Why did this Biocom Implant Fail?

You said: "I placed the implant a little bit more coronally, with the first two threads out of the bone, in order to place the implant platform at the level of the CEJ if the central incisor" If I have well understood, you tried to perform a VERTICAL gbr with a resorbable membrane, in an single tooth edentulous span, in the aesthetic zone, with the simultaneous placement of the implant. Also you placed the graft above the boney peaks of the adjacent teeth (a GTR at the same time?!) Given these premises, If this had worked, you would be a very skilled guy. Very very skilled... What I can see from the x-rays is just the resorbtion of the vertical component of the graft (that is above the adjacent boney peaks), maybe something more. Probably you have overestimated the regenerative potential of the site and the barrier effect you can get from a collagen membrane. Regards Paolo Rossetti - Milano

I agree, I overestimated, but what shoud I do now? I would apreciate any advice

This is NOT a Bicon implant.

Yes, indeed, is not a bicon implant, I wrote a BICOM implant of MIS, but was written by mistake. But I don't think that matters

Thanck you, dr Rossetti. There is no infection at the place, from outside everything looks ok. So I can throw out the implant and graft the place now, and after 3-4 month to insert the implant?In this way I could save one surgery for the patient. It was the first time I didn,t use a Biogide membrane, and use instead a spanish one. This might be a cause?

How thick was the buccal plate at the site? Was the implant contacting the buccal crestal of the site? When a thin plate is present one should not have contact with the crestal area of the buccal by the implant as we see resorption and at placement the implant needs to be positioned more palatally. a gap of 1mm between the implant and buccal crestal will fill in with clot and form bone and no graft is needed. One must consider also if augmenting the facial of the plate is needed at time of surgery and this is why flapless is not always the best approach. In this case my advise is flap the area and evalute it if any threads exposed clean any granulation tissue from them, then apply citric acid gel to the threads and bone wait 1 min rinse and repeat. then place a bone putty like Novabone a resorbable membrane and get primary closure. also means a tension free flap when done.

By the way has any one used bicon implants? I have been usi g this system for a while and I think it is simple and successful? Any comments would be appreciated.

Paulo is on to something here. Here' s a question, did your Spanish membrane work before in these situations? Probably not the membrane. It's probably case selection and placement. You have 2 options. Start over or try to salvage. Pick which you approach you prefer and it makes the comments much better

Membrane is most likely not the cause, bio oss alone wont really allow you to get vertical gain(not good enough), it would need aupport like a Ti mesh or a Ti reinforced membrane for something like that. I would say start over with a graft and after you get enough bone insert a new implant. Good luck

Bin the implant and start over. The implant has been placed too coronally. CEJ is not a reference point for implant placement. The article by prof dr Buser - Long-term Stability of Contour Augmentation with GBR in Aesthetic Implant Dentistry will provide all the answers that you are looking for.(bundle bone) Your temporary crown should never be placed near or on the fixture head. Good luck and have fun.

I agree that considering the fact that this was a flapless procedure, it is highly likely that the labial plate was thin and has been lost post implant insertion. Best to do as the poster above recommends re flapping the area and doing a GBR procedure. DrT

The site has been vertically over-grafted to cover a screw that looks too coronally positioned (I agree with Dr. Chan). If you look at the first x-ray, you may see that the graft reaches for the level of the CEJ of the adjacent teeth. There is no way that a graft like this (or al least its vertically overbuilt component) can survive, whatever membrane or mesh you use. The point is whether the implant can stay there or not. Which is difficult to say, because we do not know how many threads were exposed in origin. If a minor thread-exposure was present at time of surgery, then there is a chance that the implant will stay there for long, with or without an extra grafting procedure. If the implant was extensively exposed at time of surgery (and you relied on the graft to cover it), then (I think) you'd better remove the screw and start over again. Has the implant a polished neck? Paolo Rossetti - Milano

Let me add the following: You can't go against nature! ;)

I would open up again. Clean the area. Place HA resorb and cover with CT graft. That works.

