Slightly mobile implant with bone loss: How would you treat?

Fifteen years is not bad, remove the crown, abutment and use the neobiotech torque wrench, if not take a thin burr or trephine and remove. The crestal bone is most likely what is holding this in. It can be regenerated. I like disinfecting it with the Nd- Yag laser and grafting. See what you get then treatment plan. Resin bonded temp or Essex while graft is healing. There is most likely a perforation in the cortical bone which will need repair. I use particulate with a blood product of choice maybe a membrane depending on the architecture. Good candidate for a connective tissue graft on the anterior teeth and /or veneers for matching in the final restoration.

Agreed that this is a failing implant and should be removed. I agree with CRS for surgical protocol which is probably beyond my scope due to my lack of experience in the anterior region and the thin gingival biotype. A new implant/crown #9 or FPD #8-10 will probably not address her chief complaint of poor esthetics. A diagnostic wax up would be a good start. Even if pt decides not to replace implant, graft if for better gingival esthetics with the bridge. Also, check vitality on #10. Difficult case, teeth will be long and may need c.t. graft that CRS mentioned. The patient's smile line doesn't appear to be too high. Good luck and keep us posted!

I agree on using an implant removal kit. At the same time I would do a coronally positioned flap with CT graft on teeth #10-12 as well as on the labial of the implant site. I would use a BMP bone putty in the implant exo site after it was thoroughly debrided and disinfected

It would be very difficult to remove this implant without destroying the crestal bone. Any situation without the crestal bone is much more difficult. Think it through another way. It might be better to first remove the crown and the abutment. The labial bone wall already seems to be missing, so then flap the region and open up the lesion. Then the fun part would be to push the implant crestally, and remove it through the labial window. That way you have a chance of preserving the bone crest. It also allows the region to be cleaned out properly and regenerated.

These implants were called "Styker" back when they put this in (now Bicon). I see no indication for the use of these implants, ever. Removal is a problem because middle of implant is bigger than the neck, so trephine will make a really big hole at the crest and you will have a big defect when it heals unless your graft technique is pristine and the patient is a good healer. You have to cut the crown off horizontally at the crest, then trough or trephine around the stump of whatever is left. Sometimes you can wiggle the implant out of the hole in the buccal plate and spare some of the alveolar crest - do this if you can (easier to rebuild buccal plate than to rebuild crest). When titanium junk is gone, debride and graft. This is not a simple case, if you do not have a lot of experience with this kind of thing then I suggest that you send it out and let it be somebody else's problem. Meanwhile, you want to cantilever the central? No thank you, please. If you want to do a conventional FPD and you can't use the lateral (think "interlock" (or tubelock) precision attachment if draw is a problem), then extract the crummy lateral and go to the canine. At this point you might as well do 6-11 so it really looks nice (I would if #7 is too crowded/tilted/whatever). Good luck!

Easy case, I'm not kidding. Vertical release distal 6 and 11, full thickness flap. Your CBCT pre surgery will show you no buccal plate around the implant. (Thank god the holistic dentist let this one soak in its own filth for years). Remove the crown and abutment, then make a small slot apical to the implant and elevate to apical end out buccally. You will be able to easily remove the implant and leave the crestal bone intact. Next completely remove every fiber of tissue present until you see completely clean bone. (Remember there is no buccal plate) then graft, membrane draped over adjacent osseo us architecture 5 mm or so both buccally and palatal to close the entire defect. Over that a CT graft. Release the flap so it's tensionless and suture to primary closure. Honestly, I'd even consider placing and implant same day if possible.... As far as the generalized recession the reload flap can be repositioned to cover those areas. She's got tons of KG present on 6,7,8,10,11 sites so no need for CT graft there when you coronally reposition the flap.

One miracle at a time: placing an implant at the same time as you remove the failing one feels to me like pure idio**, or arrogance. Just my opinion. As for increasing the thickness of the gingiva, why not just place a piece of tissue allograft before suturing...no big deal. As for this being an "easy case", hmm..I would be very careful.

I don't have any experience with Bicon implants but I neglected to mention that a buccal flap needs to be raised to access the defect it may be possible to section the implant and push it thru the defect. This needs to be grafted and well healed prior to replacement with another implant.

As this is a retrograde peri-implantitis, do you understand the mode of failoure? Without understanding the reason for this lesion, I would NOT place another implant at the time of failed implant removal. Is this an encroachment into the nasopalatine foramen? Was there an apical granuloma that was not debrided? Is this primarily related to occlusion? Is there a loss of the facial plate with soft tissue ingrowth through the fenestration? Remove, debride, and attempt to understand the cause of this failure first. Then make a decision on retreatment. RJM

Actually there is something very interesting in the photos of this case. Any thoughts why the implant is out of occlusion and the surrounding dentition looks like it has supra-erupted since that implant was restored? Hint; I think the tremendous amounts of KG elsewhere is from prior root coverage surgeries.

Having placed many of bicon implants and knowing how well thy prform, I will elevate a full mucoperiosteal flap, enter through the buccal plate and with a carbide burr and plenty of irrigation section the implant horizontally right were the abutmenpost end abut the middle of the implant. Debri the area grafted and replace rhe flap. It will function asa short implant and that is about all the implant length that you need. You have nothing to lose.

