Implants Failing Badly: Suggestions?

This is a full arch case in which the patient had been edentulous for many years. He has some cardiac problems but no other health issues. He is on a calcium channel blocker and I wonder if anyone has any information on those medications interfering with osseous homeostasis. The implants were placed 2 years ago. The restoration is screw retained. I was the surgeon. The restorative dentist chose to segment the restoration into three segments for ease of restoration. The patient reported irritation around the upper left second bicuspid 6 months ago. I noted bone loss and did a flap/curettage with a stem cell graft. The area responded well. The patient called because his “bridge was loose”.

Examination revealed severe bone loss in all four quadrants including the lower molar implants. The upper left quadrant was removed. As you can see bone loss is horizontal and severe. I can remove all the implants, do bilateral sinus grafts, vertical onlay grafts and/or guided bone regeneration and create new ridges for new implants. The problem is this will happen all over again if I don’t find the cause. I must admit I am clueless (of course my wife has been saying that about me for years). Any ideas, suggestions?

Current Pano
Current Pano

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35 thoughts on “Implants Failing Badly: Suggestions?

  1. Hi,
    This is a really interesting case!
    Thank you for sharing this with us!
    It would be helpful if you provided us with pre and post-op X-rays, along with some intra-oral images of the restoration. Also the age of the patient and his medical history, besides the CCB’s and how many years was he edentulous?
    The bone loss is quite severe in the area and I would try to find an explanation, so it won’t happen again.

    Thanks a million

    1. This is an eight implant case, two had been lost at the time of the pano. The patient is 69 years old.pt is taking diovan, potassium, magnesium, nexium, and coumadin was recently changed to agrennox. The implants were placed at time of extraction. I am working on obtaining additional radiographs to post. Thank you all for your suggestions.

  2. I would suspect that the prosthetic plan contributed to this. Expecting six implants to support all that weight and long crowns may have not been prudent. Was any preimplant grafting done to restore the vertical bone loss? This will be difficult to correct short of iliac crest with titanium mesh and BMP. The patient may be a candidate for an all on four with zygoma implants. Are you going to redo this without charging the patient? I’m always curious how other practioners handle complications requiring revisions and additional fees.

    1. If you would expect four zygoma implants to support this huge amount of work, why not six in the upper jaw?
      I agree about the initial prosthetic treatment plan, this is why I would like to see some more X-rays or photos…
      My opinion is to investigate the case, find the cause of failure, so we could all learn from our mistakes and not do them again.

      Thanks a million

      1. I was referring to the all on four technique with zygoma in the distal which is a different prosthetic than this hybrid. Unfortunately it is the Wild West out there in implant placement. Many in experienced, poorly trained dentists are placing now, let’s not blame the patient if the plan is risky. We all learned prosthetics in dental school. One can’t cut corners. Also patient factors such as healing ability need to be addressed. I feel an implant is never simple and there is nothing wrong with conventional bridges, endo etc. case selection and treatment planning are key along with good judgement. However this case does not have enough information to figure out what went wrong, it is usually multi factoral. The poster is throwing out all kinds of advanced surgical techniques to fix this but without a reasonable prosthetic plan it will fail again. A big bridge has been burned here. The surgery is driven by the prosthetics.

    2. I never charge again if patient has already paid for any procedure….place urself instead…if we paid once n got nothing…..so I never charge again n always pay from my pocket …in that way I never loose my patient.

  3. Yes , this is why I always say when you do big cases you marry your patient as you have to go through the good and the bad ..and when this happens they will be at your door.
    Any way here I guess the Implants were placed immediately with extractions at the same time where perio issues were the cause of tooth loss …
    When all healed and after loading for a while literally the” tide has gone out” bone wise , patient factors are the major aspect here , not just Prio prone , smoker but poor AI issue as well …..
    So how to deal with difficult as the prospect of grafting and a second failure is to dramatic to endure . Maybe zygomatic case.
    This is our nightmare , the big divorce.
    All the best
    Peter

