Failing Implant from Smoker: Any Advice?

Looks like you have plenty of apical bone for removal of this implant and immediate placement of a longer one. With all due respect I think the first mistake you made was not ensuring compliance from this patient in terms of oral hygiene and smoking.

Dr C: This is a failing implant and you need to inform the patient about the problem and treatment options. If you would like to attempt to treat this, you need to make a flap to expose the implant and clean the granulation tissue around the implant, then detoxify and treat the exposed threads with tetracycine paste and graft and cover with resorbable collagen membrane. In my office I would use the waterlase laser to remove the granulomatous tissue and detoxify the implant surface, then graft with cerasorb and cover with PRF membranes. This is not an easy case to treat because it has already advanced to more than 5 threads and because the bar is directly screwed to the implant, you cannot bury it. The same thing may be happening to the other implant.

Dr. B, How do you ensure a patient is going to quit smoking? He told me in good faith he had stopped. I had no reason not to believe him. I am just curious how others handle these situations. I have informed the patient that the implant is ailing and that surgery will need to be done to correct the situation. I explained that bar would need to removed. Is removal with immediate placement a predictable treatment? Or would debridement and graft be an equal choice at this point?

Dr C. I agree it's difficult to ensure patient compliance. We have to take them at their word. I have a similar situation with a patient who is demanding implants which will require bone grafts and sinus lifts. He's a heavy smoker and has poor oral hygiene. I refused to place implants until he improves his home care and shows commitment to at least reduce smoking. To answer your question, I think grafting this is very tricky since the implant surface is contaminated. I would remove the implant and place a new one. Good luck and thanks for sharing.

Smoking is not a true contraindication for implants. How is the patient's home care and frequency of maintenance visits at your office? Removing the implant and replacing it with another one is an option. It means you will be taking a new impression and repairing the bar by either soldering or welding it, or remaking it. Maybe you'll feel more comfortable doing that.

How about sorting out his oral hygiene, smoking cessation and simple professional hygiene measures and reassess? All these complicated GBR techniques struggle to work as it is and putting them into a toilet will not be good for us or the patient. My thoughts are bars are horrible for oral hygiene . Convert to a ball or locator based attachments and then reassess, if the most distal implant is looking healthy ie no pus on probing , then it syour call to remove it or not. Also how much mucosa support is there, is the occlusal load too much? Likely looking at the notched appearance of the peri-implant bone-typical of occlusal overload. Hope that helps

I am actually in the process of converting from a bar to a locator overdenture. Lots of keratinized tissue in the area. No pain to percussion and no pus upon palpation. Periotest values are in the negative 3 to 4 range-so implant is non-mobile and integrated. This is the first time I have run into a situation like this. Just trying to get a feel for what is normal protocol. Is some sort of surgical intervention a must at this point?

Part of the delivery protocol for the prosthesis is information on cleaning, care, oral hygiene and professional mainenance. If the patient was placed on a recall schedule and never complied, nothing you can do but document it. He is more likely to loose a fixture or two from peri-implantitis than if he has good home care and keeps his mainenance appointments. As far as what the normal protocol is, he has moderately advanced bone loss around one fixture that we can see and the rough surface of the implant is contaminated with bacteria. Do you ignore this when it happens on natural teeth? Of course not, so you can decontaminate or decontaminate and attempt to regenerate. One of the areas where general dentists are prone to litigation is failure to diagnose and failure to treat periodontal disease(according to the latest risk management course), and this area should be treated. Converting to a 4-locator retained overdenture is an option, but it is a step down from a bar. I hope this helps. Good luck.

Dr. C, As you can tell treatment varies quite a bit between practitioners. You probably have noticed that smokers often show little or no erythema or inflammation until it's quite bad. More x-rays would be nice, to see opposing and the other implants. Saucerization around an implant makes me think about occlusion, as TOBooth mentioned. Assuming that has been addressed, you are giving yourself more options with switching to locators. I agree it is a step down from the bar, but I think the implant is being overloaded and switching to non rigid fixation will help, make sure your patient is on board because it is not going to be as nice as the bar. If you are set in switching to locators then just take the implant out and put a bigger one in the same visit. If your patient is willing to pony up more money you could place more implants and get rid of the cantilever keeping the bar design. If you decide to keep the implant you should cut away the first three threads and make it like an extended gingival collar, the other two threads can be thoroughly cleansed and grafted. In the end remember you can't brush his teeth for him, he has to do his part, so just keep good notes and tell him often(and put in chart notes) that if he doesn't do his part he's going to lose implants. He looks like a big strong guy with a heavy bite? His upper teeth are probably just torquing the snot out of the terminal implant. Good luck.

I don't think smoking was what caused the problem. It will make this situation worse..but not cause it. The cause was most likely the fact that he never returned for hygiene. From my experience in treating these types of cases, I would remove and replace. I would also convert to locators, as you are currently doing.

