Dental Implant Becomes Mobile after removing temp crown: options?
I installed an implant in #19 site [mandibular right first molar; 36] and left it for 3 monts for complete osseointegration to occur. No pathosis was visible clinically or radiographically. The implant appeared to be completely osseointegrated. I then inserted the abutment and a temporary crown. When I removed the temporary crown using crown remover foreceps, the implant became mobile. I detorqued the abutment and placed a cover screw over the implant. What should I do now? How long should I wait before I remove the cover screw and torque down the abutment and replace the temporary crown? Does this implant need more time to osseointegrate? Is there a way for me to test the success of the osteointegration?
(click to enlarge)
17 Comments on Dental Implant Becomes Mobile after removing temp crown: options?
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Richard Hughes, DDS, FAAI
2/10/2013
You can remove the cover screw and tighten the implant and replace the cover screw. You can remove said implant, clean the osteotomy, graft and give it tincture of time or remove, curette the osteotomy and go up in size and place a wider implant.
I am cureous as to the occlusion, clinical history of the area, medications and systemic health.
Pynadath George
2/10/2013
Id agree with Richard. You can remove, clean osteotomy and place wider or longer if possible. Or clean osteotomy and graft then place. You could try to retorque the implant, not sure how successful it will be.
On another note. What's the plan for the poor/ failing bridges?
Khamis
2/10/2013
Richard yeah, Actually i removed the abutment and screwed the implant till it reestablished its original stability and returned the cover screw.
patient was asymptomatic after this choice and i am waiting for 6 weeks osseointegration before i start loading the implant.
i was certain that if i keep the abutment the implant will fail due to excessive force from oclussion and implant mobility, so i went to this choice and i hope it will succeed.
patient is healthy and bone is sound without any pathogenesis.implant was successful but excessive force from crown remover made it mobile.
I hope i wont need to replace new implant and i hope the implant will re-osteintegrate
CRS
2/11/2013
Did you push the implant deeper? Near the nerve? Below the crest? If so I would do the right thing, remove, let heal and replace, it will be a hygiene issue. Also if a crown remover with hand pressure ( torque?) was enough to loosen the implant it probably wasn't fully integrated. Three months is on the low side for healing, 4-6 is a good rule of thumb depending on bone density at placement. Another thing that can happen is too much early force on the implant can necrose the bone. Now you are playing catch up. Replace the windshield wipers!
Sb oms
2/10/2013
How did you untorque abutment screw on a mobile implant?
Didn't the implant rotate when you tried to loosen the screw?
I'm confused. Are you sure the implant was mobile and not your abutment?
CRS
2/10/2013
Are you sure it is the implant that is loose? The implant would have come out with the abutment. if it was not integrated. I have heard of tightening down an implant to recut the threads and waiting 12weeks for osteointegration but we are talking maybe a couple of turns.. Is that a current panorex with the distal implant below the crest with the implant 1mm from the canal? If that is the case did the implant travel deeper? If so I'd assume it is not integrated, very deep, and not integrated. I'd take the opportunity to remove it, graft and replace it at the crestal height. Dr Hughes is absolutely correct on the occlusion and clinical health issue. Did this implant go deeper in soft bone?
Sb oms
2/10/2013
Upper left molar is in trouble. Big lesion, possible perio-endo at this point. I know that's not what you posted this case for, but if your trying to have implant success in the left posterior mandible - look around. You have a nice panoramic x-ray machine- use it. If you finally get an integrated fixture in the left posterior mandible only to lose the upper left distal abutment- your going to look like a fool.
To quote one of my mentors- " dont put brand new windshield wipers on a busted windshield."
grw
2/12/2013
good point re. the molar, but it appears like the premolar may also have decay?
