Implant Mobile: Should I Graft and Wait or Place a Larger Diameter Implant?

Dr MW: If the implant is not integrated, your safest option is to remove the implant, remove any fibrous tissue lining the defect until you have clean bleeding bone to stimulate the regional acceleratory phenomenon (RAP), graft the defect with the fully resorbable graft of your choice and wait 4 to 5 months before trying it again. A 5 mm diameter implant is plenty wide for a canine, with some literature indicating that implants do not have to completely fill the extraction socket in immediate placement, so replacing the implant with a wider diameter implant would be a mistake. You did not go over all the details, and the trouble seemed to happen in an unlikely stage of the treatment, so I would try to go step by step and try to figure out what could have caused the complication so that you don't repeat it in the second attempt. Good luck,

I agree with the previous post. At a 5mm. diameter, you are pretty wide already. To place a wider implant beyond 5mm. into this presumed failed site may be beyond the capacity of the buccal plate, if in fact it still exists. Remove and access for buccal plate integrity. If suitable you may not need more width but perhaps you can go longer for renewed primary fixation. If not suitable then, as per Dr. Boudet staated above, debride, graft, and also access the need for a barrier membrane all followed by a delayed replacement.

Dear Doc.MW. in some place you did good job, but All comments above are unacceptable. Text book "Contemporary Oral and Maxillofacial Surgery" (Peterson,Ellis,Hupp and Tucker) second edition on page 403 explaned exactly opposite to literature( which literature's dr Boudet mentioned). Implants placed in fresh extraction sockets MOST have 4 mm of precise fit along apical aspect of implant(Osteotomy 4 mm apical aspect of socket tooth), which ones was your big mistake additional than shorter implant.Your second mistake was placing Bio-Oss on ElDERLY patient than allograft.Endodontic tooth has minimum blood circulation in periodontal ligaments and sockets(which condition prevented osseointegration on your implant.However, what do you need to do now? -Defiantly, you lost your implant.You don't need grafted again.Just remove an implant, ossteotomy minimum 4 mm longer than socket of tooth #11(which tooth has the longest root in the mouth) and place a NEW implant with same as diameter as before,but more longer.Remember, as long as you have 1.5 mm bone on labial aspect and 1.5 mm bone on palatal aspect,larger diameter implant is much susceptible and stabilization.Finally, I recommend before you placing an new implant, take PA X-Ray, because SITE of the extracted hard fractured tooth(especially endodonticaly tooth) is most likly undergo to CONDENSING OSTEITIS(Which condition lack of blood on osteotomy site and interfere with osseointegration)on implant.If this is the issue, it's would be better you remove condensing bone first than place an implant. Good luck to you. Dr. VAZIRI

Dr Vaziri; I would be grateful if you could point out exactly all the comments that are unacceptable to you, because I am having difficulty understanding your writing style. First you say "You don’t need grafted again" and then you realize that the extraction socket of an old endodontically treated tooth may have poor blood supply and say "it’s would be better you remove condensing bone first than place an implant". If you read carefully my comment, you will see that I suggested the safest option "your safest option is to remove the implant, remove any fibrous tissue lining the defect until you have clean bleeding bone to stimulate the regional acceleratory phenomenon (RAP), graft the defect with the fully resorbable graft of your choice and wait 4 to 5 months before trying it again" which would allow him to place a new implant in fresh newly formed bone protected by a two stage protocol, (definitely safer than what you are suggesting). You should consider posting advise and not criticism, and your posts might look a little better.

dr varizi- your comments are ridiculous and inflamatory - (as always) I aggree with dr boudet. sorry folks- just had to say it. to dr MW- you are right in your conservative approach. odds are you will have a large buccal plate dehiscence and a fairly complicated extraction socket defect. remove the fixture, create some bleeding, graft as necessary. this is now a compromised site and it will require time to heal and consolidate (4-5 months???)prior to placing a new implant. DO NOT TRY and put a longer implant into this site immediately. It is infected, and you could create a bigger problem for your patient.

