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Bone Graft Correcting Dental Implant Peri-Implantitis Bone Loss ~ Case Example

bone loss on dental implant prior to correction by Ramsey Amin DDS before treatment--bone loss in the mid body of implant causing inflammation, redness and pain

Bone loss can and does occur around dental implants.  Often this is called peri-implantitis and there are a few treatment options.

Review signs and symptoms of peri-implantitis dental implant bone loss in this previous article.

Bone loss on implants happens on about 1-15% of dental implants. That percentage is variable depending on the experience of the dentist. How to deal with it is the big question.  In certain situations your dental implant or implants can be recovered with bone grafting procedures but in some instances the bone loss associated is so significant that the only option is to remove the implant and start all over again.  Bone grafting for peri-implantitis bone loss defects is not standardized and varies widely from dental surgeon to surgeon.  Over many years of doing this I have developed a specific technique for recovering some of the worst bone loss.

Correction of bone loss on dental implant--Ramsey Amin DDS

Bone loss can occur as a “moat” defect going 360° around the entire implant or it can be just localized to one side of the implant.   If it is 360°bone loss it is much worse than if it is localized to just one side.  The best area to have bone loss is in between the teeth rather than on the outer aspect.  This is easier to graft and has a higher success rate.

If the implant is in the front of the mouth versus the back of your mouth this can make treatment options very different also.  The back teeth are more forgiving and then the front.  The gum and bone is typically thicker in these areas. There are times when the final outcome leaves you with some metal of the abutment or implant showing but disease process was stopped.  Of course in the front of the mouth this is typically unacceptable especially if any metal shows in the smile.

In this example case I will show you the more difficult of the two….  A case where bone was lost on the outer aspect.

In this case this is a 29-year-old female that had a dental implant placed in another country.  The implant overall looks good but it has become tender on the outer aspect of the gum.  One reason in her particular situation why bone loss happened was because the bone was a  too thin to begin with and then the crown on the dental implant became loose at the abutment.  This particular dental implant crown/abutment had a design flaw which caused loosening.

If you look at the implant on a 3-D CBCT scan view from the side you can see that in the mid body of the implant there is very little bone.  Because I never treated this patient to begin with,  we don’t know if the bone was like this from day one or it dissolved to this situation because of the loose dental implant abutment.  Either way it needed to be treated.  We discussed the possibility of removing the implant versus grafting bone and saving the implant.

If you look closely at the gum tissue, of both center upper front teeth you will notice that there is more of a hump on the natural tooth than there is on the dental implant.  This was the first sign that the implant was lacking bone when she smiles.  What makes this case very difficult is that the teeth are generally very long and when she smiles she shows her gumline….  Everything is going to show so this is going to be a critical surgical correction.

You have to be really careful with these cases because sometimes the correction can make the tooth look worse if it is not successful.

The most critical factor in all of this is prevention.  I go to GREAT lengths to prevent dental implant bone loss from occurring in the first place by having a tremendous amount of bone on the outside of the implant if the patient's anatomy allows.  By having the original implant surgery done well, this is the best way to preserve the bone on the outer wall.  Also when the crown and abutment are made by the dentist, there are so many techniques and choices to make things last and be problem free for many years.  Many patients think that the crown and abutment portion are “easy” and can be made by any regular dentist.  For some patients anatomy, dental implants would not be wise choice...that is the exception rather than the rule.

IMG_6892 before treatment --loose implant abutment with bone loss
IMG_6890 before treatment --loose implant abutment with bone loss
IMG_2020 10 days after bone graft--notice enlarged hump of bone over the outside of the implant
IMG_2019 10 days after bone graft--notice enlarged hump of bone over the outside of the implant

In her case, I am certain that the result will be long lasting.  The good thing was there was no exposed threads at the very crest of the bone.  The surgery was done under IV sedation through a tunnel flap which is the equivalent of a laparoscopic medical procedure.  I was able to remove the crown and place a temporary crown during the procedure which helped with surgical access. The sutures seen here are designed to be dissolvable because the incision is far away from the actual tooth being treated.