Dear Dr. C, The big question is whether the implant is ailing or failing. Ailing is bone loss, inflammation,... Failing is when there's already mobility. I don't think you can blame this on smoking alone. IF he popped a tooth off the prosthesis, there are probably occlusal issues or passive fit concerns on the bar. There is probably a high concentration of MMP's and other inflammatory cytokines based on his crappy home care, buildup,... SO - treatment - Dr. Robert Miller hss shown cases with use of laser for surgical treatment of implants. I find that laser, tetracycline, bone graft, barrier and lots of sutures may help. Prayer is a little more consistent. The best therapy is to remind the patient what HE has lost and start on a new implant. The site may have been compromised when you placed the implant in addition to the first possible factors I mentioned.

Treatment depends on the patients oral hygiene and smoking habits. If he stil smokes and has poor hygiene peri-implant surgery is pointless. I would convert to locaters to make oral hygiene easier. Monitor for a while if hygiene and smoking improves peri-implant surgery and grafting might be an option if not remove the implant, he should still funtion well enough with 3 implants and locators. If he improves on his oral hygiene and stops smoking you can allways place a fourth implant if needed. If he doesn't improve leave it the way it is.

There is also bone loss on the implant to the right of that one your concerned about. I would radiograph all the implants and evaluate all of the fixtures. With the amount of bone loss on the fixture your concerned with (about 50%) any attempts to salvage it will just delay the inevitable. I would suggest section the bar midway between this fixture and the adjacent then remove the fixture and place a longer one. allow to heal for 4 months 9do as a two stage surgery) then uncover and take an open tray impression of all the fixtures the lab can then wax and cast a new section and laser weld to the old bar

When I see a saucer defect on the most distal implant, I find that the problem is usually occlusal overload. On these overdenture cases, you have to make sure that he is having regular 5 year relines. Otherwise, you need to lighten up his occlusion on his molars. In fact, I rarely allow any contact on the 2nd molars. Finally, I would not try to surgically repair this, as it would require removal of the bar while the graft is healing, if it heals at all. There is still plenty of bone around this fixture. Just degranulate and use a round carbide followed by a footbal finishing bur to eliminate the exposed threads. This way, he'll be able to keep it clean. Finally, you must emphasize hygiene with a water pik used daily with 1 part rubbing peroxide to 3 parts warm tap water. His gums will look incredible. He also must floss regularly. Just tell him once a week for now. Schedule him for 6 month recall to ensure his occlusion is not traumatic.

Doing dental therapy such as implantology is considered advanced ... it is a treatment that involves a huge undertaking on the part of the dentist and the patient. Unfortunately, there seems to be a disturbing trend towards implants being thought of as a 3rd set of teeth that will never fail ... perhaps a second chance to make it right. This should be the proper approach: For any patient that loses adult teeth, you need to properly discern why these teeth were lost. Many factors can be associated or cause the tooth loss ... so proper pre-operative diagnostics at every level is imperative. All the conditions that made natural teeth fail in this individual will also lead to implant failure. In this case, for a smoker, especially a heavy smoker, this patient in my practice would have to be involved in a program where his family physician and the dentist are actively involved in supervising a smoking cessation program, where the dental hygienist and the dentist are actively involved in modifying the oral hygiene behavior, etc etc BUT BEFORE THE IMPLANT THERAPY ... otherwise, there will be no implant treatments. And, let us not forget the consent forms. In my opinion, unfortunately, you have a long term problem with tis patient. Good Luck.

Dear Dr. C If the patient has poor oral hygiene and will put the best implants and prosthetics, they will fail if no patient cooperation. Patients lying cause headaches, need to be educated and signed informed consent. I would not do anything until we achieve a hygienic oral cavity. Regards,

Dear Dr., Since the main causes of the bone loss around this implant are: 1. cantilever loads, 2. poor oral hygiene, and 3. heavy smoking, elimination of all of these risk factors are mandatory. In addition, surgical intervention is a "must" in this case. The lost bone will not be reconstructed or even stopped with non-surgical methods. But, based on patient's history and presence of high risk factors, regenerative surgery is not a predictable choice in this case. I would choose resective surgery, if he was my case. Hope you sucess, Neda Moslemi

I would like to add one more comment, please. This case should be referred to a more experienced "implantologist", before our colleague, who was well-intended to begin with, gets into more problems with this kind of patient. Does anyone agree?

Dear DR.C I can't agree with removing a functional, non-mobile, denture supporting implant just because it shows a few millimeters of bone loss around its neck, and, I can't disagree more with Dr. Moslemi's viewpoints about the regenerative surgery being of no use in this case.What might be of great concern to me -in this case- is the role of detrimental occlusal forces as well.It would be very hard for me to believe that all these regressive changes around the fixture(s) are just because of smoking and low oral hygiene and and not a wrong prosthetic design or destructive dissipation of occlusal forces have ever been involved.