Dr.Boudet Your answer is on text book as I mentioned above and perhaps if you would not underestand it minimum you will see at least one text book in your filled.RED COVER BOOK "Contemporary Oral and Maxillofacial Surgery", second edition on page 403. -Yes you are right you having difficalty to underestanding my writing style an you ANSWERED it,but I understanding your writing style an answered it by the book. Dr.Sb oral surgon; -Regard to explanation of Doc.Mw.Placement an implant after 120 days means osteo-integration was occurred property,even he restored an implant. 3 weeks later, he noted some swelling on the buccal aspect, means infection occurred recently after taking impressions(which source of infection is NOT belong to implant and hard tissue and it was supra-boney at that time).Dr.Mw took second time impressions on implant and restored it.Infection would be more possibility belong to ischemia RESOBABLE MEMBRANE and some necrotic tissue(which soft tissue graft rejection most common after some times on elderly people)and make some swelling on supra-boney first.Changing from supra to infera-boney after 3 weeks of restoration process and additional one week taking medication is plenty of time for those circumstance. Finaly implant lost some coronal bone structure and fail to mobility stage, but site of the implant still is not infected at this phase,however, I'm so contemptible for oral surgon(who doesn't realize soft tissue (supra-boney )infection from infra-boney!). Dr.Vaziri

Dr. Boudet, Not only is your suggestion the safest. It is the most logical. That is what I would do and have done.

Dr.Vaziri, You could be either very well versed and opinionated in implantology and just having trouble expressing your points( because I can't understand one dang thing you are saying ) or you just need to take some more ce courses. by the way, I agree with Dr. Boudet of his suggestion. Safe and sound technique.

I totally agree with Dr. Boudet . Additionally I would recommend a longer implant to try and get some more apical atability in host bone. Definitel;y nothing wider . Eric

Let's look at the dynamics. A compromised socket (endodontic root for extended years, fractured root with probable microbial migration and short length) in an anterior region and probable facial prominence (thin facial bone). Also, although not stated, I will venture to guess that the tooth was supporting an upper partial denture with no teeth distal to it. A 5.0mm implant will be significantly larger than the apex of the cuspid which will ensure a facial dihiscence as Dr. sb intimated unless you are very experienced and took precautions against this. At 35Ncm torque, you had reliable stability unless the surrounding bone was at it's limits at that time. After healing, there was no more added strength due to the short length, facial dehiscence and short healing time. You restored it and put it in function. The partial denture added too much force which broke loose the implant. Resident pathological microbiology might or might not have had a chance at this point to grow. Immediately drilling deeper in such situations is counterproductive. Do what Dr. Boudet said and try to go longer after everything has healed up. Many of the newer implants have substantially stronger head strength so you can go with a small diameter implant and get better circumferential bone support and go longer for increased torsional stability.

Dr MW I think you have had excellent posts on the subject that should answer your points Clearly wait ..allow healing and try again It ought to be a 5 wall defect so bony infill will be predictable You can use almost any graft material as a result Do not use wider than 5mm but use longer than 11mm you need 3-4mm longer than socket for good fixation The implant angle is also typically going to be steep I teach my students not to go to the apex but to enter the pilot drill palatally just short of the apex.Good fixation is key Second time around i would probably be inclined to do delayed loading There are a number of reasons you could have had failure impossible to say without more info. I would recommend you ignore Dr Vaziris comments ,his command of the language is insufficient to offer any advice in English even if he does know what he is talking about Dr S

Bio Oss is the worst bone graft to use. It is not osseoconductive and it will only cause an inflammitory reaction and will never be resorbed. Socket Graft is an ideal graft material because it is a biocement and bonds to immediate implants while stimulating osseogenesis. Socket Graft stimulates the osteoblast to produce the patients own bone with great viatality and mineralization. Please visit the website for steinerlabs.com and check out the immediate implant that was floated in Socket Graft.

Take aways: #1 If you have to ask the question, go back to basics. KISS #2 Don't use BioOss ever with immediate implants. #3 When in doubt don't do immediate implants #4 Graft extraction site with some allogenic product, wait 8-10 weeks, place an ideal sized implant in and ideal site, wait 10-12 weeks and enjoy 98-99% success. #5 Don't start stretching the limits until you have hundreds under your belt through either training or experience. Immediate implants are stretching the limits for both the patient and the novice provider. #6 Why accept ~ 80% success when 98+% is available, albeit with 3-5 months delayed restoration. Give the patient the choice, particularly as they are the ones shelling over the money.