I know these specific and detailed articles but a lot of this information does not exist on the Internet.  I hope this helps those of you that have this problem and those of you to prevent if possible.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

26 thoughts on “Bone Graft Correcting Dental Implant Peri-Implantitis Bone Loss ~ Case Example

  1. Hello,

    I have an ongoing issue with my dental implant (upper front tooth). When I was younger the tooth came out due to a fall. It was saved and placed again. Years later, I had the tooth extracted as recommended and had bone grafting done. A dental implant was placed about 5 years ago. After the 1st year of having the implant, I began getting infections periodically. It is now to the point where it gets infected every few months. I have taken antibiotics, had laser treatments, have had the crown removed and the area cleaned multiple times, as well has bone grafting that was unsuccessful. I noticed that when I went without the crown for 6 months I did not have an infection because I was able to keep it clean. No matter how much I try to keep it clean while having the crown, it always gets infected. I have used a waterpix and everything else that was recommended to me. The oral surgeon is hoping to keep the implant because it is solid in the bone. However, I am concerned for my health. I feel that there is nothing left to try and would like to remove the implant at this point. Are there any other options or should I just have it removed? It is difficult for me to talk with the flipper or Essex retainers and I am anxious because I speak a lot at meeting for work. I will need to mentally prepare myself if I have to remove the implant. Please provide any thoughts. Thank you.

    1. I forgot to mention that the bone around the gum line is gone. This is why the implant keeps getting reinfected.

  2. I have two upper implants 15 years old. Upper 5 and 12. One implant had some recession measuring about 4. The second was quite a bit less. Neither implant bothered me. I just had the worst removed, replaced and bone grafted. I was wondering if there is a percentage of
    Loss which determines bone graft on exhausting implant vs removal? I was wondering how dire it is to remove it, graft it or recrown the existing implant as it is. Seems like this last one could be grafted vs removal. What determines this type of decision because it was never mentioned to me as even an option.

    1. Great question. The choice to rescue or replace a dental implant is multifactorial. Often times the decision to remove it is because it cannot be cleaned enough to accept a bone graft. If the implant has lost 30 to 40% of the bone it certainly is not worth trying to rebuild the bone back as it will likely melt away again. Depending on the situation sometimes leaving it in place will cause the bone to be lost on adjacent teeth. Sometimes they need to come out right away to prevent this. Sometimes just good oral hygiene with a WaterPik and frequent cleanings can help delay things for many years. Like I said it really depends on so many things and dentist experience is also huge as well.

