Ideas on bone loss and failing implant bridge treatment?

This area has been something of a nightmare. Thankfully the patient is very understanding. Having successfully placed and restored implants in the #14 and 18 positions, she understands and appreciates the process. She also understands the complications which can arise, as I had a previously placed a Bicon implant in the #31 position in 2010 which was the distal abutment of a 3 unit bridge. Patient had to transfer to another office due to insurance and had not been seen for 5 years. When patient came back, #31 was found to have failed. The three unit bridge was sectioned between #29 and #30 pontic and the area was grafted with allograft on 1/5/16. After a period of 1 yr the current implant was placed 1/17/17. This implant is an Implant Direct HA coated Legacy 2 10 x 4.7, 4.5 platform. Flapless surgery was uneventful. The lack of attached gingiva was a concern but it was decided that a graft would not be done due to patient’s wishes. #31 was initially restored with a cement retained bridge, but came loose (3/23/18) and was ultimately replaced with a screw retained distal abutment, 5/22/18. Patient was seen today, 10/19/18, and reports on and off soreness there. The radiographs included with this case clearly show the implant is failing. Although I think I know the answer….remove, graft and start over…from reading posts here and through my own experience, has anyone had some “thinking out of the box” success treating this situation without doing that?

16 thoughts on: Ideas on bone loss and failing implant bridge treatment?

  1. KPM says:

    The radiographs are out of order, I apologize. However, for better or for worse you will be able to put the radiographic story together based on the condition of the bone. In addition, the introral photos include one of the anterior region. Patient has a deep bite and a traumatic occlusion. However, you can see that there is actually no contact in this area.

  2. Dennis Flanagan DDS MSc says:

    It’s a good idea to not allow patients to dictate treatment. They are in no position to make clinical judgements unless that person is a dentist. You have an exposure.
    Lack of attached tissue was probably the cause of the failure. You may consider 3 mini implants if the bone is type 2 avoiding the failed site. If the failed site was a failed endo that would be a cause as well.

  3. Dr. Moe says:

    This is just trying to understand, I am sure plenty of other docs will correct me, But I have seen maybe 3 or so cases where Implant and tooth borne bridges work. Pretty much everything else I have seen, Tooth intrusion, needing Endo and then subsequent failure of these cases.

    There are all kinds of micromovements that happen when you splint a tooth with an implant. That would be my first thing to think about. I am figuring, amongst other things that are missing that are pointed out by others here, the bridge between tooth and implant is the issue. One has PDL, other does not. One can take lateral forces, the other cannot. And you have mentioned Traumatic occlusion, that might be the reason for the failure.

    I would love to hear other Docs responses.

    • KPM says:

      Thanks for the comment. I have considered traumatic occlusion and think I have addressed that as can be seen in the intraoral pictures. From what I understand the debate on splinting implants to natural teeth is far from settled. Personally, I have splinted many cases and have not seen any kind of intrusion of the natural teeth. However, you have got me thinking about a possible failure/affect in the OTHER direction. That is, does micro-movement of the natural tooth negatively affect the implant stability and risk failure? Though, it looks like this implant was failing even before I went ahead with the bridge restoration. One of those cases where the treatment had been long , patient (and I) were looking to conclude it and I think I was blinded a bit by optimism. Not one of my better calls for sure. That being said, what I am really looking for here is the “magic bullet” to remedy this case short of sectioning the bridge and redoing the case.

  4. Peter Hunt says:

    Perhaps this is a situation where a minimally invasive approach is not the best approach. There is no evidence that the initial socket regeneration was effective (it probably would have helped to open flap the region to ensure complete debridement and than to augment around the outside of the socket). Quite probably the ridge narrowed down with the loss of all the teeth in the region (without a CBCT cross section view it is hard to know the width of the ridge). So placing another implant by a trans-gingival approach might leave the implant with exposed threads or rough surface leading to another failure (the implant placed was relatively wide as well,4.7mms).

    At this point, it would be better to open flap the region, to regenerate in the socket and to widen the ridge. Let that heal and then come back with another open flap approach (to see how effective the regeneration was). Then place another implant making sure the whole implant is surrounded by bone.

    I hope this helps. Best wishes

  5. Timothy Hacker DDS, FAAID, DABOI/ID says:

    Dr. Flanagan has you on the right track. Have you heard the expression, “Bone sets the tone, but soft tissue is the issue?” So, both occlusion and soft tissue problems impact this case. It’s a difficult case in a difficult area. Time to remove the implant, graft, wait as long as a year and implant again. Only next time use a strategy that utilizes as much bone as possible such as 2 implants or 3 mini implants (if bone width does not allow wider implants). Don’t splint to natural teeth unless you have a stress breaking joint in the prosthesis. Be grateful for your understanding patient.

  6. Oleg Amayev says:

    The loss of attached gingiva will not cause this issue . You have bone loss 360 degrees around coronal part of the implant.
    I belive this happened due to solid rigid connection between implant and natural tooth. As you can see on the X-rays increase ligament space around natural tooth.
    When rigid connection established usually causing displacement of the crown on natural tooth or displacement of actual implant. The treatment that I will do:
    1. Remove implant, bone graft
    2. If the tooth need RCT then do it if not put new crown
    3. Wait 2-3 month
    4. Take CT scan
    5. Fabricate Surgical guide
    6. Place implants 30,31
    Good to have good understanding patient. Things happen sometimes. Don’t worry. Everything should be just fine.
    I hope that will help.