  4. Hello.

    Thank you for sharing this . Yes this is a nightmare and I haveca feeling it is happening a lot more than some dentists/ surgeons care to mention. Was not a coincidence that a larger portion than ever of the lecturers at the last ICOI meeting I attended spoke about periimplantitis and ways to posdibly treat it . Implants have been placed now fairly aggressively over the last 10 years with manufacturers and their chroney lecturers touting over 90 % success rates andcon and on. This is simply showing uscthst now things ate coming home to roost and we in general are pretty helpless with pretty much NO predictable treatment to use . Ten years from now I bet you things will be a lot different in selecting who should and shouldn’t be having implants . We are still guinea pigs at this stage of this process and let’s hope we don’t lose our shirts we too many large failed cases like these in the mean time. Sorry wish I had an answer for you but really I doubt any one of us really has . I am becoming much more selective and conservative with implant placement and prefer going the distance now to save an existing natyral tooth over extracting and placing sn implant if at all possible . Even going against the crowd and doing bridges if possible . Don’t think it was a coincidence that an endodontist friend of mine in Boston says he is all of a sudden sxtremely busy and noticed that many patients all of a sudden were chosing to sabe their teeth vs placing an implant because they were experiencing too many failed implants . Food for thought and good luck !

    Eric

    1. Eric thank you for your reply. Your comments give food for thought. I have placed roughly 7000 implants. I have had my share of failures but I was always able to redo the case successfully. This one has me stumped. Still, it is nice to hear from colleagues that I am not alone.

  5. There is much more information required to help you find the etiology of these failing implants. Things that might help are full pre-op and post -op photographs study models. Sequential Xrays, starting at the time of implant placement. A full description of you protocol including timing of all phases of treatment, etc. It is really rather difficult to do much more than speculate based on a late stage pan.The two most likely causes are forces and bacteria. If this patient has a deep overbite and any parafunction, given the apparent crown to implant fixture ratio, the forces would have been against you from the start. Typically cornonal bone loss exposes the threads and once the roughened surface is contaminated with oral flora the progressive bone loss contiues. This is exacerbated by the unique oral chemistry of the patient. We see patients with some thread exposure that have very slow or minimal horizontal bone loss over many years and others that just melt away. If all things are eual (read forces) then that is oral chemistry. I have had some interesting conversations as of late with other experienced implant surgeons as to the effects of large amounts of daily alcohol intake. We all shared cases that did very poorly in these patients, essentially alcoholics. I think this is one class of patients that we might want to think about when we plan implants.
    Hope this helps somewhat
    Rob

  6. When I first started restoring implants 30 years ago if you were a smoker, you couldn’t have an implant. If you were diabetic, you couldn’t have an implant, If you were a bruxer, you couldn’t have an implant. If you had perio you couldn’t have an implant. Now it seems the only criteria is that you have a credit card. Seriously, I think dentists in general and salesmen in particular looked at our success rates and drew the wrong conclusions. That implants were so successful and reliable that everyone could have them and that anyone could place and restore them. Now I am seeing catastrophic failures.

    We must be more selective in some cases and realize that many of these patients are high risk. And the more of these factors that exist i.e. occlusal issues, parafunction, systemic issues, etc. the more diligent we must be in case selection and treatment planning. Just because we can do something, doesn’t mean we should.

  7. greetings,

    patient selection is the most important as most of the colleges mentioned earlier ,
    however, the guy here wants some suggestion.
    I believe that this patient should not go for any further major surgical procedure .
    check the bone loss. it is related only to the implants… bone level at the teeth level are acceptable. so what could be the reason!!!
    Ca channel will cause this dramatic loss
    how old the patient . how did he loose his teeth, and what implant system is there ..was there any bone graft before during the previous implants !!! take the history very carefully and update us .
    best luck
    cheers

  8. Everything stated above is true, but there is still some doubt about what to do. The best this guy can hope for in the near term is an implant retained overdenture with partial tissue support while you rebuild other areas. I would use antibiotics and topical antibacterials (maybe 0.25% NaOCl) to buy some time while placing implants in upper canine sites and healing for a couple of months (eat soup in the meantime). Make a FUI with flat plane occlusion. Remove everything but the stuff you just placed and hook up a couple of Locators or similar, while grafting ridges where you remove implants. Get rid of all infection in the mouth (lowers, too; take out anything that you can’t clean up effectively). When free of infection, get models and scans and start from scratch – you need cross arch stabilization and perfect occlusion and a lot of luck. Some pts just have piss poor protoplasm and there is nothing you can do… so don’t beat yourself up if you are stuck with one of them.

