Patient with Acute Periodontitis Presents with Failed Implant: Best Way to Proceed?

Implant #23 looks to be the only one in adequate bone. According to the ct it looks as if the other two are failing and possibly perforating the lingual plate. Open the area, remove, graft and obs.

i would take, first, an imprint of the anterior mandible site, then put in programmea periodontal cleaning under antibiotical therapy and contestually extraction of three implants and perhaps one toot and contestually put deep inside chin sinfisis almost three implants of 2,5 - 2,8 mm. large and 30 mm. long . naturally the whole area must be covered with osseous graft and membrane. this choice is for me strictly personal, so for the tipe of implant.

I am not sure that is peri-implantitis, but I am sure that you are entering the realm of pink plastic. t

I think you need to recognize that two of these implants have perforated the lingual plate at the time of placement.

Hi, why do you need a ct to disgnose these failing implants whats wrong with periapicals and periodontal robe and palaption...very inappropriate i feel.Maybe its just my Englishness!!!The referral criteria for a ct are jst not there.

totally agree with dr. carnazza

dr.tobooth 2d radiographs are going out of style as fast as 8 track tapes did in the 70's.. buy a low radiation cbct and you won't be taking pas all the time.. you couln't see the lingual perforation in 24 25 with 2d..

I'm not sure what to say with regards to this case. If this landed in your practice and you are not immediately certain looking at the ct, which implants need to be immediately removed and have a good idea of the sequence of risk factors and possible complications, then refer don't touch it. If you did this case, then I strongly suggest you sit down with an experienced colleague with whom you can talk openly and trust, and talk the case through at length. All the best, mike

Refer to a specialist. not the same one who did any of these implants. Not good

First remove the 3 implants, debride the sites and allow for epithelialization. Then reopen and graft with either a block graft or a titanium barrier over autogenous bone chips. Barrier needs to be fixed with pins or mini screws. Patient should wear an essex bridge so as not to impinge on the graft. After 6 months re evaluate for 2 new implants. Reevaluation of #22 & #27 is important. Indeed the prosthesis will need pink porcelain. If you are new at placing implants consider using a computer generated guide such as Materialise's product. This will allow easy placement at good angles.

I'm not sure by what criterion you say 1 implant is failing and the other 2 are ok. None are ok and have no long term prognosis. They will all have to be removed. I would strongly suggest you get a colleague you know and trust to lead you through some of the mistakes that have happened, and discuss the requirements for longterm stability of an implant before you attempt to do any further implants.

Since you did not do these implants, I can say that it is a wonder that anyone could ever make the mistake made in alinement/position and implant choice in this case. Clearly, this is a person that should not be placing implants.. I would venture to say, never. Reason? Because even a beginner should be more talented than the "placer of these implants"!! Wow.

Just say it was done badly, Mike !!(No insults intended, just an honest opinion). I am not going to comment on the justification of cbct in this case. However, the dose could be reduced with a small FOV centred on ROI. It seems to me that the implants were inserted following the long axis of the natural teeth (immediate implants?). #23 and #24 are retroclined and #25 is proclined. This probably won't have happened if its natural predecessors were straight ;) The implants should be removed and site treated as per Dr Carnazza's post. It may not be easy to remove #23 if it is integrated.

Opinion offered - Since a ct scan was done initially, it is a pity a surgical guide was not made at that time so that the three implants could have been placed ideally within the confines of the available bone. All of us reading this forum are very interested in dental implants, however that being said, in a situation where a patient is suffering from acute periodontitis, it is likely that dental implants will end up with the same prognosis. There is nothing wrong with restoring such patients with a well fitted removable prosthesis,and try to control and eliminate the periodontal problems before implants are once again attempted. Sorry my dear confreres, implants are not for everyone. Gerald Rudick dds Montreal, Canada