Agree with Dr G , not a big deal can be removed with a site specific flap at the gingival / mucosal junction after crown removal ( Tap Off ) should be able to remove easily .... Then let heal for three weeks flap and standard SRP again..

Thanks for all the comments. I removed the implant today, it was not possible to tap the crown off as the implant was mobile and I was concerned about breaking the crestal bone. As it happened, it came out with the crown as I rotated it with my fingers together with the most foul green material I have ever seen. I laid a full thickness flap, curetted the area thoroughly- there was extensive bony destruction but the palate was not breached. The crestal bone was only present on the palatal side. I elected to use dual phase calcium phosphate mixed with B-tcp granules from Steiner. This is the first time I am using this type of material and thought this would be a good case to try it with. I did ask the patient if she had any previous oral surgeries and she said only the implant placement at #9. As far as placing an implant at this time I think it would be highly unadvisable and frankly just not possible due to the amount of bone loss. Peter, in retrospect I think your idea of waiting for healing after implant removal would have been a better idea and is an approach I will be using from now on. One concern I had was the amount of bleeding in the bony defect. It looked like I had hit a blood vessel as the blood was welling up and would not stop. Any ideas on the source of this and ways to stop the flow during surgery. Once the graft was packed it did appear to stop but I was concerned about this. Thanks again for all the tips. Dr. Y

Sounds like there was encroachment into the nasopalatine foramen after all. Probably transected the nasopalatine artery. RJM

Hi Dr Y , as Dr Millar has suggested there may have been some damage to the artery but curretage but , I think the severe infective state could also have this effect . This is why I suggested allowing to heal for a few weeks prior to grafting .... Greg Steiner makes some great graft materials and has a lot of experience but all of us involved in material development can see the possible issues which may affect the material performance and this excessive bleeding would not help when associated with incomplete closure.. All the best Peter

I would have used the Nd-yag laser to disenfect it first going around the implant prior to removal, if there is granulation tissue it helps encapsulate it and gives you a nice margin with good hemostasis Then remove the implant and treat the bed again for disenfection and hemostasis The granuloma most likely was in contact with the nasopalatine contents and may have been torn when blindly curetting the pathology. Bleeding can be controled with digital pressure on the palate, possibly using a suture to keep the pressure on. I would have placed some particulate bone in the bleeder or used Hemcom. This sight most likely has bacteria a few mm of penetration deep to the bone margins. Usually pigmented bacteria seen in perio disease. I doubt you transacted the artery, a pressure suture would have been necessary. With that much pus I would have cultured prior to the laser to see what your are dealing with, I have seen actinomyces which is very difficult to erradicate, at that point I get my infectious disease colleague involved in the management. What most likely happened is that the original tooth may have been an old RCT or fractured with the original bacteria getting a nice head start in the bone. This is a localized osteomyelitis if it has been present chronically. So two issues addressed, chronic bone infection and hemmorhage management. You're welcome☺️

Now the implant is removed , granulation tissue removed , flap sutured . Good . Wait for nature do healing. Bleeding must have been due to granulation tissue. Once you currate well , it stops. Does not stop till granulation is completely removed. Many a times pains in spite of good local anesthesia. Would have prefered CBCT.

This might sounds crazy but, why don't you try taking the implant out through the vestibular plate? That will give you access to decontaminate plus maintain the crestal bone and papillae. Allograft and a membrane won't be that difficult after that. I would consider that if I were you. Perhaps you just need to remove a few milimeters of bone in the appical portion since you say it moves already.

I have used Bicon (DB, Stryker) since 1986. If the implant is mobile and you can feel it moving on the buccal, use a finger, I think it will be easy to remove. Hold the crown or abutment with an extraction forceps...twist and pull. Implant out. If not the abutment will come out. Then use a trephine one size larger then the implant with very cold water and carefully remove as little crestal bone as possible. Once the implant is out curette and graft with whatever you use. I prefer AlloOss with PRF and covering with PRF members. Then treatment plan with the patient. I like Raul's idea...but he is a lot more optimist and creative then I am. Good luck and thanks for posting!

IMHO do not try to remove that Implant. Expose the buccal Bone plate with modified periosteal flap design preserving the Papilla and attached Gingiva giving a semi-lunar incision. Remove the thin buccal bone, if present and expose the Implant. Remove the Granulation Tissues just the way it is done in Apicecotomy. Disinfect the lesion with Tetracycline / Clindamycin slurry and then with Laser, Diode or Nd yag. After copious Irrigation with normal saline, pack it with CGF Blocks and Graft it with Sticky Bone. Close the bony window with Resorbable Collagen Membrane and then with CGF membrane. Close the flap with pTFE Sutures. Give Antibiotic Prophylaxis of Amoxycillin + Clav 625 mg twice daily x 7 days. I bet you and your patient gonna be the happiest person in this World. God Bless you. Sandeep Singh India

• It is amazing to see the crestal bone gain in this case. It is the dream of every implantologist to have bone growing over the crest of implant. This adds to the intrabony length of the implant, improves the crown implant ratio and support the interdental papilla . Almost in every implant case there is some crestal bone loss and literature says that it stops at the first thread. Also the crestal area is the starting point of most of the implant failures. The crestal bone in this case is almost in level with the adjacent natural teeth. This show that there is something admirable in the Bicon design and protocol

One may be able to twist off the crown. And treat the implant as per CRS and Fisal's recommendation. One may not like the Bicon implant but it is still a viable system.