It's not the implant that's the problem, it is the graft material that was used. Countless times I have tried to convince clinicans not to place Bio Oss in extraction site defects in direct contact with implants. You have an exceedingly low bone-to-implant contact, fibrous integration at the crestal 1-3 mm of bone around the implant resulting in an inflammatory response that ends up resorbing the facial plate. Yesterday I had the "pleasure" of removing a failed implant placed by an oral surgeon in a Bio Oss grafted sinus. Upon removal, there was virtually NO bleeding. The avascular nature of nonresorbable xenograft grafted ridges is antithetical to everything we do in implant dentistry. Success in implant dentistry is a BIOLOGIC phenomenon, NOT a mechanical one. Virtually every failure we see, whether early or late, is ultimately tied to a failed biologic response. The use of a nonresorbable graft, while it looks great on a radiograph, cannot be acceptable by any standard, regardless of who is teaching it. Now I know I will be excoriated by the "Bio Oss Boys" after this posting, extolling the virtues of xenografts, but you can't fool Mother Nature. Perhaps you just need a few more failures to move your paradigm along........ RJM

This message for dr Scheaffer , how often do you use bicon implants,? And what is your success rate? Do you do immediate bicon placement? Thnx

Dear Miller, what we see here is not a graft that "looks great on a radiograph", and being characterized by poor vitality. What we see here is a graft that has resorbed long before having a chance to "look great on a radiograph" and to show its poor vitality. Something went wrong with the integration of the graft (before it could turn into bone or into whatever else). Rarely I have seen grafts, that were placed up to the Cej, survive. In my opinion the implant was positioned relying on a graft, whose success was highly unpredictable (vertical gbr, with a resorbable membrane in a single tooth edentulous space...ouch!). Overestimating the regenerative potential of the procedure was probably the mistake, and positioning the implant according to that estimation. As for Bio-oss, if it was the MAIN responsible for this kind of unsuccess, I think it would have disappeared from the market long ago. I have never used it anyway... Regards Paolo Rossetti - Milano

I have placed probably over 100 Bicon implants. That said, to date, this is the first and only system I have ever used although I have recently purchased Zimmer's system and will be incorporating that into my practice when I want to use a "screw type" implant, namely in the anterior region. Bicon is a "press fit" type system where you create the osteotomy and then just push or tap the implant into the position you want. It is absolutely essential to counter sink the implant for predictable integration. At least 1mm, ideally 2. The GREAT thing about the system is the belief of the designers that longer is not nessessarily better. For instance, I routinely use a 5x6x3mm implant in maxillary posterior regions thus avoiding the sinus areas and the need for a sinus lift. I, as well as my patients, love that. The BIG negative and the reason I am incorporating the Zimmer system is the restoration of the implant. I can only imagine the learning curve if one has been placing and restoring screw type implants such as Nobel. There are no screws to retain the abutment and/or crown. Everything is precision fit. A "cold weld" which, when done correctly, works very well. However, anterior esthetics can be a challenge. Bottom line is that the Bicon system is a great system but you should come to Boston and take their course before implementing the system in your practice. It would be WELL worth it.

I agree with Dr. Schaefer is Not a Bicon Implants, the issue with this matter is that company try to copy the Bicon name and the real name is Biocom what coincidence???

Drs Miller and Rossetti have said it as well as it can be said in regard to what caused the problem and now the question is what you can do about it. Because of what Dr. Miller stated once you have grafted with a material that produces sclerotic bone you will never get bone to grow on its surface because it has no vascularity or cellular vitality. Doing a ridge augmentation over the implant is very difficult because again where are the osteogenic cells going to come from? While we don't have all of the details I see two options. If the implant is stable and no inflammation is present then you could do a gingival graft for esthetics. The other option is to remove the implant and do a ridge augmentation. However, you must be able to identify and remove all of the sclerotic bone produced by the graft material which cuts like chalk due to a lack of vitality until you reach bleeding cancellous bone. Then graft with either autogenous bone or a resorbable synthetic. Using either an allograft or xenograft will put you right back to where you started. Greg Steiner Steiner Laboratories

