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Q A middle aged patient presented with an edentulous maxilla and almost complete mandibular. He suffers badly from bruxism and gags easily. I am worried about using implants for an over-denture due to his bruxing. I thought about custom abutments but then cost may become a factor. What would you recommend?

A Have you considered a denture supported and held by implants commonly known as an over-denture. The advantage of this is that it’s not permanent and therefore can be disconnected at night avoiding any damage. The patient can also wear a soft night-guard over the lower arch if they begin to experience trauma to the anterior upper arch.

Q I was interested if there has been any research carried out for implants in younger patients or if anyone has first hand experience they could share with me?

A. X-rays of particular ossification centers within the carpal bones is now insufficient to represent solid evidence of bone age and development. In 1994 Kikich proposed that facial growth was not always represented correctly by the results of a carpal bone study. It is believed finished when alterations on a cephalogram have ceased during a year of one another.


The upper and lower arch have separate growth centers and growth courses. It relies on the amount of full growth in these separate sections that must be evaluated along with the point in time the treatment is carried out as growth will be finished at separate periods. You need to work out precisely when formation in these sections has finalized to arrange the appropriate timing of treatment.

You may notice in a lot of oligodontic or anodontic patients it is recommended to insert implants previous to growth finalizing. By inserting the implants pervious to growth completion you are allowing for the best chance of anchorage for orthodontic treatment. When it comes to situations like these it is typical to anticipate malpostition of the implant. However the advantages more than allow for the potential complications. In situations such as this once growth is finished, malaligned implant bearing bone sections are moveable to the suited placement area via intraoral, extraosseous, multidimensional distractor as suggested by Watzek et al.

Q I had a patient recently who required 3 implants but also needed a sinus lift and bone graft. The first few weeks of recovery were without complications however on review the patient suffered swelling in the cheek and intraorally showed further swelling around the lateral window. I prescribed Augmentin and Metronidazole and will see the patient after this course to see the effect. Are these antibiotics suitable? If nothing changes should I get rid off the graft and leave this section to settle before redoing the surgery?

A. This demonstrates typical indications of a bone graft infection. I would advise prescribing a broad spectrum antibiotic for an extended period of time, possibly around 2 weeks. Keep in mind the bone graft doesn’t have a blood supply so whatever you perscirbe will have to be able to diffuse through the graft. I would recommend Co-Anoxiclav (Augmentin) 625ms tds for a fortnight, I myself wouldn’t feel the need for Metronidazole however this completely covers all aspects. Treating this infection rapidly with a prolonged course of these antibiotics should entirely resolve roughly 65% of the bone graft infection. For the remaing infection you need to clean out the bone graft and the implants involved.

Q A couple of months ago I had a case with 4 x 10mm implants located at A B D and E on the anterior mandible. At location D and E there are 4 to 5 threads showing and 2 threads at A and B. However none of them display any movement. How should I continue with this?

A. You first move is to work out why these implants are unsuccessful otherwise you will not learn from this complex situation. You need to ask yourself questions like was there sufficient bone bucally? Did you perform surgery using a flap? Are the implants extremely close to each other? Is there a flipper on these implants? Are the covered with healing abutments? Is there any variable factor from the patient ie. Medical history? You need to uncover the implants to establish the sort of defect surrounding the fixture. The more surrounding walls the higher the possibility of bone producing cells and vasculature to penetrate your bone graft, therefore the higher the potential of restoring the bone. Also try detoxifying and disinfecting the area using a waterlase or a comparable laser rather than chemicals alone.

Q Just over a week ago I removed a failed implant. I debrided the region and the area shows no signs of infection and appears healthy. There is no presence of abscess formation. What is the recommended healing period prior to replacing this fixture? Is it improper to retry instantly Or would it be wise to hold off until the bone restoration is complete? Also are there particular measures I should think about before reattempting this surgery?

A. There are a few questions you need to ask yourself to determine the reason for this failure allowing you to compensate for this and avoid the same result on your second attempt. I’m under the impression you didn’t require a bone graft, if the bone level in your patient has been affected by this failure a bone graft will most likely now be required to sustain the ridge, if this is applicable to your patient The quicker you apply the graft the sooner it will heal therefore allowing you to repeat the procedure in less time. The implications of instantly replacing the implants are infection and failure to provide solid stability. In my opinion it would be best to allow soft tissue closure which will take 4 to 6 weeks before attempting anything. Then place a bone graft if required and attempt to place the implant 4 months after that. If there is anything you are not 100% on read up on it and make sure you are completely confident.

Q I referred a patient to my periodontist who removed the tooth and instantly fitted the implant, the patient then came to me later that day and I loaded a temporary crown. The patient had several appointments with me in which I removed the crown and placed flow composite to correct the soft tissue. At the most recent appointment I took a PA revealing there was 5mm of bone loss distally of the implant. The periodontist informed me that a bone graft was required. The surgery took place 8 weeks ago, will the bone reform distally in time? Is it best to send the patient to the periodontist? Should I explain all this to the patient?

A. To place a temporary crown instantly onto an implant is highly dependant on how secure the implant is in the bone, it should be a minimum of 40 Ncm. This should be loaded no longer than 7 days after the implant is placed, however the sooner the temporary is placed the more chance of success it will have. The temporary crown needs to be kept out of occlusion during excursive movements, and contact must be extremely gentle and light in centric. I wouldn’t advise removing or disturbing the temporary crown for up to 12 weeks after it is placed. The fact that bone has disintegrated distally could represent a whole range of complications, definitely refer the patient to the periodontist as they have more experience in this area.