Did fibro-encapsulation occur? Next Steps?

This case involves a 56 year-old healthy male, non-smoker, 250lbs and bilaterally edentulous. 6 Nobel Active implants (#2-3-4 and13-14-15) were placed (#13 was immediate on extraction) in late February 2016 with a plan to do 2, 3-unit FPDs. Bone density for this patient was between 210-240HU and initial stability was between 35-45Ncm for all implants. I routinely prescribe 0.12% chlorhexidine, 7-10 days antibiotics and 2-3 days steroids post-surgery. I would’ve liked to have waited at least 4 months before loading but patient wanted teeth so provisionals were made after 3 months with light occlusion. Provisional bridges originally did not fit passively so I sectioned them, resplinted them with GC pattern resin and screwed down. Specific post-op instructions were given not to chew on the provisional.

After a few months (delayed final restoration due to switching to a new lab), patient returns with some splint material loosened, thus provisionals have been functioning as individual crowns. And like many patients, they forget instructions – my patient has been enjoying cornnuts! Patient reports tenderness when I unscrew provisionals on teeth #’s 13 and 15, while remaining implants are WNL. Tissue is inflamed, tender and bleeds on 13 and 15. Patient says they’re only tender when I screw/unscrew impression posts or provisionals, no other time. When impression posts and provisional are screwed on, I can just barely detect movement of the implants. I tested with Implantest (same as Periotest) and get variable readings, some of which say osseointegration has occurred. Is it my imagination? My thoughts are that heavy occlusion on the temps caused micromovement and some fibro-encapsulation to occur.

Out of >150 implants placed, I’ve only lost 1 due to non-integration. That implant had a similar clinical presentation and easily reverse-torqued out under finger pressure (around 15Ncm). Basically, I’m saying that I don’t have enough experience with non-integration. At the last appointment I placed healing abutments on the affected side. I plan to retest #13 and 15 and will attempt to reverse-torque to rule out non-integration. If the implant(s) don’t easily unscrew, what is the maximum torque should I try to reverse before I call it integrated and take the final impression? 40Ncm? 50Ncm?

Also, if I end up removing the implant(s) and debriding the socket(s), can I immediately place a new longer/wider implant or should I just graft and wait? I don’t expect any purulence and would rather immediately place than chance losing bone during grafting.

Thanks for reading.

10 Comments on Did fibro-encapsulation occur? Next Steps?

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William J. Starck, DDS

10/4/2016

Ahh, patients not following instructions - the bane of my existence! It's too bad, you did a really nice job with the placement. A few comments: -Are you sure those are NobelActives? Those don't look like any NobelActive I've ever placed. --There used to be something called regionally acceleratory phenomenon in bone, which might mean that the effects of the fibrous encapsulation might have caused to zone of remodeling to extend out farther from the implant than you expect. -which in turn might cause a wider implant that you place to have problems integrating. Safest bet is to take out the bad actors, graft and reinstall new fixtures in 4-6 months I once had a female patient that I placed and immediate #6 implant with an immediate temporary (out of occlusion of course, and instructions for soft diet) When she came back in a month later with a grossly mobile implant, I asked 'What have you been eating'? Her reply 'Carrots and celery sticks' Sheesh! Good luck, let us know what you decide to do

Gene Allen Herrera

10/4/2016

Thanks for the input. I checked and you're correct, for this case I used BioMax implants by BlueSkyBio. I use both BioMax and Nobel Active. I've already set the patient's expectations so that they know it may take a bit more time to get good results by grafting first. Also, I will read up more on regionally acceleratory phenomenon and it's effects on a wider zone of remodeling.

Ronald Wright

10/4/2016

It is possible to have partial integration. The loading and non-compliance of the patient could easily cause the implants to fail. I would check the implants with an Ostell and treat the implants based on the readings. If the implant is a failure, it is normal to remove and replace as long as you have primary stability and quality bone.

Alejandro Berg

10/4/2016

Hi, are you sure these are Nobel? DonÂ´t worry , this will happen more and more over time untill you get more, much, much more milleage... one gets cocky with some experience and implants have a way of returning you to "honesty". (I also still do struggle with patient compliance). Just remove the suspects by counter clockwise rotation( use a removal kit maybe the neobiotech that is nice, if needed, but i dont think you will need it), debride correctly and you have the chance to re install directly with longer implants and maybe also wider implants , seek bicortical fixation. Remember that primary stability based on torque is like the song, "feelings, nothing but feelings", go for the ostell if you want some real assurances. You should not have more complications now that your patient knows that he can really screw this up. best of luck

Gene Allen Herrera

10/4/2016

Dr. Starck's first post motivated me to check the patient's chart for accuracy and I've confirmed that these are BlueSkyBio BioMax implants, a Nobel Active "clone". Yes, as much as I appreciate how much faster and easier the surgical procedure has gotten, cases like this ( as much as I'd like to avoid them) help to keep me grounded and make me realize there's still a lot to learn. The Osstell is next on my wishlist.

Dr. Gerald Rudick

10/4/2016

If the presenter has placed 150 rootform implants and has had only one failure......I say this is remarkable, because in my 45 year experience, I find I get a failure rate of about 8% ........ which can then be managed and retreated and hopefully obtain success. When the pioneers of implantology introduced this type of dentistry, there was a strict protocol to respect the bone while drilling into it with plenty of irrigation, and leaving implant dormant and out of function for 4-6 months...... they did not rely on electronic gadgets to determine if integration had taken place....it was time and respect. Bear in mind as well, that when middle aged people present themselves to get dental implants because they are missing teeth, there is a history that may be unknown to us as to the reasons why they became edentulous...... previous periodontal lesions have a habit of leaving a few dormant granulomatous cells around that lay dormant in the edentulous stage, and then seem to wake up when the bone is traumatized and an implant is placed........ If an implant did not become well osseointegrated after a normal resting time, then it is best to remove it.........scrape the osteotomy, and leave if for a month or more, before returning with a larger implant....then the RAP will have a chance to work. I still have all the respect for the Branemarks and Linkows who gave us this wonderful dental specialty.....and allow nature to do its wonders and not allow our patients to push us into immediate or early loading, when there is a risk of overloading because of an excessively forceful occlusion, bruxing or, clenching.....regardless of what the electronic gadgets are telling us.

Gene Allen Herrera

10/4/2016

Thank you for your comments, Dr. Rudick! Yes, I suppose I've been fortunate so far that I've only had 1 implant fail to osseointegrate (not including this case). My mentor teases me that it means because I haven't placed enough implants. I have placed implants that've fully integrated and when it came time to restore, I wish I would've had the foresight to recognize could've been in a better position. Implants placed too far facial or tilted too mesial/distal. In this regard I've had less than ideal outcomes that had to be corrected with special abutments. I appreciate these cases for the learning opportunity they present. Ultimately, I know that over time my failure rate will come closer to industry standards.

Gene Allen Herrera

10/4/2016

As for the comments made thus far, it seems like a balanced recommendation of graft and wait versus remove, debride, and place longer/wider. Any and all recommendations based on your experience is welcome and appreciated! Thanks!

Albert Internoscia

10/6/2016

yes remove because these implants will fail under function. I fall in the remove and drill a slightly wider and deeper as long as you have adequate remaining bone. If not currette the sockets out as much as possible, get some bleeding and graft. Good luck and cross your fingers on #15.

Christopher Rooney, DDS A

10/12/2016

you can't do implant surgery with a full hygiene schedule