Failing implants after loading: Why is this Occurring?
In December 2011, I placed 4 dental implants in the maxilla of a 60 year old healthy male patient. 3 implants were ITI bone levels and 1 was Blue Sky Bio tissue level. Below are the films. The implants appeared integrated. They were uncovered, healing abutments placed and later locator attachments were picked up in his provisional full coveraged denture. The implant in the 6 position showed signs of failure. The problem is that now the 3-4 position implant is also loosing bone, although it is asymptomatic. I removed the locators and asked the patient to use adhesive as needed till I can uncover the new implant. However I am quite concerned as to why this is occurring? (the denture fits well with decent occlusion). Any thoughts or comments are welcome.
(click images to enlarge)
![]failing implants after loading: post insertion](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/nar1.jpg)post insertion
![]failing implants after loading: left side](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/nar212.jpg)left side post insertion
![]failing implants after loading: february](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/nar2121.jpg)failing prior to problems in feb 12
![]failing implants after loading: april](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/nar412.jpg)failing implant in april
![]failing implants after loading: 3/4 position](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/nar612.jpg)other implant in 3/4 position, note new implant in 7 spot
40 Comments on Failing implants after loading: Why is this Occurring?
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Gregori M. Kurtzman, DDS,
7/24/2012
How was the arch temporized after implant placement? Was there a soft liner over the implants?
gary weider
7/25/2012
yes, tissue conditioner
Baker k. Vinci
7/26/2012
In my opinion, placing anything on these integrating implants, is ill-advised. If there were any questionably salvageable teeth, I would suggest saving as many as possible, allowing for reasonable temporization. These have failed and you have, if I understand correctly, attempted to provide your patient with a standard denture, with palatal coverage. This is why the immediate" all on four", is such an "abortion" of good restorative principles. Bv. Vinci Oral and Facial Surgery. Baton Rouge, La.
Michael
7/24/2012
signs of failure, can you specify the signs?
gary weider
7/25/2012
bone loss, redness and B O P.
Theodore Grossman DMD
7/24/2012
More details would be helpful. Inflammation, Plaque & hygiene, mobility, prosthesis causing pre-mature loading, systemic issues, occlusion, etc. Help us to help you.
gary weider
7/25/2012
Home care was average, although the patient reported taking out the provisional overdenture and eating with out it . he felt that he may have got some food stuck in the early failing implant. No systemic health issues. The denture is full coverage except for about half the palate due to gagging issues,....of course the patient also hates using paste.
Alejandro Berg
7/24/2012
Single implants are succeptible to the undo pressures of the tounge when supporting a removable. Generally speaking I don´t go for locators or ball attachement in the maxilla. maybe a simpler and more self strenghthening solution would be a dolder bar, since these are muco supported implat retained prosthesis.
Also "decent oclusion" maybe not good enough.
Best of luck
DrT
7/24/2012
Implant is #3-4 site on the post insertion PAX shows rather large lateral radiolucency. I wonder what happend during the insertion of this fixture?
DrT
gary weider
7/25/2012
are you referring to the sinus?
Greg Steiner
7/26/2012
Gary If you have concluded that the radiographic appearance of this patients bone is unusual I find it best to write a letter to the physician describing your findings and request that the patient be evaluated for the possibility that systemic disease may be the cause. He will know what tests are necessary to screen for diseases that effect bone. If the bone is abnormal a dental radiologist may be able to make a diagnosis from the radiographs. Greg Steiner Steiner Laboratories
Carlo Maria Bolognesi
7/24/2012
Generally speaking implants placed in the maxilla for overdenture retention should be joined together by a bar, like Alejandro says, unless you can provide almost perfect parallelism between them all. The nature of maxillary bone and the vector resulting from the implant angulation and loading axis put them at risk for long , and even short term,success.
Gregori M. Kurtzman, DDS,
7/24/2012
I dont have issue with free standing implants in the maxilla using attachments to retain the denture but IMHO you need to maintain the palatal coverage so that the implants only serve to prevent lift off and lateral loads are limited on the implants. If they dont want palatal coverage or there is a shallow palate or ridge height crestal to the depth of the vestibule then a bar is needed.
gary weider
7/25/2012
I am hesitant to go to the originally planned final "palateless" overdenture and definitely the cost and time involved in placing a bar.
BARROW MARKS, DDS
7/24/2012
From the radiographs I suspect that this is an example of class four bone. Note the radiolucencies and the wide trabecular patterning.Adding to this situation is the immediate load of the denture. This is no fault of yours. But sometimes you are stuck with bone that is more like styrofoam than oak.Even a soft liner can be traumatic. Extensive relief of the denture base and at least six months without loading would be indicated when the bone is of such poor quality.Keep up the good work and your next case will be more rewarding.
dr. dan
7/24/2012
My guess is overloading with occlusion on the implants if not inflammatory.
Most implants if not platform switched will gave a microgap with 1.5 mm of bone loss on average after the abutment is placed.
Greg Steiner
7/24/2012
The trabecular pattern in this patients bone does not appear to be normal. There are a wide range of diseases and medications that effect trabecular patterns and bone health. For example a recent patient who presented with an unusual trabecular pattern was referred to her physician and found to have elevated parathyroid hormone as a result of a benign tumor. If you compare this patients bone to radiographs of your other patients of similar age and you see a significant difference I would advise the patient to see his physician for a thorough evaluation. Sometimes it is not our therapy that fails but it is the patient that fails to heal. Greg Steiner Steiner Laboratories
gary weider
7/25/2012
Thanks, refer to a physician and ask him to run what tests?
