Failed Nobel Tapered Groovy Implant #30: Possible Causes?

10 days post placement possibly not the best time to reverse the Implant but also looks like possibly and area at the apex of the Implant ?? Peter

It must be the betadine!

10 days is too short to have deemed that osseointegration has failed. What u have is a 'spinner'. Next time, even if the implant is out of the osteotomy, hold the implant with a sterile forcep, remove the healing abutment, replace the implant back into the osteotomy, place a cover screw on the implant & close the site (primary closure) with sutures. Bury the implant. Wait & observe 6 mths. It Shld osseointegrate.

The healing abutment may have been receiving occlusal forces during eating, next time bury it.

The distal root of #30 had rarefaction and widening of periodontal ligament. if the RC treated tooth was infected some residual infection in the socket could trigger. Implant failure occurring within the first week is mostly due to infection. Also, in such cases, I usually prefer to bury the implant for 3 months and re evaluate. Additionally, I don't recommend a tapered groovy for this case.

I am with VNT. I don't think you overheated the bone but you sure killed it. I don't want to be harsh but who could be recommending soaking the osteotomy with betadine for one minute? This was a delayed implant and there should be no pathogens in the first place. Bone cells live in the most controlled environment in the body and have no tolerance for conditions outside a narrow physiologic range. I checked the pH of betadine and it is 3.7 which enough to kill bone cells if the chemicals don't. Greg Steiner Steiner Biotechnology

1) Bad luck or bad protoplasm 2) Let it heal 3) Avoid the Betadine...

I would agree with two comments that have been made here 1. betadine irrigation? not sure who recommended that but betadine is toxic to osteobalst cells and by using it as a final irrigation you most likely started an area with no viable cells adjacent to the implant. below is one article discussing the toxicity issue. 2. the healing abutment is too tall and the patient could have been inadvertently loading the implant IMHO the failure is due to a combination of these two factors. I would remove the implant currette the osteotomy out very aggressively to get bleeding and close the site. wait 4 weeks and place another implant that is wider and skip the betadine irrigation and place a low cover screw and let it heal J Orthop Trauma. 1995;9(4):303-11. Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts. Kaysinger KK1, Nicholson NC, Ramp WK, Kellam JF. Author information Abstract Irrigating wounds with solutions of antiseptic or antibiotic agents is routinely performed in orthopaedic surgery to reduce the incidence of microbial infection. The effects of these agents on healthy bone tissue is unknown. Three commonly employed antiseptic agents (hydrogen peroxide, Betadine solution, Betadine scrub) and one antibiotic solution (bacitracin) were tested on tibiae and osteoblasts isolated from embryonic chicks. Osteoblast function was evaluated by glycolytic energy metabolism (lactate production), cell number (DNA content), and collagen synthesis ([3H]proline hydroxylation). Two series of experiments were performed. To study concentration-related effects, tibiae or cells were exposed to a range of concentrations of the agents (diluted in saline, 0.9% NaCl) for 2 min, rinsed with saline, and incubated for 24 h in medium containing [3H]proline. For the recovery study, the cells were exposed to an effective, but nonlethal, concentration of the antiseptic agents for 2 min, rinsed with saline, and the incubation was continued in complete culture medium for 6, 12, 24, 48, or 72 h with [3H]proline added for the final 6 h. Solutions containing the antiseptic agents were cytotoxic to both bones and cells at concentrations well below those used clinically in irrigation solutions. In contrast, bacitracin at the concentrations tested was safe for osteoblasts and tibiae. These results suggest that the use of irrigation solutions containing H2O2, Betadine solution, or Betadine scrub on exposed bone tissue should be considered with caution.

Great article...thanks

I think there are a lot of good comments above. Agree with spinner. I personally had lower suggest with nobel and 3i Biomet I think ASTRA has the best results long-term - I have hundreds going on 20 years in function with no appreciable bone level change so consider switching systems. Also I noticed that you bone grafted and it still looks granular in PA. There could be any sort of microbes in there. Stick with cadaver and bovine in your socket grafts. I had a patient come in for 2nd opinion last week with complaints of chronic bad taste around grafts implants. The graft material didn't ever integrate so it's sand with microbes, not tissue

Did you perf sublingual?

Failed endo is, I believe, a very real problem. After the extraction, debridement is crucial. Total complete elimination of all bacteria is improbable. Many of these pathogens are capable of conversion to a vegetative form. They can remain vegetative for years, probably even decades. I don't think it was implant design, brand or irrigant. Although a bacteriocidal irrigant would be a help. Additionally, a large diameter implant displacement may be a physical barrier to remodeling. Dennis Flanagan DDS MSc

1. I have placed over a thousand noble implants and I must agree with one of the previous , I continue to have the worst results with Nobel fixtures 2. Betadine is a no no. We no longer use it as a post surgical rinse for any of our procedures due to its toxic effect on all immature cells 3. I would always bury a nobel implant not only to avoid occlusal forces but to avoid the even more destructive lateral forces of the tongue. 4. Looks like you perforated the lingual plate 5. do not us ANSAIDs. so many patients are on a maintenance dose of ANSAIDs and this can totally hinder integration. PS. It happens to all of us. Thanks for sharing

I'm conservative. Scrape the heck out of the socket post extraction. Graft with cadaver bone. Wait 4 months. I get pink bone. Implantation and bury for 4 months. Uncover for healing. Restore. I know it's " old fashioned" but I have very few failures. I don't push biology. But, I do incorporate clindamycin injectable into the graft. Just for safety. It's gone by implantation.

