Implant Does Not Osseointegrate: What was the problem in this case?
I treatment planned this case for 2 implants to be placed 8 weeks after extraction of #4, 5 [maxillary right first and second premolars]. After extracting #4, 5 I thoroughly debrided the extractions sockets.  I then drilled the osteotomy sites and installed 2 Osstem implants — a 3.5×10 and a 3.5×11.  At the time it was somewhat difficult to achieve good anesthesia for the #5  site and because of that I was unable to torque the implant to  35Ncm and I did not achieve good primary stability.  The post-op period went uneventfully but at  2 weeks you could see the cover screws; she was wearing a flipper (not relined with soft liner but relieved for pressure).  After waiting 4 months you can see on the radiograph, a radiolucent area around implant #5, especially on the mesial. At the 2nd surgery I torqued down the implant  35Ncm.  This went well and there was no mobility, no suppuration, no symptoms but I still decided to remove it, which I did with reverse torque. Could the implant diameter have been a problem in this case? should I have placed a 4.0/4.5 instead? How can you be sure the periapical pathology has resolved before placing the fixture? Helpful comments and suggestions are very welcome.
27 Comments on Implant Does Not Osseointegrate: What was the problem in this case?
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Dr. Juneja
5/21/2012
Dear Dr.
Lack of primary stability during the implant placement is the primary cause.
Did you use a graft to fill up the gap between the implant and the socket wall?
flipper was a total NO in this case.
At 4 months there must have been a lot of granulation tissue around the implant as it dint fix in the bone. Now even if you torque this implant and get primary stability the granulation tissue should have been removed.
I also believe that you should have used a little longer implants to achieve the primary stability from the apical bone.
A proper curettage of the periapical pathology and irrigation with saline would have helped you to achieve a clean socket.
Now that you have removed the implant. I hope you grafted the site in order to get good bone after 4-5 months.
Take care
Leal
5/21/2012
Not STRITCLY necessary to graft. If you reopen 1,5months later and dril with the 1,5mm wide initial bur and use osteotome 2,5mm wide into sinus floor (or 2mm wide if type IV bone) to full length, 3mm wide to half length insert two "4.0" USIII Osstem implant: the distal with the sinus floor cortical plate will have a nice stability (4 X 13mm). The mesial one go on and insert a 4 X 15mm. These are premolars. Why would you insert anything less then the 4.1 Branemark?
Good luck
Dr. Alex Zavyalov
5/21/2012
Initially, the implant diameter was too narrow in the neck area #5 (fibrous tissue surrounds fixture), and stability was reached in apex only. Definitely wider implant is needed to fit the neck socket zone.
Dr. Pedro Rodrigues
5/22/2012
Dear Dr.
What was the initial buco-palatal width of the extraction sockets?
What temperature was the solution you used to refrigerate?
What was the previous usage of the drills you used?
How much time did you insert each drill?
How was the socket bleeding after curetage?
Poorly curetted extraction sockets, along with with burr overheating and overdrilling, thin vestibular/palatal walls could be considered. Furthermore, a gap larger than 1,5mm should be filled before or at implant plcement surgery. I must agree that certain stages of fibrousintegration can be clinically resistant to torque tests and I can totally relate toy your surprise when remving the implant. Still, I'd checklist everything from day one to now. Kinde regards
Jaime Ramos
5/22/2012
Use the sinus cortical plate for anchorage and a fixed temporary bridge instead of flippers . You can go in 1 - 2 mm into the sinus if needed . Tried the co-axis in this situation . You have at least 15 - 18mm length on the 14 . Should also have submerged the implants and used GBR if needed . Book by Garg .
Dr. Juneja
5/22/2012
Can you put some light n how to fabricate a fixed temporary bridge. If you can quote some references with pictures that would be of great help. Thank you.
Dr. Pedro Rodrigues
5/22/2012
I'd just like to add that osteointegration is not an objective bu a means to an end. You should plan you fixed rehabiitation and only then you should manipulate everything surgicaly speaking to get osteointegration. Implant position does note depend on bone availability but intead of future crown location.
Dr. Pedro Rodrigues
5/22/2012
still getting used to ipad sorry for the misspelling
azizatarmissi
5/22/2012
i suggest you to but an abutment as you said it is not mobile and see if the micromotion which is less than 30N well be any change in periapical lesion and you can deprided the granulation tissue and augment and or remove it and wait 2 month to but large implant but your problem in my point of view in propre implant bed prepration.
Gregori M. Kurtzman, DDS,
5/22/2012
IMHO the diameter of these implants is too narrow for the space present and use of a wider fixture (4.0-4.5) would have given primary stability plus eliminated the gap present on #4. I also think you could have gone longer on 4
DrT
5/22/2012
I agree with all of the above. I would add-- since I like to think that even though we are talking about implants on this site, that we are still first and foremost thorough diagnosticians--that placing any implants in this area was ill advised given the apical pathology on the first molar. When I see cases like this, I am often wondering if the implant treatment isn't being primarily pushed by considerations of financial gain. It would be nice if you were at least treatment planning for a quadrant, if not for the entire mouth. The whole discussion of implant diameters, primary stability etc seems to be totally mis-directed.