  7. Greg Kammeyer, DDS, MS, DABOI says:

    Many great comments: I believe that lack of attached tissue causes bone loss. Bacteria get into the sulcus and don’t just eat at one spot. Attaching to a tooth adds to the level of risk. I strongly encourage you to separate the implant from the tooth while the tooth is still viable. No advantage to making this a bigger problem. Lastly the bending moment on a mini implant is inadequate for posterior teeth to have predictable cases. Yes, i would redo the case and caulk it up to my “tuition cost” of placing implants.

    Also consider a couple things: Patients count on us for our best advice. For elective treatment that is stressful for them, costly and takes more visits than a new denture, this means they place alot of trust in us TO DO IT MOST PREDICTABLY. The most important thing that Dr Carl Misch taught me is predictability is KEY. Notice how all these extra visits affects you, your team and your bottom line as well. The giants of implant dentistry that got us this far did so by working on predictability first. So I’ll encourage you to do a Meta-analysis lit search on splinting to natural teeth. Then ask yourself: if this was crown and bridge word I accept this average rate of failure that occurs in the hands of those that do research? That question keeps me out of trouble??

  8. Dr Dale Gerke, BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    35 years ago I was taught to never attach a bridge to an implant and a natural tooth – for obvious reasons. I have kept to that philosophy.
    I realise in the last 30 years, the boundaries have been stretched – sometimes successfully and sometimes not.
    However, if you break the rules, the problem you will always face (if you have a failure) is identifying what the cause is. For example in this case, was the failure due to attaching a bridge to a natural tooth and an implant or was it due to other issues that have been mentioned? The truth is, “Who knows?”
    I would best guess that your main cause of failure is because you attached the bridge to an implant and natural tooth – especially with such a large span.
    I can understand trying to splint one natural tooth to an implant if the two were adjacent (I would not do, it but I could understand why someone might). However on a span this length, I do not believe the case can be successful.
    I would suggest you could section the bridge and salvage the crown which is on the natural tooth and then sort out the pontic-implant situation. If the loss of bone is due to diverse stresses, then perhaps putting a cover screw on the implant and covering it (with or without grafting and after removing inflammatory tissue) might give you an indication as to whether healing is likely to occur. You might even get away with just placing a healing cap.
    My recommendation is that at the diagnostic and treatment planning stages: over estimate the forces on the restoration you will place and then over-engineer your treatment. It seems to me that in this case, two implants supporting individual crowns (thus allowing easier maintenance) and crowning the natural tooth would have been an excellent treatment plan (and only a little more expensive that your initial treatment – but considerably less expensive that having to fix the problem you have now).
    I understand the dilemma about costs and getting patients to accept an over-engineered treatment plan, but it is always wise to consider the possible consequences of expecting too much performance from a minimalistic approach.

  9. Z says:

    I think your description is really excellent and may provide some clues. I’m leaning against attached gingiva being the problem because this *second* failure happened relatively quickly, less than a year. This is a second molar which, according to misch, is a less predictable site for an implant generally, has most occlusal forces and highest risk of failure. Also the patient doesn’t have periodontal disease from the x rays I see, so the odds of something infiltrating below the attachment and being virulent enough to trash everything so quickly is low in my mind. The first bicon implant failed after 5 years, why? The cement retained bridge popped off, why? I’m thinking there has to be some occlusal issue. Patient has a habit or bruxes in a weird protrusive or lateral motion to create contact back there. I’m convinced that the cement bridge that came off was the smoke before the fire, and screw retaining it and giving it no fail safe mechanism to stress break (bridge pops off) transfers all the force to the implant. Also, since splinting to nautral tooth, if the tooth ever so slightly moves up and down in the socket, it will put an up and down force on the implant with the rigid splint causing bone loss. I think the real clue is why did the cement retained bridge come loose after only a few months?

  10. Sergio says:

    As the op stated above, splinting an implant with a tooth is still controversial. Sure I’ve seen it work but I’ve seen it fail whole lot too. Now that this failed whether splinting to a tooth did it or not, I’d try a different way. Put two implants or three minis as Dr. Flanagan suggested.
    Someone else used the term ‘bending moment’ of mini implant and all. There has been one study about fatigueness of mini implant with certain amount of vertical loading cycles, not about when it bends. Pure titanium implant maybe will bend ( see a particular implant brand used in India, Germany, and Italy ). 3 Minis splinted together will work fine as a mini is made of titanium alloy.

  11. KPM says:

    This is a very good and informative discussion. I took Dr. Kammeyer’s suggestion and did a simple search for “implants connected….”…..didn’t even have to finish the phrase as “… natural teeth” came right up! Full disclosure, I did just read the one attached paper but it’s from The JOI so that’s good enough for me at this time. Interesting read and I’d be interested to hear what doctors that have written on page have to say.

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