  9. Thanks for sharing. I’m guessing that if pt was edentulous before then he probably was wearing an upper denture. So why not just make an implant supported overdenture with an open palate?

    They are a heck of a lot easier to do, esthetics can be awesome, easy for someone to clean that shows they have a problem cleaning their teeth in the past (and they are NOT going to change this behavior), cheaper for the patient and easier to fix if you get a failure.

    I’m just not a big fan of these round-house, expensive and mostly ugly and not maintainable bridges. IMHO

    I’d extract, graft and place implants and then an overdenture.

    Good luck and again, thanks for posting

  10. The details presented are insufficient. But as rightly said in earlier response one must consider parafunctional habits and occlusal imbalance as main causes. Cross arch prosthesis is better.

  11. Tough tough tough. My guess (only a guess since we don’t have all the data) is it is not systemic or from medical issues. The lower implants are fine.
    1) overload seems like the most likely answer (again a guess). It can also be overload if any of the implants were not fully integrated. I’ve seen some ct’s of pts I’ve done implants on and it seems good via pa or pano, but with a ct sometimes shows a not so optimal result (like 60% integrated but a slight lucency around other areas). So with this case, that’s a lot of loooong teeth with not so many implants. And if any implant integration are not ideal, that puts a heck of a lot of load on others, hence the bone loss

    2) I had bone loss like this on two pts. And both were screw retained bridges. Since those happened, My gut feeling is that screw retain puts a lot of possibly non ideal forces at the implant/prosthetic interface. You really just need one area to fit nicely and if there is a passive screw down, we assume that the forces are fine. I bet if we took a thermal imaging of the torque areas, we would be shocked at the non ideal forces at this interface. So since then I favor cement retained. I say heck with retrievability. It’s easier to remake a bridge than to redo everything. At least I know when i cement in a bridge there is no additional direct torque on the implant.

    I feel your pain. I redid everything at no charge. (Yes ouch. But I’ll sleep better… I guess)

  12. The horizontal bone loss is interesting and a clue! I have had the same thing happen on a bar overdenture case. The similarity is the medications. Coumadin, Nexium (proton pump inhibitor) and possably the calcium channel blocker may be the culprits that disrupt bone physiology.

    This is just speculation to the cause. Everyone has made valid comments.

    One can regraft and restore with a bar overdenture using O ring retention. Worst case, remove the maxillary implants and return to the denture. These things happen.

  13. Attached is the pre-restoration pano. Im not sure what the comments are regarding “so few implants” as this is an 8 implant case. I was in error when I stated that it was a maxillary edentulous case. The implants were placed at the time of extraction. I will post that xray as well. There was quite a bit of grafting done especially on the lower. The lower right was grafted after the extractions, allowed to heal for 4 months, then implants were placed. If you look carefully at the original pano I posted you will see that the bone loss on the lower right is as severe as the upper. That seems to eliminate occlusion as the culprit although I’d like to hear more ideas.

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    1. Did you placed a provisional removable? Usually this happens to implants that don’t get immidiate loading. You already had bone loss before placing the final bridge.