Thanck you for all the opinions. Dr Rossetti was the dr that understood the situation best. 2 more details: the surgery wasn't done flapless, as I stated and second:the implant does have a polished neck. I didn' t rely on the graft for succeding the procedure, but only the last 2 threads of the implant and its neck were left outside the pacient's bone and grafted.At this moment I have no inflamation, no pain, and only the RX shouws the failure of the graft .Also, the implant was placed 3 month after extraction, not in the moment of the extraction. The labial plate was intact in the moment of the surgery, I grafted yhe bone mostli on the screw, in a verical adition, on the buccal plate I added just for esthetics there was no bobe perforation on labial

My problem now is wether to take the implant out or not

Take it out!! You will be chasing your tail with this one for ever. It has been proven that there is a place for this graft material, but not the way you have attempted to use it here. Autogenous bone is the only way you are going to get the 1-2 mm of height that you were trying to get. Many of my referrals ask me to place the implant in this situation 2-3 mm below the adjacent cej's and their restorations are very satisfactory. Some occasions require coming back and augmenting the buccal aspect. This is where you can exhaust your supply of bioss. Hope this is helpful. BV. Vinci Oral/Facial Surgery Baton Rouge, La.

I took it out, but the suprise was that the labial plate was intact, but the big resorbtion was on palatal. The implant was stabil, I had to use the torque in order to remove it. Thank everybody for trying to help.

Hi Dr. Herscovici: This is a typical case where the implant is not placed on the right position. When placing an inmediate implant the head of the implant should be 3mm above the CEJ from the adjacent tooth and you placed it at the level of the CEJ. That means that you didn't sink enough the implant so the head of the implant was to exposed and after the 2mm crestal resorption that always happens you probably had to much exposure of the implant. Fortunately, you already removed this implant. Graft the area and go back again in two months. Good luck next time.

Dear Herscovici, thank you for sharing your experience (almost in real-time, I have to say). Since you removed the implant, I have a curiosity. Was the graft completely resorbed or some of it had integrated? Did you notice some resorbtion of the patient's own bone? (you said the palatal bone. Can you be more precise about it?). Now that you have taken out the implant, can you guess what happened? Thank you.

I was trained by Bicon 12 years ago,and for no good reason have done only screw type implants for the past 7 years after takingNYU training. I am asking for your experience and input as to why you favor Bicon? I am Gp and prefer to do my own placements. Thank You, Joseph

I suppose the quick answer is that it's the only system I've every used. The oral surgeon I occasionally refer to uses them so I thought that was a good place to start. Although, as I said, that is changing shortly as I want to take advantage of the restoring side of screw type implants. Where I anticipate continuing to use Bicon extensively is in the posterior of either arch where anatomic structures are an obstacle.

This is a response for dr Rossetti: A part of the graft on the labial plate was still in, but all the graft that I put above the screww was gone. All the labial plate was intact. On the palatinal, the implant was uncovered by bone till the last 3-4 threads. All the bone loss I`ve seen on the RX was on palatal, I don't know why. In the moment I place the implant, I raise the flap deep on the palatal, so I'm sure I had no perforation of the palatal bone. There was no tension, since I left the implant a little bit outside. Best regards and thank you

Dr Rossetti, you were right, I shoudn't have done any bone graft , but only implant placement, and placing the implant at the bone level I had at the very biginning.But I was afraid that , in case of placing the implant at that level, the crown should have been apear longer than the adjacent natural crowns. So my mistake was by placing too coronally the implant,that caused palatal resorbtion,and not because of grafting the area, did I understood well?

