BioHorizon Implant causing constant dull ache 6 months after restoration?
I placed this BioHorizon 4.5×10.5mm internal tapered implant in the mandibular right first molar site a year ago. After 6 months, I restored this with a UCLA abutment and a cement retained crown. The occlusion was fine, but the patient started having soreness under the crown.
I showed her how to clean under it using superfloss and Te-pes. But she said she could not get this underneath the crown, so under local anesthesia I adjusted the crown undersurface and trimmed the crown so that superfloss and Te-pes could get underneath easily. From this she had delayed healing, but then after 2 weeks the gingiva healed. This seemed to make some difference.
Then the abutment screw became loose. I had trouble getting the crown off even though I had used TempBond. So eventually had to use a crown and bridge remover to tap the crown off. She keeps saying ever since using this force to get the crown off, the implant has hurt and when she placed her finger on the cortical plate of the implant there is pain and a constant ache from the area. She says she sometimes has to take analgesics for this.
I have taken the UCLA abutment off and got an Ostell reading of 80. There is no swelling, no purulence, no mobility of the implant. All the radiographs show good osseointegration. I left her in the healing cap, but after 2 weeks she says the pain is still there. Today I removed the cap and placed the cover screw back on to see if this help. My gut feeling as I am am writing this is that the implant has failed. But why are there no physical signs to indicate this? Has anyone had this and what do you recommend that I do?
29 Comments on BioHorizon Implant causing constant dull ache 6 months after restoration?
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Nigam
4/12/2016
Possible implant body fracture
CRS
4/12/2016
Question would a fracture in the implant body change the ostell reading? I don't think the implant can be anti rotated with that reading. If the third molar was the culprit I think the pain would be localized more distally. That said tap on the third molar I still would go with a buccal plate or implant fracture
Damir
4/12/2016
Check pulpitis of neiboring tooth!!
CRS
4/12/2016
Could you post a CBCT there could be a buccal plate fracture. If there is two things may happen, it will heal or the implant could get infected. What makes me a bit suspect is the abutment screw loosened which could point out an occlusal issue. Your history is good and could point to the diagnosis. There is a sign, pain. In hindsite a screw retained retrievable restoration would have been the way to go. I would not advise a crown remover since it puts a lot of force on a fixed implant which gets transmitted directly to the bone, no PDL. I would have cut the crown off. Now the patient will associate the crown removal with the start of her problem. I suspect that the occlusion was the problem originally since hygiene issues usually don't cause much pain. Adjusting the occlusion or remaking the cantilevered crown vs grinding on the underside may have been a better choice. Please note this is 20:20 hindsite and not a criticism but trying to assess what happened and giving some pointers. Good Luck.
Dr.Ahmed Tarek
4/12/2016
Hello, CBCT will help for sure, mostly u have buccal plate defect...
i suggest anti rotation of the implant on 40 Ncm, this dull pain mostly the implant lost part of the ossteointgration ...You can never know
Dr. Gerald Rudick
4/12/2016
HOLD YOUR HORSES!!!!!!!!!
Check out the third molar as seen in the 2nd xray...there is a deep carious lesion into the pulp...this could be the source of the pain, and nothing to do with the implant.
FS DMD
4/12/2016
2nd molar restoration could use a little work, as there appears to be a fairly good size overhang, possibly even an open margin on the mesial as well. Both the 2nd and 3rd molar issues should be addressed before you condemn the implant.
Dr Dubover
4/12/2016
Totally agree with prior comment
Evaluate #31 and# 32
Nothing wrong with implant
Dr. Marc B. Hertz
4/12/2016
I agree with a number of the aforementioned recommendations. Tooth number 31 and 32 certainly have their own issues beyond a shadow of a doubt (pun intended) and need to be addressed. it does not seem like the implant is failing. A CBCT is a must to rule out/in buccal plate fracture which, in this case will in all likelihood heal over time if left with cover screw only over the next 2-3 months. If the patient remains assymptomatic , then you can restore after the healing period. I do recommend follow up visits with periapical xrays during the healing process to be certain that no radiolucencies develope.
Dr. Cary Shapoff
4/12/2016
I have placed many BioHorizons implants. The patient complication is unrelated to implant manufacturer- issue could occur with any implant, just happens to be BioHorizons. A number of issues come to mind
1. Did you take out tooth and graft site before implant placed
2. Implant fracture, if it occurred would be horizontal and bone change would be visible (I have never had a BioHorizons fracture)
3. Note cement on mesial of implant crown
4. note other issues mentioned by others
5. If implant placed close to buccal plate and post-graft remodeling caused horizontal resorption, could have implant body threads in contact with buccal tissue.
6. Patient appears to have very flat occlusion- is is likely a grinder- bruxism
7. I agree that a CBCT should be considered, keeping in mind that thin bone adjacent to metal implant may be hard to read on scan
8. In order to comment further, I would need to know more pre and intra-operative details
Just my opinions.
MP
4/12/2016
Implant looks quite ok ! By the way, this is not Tapered internal 4.5* 10.5 ! On X ray I recognize well-known silhouette off BioHorisons Tapered 4.6 * 10.5 implant.
Luca
4/13/2016
Do you used ucla with golod ring? or totally plastic? The crown is it with golod or NiCr? Maybe the problem is it.
Check another possibility.
Peter Fairbairn
4/13/2016
Yes this is simple eliminate the other tooth related issues first ..... if still has symptoms then move onto Implant assessment ...