Dear Dr C., A few questions and comments: A tooth has broken off the denture.s Circumferential bone loss around one implant and possibly other implants in the vicinity. What is on the maxillary arch? What is the functional occlusal scheme? What is the mandibular prosthetic design in terms of biomechanics? Is ther bruxism, is there clenching, nocturnal, diurnal, or both, or other parafunctional issues? Are there any TMJ issues? What is the characteristic of the patient's muscle dynamics. The point is that smoking and poor oral hygiene are important negative factors, but they are not necessarily the only negative factors that may be contributing to the apparent ailing implant(s). Detrimental occlusal forces in magnitude and direction are also an important consideration, among a multitude of other factors. If all the contributing factors are accurately identified and corrected, the prognosis may be significantly improved.

Inform the patient about the possable future of the implant. Put the patient in a bruxing appliance at night. Treat the implant site by way of DETOX, DECORTICITATE, DEGRANULATE AND GRAFT. You may have to remove the bar for some time for the graft to turnover. Do this at least once, after that you have several options: remove the implant and place a new one and fabricate a new bar, remove the implant and cut the bar, etc.

I have to agree with Dr. Jafari's assessment of this case. While virtually all of the comments regarding the etiology of this problem are within the realm of possibility, I will add two more to the list. If you look at the adjacent horizontal bone levels, it seems that the implants may have been placed too high in the osteotomy. If the patient was wearing a denture during the healing phase, you can expect to see significant remodeling around the neck areas from simple microtrauma to the tissue. In these types of cases, subcrestal placement is desired. Second, some implant designs are predisposed to this type of remodeling regardless of crestal position. Resorption to the second or third threads in these designs is expected. While I treat peri-implantitis cases routinely in my practice, the decision to graft is directly dependent on the adjacent horizontal bone. If this is an infra-bony defect, we debride with an ablative laser and graft. If the implant threads are superior to the adjacent bone, short of removing the prosthesis and doing an onlay graft with primary closure, there is no way to repair this defect. We perform an implantoplasty, removing the threads and creating a long polished collar. Long term, this is your best choice. RJM

...How about Tigran? Could it be a possible Solution for this Case? Had anyone Experience using Tigran? THX a lot for Sharing.

With all that good bone apically why was such a short implant placed to begin with? Especially, in the cantilever position.

Dear Dr C, you are right, go ahead with locator attachment or better still ball abutment, cut off the extra bar distal to the implant You can the open implant site under antibiotic cover , clean up implant surface and graft with BCP(Novabone) and close, Please also correct occlusion at the implant site!!!

As u hav already mentioned "Hygiene was horrible, plaque and calculus were all over the bar and attachments" here the local factors cud be at play & not only smoking as the etiologic factor. Apart from quit to smoking U also need to train the patient regarding maintenace of the implants before trying any other procedure

As u hav already mentioned Hygiene was horrible, here the local factors cud be at play & not only smoking as the etiologic factor. Apart from quit to smoking U also need to train the patient regarding maintenace of the implants before trying any other procedure

We are assuming that the reason for the failure is the smoking, If implants fail due to smoking usually will happens before osteointegration.By looking at x rays we can see as one the colleague mention before that there is plenty of bone to place a longer implant, threads are already showing. Notice that the most distal implant presents more bone lost than the anterior. We do not know how far distally the prosthesis goes if any rocking motion in place etc etc. For a better long term prognosis I would replace any implant that is failing, when possible use longer implants and last but not least good analysis of the prosthesis.

Just one factor cannot cause a disease.The combination of smoking, poor mouth hygiene, occlusal overload and maybe not enough bone amount around the implant could be the answer. I wouldn't explain it. i would remove the bar,surgery with grafting -u might have a gain of two threads new bone- and i would polish away the rest of the implant threads.

I love these boards and the discussion is great - don't get me wrong. It seems that there are a lot of armchair quarterbacks with a lot of unfounded assumptions, though. I agree with Dr both. There are many factors that lead from health to disease - not just one. I don't see anything wrong with the original implants as some have sepculated. Not a big fan of all that cantilever but I've seen it work in some patients for a very long time if we 'follow the rules'. This patient needs a good 'talking to'. After spending all that time and money, he will need to clean his mouth, stop smoking and come in for followup or else he will lose the whole thing just like he lost his teeth and wind up with dentures. Once you get some committment to stepping up his game, unscrew the bar. If there is no pain or mobility on the ailing fixture, I'd open it up and clean it out as was suggested by some. Decontaminate it and try to graft. I actually think I would replace the bar and relieve the flange of the denture in that spot as this patient will probably not listen to you if you tell him to not wear anything. At least the bar supported denture will keep the pressure off the tissue. Smooth off the threads later on after healing for whatever does not take and advise him that he could be living on borrowed time. Double check your occlusal scheme and 'off he goes'. If the implant seems dicey when you open it up, take it out, graft it, place a fixture to the distal if you can and convert to a locator. IMO - I wouldn't spend this guy's money on another bar restoration if compliance will be an issue. Best Regards, Ryan

You make a good point, Ryan. As clinicians, we should be much more vigilant about proper patient evaluation before any treatments are executed, especially in implantology-related treatment plans. The next big wave in implant related treatments is going to be called EXPLANTOLOGY. Enough said. God help us all!