Hi Greg, I would use a bacteriocidal irrigant, yes, dilute sodium hypochlorite, 1:10 is still effective but will not damage tissue. Others may work too but there are no credible studies. Systemic bacteriocidal antibiotics are a good option as well. Dennis

I have placed many of the same implant and have an opinion to share. The Nobel Replace Tapered Groovy is a tissue-level implant and it seems you placed the 5x13 too far apically at bone-level. The threads should be buried in bone but at least a part of the neck has to be in soft tissue. The necks of the healing abutment is meant to contact soft tissue, not bone. I think you were in direct contact with bone on the distal, which might explain the discomfort. Had you left the implant in place, you could expect osseointegration with bone loss down to at least half of the neck of the implant or more. It still would have worked with a custom abutment, preferably with a custom healing abutment and matching impression coping placed at least two months later. Even if the discomfort was triggered by betadine, that alone would not cause loss of the implant internally. The main point to consider is that the implant was probably OK as it stood, but reverse-torque on ANY tapered implant at 10 days would probably cause it to be lost. If you like Nobel products, the Nobel Replace Conical Connection implants use the same instruments you already have (mostly), but are bone-level with platform shift in the larger sizes. One-stage, two-stage, immediate placement, immediate-load all work just fine.

I think it is a pure bad luck,because i have seen people using betadine successfully.The other factor may be the implant is not in center buccolingually,that means one of the (buccal or lingual )wall is not engaged?. Take cbct and check the implant position buccolingually.Third factor may be occlusal forces on the healing abutment.

For those apposing betadine irrigation can you post some lit references to support this as I can find none in favor of it but there are those that support not using it due to its cytotoxic effects on bone cells

I do not irrigate with anything other than sterile saline and have had no implant integration issues in 10 years. Handle the implant in a sterile fashion and do not let it touch the tongue or saliva and just get it into the socket ASAP. CHX is germicidal and cytotoxic......so I stopped irrigating with it many years ago when doing apicos with osseous grafting and having osseous graft failures. My periodontist at that time was very informative on this issue and a great help. I still feel most comfortable with systemic antibiotics after most oral surgery but those whom I received my training from did not Rx any for implant placement. Although I preform PROPEL and aware of NSAID issues that would make teeth LESS mobile for ortho, I have not personally seen any implant or osseous grafting issues using them. I am always open to change!

I was always taught to leave fresh blood products in the final osteotomy prior to placing the fixture. Thus providing an ideal fixture thread/osseous interface to initiate the vital 72 hours commencement of fibroblast genesis and angiogenesis . Certainly no extrinsic materials prior to placement. Perioperative Chlorhexidine mouthwashes ARE acceptable, but that is all.

Some more lit against betadine and its affects on osteoblasts Spine (Phila Pa 1976). 2015 Dec 3. [Epub ahead of print] Povidone-Iodine (PVI) has a Profound Effect on in vitro Osteoblast Proliferation and Metabolic Function and Inhibits Their Ability to Mineralise and form Bone. Newton Ede MP1, Philp AM, Philp A, Richardson SM, Mohammad S, Jones SW. Author information Abstract STUDY DESIGN: A study examining the clinical protocol of scoliosis wound irrigation, demonstrating Povidone-Iodine's (PVI) effect on human osteoblast cells. Primary and immortal cell line osteoblasts were treated with 0.35% PVI for 3 minutes, and analyzed for proliferation rate, oxidative capacity and mineralisation. OBJECTIVE: To model spinal wound irrigation with dilute PVI in vitro, in order to investigate the effect of PVI on osteoblast proliferation, metabolism and bone mineralisation. SUMMARY OF BACKGROUND DATA: Previously PVI irrigation has been proposed as a safe and effective practice to avoid bacterial growth following spinal surgery. However, recent evidence in multiple cell types suggests that PVI has a deleterious effect on cellular viability and cellular function. METHODS: Primary and immortalhuman osteoblast cells were exposed toeither PBS control or with 0.35% PVI for 3 min. Cellular proliferation was measured over the duration of 7 days by MTS assay. Oxygen consumption rate (OCR), extracellular acidification rate (ECAR) and proton production rate (PPR) were analysed using a Seahorse XFe24 Bioanalyzer. Protein expression of the electron transport chain subunits CII-SDHB, CIII-UQRCR2 and CV-ATP5A were measured via Western blotting. Mineralised bone nodules were stained with alizarin red. RESULTS: Expressed as a percentage of normal osteoblast proliferation, osteoblasts exposed to 0.35% PVI exhibited a significant 24% decrease in proliferation after 24 h. This was a sustained response, resulting in a 72% decline in cellular proliferation at 1 week. There was a significant reduction in OCR, ECAR, and PPR (p < 0.05), in osteoblasts that had been exposed to 0.35% PVI for 3 min, coupled with a marked reduction in the protein expression of CII-SDHB. Osteoblasts exposed to 0.35% PVI exhibited reduced bone nodule mineralisation compared to control PBS exposed osteoblasts (p < 0.01). CONCLUSION: PVI has a rapid and detrimental effect on human osteoblast cellular proliferation, metabolic function, and bone nodule mineralisation.

