Topic

[Surgery]  Implant Failed after placement: Suggestions?


We received the following inquiry:

 

Hi,

So I placed 2 implants on a male patient aged 49, one at #26, the other was an immediate placement of tapered groovy npx13mm, following extraction at #22. This was nov. 19. 

 

On nov 22, he had swelling and some discomfort, I prescribed clavulin. 

 

On dec 26, I removed the implant, which had come completely unattached.  Buccal and lingual bone seem solid to palpation. We are going to try again, how long should we wait? does he need bone graft first? any other info you can give me?

 
Thanks.

________________________

 


by Bernard Jin at Fri, Jan 14, 2011 5:14 AM

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Bernard Jin Replied at Fri, Jan 14, 2011 3:12 PM

3 months can be substantial - leading to significant bone loss if the infection is significant. But if the infection was small...and no longer present, then it should be ok. Bernard Jin



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Bernard Jin Replied at Fri, Jan 14, 2011 3:10 PM

By simply removing the implant and placing the patient on antibiotics, you would typically address the infection once and for all. However, if the source of the infection is indeed coming the adjacent dentition, then the implant removal alone wouldn't be enough. You may need to flap the site and debride/treat the adjacent teeth/gingiva accordingly. Personally, if you have question about the amount of bone present, I would recommend a CT scan localized to that site. If the scan shows a significant defect, then I would graft the site. 'Just my thoughts' Bernard Jin



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Bernard Jin Replied at Fri, Jan 14, 2011 3:05 PM

All depends on how bad the infection was. Only way to determine availability of remaining bone would be ct scan. Or you can fund out by doing bone sounding with endo plugs. - mark



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Bernard Jin Replied at Fri, Jan 14, 2011 3:04 PM

Response by Doctor: I did flapless, to preserve soft tissue. Patient had an infection, about 5 days after surgery, quite swollen for a couple of weeks. Implant seemed solid and painless at the time. Do you think I should go in and place graft, or would it be best to wait so we do only one surgery? how much bone loss could occur in 3 months?



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Bernard Jin Replied at Fri, Jan 14, 2011 3:02 PM

Also other possibly may be due to unwanted Lateral or forward excursive movement adding stress to temporary crown. I Also see that you've used metal housing for temp crown. I normally use plastic housing it puts less stress on the fixture in case of overload. Just my two cents, - Mark



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Bernard Jin Replied at Fri, Jan 14, 2011 3:01 PM

Any possibility of retrograde infection from 21 or 23? Was the procedure done flap or flapless? PA looked good. Was failure due to infection? Anyways, you should wait few months for good healing (at least two months) Take CT scan if you have access to it. If you do need grafting , either particulate or block grafting will work. Please rule out any possible infection from adjacent teeth ? Remember ! Sometimes teeth are the problem. Hope this helps. - Mark



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Bernard Jin Replied at Fri, Jan 14, 2011 5:19 AM

Thanks for your inquiry: After removal of the implant, you mentioned that you noted there to be adequate bone in the buccal and lingual plates for site 2.2. Out of curiosity: Were you able to confirm the bone integrity from within the implant osteotomy site or was the assessment performed from the outside (epithelium). If you sounded the bone from within the osteotomy site (and indeed the buccal & palatal walls are intact), then you should have adequate bone in 6 months. Of course, if you performed a "ridge preservation" graft after the removal of the implant, then you will most likely get a good dimension of bone (both laterally A-Pwise, and vertically) when you revisit the site. Even if you didn't perform the graft and the plates are intact, you should still get a good ridge. If you estimated/sounded the bone from the epithelium (outter) side, then there's always the possibility that the soft tissue could be misleading. The soft tissue, especially if the thickness & gingival attachment is thick enough, could easily mislead a clinician to think that there's enough bone and that the bone is intact. There are 2 sure ways to find out the bone integrity/amounts. The first is obviously to lay a flap and observe what is actually present. The second is to have the patient return for another CT scan. Secondary to the loss of the implant in the 2.2 site: my thoughts on the possible factors. Looking at the original photo - I anticipate that infection may be present at the apex of the root tip. Sometimes debridement can be tricky. If inadequate debridement is performed, recurrent bacteria could lead to the failure of the implant. More than likely, I suspect that the implant failure may be attributed to traumatic occlusion of the implant itself - or at least, it's a possibility. When I observe the photograph (pre-op) and the radiograph of the periapical (with immediate temporization), I suspect the patient has very little clearance especially when her performs lateral excursions. It's very possible that his parafunctional habits may have contributed significantly to the failure of the implant - with lateral luxation of the implant nocturnally. This can be significant. I compare this with the success of the implant placed in the 2.6 site - which is successful - (I anticipate) largely because it is not loaded occlusally. Lastly, timing could be of significance - after an implant is placed, osseous remodelling will occur immediately. By that, the torque you would have when you placed the implant initially actually drops from day 2 onward; it will stay 'low' and very slowly 'climb' up again. It isn't until about week 12+ before you would get the same amount of torque 'resistance' that you originally acquired when you 1st placed the implant. From Nov 19th, to Dec 26th (~5 weeks), the remodelling process around the implant places the implant in a compromised position - allowing for easier removal or luxation. My suggestion - if you are unsure, may I suggest a CT scan to evaluate the bone in three dimensions. That way, you can determine if you need to graft the ridge. If you are absolutely sure the plates are intact, then all you need to do is wait about 6 months. If you are familiar with PRF (Platelet Rich Fibrin), you could reduce the wait time to 3-4 months. Hope that helps! Keep us posted with the progress and feel free to send more questions. I'm sure many other doctors are probably experiencing the same issues and would benefit from seeing how you're handling the case. Bernard Jin