    2. In checking back and reviewing this this presrestoration panorex was very telling. This where the pregnant pause needs to be made. I would speculate that the first red flag was the initial loss of two implants. Looking at this, there is not enough bone base around the implants. I would have staged the implants to protect them while healing. Immediate placement is NOT a substitute for a surgical stent coordinating the prosthetic plan with the bone. There is often much resorption of bone in immediate cases often due to infected teeth, unprotected implants from a mobile prosthesis and occlusion. And sometimes it is just physiology of bone. Some of these causes can be mitigated but the bottom line which I state to all my patients is that we have to see what we get with healing. Treatment plans and prosthetics need to be adjusted, when you have a good blueprint to start then you modify. These cases also need a period of provisionalization. Placing a large restoration without it is risky. I like to quote Gen Patton, “I don’t like paying for the same real estate twice! I have realized over the years that even though I’m a pretty good Oral Surgeon, I am only as good as the prosthetic plan and my restoring partner and patient!

  14. We need back to basic, prosthetic planning and CBV( critical bone vol.) can save you outcome. Especially this case ,we keep an eye on crown / implant ratio.

    1. This can be a very nice debate!
      Crown-implant ratio seems to be not that significant as it used to be in the early years of 21st century…
      Personally speaking, I believe that the crown to implant ratio is over-estimated!
      Birdi, H., Schulte, J., Kovacs, A., Weed, M., Chuang, SK, Crown-to-Implant Ratios of Short-Length Implants, Journal of Oral Implantology, Vol. XXXVI, No. Six/2010, p. 425-433
      Apart from that, I totally agree with Wally about going back to basics!…

  15. Hi
    Lots of excellent comments. You might want to check the patients systemic vitamin D levels. There is some data out there that suggests this might be one of the issues involved with patients with multiple failures

    In our implant practice of 30+ years we have accumulated our share of patients who have had failures in multiple areas , multiple times. We checked the ones we could recall, and tested them for vitamin d deficiency. Many of them were found to be vitamin D deficient. They were then medically treated for vitamin D deficiency. When they responded and the tests were normal again, they were retreated , and our small sample size is doing very well now.

  16. Sometimes it is the patient. Noticed he is taking nexium he will have poor calcium absorption. If you can get him to reduce or quit nexium. Start a regimen of boron,,vit, k2, calcium, vit d and lithium. He will need therapeutic levels. It wont make it come back but it may stop bone loss . Then you can reevaluate tx plan. You can get info at examine.com I use it all the time for myself and patients

  17. David,
    Were these implants submerged completely in bone circumferentially?

    Or

    were there some threads exposed?

    Just curious. The bone level appears to be below the implants on the sugery post op film. May be bad lighting too.

  18. The implants on the lower were placed at an ideal height when there was no bone present. There was no compensation for the loss of bone height due to infection of #’s 28 and 29. This explains the bone loss. This case should have been completed in 2 surgical stages – EXT/Graft —- > implants 6 months later.

    You cannot expect the height of bone to regenerate to the height of the original crest after implant placement. I’ve learned this the hard way. Usually it’s easy to predict.

    Compare the radiographs on the lower arch from pre-op to the final pan —-> the bone level is exactly where it should be!

  19. Herb is right about how in retrospect a safer course would have been. In addition were the upper implants immediately loaded? If it was then without cross arch stabilization this case was doomed from the start. If a temporary denture was used and there was any contact with the healing abutments the movement of the denture would have contributed to the failure. Of course the immediate placement of maxillary implants require complete control of the case from start to finish and a clear understanding of ideal depth and position within the socket avoiding the buccal plate. Cracked or missing buccal bone should be grafted without implant placement.

  20. Honestly at this point with the amount of bone loss you have on top I would probably bite the bullet and go with a full upper denture with snap retention. Is it the best? No but Honestly, if you go another round and the bone loss continues then what? Is that a risk the patient is willing to take? Keep a flat plane occlusion. For the bottom maybe go with another plan as there is still some bone, but only maybe……. I would really explain the whole dilema to the patient and let them make the hard call.

  21. Please get the patient to stop taking the cumadin and talk to his MD
    Do a bone density test and also talk to his doctor after you get the rsults.
    Stop blaming the dental procedures or the qualifications of the dentist and look the causes under your nose. Drug therapy is the worst enemy of the implants,

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