  3. I will try to make a long story short I chose the wrong dental practice to go to I chose long with a doctor connected to a surgeon which caused me to have to use three different surgeons just to get the bottom four implants placed. The first surgeon only put two in when I asked for 4. And put them in the wrong spot too far back for two implants I worked my but off to save that money up in time. So I had to get a second surgery which in between the gums Rock so much that I lost an insurmountable amount of gum for a small amount Of time there’s Maybe 10 months in-between next surgery which completely fails when the new surgeon literally pins made to the seat tells me to shut up that he’s the boss or surgeon I don’t know he had a a complex.2 months later he told me my implants failed because I didn’t use a waterpik water flosser when I use everything else at my disposal and the first two implants were fine on thinner amount of gum.the reason the rear ones failed was because he allowed me to wear the Dentures during that time so that I could work I had a good job waiting tables making a lot of money. The whole 4 months I was complaining every week or two calling them over and over again not trying to annoy them but trying to get through to him saying that there was a problem and the one time I did come in he said there wasn’t a problem without looking at my mouth and the other couple times he stuck me in the back room and didn’t see me all day and then told me I had to come back again cuz he got caught up with too many other surgeries when it’s the dentist he just needed to look at my gums really quick and maybe do a quick adjustment on my denture with the drill. So I wanted to leave the practice but they made me stay because I have his dentures their front implants which he said they would cover if I left so after trying to get the second surgeon to replace the implants or do something they were just in a in a heated battle between each other the certain wouldn’t come to the office I go to so I had to go further out no big deal but he literally blamed it on the other dentist. Or my mouth and it wasn’t. I’ve done an extensive amount of research on dental implants and when the correct time to get them is how long you should wait and I could have waited longer and still gotten great implants with bone grafting and they push me to get work done too early which is the same thing the second oral surgeon complained about is why he left. So I went to a different Gentle Dental get to get the back ones replaced which he said he would replace all four of them so I kind of got caught up in that didn’t realize he wasn’t doing any bone grafting he actually filed a lot of my gum down further to where I have the weakest looking gums possible they’re so thin that I’m depressed every single day I’m devastated and embarrassed that I stayed there. I’ve lost friends my job because I didn’t tell them in the correct amount of time when I needed to leave. And to top it all off a week after the third surgery I felt some weird pain in my mouth and they kept saying I was nothing it’s normal your healing but that wasn’t normal that hadn’t happened ever I figured out it was nerve pain but they said I’m paranoid that doesn’t exist but then six months later when they uncovered the implants the assistant said you’re going to have to deal with that for the rest of your life and I said what the nerve pain and she said yeah I said why didn’t you tell me that earlier she said what it has made a difference and I said most definitely would have. You can tell that one implant is angled weird toward the front cheek instead of toward the other implant in order to miss the nerve. It could have also been the excessive amount of needles I don’t know but it bothers me everyday and I can’t get it off my mind and this is more depressing than when I first lost my teeth. If there’s anything you can do to help me I would be forever in your debt.I’m willing to come all the way from Massachusetts to California to see the best because what I have may not be the worst but it’s almost there at least implants fail I will have nothing and they aren’t even full size implants I’ve made such a mistake. Or if you can refer me to someone out here that would be just as helpful I appreciate it I don’t know who to go to I don’t trust anybody but I seen your videos and everything that you say makes sense nothing xxx dental has said has ever made sense besides their original lies that he will come on his days off this that but he took months off at a time causing delays on surgeries. I’m sorry I type such a long message and I didn’t email you I hope the whole message doesn’t take up all the room on your blog. Thank you very much before your time I know you’re probably one of the busiest surgeons in the country.if not the busiest due to this blog and your YouTube videos the heck was that Spider-Man dropping

    1. Sorry this is Kevin again I didn’t mention what the question was which is exactly what he did in the original post I’m wondering if that can be done on the backside of my right implant to thicken the bone because I had some weird infection right after the third set of implants were taken out the back right implant turned all white on one side of it and I looked it up and I thought it was something called leukoplakia with they said doesn’t exist I’m tired and I don’t look at the internet but exactly what I said happened it said it can either become cancerous or it can go away and take some bone with it and that’s exactly what happened he didn’t want to do any type of therapy to save it but implant didn’t fail even though they don’t use 3D technology here so you cannot see the backside of the implant and you really can’t tell from the panoramic because it was blurry I feel like I’ve had the worst luck ever I mean obviously I didn’t make a great decision by staying there but they had all my money held up I couldn’t.once again I apologize I’m not great at making short statements about something that happened over 4 years with three different surgeries four if you include taking the teeth out. Thank you doctor I mean I appreciate your help very much because before all this and in between they kept saying my gums are healthy big but everything I’ve seen my I have a very small gums there tiny now I mean they didn’t even use full size implants. I’m only 32. Sorry, I didn’t mean to sound like I’m complaining it’s just been a long and arduous and I want to get back to work and my dentist still will not make my teeth until the 26th every month I come in and tells me one more month like it doesn’t take three months after you uncover the implants does it.. I’m sorry if I took up more room I apologize

      1. first off thank you for your very kind words and sorry for your troubles. I am guessing you are seeing some sort of corporate dental office rather than a private office?

        That being said sometimes these clinics can be a revolving door where there really isn’t one person that cares as much as they should since is owned by a corporation. If you’re only 32 years old and having this much problem I’m guessing that you smoke… But that is just an assumption.

        In general going slow is better than going fast. In general not wearing a denture during the healing is the best option or to have immediate bridges placed on to the full arch. It sounds like you have a full lower set of missing teeth. I would go ahead and have the leukoplakia biopsied.