Dr. Alan Helig
5/22/2012
I attended a lecture a couple weeks ago given by Dr. Tarnow and he showed a case he did where he got good primary stability but had a large gap between implant and bone. He did not graft it nor did he close the the tissue over the implant. He said all that was necessry was that the gap had a good blood clot. He said the clot is the epithelial barrier and that bone will fill in.
Leal
5/23/2012
Thank you
George Felt, DDS, Perio,
5/22/2012
Because you waited 8 wks your healing socket was not really bone, it was osteoid and when you put a too-small implant into osteoid without excellent insertion torque (good grab on bone apical to orginal socket)and then load it (accidentally or not) you have a prescription for healing by fibrosseous encapsulation. Why is this a surpise to anyone? Suggestions: 1) Don't sweat it. You did the right thing by removing the implant. Let the socket heal for another 3 months wearing flipper. Put in another implant (try to go 4.5-4.7mm diameter), and get it a little (say 2mm) more apical for better bite on apical bone and less risk of stress at crest). Then finish the case. No big deal. Have fun! BTW what's up with the comment on the PAP at the molar - you have to be kidding, and on top of an irrelevant diagnostic issue you suggest tx planning for financial gain? Try taking some SSRIs and getting counseling.
Baker vinci
5/22/2012
You do understand how a low ph disallows your local anesthetic from being completely efficacious?? Not sure why you would not make sure the implant was completely seated, or why you would think 3.5 mm is enough implant for posterior occlusion. If you had placed an implant closer to the diameter or slightly greater than the diameter of the tooth of teeth you were replacing, you would have gotten more than enough "primary stability". Bv
Dr SenGupta
5/22/2012
Almost every principle of immediate placement was omitted.
You need socket obliteration for at the very least the apical third
Around 3mm beyond apex of the tooth.
It is very clear that 3.5 diameter implants are too narrow ...they usually are for extraction immediate placement .
Primary stability is a pre requisite.
I doubt that these implants will make it .
Dr G. Subraya Bhat
5/23/2012
it looks like that , implant selection diameter was smaller than the the socket was the reason for the failure morever apical integration is not seen. that probably added the addition effect. but i dont agree totally with the fact that not to use bone graft or GBR procedure and leave it to blood clot alone as it was mentioned in one of the suggestions.
peter fairbairn
5/23/2012
Dr Helig are you sure he said that as it is common sense that the soft tissue will interfere especially at the cervical area . Grafting peri-implant is critical but must use a fully bio-absorbable material.
Peter
Saptarshi
5/23/2012
I thing u did not curettage the the socket,and may be tissue incorporation must have happened while placing the implant.
Seth Rosen
5/23/2012
I always find that if the 3.5 osstem (looks like the old style external hex, why?) doesn't achieve primary stability, but you have more room, go up two sizes and two lengths. Please switch to an internal platform, HiOssen is a wonderful implant!
I also agree that there is an issue with the technique. Would have been better off curetting and placing at extraction, as long as you go wider and longer. 8 weeks does not a healed site make. 8 months maybe...
Allen ong
5/23/2012
I think the main problem is primary stability, insufficient implant diameter and without bone graft filling into the large space around the implant cause the soft tissue grew in.
Re-implant with larger diameter and longer fixture is necessary.
Dr D
5/23/2012
Yes. Dr Helig is correct. I have seen Dr Tarnow mentioning that is not necessary to graft a 2mm gap to achieve osseointegration. However, other principles must not be forgotten: primary stability, including engagement of the implant into apical mature bone, and avoiding premature loading. I do not use flippers ever...I use a FPD as interim when dealing with one implant, or an Essex appliance.
rsdds
5/24/2012
try using septocaine (artiecaine) next time. i've done many cases like this and most of the times the buccal lingual diameter permits a 4.5, 5.0 and even a 5.2. as long as it fits mesial distally the greater the diameter , the greater the stability. remove both implants,degranulate and make sure the buccal plate is intact. graft or no graft wait 3 months and implant..
Baker vinci
5/24/2012
Or try using an omfs, that can put your patient to sleep, thus allowing the implant to be completely torqued down. It's really unacceptable to leave something half way done, because of inadequate pain control in 2012. Do yourself a favor and get certified to at least sedate your patients. I personally believe dental school should be a minimum of five years, with one year soley dedicated to medical management and anesthesia. Bv
Nilo Faria
5/24/2012
In my oppinion, the implants diameter wasn´t enough to fill the socket completly. But, the lack of primary stability can be an issue as well. Since the patien is wearing some provisional, I suggest to remove the implant, debrie the socket and fill it with bioactive glass. Wait for 120 days and place your implant. It can´t be wrong.
DR. Ali
5/25/2012
Youtold :it was somewhat difficult to achieve good anesthesia for the #5 site and because of that I was unable to torque the implant to 35Ncm and I did not achieve good primary stability.i undestand there reason may it was infectous. and i saw the edge with tooth and implant was similar at mesial side so the connection was fibrosseous encapsulation and some poits may there was osteointegration therefor u found no mobility, no symptoms, so i agree with you to remove it
rsdds
6/27/2012
implants did'nt osseointegrate because they were swimming in the socket..