From the images, all the implants seem to have poor bone support... and hence poor prognosis. None of them can survive in the long run. They've failed due possibly due to three reasons... the poor bone condition, tendency towards periodontitis causing increased bacterial colonisation in the crestal regions and the improper positioning of the implants. My choice of implants in such areas are the basal implants - the BCS & the BOI (of Dr. Ihde Dental, Switzerland). I routinely place basal implants in the mandible - anterior regions - in patients with history of acute periodontitis... they are placed immediately after extractions, curettage & debridement... the ones I use are mostly BCS 3.5 / 4.5 mm. dia and of lengths 14 / 17 / 20 mm as required. They are single piece & immediate loading. They cannot be affected by peri-implantitis as their stability and retention comes from the basal bone and their long polished necks which come to be positioned in the crestal bone regions cannot create a fertile region for bacterial colonisation.

I think more than the worry about perimplantitis, the problem is simply that the Implant was not confined to bone. Whether its eventual fenestration or initially perforated lingual plate, failure is just around the corner if this happens. A good stent fabrication could have prevented this along with a computer guided technique if possible. At this point, the implant needs to be removed, i dont see a good prognosis at all in trying to salvage the implant. Start from scratch, graft if you have to, do your stent, consider always the prosthetics then do your surgery again.

At the virtual midline (slice 100-101 mm in this case) the software (Xoran/iCAT?) flips the slice images. So, I think that 24, 25 originally followed the natural tooth axis (sort-of. They may or may not have moved.) - #23 might remain stable for some time IF the patient has scrupulous homecare & professional care. #22 & 27 have lost their mesial bone. Until she is periodontally stable, I would advise against new implants or bone grafts. - You find yourself in a "bone preservation" situation. Early removal of 23 might help in preservation. Homecare & Periodontal therapy must become her priority if she want to keep her teeth. Dominos, anyone? Also, check for tongue thrust & other parafunction before any restorations (even the pink plastic type) and percussion test #19. It may need a retreat.

I think a partial denture is the way to go here, unless the patient is willing to accept several 'major' procedures that might fail s.a. autologous cortical bone grafting, or distraction (the horror!). Bet he will choose an RPD or a bridge.

This looks like a disaster. The imlplants are perforating the lingual plate; can be very dangerous for hematoma at time of placing! The prognosis is bad for all 3 implants.This mess is made by a unexerienced colleague. It is hard to say how the osseos condition was of this area before placing implants. At this moment: remove implants, check the bone levels mesial of teeth 33 and 44, and it looks that they are lost also. Let it heal for 6 weeks, negociate with the patient if he is still interessed in 2 new implants in area 33 and 44 after this adventure, take a CT, place 2 implants or make an other prostetic. Good luck

I am of the firm belief that only basal implants can work in these situations. I have performed several cases in similar periodontal conditions both in the upper and lower anterior jaws by now... they are all doing extremely well. - Dr. Prasanth Pillai

extract 22 & 27; remove implants; osteotomy 18.0 mm from incisals; Place 3 Nobel Active implants in sites 22, 24, 27. Place fixed removable hybrid bridge immediately at surgery. 4 months later place definitive fixed removable milled bar hybrid.

I'm assuming a cbct was not taken before tx. I disagree that a cbct is not indicated. You need to stabilize his perio condition first, is that a huge vertical defect distal to 18? I say remove the implants and make a temporary partial. The patient needs to be committed to establishing and maintaining his oral health before treatment continues.

Well the two implants in the lower anterior need to be explanted and I think 23, 25 and 27 also will need extraction due to the bone levels. would at that time currette and graft then place titanium mesh to tent the area, get prtimary closure and allow to heal for 3 months then flap and remove the mesh and evaulate the density of bone. if dense enough place fixtures and allow to heal for 3 months before loading. An Essix temp would be good during the healing periods as this will keep pressure off the site.

Take that mess out , let it heal and start over and try not to perf the bone. If the perio is so bad then go removable or a fpd with pier abutments. Implants are not for everybody!

the immobile implant : what about soft laser debredment of periodontal pocket mobile implant : remove , excavation , irrigation , laser cleaning of the bone , bone graft , later new implant