        You probably just want to leave the practice and be taken over by somebody else. Unfortunately you fall into the redo/revision category most likely. You may need some tissue grafting from your palate to thicken up your gums. Dental implants are not permanent unfortunately but they sure can last a very very long time.

        I would suggest you find somebody in your area that practices to a higher level of care, compassion and integrity

  4. Hi, I had an implant on tooth #9 6onths ago. My dentist referred me to a specialist to extract and redue my implant. My gum looks thin and I can see the implant slightly and it’s grey through the gun. There was bone graft that didn’t heal properly when done. Is a replacement necessary or can I just have a bone graft and gum graft done? Thank you in advance.

      1. Yes of course. So, when my implant was done along my bone graft. There was a white substance that didn’t heal right and I was told by the general dentist that if have to remove my implant and do it again. I recently went to see a specialist and was told I could get an angled abutment which I hope that’s an option since my gum line is unnoticeable and the implant is angeled going towards my lip. My question is is it perfectly safe and will it last forever to have a custom abutement and crown or do I need to redue my implant and/or have gum or bone graft?

  5. 3 1/2 yrs ago I got an implant on #4. I have been in torture ever since. The Dr also did a sinus lift at the same time. Ex-rays (from another dentist) show the sinus is entangled with the implant/bone graft. My question is, is it possible to remove the bone graft, without removing the implant?

    1. It is very common for an implant to engage the sinus floor… On purpose. Unless the graft did not consolidate and become part of your bone, it is really impossible to remove just the graft and leave the implant behind. The bone would have to be loose, non-integrated, inflamed and possibly infected for it to be causing you pain… But of course I have never seen him before. I hope this helps you answer your question.

  6. My daughter lost her front tooth when she was 9. She was told to wait until 18 when her facial bones quit growing. At 19 she had the first implant try — which failed. Last summer she had a bone graft and the implant failed for the second time this week when she had her final procedure. She was told still not enough bone. Are there any new procedures or is she doomed to wear a cemented tooth and flipper?

  7. I understand that it is possible for bone grafts to dissolve if you don’t have your implant placed within a certain amount of time (say within a year or two after the bone graft). Is this true? It has been a year and ten months since I had my bone graft and it feels like I have lost some of the bone that my doctor grafted.

  8. Hello
    Excuse me to ask you this question but I’m really confused
    I had a dental implant in the upper bone jaw, the implant apex penetrating into the sinus about 2-3 mm
    Is it okay ?
    This is my dental x ray

    Also it looks a way too close to the nearest actual tooth but i heard if it is close only 1mm, it will be fine
    What do you think ?
    Is there anything wrong with me dental ?
    I read a lot of your articles and answers and i trust your opinion.
    Thank you.

  9. my question is i have 2 implants in my loser jaw.2 weeks later(in a shelter during hurricane katrina) both crowws fell out.went back to the same dentist and was told because of my bite i stripped the crowns,i do not believe this as he charged me 500.00 extra dollars to gluue the crowns back on.needless to say 1 came off again and some how was lost. when i went to have my teeth cleaned the xrays were showing bone loss around the implants. this has been about 3 years ago. if i have to have implants removed what does this usually cost(i know u cant give an exact estimate but somewhere around it)had to go to er 4 days ago for severe pain and swelling .i am hoping u can answer this ?.thanks and god bless.peace jacqueline mutz

    1. Ugh. What a mess. The lower back teeth maybe more costly to remove the implants if they are close to the main nerve and have to be drilled out. If they are loose they can easily and cheaply be reversed out.

  10. Hi Dr. Amin,

    Thank you for writing great articles. I just had two wisdom tooth extraction – tooth #1 and 32. Number 32 doesn’t have a tooth next to it.

    I just want to know if bone graft is required for both teeth. My dentist did bone graft for both but I wasn’t told about it until during the procedure. I am now wondering why bone graft was done when I don’t have any plans to have an implant to replace my wisdom teeth. I wish I had seen your website first.

    1. Not necessary in 99.9% of cases. I don’t know what the rational would be unless you had distal bone loss on your second molars. Even then it is not needed really. Sorry.

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About Ramsey Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.