Greg Steiner
7/26/2012
Gary my reply was posted above. Greg
Baker k. Vinci
7/27/2012
This is a " far reach ", at best. The implants were loaded early, in soft bone. It is highly unlikely that this is a result of a systemic condition. Bv
Carlos Boudet DDS
7/24/2012
Assuming that the implant placement was done without thermal trauma to the bone and adequate initial stability, two suggestions come to mind.
Due to the poor quality of bone, longer implants engaging the floor of the sinus should have been placed.
Also the implants could have been placed slightly subcrestal to prevent any pressure from the denture while osseointegrating.
After loading, Clenching, sleeping with dentures and off-axis forces can cause the bone loss.
Look closely at the case and see if any of these apply.
Ä°lker Erdogan
7/25/2012
Sometimes if you are using electrosurgery when you are applying the gingiva formers,because of the overheating of the periodontal tissues and the bone necrosis can occour which may lead to loss of implant.......
rsdds
7/25/2012
is very hard to tell because i wasn't there for the surgery but let me ask you, all other things considered 1- how thick was your buccal plate ?? 2- how much torque did you use? 3- did you use osteotomes ? 4- i would'nt do this case without a cbct (that is the standard of care)
gary weider
7/25/2012
appreciate the thoughts, no I did not use osteotomes, the torque used was with a hand wrench and as the other docs noted the bone was very soft so I doubt I overtorqued them. I did obtain solid initial stability. This is all water under the bridge...the question is what to do now?
gary weider
7/25/2012
CBCT standard of care? Are you sure you want to go there? The lawyers love that thought. I hope you have a radiologist read every scan cause if you miss something, say a growth somewhere and you are on the line.
Baker k. Vinci
7/30/2012
Gary makes a legitimate statement, in my opinion. If you can't fly the plane , then don't buy it. Same goes for cad cam machines and ct scanners. If you need a radiologist to read every scan, then you shouldn't have one in your office. I do send all questionable pathology off to be read . It is not uncommon however, for me to have to call the radiologist and point something out, the he or she may have missed. Bv. Vinci Oral and Facial Surgery. Baton Rouge La.
james butler
7/25/2012
i agree with systemic factors, irregular trabecular pattern and possible overloading. i also like butressing the tip of maxillary implants in the denser bone close to the floor of the sinus and premaxilla. splinting helps, in robust bone two locators can usually be enough, multiple locators can increase lateral forces with the relatively rigid locator connector. lowest vertical cantilever possible although i cannot tell the gingival height. offloading and waiting ia a good idea with a medical workup in the meantime. good luck!
TMG
7/25/2012
The thread design for those implant is NOT the ideal one, given the type 4 bone....
But do you have a CT scan or CBCT post op? There a high probability that the implants are placed too buccal.....
gary weider
7/25/2012
no CBCT , just a PAN.
TMG
7/26/2012
PAN will not give you the bucco lingual relative placement.
Can you do a CT Scan?
Dr. Alex Zavyalov
7/25/2012
Most likely, the base of the removable prosthesis did not settle in and vertical axis rotation took place.
Juan Rumeu
7/25/2012
I agree with dr Boudet. No matter how well implants are placed on the maxilla, if the provisional is a full denture then bone loss will occur. It is always much better doing inmediate loading (all on four or just loading with hybrid structure) . patients clench too much so that the experience that you have had, I have had in the past until I stopped using full dentures as provisionals.
Harris Mann
7/25/2012
Before I question the health of the patient, the quality of the implant or the type of maxillary restoration, I would look at the obvious. Is there a fixed restoration or a natural dentition opposing the implants? If this does exist, is the patient taking his denture out at night and bruxing on the abutments?
gary weider
7/25/2012
YES, there is fixed dentition which I restored about 6 months earlier...I will inquire re. night time usage, very possible.
gary
7/25/2012
I think you are on to something . this patient originally presented with an extremely worn dentition. A classic case of broken and worn teeth on a porcelin upper bridge opposing a severely worn lower dentition. Severe bruxism and a collapsed vertical which I restored to what I think is the proper vertical dimension.
Baker k. Vinci
7/26/2012
I wonder if the original poster, would be so kind as to show us the pre-extraction radiograph? Bv Vinci Oral and Facial Surgery. Baton Rouge, La.
dr. bob
7/25/2012
The use of implants in overdentures that are tissue supported is not so simple to do. The implants should stabilize and resist displacement of the denture. When the patient bites on the denture the forces should be mainly upon the tissues and not the implants. It is best if the retentive element is designed such as to allow the denture to settle into the soft tissue with little load applied to the implants when vertical pressure is applied. Palatal coverage ( as much as the patient will allow)is needed to prevent overload of the implants with horizontal forces. Occlussion needs to be dead on so try to use gothic arch tracing. If the implant location can be felt by application of vertical pressure on the denture the attachment should be reseated or the denture needs to be relined. It should feel as if there are no implants in place with force applied in this direction.
dean tanaka
7/26/2012
I always feel the hardest place to place implants are in the maxillary premolar area. Not so much for the bone biotype, but just the angulation of the alveolus. It goes way palatal as you go apically. Maybe a CT will show buccal dehiscence, fenestration, etc etc.
But also, maybe the implants were very well placed, and just the lateral load of the locators made the bone go away. (which in my opinion is most likely what happened here).
maybe splint the implants with cast on locators on them instead?? No black and white answer. Good Luck!
CRS
8/7/2012
It's probably the occlusion or the patient has a systemic issue, however sometimes implants just fail and we don't have an answer.
Carlo santos
9/4/2012
RANKL read about this. Helps me a lot in understanding resorption, loading etc.
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