I also am curious as to why there was so much palatal resorption in this case. I cannot see why the coronal level at which the fixture was placed should have anything to do with this problem. DrT

Advanced Help Result Filters Display Settings: Abstract Send to: J Long Term Eff Med Implants. 1998;8(3-4):201-9. BIO-OSS--a resorbable bone substitute? Schlegel AK, Donath K. Source Department of Oral Maxillofacial Surgery, Ludwig Maximilians University, Munich, Germany. Abstract BIO-OSS is an allergen-free bone substitute material of bovine origin, used to fill bone defects or to reconstruct ridge configurations. Seventy one patients (39 female, 32 male) received 126 BIO-OSS implantations. Some health parameters or habits were documented to eliminate possible risk factors of influence. The diameter of jaw defects filled with BIO-OSS was measured. There was a significant influence of the defect size on the healing result. In X-ray controls, BIO-OSS served to identify the surrounding native bone. The density of the BIO-OSS areas was higher than in control sites. These radiological results were supported by bone biopsies. Histologically, the permanency of the BIO-OSS was still recognizable after 6 years and longer. The ingrowth of newly formed bone in the BIO-OSS scaffold explained the increased density of the implanted regions. There were no clinical signs of BIO-OSS resorption. Therefore, we can assume that form corrections achieved by BIO-OSS insertions will last. PMID: 10186966 [PubMed - indexed for MEDLINE]

I knew it was only a matter of time before the "Bio Oss" fans would post a response. Two things to note: the previous poster is anonymous and the paper quoted deals with grafted ridges, not grafts adjacent to implants. I will agree completely that Bio Oss is an outstanding graft where maintenance of ridge architecture is a must, especially where bridge pontics are employed. However, our grievance deals specifically with the use of xenografts to fill extraction site defects after implant placement. Two completely different paradigms with entirely different clinical outcomes. I will restate my premise that xenografts are contraindicated when grafting extraction site defects for immediate implants, and should be used cautiously when used as the sole graft in delayed implant placement. RJM

Halaalsakka, Sounds like you work for Bicon.

PLease, Dr Rossetti, give me un answer: Can the palatal resorbtion has been caused because of placin the implant too much coronally? It doesn't seem logically to me. I do understant why the graft resorbed, but I don't understand why his own natural bone has been resorbed

It seems that the Bio-Oss-Boys are trying to build human bone with their magical Bio-Oss-Pens in a Harry Potter manner and they are dreaming about hany-panky and hocus-pocus. In the literature are several lies in print. Please do researches in a scientifical way and read the literature correctly. Where is a place for wizards? Osseointegration, osteoconductive effects, volume stability, scaffolds are clever expressions for naive people. Most of the published literature was paid by the industry. Your colleagues in orthopedics do not use xenografts. These doctors build bone with resorbable bone substituts. After the substitution resorption of the foreign material the patients have human bone! Waht happens in dental implantology? Bio-oss does not resorb under normal conditions. Only in a very sour milieu it will resorb. All augmentations with Bio-Oss are foreign body reactions and inflammations. Nothing else. With x-rays you will see immediately after augmentation that the bone is healed!? Under the microscope you will find the true answer without any magic. Some facts: 1.) After years you see sometimes with x-rays less bone than after augmentation directly. What has happened? After the augmentation you have a big space between the hydroxylapatit with blood etc. After years the HA is compressed and packed. For everytime (?) a lifeless chunk of bovine HA in the real human bone. There is no resorption at all. Histologically you will find the same amount of HA. 2.) Bio-Oss has a too sharp structure. It leads to problems in the soft tissue and scares. 3.) Sometimes the Bio-Oss-particels will move out of the bone and soft tissue. The unresorbable particles can move in the whole body. Patients have problems for everytime. 4.) Bio-Oss leads to a cytotoxic effect of the cells in the culture of fibroblasts. Therefore it is not suitable for augmentations. 5.) The low temperature and the chemical processes do not reach a complete reduction of proteins in Bio-oss from cows. 6.) Why does sometimes the real bone resorb with Bio-Oss? 7.) 1997 the WHO suggested that "cow-material" should be avoided for medical products.

