rehab...................................................thnx for such a wonderful case on discussion........................