Open Dent J. 2009 Oct 16;3:208-12. doi: 10.2174/1874210600903010208. Effect of short-time povidone-iodine application on osteoblast proliferation and differentiation. Schmidlin PR1, Imfeld T, Sahrmann P, Tchouboukov A, Weber FE. Author information Abstract BACKGROUND AND OBJECTIVE: Povidone-iodine [polyvinylpyrrolidone-iodine complex (PVP-I)] is a broad-spectrum antimicrobial agent, frequently used in dentistry. In this study we investigated the short- and longterm effects on osteoblast number, viability, and function after short exposure to PVP-I with and without additional bone-morphogenetic protein-2 (BMP-2). MATERIAL AND METHODS: Confluent osteoblast-like cell line (MC3T3-E1, subclone 24) cultures were exposed to pure PVP-I solution (7.7 mg/ml) and dilutions of 1:10, 1:100 and 1:1000 for 10 seconds and washed with phosphate buffer solution. Cell proliferation and viability was determined by MTT and differentiation status by alkaline phosphatase (ALP) activity 6 days after initial plating. In a separate experiment, long-term cell proliferation, viability and function were assessed 4 weeks after PVP-I treatment by MTT and deposited calcium using an Alizarin-red staining test. RESULTS: PVP-I decreased ALP activity substantially. Stimulation by BMP-2 recovered ALP activity to near control levels at 1:100 and 1:1000 dilutions of PVP-I. The MTT assay showed reduced proliferation of the preosteoblastic cells for all treatments, irrespective whether BMP-2 was used or not. Only at PVP-I dilutions of 1:1000 proliferation rate was back to normal levels (95.6±2.4 %). No adverse long-term effect of PVP-I on mineralization of the extracellular matrix (Alizarinred) for dilutions higher than 1:100 was observed. Interestingly, undiluted and 1:10 diluted PVP-I even showed a significant increase in mineral deposition, especially in the presence of BMP-2. CONCLUSION: Short-time application of PVP-I in concentrations of 1:10 and higher lead to decreased viability and impaired differentiation. However, surviving cells showed good recovery and mineralization potential.

and on the negative effects using CHX as a irrigation in implant placement Clin Oral Investig. 2007 Jun;11(2):155-64. Epub 2007 Jan 11. In vitro comparison of chlorhexidine and povidone-iodine on the long-term proliferation and functional activity of human alveolar bone cells. Cabral CT1, Fernandes MH. Author information Abstract This work reports the behaviour of osteoblastic human alveolar bone cells (first subculture) in the presence of chlorhexidine (CHX) and povidone-iodine (PI). Short contact (2 min) of 24-h cultures with CHX, at 0.12 and 0.2%, and PI, at 5 and 10%, caused cell death within minutes; contact with 1% PI resulted in loss of the elongated characteristic cell shape. Cell adhesion was adversely affected at concentrations higher than 5 x 10(-5)% CHX or 0.05% PI. Long-term exposure to CHX at 10(-5) and 10(-4)% or PI at 10(-4)% had little effect on cell growth and caused an induction in the synthesis of alkaline phosphatase (ALP). Concentrations of CHX and PI similar and higher than, respectively, 5 x 10(-4)% or 0.05% caused dose-dependent deleterious effects. CHX affected mainly the cell growth, whereas the effects of PI were observed mostly in ALP production and matrix mineralization. Considering the levels of CHX and PI used routinely in the oral cavity, results suggest that CHX has a higher cytotoxicity profile than PI. This observation might have some clinical relevance regarding the potential utility of PI in the prevention of alveolar osteitis.

Gregori Thank you for the lit review. Greg Steiner Steiner Biotechnology

I think story over betadine osteocyte toxicity is not as important as the question: does betadine prevent blood clot attaching the implant surface? Does it spoil blood clot quality? Are osteoblasts first line cells coming to osteotomy enviroment? They are not, most certainly. Has anyone ever investigated if saline maybe rinses off some high quality growth factors out of osteotomy walls? Dental implant is another osteoconductive surfaced foreign body inside bone wound made by surgical trauma...

I did not mention the bone graft but this is another significant potential problem. Take a look at the other current thread on site -Protocol when bone is very dense after grafting? Greg Steiner Steiner Biotechnology

The last picture shows that the implant is surrounded mostly by the grafting material. So, 10 days is not enough for rebuilding the tissues to fix the implant.

The other possibility is that your drill bits were dull and you consequently overheated the bone when drilling.

Actually you chose the wrong time to disturb the implant.It is weakest between 8th day till 20th.