And please ask your ENT-colleagues. You will get the true answer that they try to remove Bio-oss out of the maxillary sinus with chronic infections. A dissertation about that topic is in progress. paul carie May 31, 2009 at 10:57 pm | Permalink I can’t believe you guys. I had bio oss used on me 5 years ago. Never resorbed, still having chunks that have migrated everywhere taken out, gross sinus problems because of migration into the sinus. Dysguesia also. Why would any of you use this product? My dentist has photos of chunks he has been taking out. The company should be sued as well as the people who use this garbage. david salzman September 13, 2009 at 10:38 pm | Permalink I have bio oss attaching and spreading everywhere. Some has been taken out, the implant was taken out. I now have a glob of this garbage attached above #16, some in the soft palate by 16. Salty bitter taste coming from there as well. Do any of you folks know of someone who can remove some of these particles. My ENT just removed several pieces from my upper lip. The bio oss was originally placed in #14, obviously did not stay there. Cannot believe anyone in good conscience would use this stuff. Please let me know if any of you know of someone in your profession

This thread ia about theBiocom Implant, not BioOss. That said, BioOss does NOT resorb. It at best is a filler. On page 89 of Daniel Buser's book "20 Years of Guided Bone Regeneration in Implant Dentistry", 2nd edition it states Thus in daily practice, xenografts must be considered close to nonresorbable. Pages 86 to 89 covers this in a very clear manner.

Reply to Herscovici: Oh Judith, Judith... I wish to thank you for your kind consideration, but I am not the only dentist on this forum that can provide you with a competent(hopefully) opinion. Many others here are far more experienced than me. Having that said, I think that your questions will remain unanswered. There are some details of this case that are out of my comprehension, above all the shape and nature of the radiolucent area around the implant, that you can see on the third radiograph, which I think has to be considered at least atypical. The radiolucency looks very large and extends far mesially and distally, being overlapped to the root of the central incisor. One would expect that a large defect like this has been caused by a bad infection, but no infection was there, as you said. Secondly, from such a large resorbtion, you would also expect that the marginal bone has been involved, but you can still see on the x-ray that the marginal bone is preserved, (and you could observe it during the removal of the implant). Third consideration: the margin of the lesion looks very well defined, which is typical of a lesion that has developped deep into the bone (from the surface). But the lesion has to be shallow, since the relatively thin marginal bone looks preserved. Last but not least, the timing of the development of the lesion: after three months of healing without infection, the native bone should be considered free from risk of resorbtion, especially if a resorbable membrane was used. All I can guess is that a large and shallow resorption of the palatal bone might have occurred, due to the elevation of a large palatal flap. The defect may have uncovered the most palatal edges of the threads, being the implant close to the palatal surface, which is not a serious inconvenient. Your digital x-ray system may have done the rest, causing an over-estimation of the defect (a radiological artifact) (or you like joking and are a good photoshop user :) ). Please note that the implant was osteointegrated. Sorry for the guess game in the CSI-Miani fashion and the delay in my answer.

...In my hands, Bio Oss doesn’t work at all. Any implant failures I have had are all associated w/ Bio Oss. I gets encapsulated and I hate seeing the mush when I reenter. Since I stopped using it 2 yrs ago and switched exclusively to autogenous (gold standard) or...

...or WHAT??

...“Do not reconstruct the Facial skeleton with Tupperware!”... ...However, I have seen too many late complications (more than 5 years after implantology) with Bonesubstitutes, reffered to us and in our own clinical experience: chronic perimplantitis, chronic soft tissue infections, granuloma sometimes not in direct contact with the implant luckily, complete bone-loss because of chronic infection/irritation...

...BioOss is only a filler. It can’t make the body to grow bone. The problem is it is dense HA that does not resorb...

Dr.Herscovici, Very interresting post. You said "In the moment I place the implant, I raise the flap deep on the palatal". The palatal bone resorbed because of the deficiency of the blood supply.The palatal bundle resorbed first followed by the resorbtion of the palatal wall bone. Elie

Bio-oss is inert. I use it in sinus lifts mixed in with the allograft for a radiographic marker. The blood supply for the graft is in the socket. The failur looks like violation of biological width which gives resorption usually back to the first thread. How does the soft tissue look is it esthetic? Can a soft tissue graft be placed and is the implant stable.