Gian
4/19/2016
Hi, I still have used BioHorizons implants for years and I have had a similar case a year ago. In my case at uncovering I suggest I have possibly and inadvertently compromized the platform smoothness while working on the crestal bone that was partially covering the cap. After a period without the abutment and a good polishing, now the pt is complaing very little discomfort, not continuously, and no evident probing nor Xray signs of patology are present. Among the many suggestions, all of them correct, maybe also this one could be worth considering: inadvertent roghness-making of a manufactured item in a biological environment. Hope this can be helpful.
Paul McDonald
4/13/2016
If pain is the only thing to go on then a thorough pain history is vital (SOCRATES: site etc.)
Odds on it is the carious molar behind.
Dr KG
4/13/2016
There are excentric forces here due to implant position, hence the abutment loosening. Removal might have caused buccal plate fracture. For any case, I would put healing abutment for 2 months and then restore with a screw-retained crown with occlusal relief.
varsano clinic
4/13/2016
hi
treat first caries lesion at tooth 48
than check possible pulpitis at tooth 47 with the crown
for sure its not from the implant
good luck
please inform us after the problem is solved
mpedds
4/13/2016
This is not a criticism as I do not know the circumstances but I always recommend placing and restoring an implant in as healthy a situation as possible. This means total dentistry, ideal dentistry. In my practice I would advise the patient to take care of all other pathology first, at least in that quadrant. This means restore all caries, replace adjacent crowns if necessary to ideal contacts and contours, treat the perio. As was mentioned before we need a good foundation to build a house on. Now place your implant into a healthy situation with prosthetic driven implant placement; in this case in the center of the edentulous space to eliminate any cantilever effects of occlusal forces. Now if you have a problem in the future you have already ruled out a lot of potential causes. Sometimes a surgical guide is necessary even for single teeth that look like a slam dunk.
Justin
4/13/2016
From the outstanding history the treating dentist gave us I would hedge that he/she gave an honest attempt at total dentistry. I'm super critical of myself in terms of placement, but this seems acceptable at least to me. After re-reading your comments, I find myself nodding to everything you said. I just think it came off a little too critical the first time I read your comments...
Also, I see cement in only one of the radiographs. Maybe it was subsequently removed after it was noticed. +1 for occlusion, 3rd molar pathology, possible buccal plate fx, cbct eval, and perio concerns for evaluating this challenging case.
Good luck and keep us posted. Looking forward to finding out the source of the pain.
Jawdoc
4/13/2016
All signs point to the implant being ok. Unless a CT shows otherwise (are u taking one?) It's probably 1 (or more) of the neighbouring teeth (my guess would be the 3rd &/or 2nd molar). Btw, since uve removed the abutment & crown, as rightfully pointed out in earlier comments, refabricate a 1-piece (screw retained prosthesis -SRP) instead of the current 2-piece (screw & cement retained prosthesis - SCRP).
CRS
4/15/2016
Betcha it's the buccal plate fracture!
Jawdoc
4/16/2016
It may well have been. I do not disagree. That's why till further definitive evidence shows that ( i.e CT), all evidence so far, like I mentioned, 2-D X-rays - wise does not conclusively point to a buccal plate fracture :) & if it indeed is a buccal plate ( the strongest clinical symptom so far would be that of tenderness upon palpation of the spot), like u mentioned, it may also heal. & I even then, think it would cos the overlying soft tissues & periosteum would likely be intact & hence blood supply uncompromised. In fact, there's a staged split ridge technique by the Koreans (Cho et al) that has utilized this scenario for implant placement.
JS
4/16/2016
I would think a buccal plate fracture would be seen clinically, perhaps a fistula or severe localized inflammation. You could also take a plastic probe on the buccal and see if there is any pocketing. Otherwise, I second the notion of that 3rd molar being suspect.
CRS
4/17/2016
Post a cone beam it will also help diagnose the other teeth. Stop guessing.I am suspicious of the crown remover intervention, better to know in case the implant fails in the future. A fracture should heal if it is non displaced and reduced. The history is giving the diagnosis I would not jump in on the other teeth until this is diagnosed or resolved.
r.mirmooji
4/18/2016
If it is a greenstick fracture of the buccal plate ,when the load i relieved i.e. crown removed the pain should disappear.my suggestion before taking a ct is to put a healing cap on the implant and wait a good 4-6 weeks. if the pain is present during this time then look into neighbouring teeth, if not place a temporary crown on and see if the pain returns or not. if it does come back then a ct.
CRS
4/23/2016
Failure to diagnose, I'd take the CBCT to rule out the fracture. The clinical symptoms, pain swelling if there was ecchymosis and a hematoma in the first days are s/s of a fracture. All these suggestions skirt around the diagnosis. I treat a lot of fractures. That's how it's done. The film needed to be ordered immediately.
M.valifar
5/20/2016
I agree perhaps this pain is due to wisdom tooth
Dr.Aptekar
7/18/2016
Hello
I do agree to eliminate the other dental factors in play, such as the caries on the 3rd molar.
I have placed a ton of biohorizons implants, and i definitely dont think it has anything to do with the implant itself.
Another thing to look at, is if there are any pieces of the tooth left that was previously e. Is there a sliver of the tooth root still present. This is hard to assess via a peri-apical due to the 2D factor. I have seen situations where if a piece of the root is left and is in close proximity to the implant, even if the implant is fully integrated, the leftover tooth cause discomfort or soreness. Once again, as mentioned previously, a CBCT will help provide more information with respect to this, and all other possiblities as mentioned above.
zk
4/19/2017
Abutment shoulder possibly impinging on biologic width. Remove abutment and wait a week, see if it feels better.
