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Grafting 2 years post implant restoration: any recommendations?

Last Updated: Jun 14, 2019

Hello, Doctors. This is not my best case. Of course I wouldn’t be seeking advice if it were, I suppose! I placed these Bicon implants two years ago and right from the outset, they weren’t ideally positioned, I know. Bicon’s design mandates a “counter sink” of the implants. That is, the implant shoulder should be buried subcrestally for predictable integration. Having placed around 100 Bicon implants, I have found this positioning to yield the best result. As you can see from the films, neither of these implants were counter sunk. Maybe they were doomed to fail from the very beginning. That said, they integrated enough so that they presented very solid 12 weeks later. Patient was asymptomatic and so I proceeded to restore the case.

The fit of the abutments into the implant well was good and the esthetic result was excellent. A year later when recall films were taken, I had not yet started mandating the automatic taking of PAs of implants in patients, placed by myself or otherwise. AS a result, I did not see the bone quality around these two on the bitewings taken at the time. Just the crestal bone height. However, last December, 2012, I had started to mandate these PAs and it was then that I first noticed some loss of bone density around these implants. I decided to wait for another 6 month recall to take another round of PAs to determine what was going on. Well, as the films show, bone loss is indeed occurring at a slow but steady rate. I believe that if left alone, one or both of these will end up either symptomatic or at least mobile which will then necessitate doing something.

Obviously, I would like to not remove these for any and all of the reasons one may think of. That said, I would like to attempt to solidify this region, possibly with a grafting procedure. I have done grafting with mixed results, both at the time of placement (especially if immediately placed after an extraction) as well as where there was to be a delayed placement. Truthfully, I would like to become better at it and have it be more predictable in my hands.

My question to you is, has anyone had success grafting an area around an implant(s) after the implant(s) has integrated and been restored? And if so, what have you found to work best? On the positive side, clinically the soft tissue margins are up at the crown heights and the implants are very solid, exhibiting zero mobility. On the negative side with respect to the gingiva, the tissue is thin and there is substantial pocketing as can be seen. Clinical pictures and radiographs are included so that you may hopefully get an idea of the situation. I’m not sure what order they will come up in. However, regarding the two radiographs, the one with less density of bone is unfortunately the one taken in June! Thank you for your time and consideration.

(click images to enlarge)

(December 2012)

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(June 2013)

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15 Comments on Grafting 2 years post implant restoration: any recommendations?

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CRS

6/14/2013

I can't fix that. I would let the implants fail and remove. In the meantime I would evaluate the periodontal health of the mouth and treat. Also check the occlusion. Then I would replace the implants with conventional length implants on the film there is quite a bit if room from the nerve. Grafting for lost width and removal of the implants will be needed. This case will end up costing chair time and money on the back end of treatment. You are at the stage in your experience about 100 implants when you may be pushing the envelope and having poor case selection. Work with a good specialist and concentrate on the restorative. Pick your cases wisely and do what you are comfortable with and life will be good! This stuff takes a long time to learn and unless you enjoy fixing these cases I would refer the harder ones. Technology and the marketplace for gadgets ie short implants is a poor substitute for experience and training. It is not a good business model and not great for word of mouth referrals. Hang in there I complement you for being honest and posting. Implants are not easy! Good luck!

Peter Fairbairn

6/15/2013

I have seen many great results with Bicon and friends love the system ( Bill Scheaffer etc ) which although designed in the late 70s ( Tom Driskelll ) is still a very effective system today especially in this area . But if the protocol is not closely followed the this can happen and I have seen countless cases with this exact bone loss where the suppuration is the reason the patient comes in and on x-ray this deeep bone loss is seen . What to do , as CRS has said just leave and they fall out then re-graft and replace new implants. Things happen to all of us but with time and experience we learn how to avoid in the future. I feel that the protocol for Bicon may be difficult for the more inexperienced surgeon leading to buccal plate perforation and hence this result . Good Luck Peter

CRS

6/15/2013

Peter don't get me wrong I am not down on any specific implant systems since I don't know what I don't know, so I don't want to make it about that. I try to see the value in all techniques and an always ready to try different things.

Peter Fairbairn

6/17/2013

Hi CRS , I know you are not , I have never used Bicon myself , although I did a coures on them in the early 90s . Just could not grasp the concept myself but others love them . Peter

Sam Jain DMD

6/15/2013

There was enough height above the nerve, conventional proper length implants could have been placed. Now at this point, just unscrew the implants out flap less and bone graft, I would use Bmp with the bone graft and later place thinner regular implants.

Dino Oral Surgeon

6/16/2013

I agree with Dr Jain . The best way not to loose more bone is to remove the implants, even if the apical part is osseointegrated exist some tools ( like BTI extractor set) that you can remove them atraumatically , then you can proceed with aumentation procedures wait do a CT and decide wich size and brand of implants you may use.

Richard Hughes, DDS, FAAI

6/17/2013

I agree. Let them fail and remove in an a traumatic manner. I am not certain as to what caused the bone loss with the implants. Again, remove, clean up the site and graft. Start over at a later date. I dould take a new medical Hx to see if this reveals anything.

paolo rossetti

6/19/2013

Successfully grafilting a defect around an osteointegrated implat requires an accurate decontamination of the implant surface. This can be done quite predictably if the defect is small and easily accessible. The implants shown here are impossible to decontaminate, due to the extension and the anatomy of the defects. Any attempt to graft would lead to a failure. I would remove everithing and start all over again.

Erik Olson

6/19/2013

I have never place a Bicon implant but I am concerned that they seem to have a large thread depth but they are press fit. Which means upon tapping in there is a large gap between bone and inside thread interface. I agree with others remove both regraft and do cbct in 6 months to evaluate bone.

Alejandro Berg

6/19/2013

those bicons are done... remove as atraumatically as possible, desinfect, graft and implants at a later date

Baker Vinci

6/19/2013

I have grafted some implants, well before the bone loss reached the apices of the fixture, with satisfactory " success ". While it is pretty obvious that you don't get true integration, I feel like there is a place for this type of care, but these implants need to go. Bvinci

Carlos Boudet, DDS

6/27/2013

Followup radiographs are the standard of care. These implants cannot be salvaged. Any attempts to decontaminate or graft will subject the patient to unsuccessful additional surgeries. Everyone is in agreement that you should remove them, graft and try again. Good luck!

Nouman Warris

6/28/2013

Dear colleagues, What if we raise a flap, debride everything, rinse with CHX, do a minor GBR procedure, approximate nicely and most importantly alter the prosthesis design on top as we know the most probable cause for this bone loss is occlusal over loads. And then follow up. Just my two cents, i would love to know what my friends here think about the plan. I personally have difficulty stomaching the idea of leaving them as they are untill they fall out themselves, that would mean extensive bone loss i.e horizontal bone loss, which we all know is a pain. Nouman.

CRS

7/9/2013

You could try that to appease the patient advising that it may not work and removal will be needed. Depends on your office protocol and failure policy.

Gregori Kurtzman, DDS, MA

7/23/2013

I would agree with the other posted comments these implants are not salvagable due to the extent of bone loss and very difficult to decontaminate between the fins of these Bicon implants. best to remvoe clean the site graft it let it heal then in a couple of months place new implants

grafting an extraction site even when the buccal cortical plate is intact grafting 1 2 walled defectsocket discussion