Dr. Amit Gaba
2/10/2013
Dear
Remove the abutment, place a cover screw and wait for minimum of 4 weeks. without putting any load and reassess the status of mobility with the help reverse torque measurement using a torque wrench.(if it is more than 25 you can load it) Put patient on vit d and calcium suppliment . Ihope this will work for you.
best of luck
john townend
2/12/2013
I agree with Sb oms - the upper left bridge looks very dodgy. Not only is the molar non-vital but there is recurrent caries under the second premolar crown. The crown and bridge work on the right doesn't look too special either.
I suggest it is not a good idea to embark on implant treatment until the restorative work which is already there has been brought up to an optimal level - any more than you would consider implants in the presence of periodontal pathology. It leaves you very vulnerable if the patient decides to go off to a lawyer.
I would say the analogy of putting new wipers on a busted windscreen is not entirely apt. This is more like putting new windscreen wipers on a clapped out rust bucket which needs to be traded in for a new motor!
CRS
2/13/2013
Just a thought, perhaps using the failing bridge as a posterior stop is an option. First place and restore the lower implants, then work on replacing and restoring the failing bridge with implants. Another option is replacing both areas simultaneously with implants requiring a good wax up and proper prostodontic planning. Some patients like this staging allows more time for them to adjust to the new occlusion and helps their budget. Another option would be to keep them in provisionals while both arches are integrating. I like to give the patient an overview without overwhelming them that way there are fewer surprises. I tell them when remodeling the house one needs a good blueprint but you may not want to rip out all the bathrooms at once. The treating doctor just needs to swallow his pride, replace the posterior implant and move on. Three months was not enough time in this patient
Sousadds
2/12/2013
The best thing you can do is say to the patient that you are concerned about this fixture and in light of that, doing what is best for them is what you want. If the implant is mobile I would unscrew it, decorticate and be sure there is no soft tissue left in the osteotomy, graft and wait 8 -12 weeks and replace it. Your patient will appreciate your concern and your integrity.
Dr. Bill Woods
2/12/2013
Remove the implant and replace it. What is another 4-6 months or more if you wait for osseointegration? 3 months isn't enough time in my view. I just had an abutment turn on me when I torquing it. Slight movement . Pain was strictly confined to gingiva. So I think that it was not seated all the way. I cut it off, put another on one and impressed and no detectable movement when removing it from the mouth. But I am watching this one closely. May have to explant and regraft. If that's what it takes then that's what it takes. The patient understands. Basics are good to stick with. Hope that helps. Bill
CRS
2/13/2013
Well said.
gerald rudick
2/15/2013
Mandibular right first molar in Canada is #46.... we are speaking of #36.
Three months is not adequate time for "complete osseointegration" according to Dr. Branemark.
Removing a temporary crown on an implant should not be done with a forcep... a plastic instrument placed at the buccal margin will push it off....if temporary cement was used .........a C & B forcept could possibly rock the implant out of its socket...which is what occured here ......once desturbed, the chances of the implant retightening has about the same chance as beating the odds against the house in Las Vegas.
Dr. CWE
2/17/2013
One concept I would like you to consider is to use a screw retained temporary crown on custom contoured abutments with proper emergence profiles. Most healing abutments are round unlike the emergence profile we wish to have. If we customize the emergence profile, the new crown can then have better interproximal papilla pand appear as if the crown is extruding from the socket, thus an esthetic result.
Also, using the said temporary and custom abutment will prevent further trauma or possible chance of backing out the implant. Looks like this is possibly D2 bone. Allow 4-6 months for complete integration.
FCampos DDS,FICOI
4/14/2013
When placing an implant one of the goals is to get primary stability if the osteotomy was too wide, you can always go with a wider implant.If primary stability was not achieved then osteointegration would be less probably .Did you go for one stage or two stage aproach, just to ruled out early loading. At time of abutment placement how much torque did you got,did you notice any mobility . I think that should be all about predictability . I believe you are not going to get osteointegration by putting back the cover screw. If mobile you shouldn't have any problem unscrewing the implant ,good debridement bone graft a membrane and wait 3 months before going back and place another implant. Best of luck