I would suggest removing the prosthetics and then flap the site and determine if it is the fixture that is really mobile. if it is remove it and currette the socket and graft and allow 3 months before attempting a new fixture. Placing a wider fixture in this site at the same time as explantation may cause buccal plate damage and you may get some die back in the socket leading to mobility of the new fixture

I do agree not to use bio oss in immediate implant cases rather use autogenous bone 4 jumping distance. in this case 5mm wide implant has been used hense no chances of jumping distance. I would feel removal of implant,curattage,wait for few months,augmentation&membrane depending upon situation.

Take the advice of the oral surgeon jsb. You have burnt your fingers once so stand back and re-evaluate - your patient will appreciate it too.

sb oral surgeon, you are correct.

While I agree with virtually all of the previous posts, one additional thing has been left out of the mix. The selection of a 3i implant with a nanotite surface may, in fact, be one of the problems. There have been anecdotal reports of a high failure rate with this implant surface. One of the studies I have been a part of indicates that there may be an extended catabolic phase with this surface as determined by reverse torque studies. This was tested in healed osteotomy sites. Now you add to that mix an extraction site with chronic granulation tissue and add a poor choice of graft materials. The final result, in my opinion, is almost to be expected. How did you debride the osteotomy after extraction? Was there bleeding at the site? Why did you choose a non-resorbable graft material? In the end, you did not control the biology of the osteotomy; it controlled you. Stop listening to marketing hype and read the literature. the choice of implant, graft, and methodology should reflect our current knowledge of biological interactions. RJM

Robert well said , lots of good advice in this post but this says it all.

The primary cause of the failure could be systemic or local. The patient is middle aged, with high BP and high cholesterol, hopefully controlled. Check the patient for diabetes and treat if necessary. Dues should be paid to Dr Vaziri for highlighting the possible local causes like residual infection left behind by the endodontically treated tooth and the possibly low blood supply to the periodontium of such teeth that may prevent proper osseointegration. Having said that, Carlos Boudet gave a very reasonable and workable local treatment response to the problem. But the possible systemic causes should be looked at first. Lastly, a larger diameter implant is an absolute no no. Besides all the eloquent reasons given earlier by the learned dentists not to do so, I would like to add one more. Every dental implant we place also comes with a periodontal pocket....yes a pathology.... an iatrogenic condition. Bone will forms a biologic bond with titanium but the gums do not. What we have is a far cry from the sophisticated gingival cuff around a real tooth with the epithelial attachment and a well planned organisation of different types of fibres all designed to prevent infection from penetrating the emergent margin of the tooth. If we have to make a perio pocket everytime we place and implant, it makes good sense to make a small diameter pocket rather than a larger diameter pocket that comes with a larger diameter implant. If we have to make a hole in the gums, make a small one as far as possible.... a smaller diameter ....not a larger diameter. Cheers.

I completely agree with dr.Vaziri and dr.Chow. I have seen similar symptomes in couple of cases.

Dr.Danesh,Iran Dear colleague; Most of the comments posted here ,are good ones, but I was thinking that the pt. has been waiting for almost 5 months, w/o a good result at the end. The patient's age, means to have implants just to support his denture. Since I don't have the thorough analysis ,his panorex and the cast , what I suggest is; If possible change the site of that implant , in order not to wait too long . Then to use the mini implants to secure your denture for the mean time as the temp. After 4 months load the implant , and proceed to your final removable partial denture. Good luck.

I always use LifeNet allografts for my surgeries. I dont know with other doctors but I am more confident using this product because its 100% human tissue. Very agreeable to my patients.

Info is slightly insufficient, however, my first thought is that abutment did not sit completely because of the bone around the implant shoulder. There could have been false sense of proper fit, but when compressed bone resorbed - abutment became loose. I disagree that BioOss was a wrong way to go. Being a graft of extremely long resorption time it offers exellent protection from vestibular dehiscence, that was going to happen after tooth extraction. I also agree that immediate placement is for experienced operator. If in doubt - wait a while, then implant.

I like Dr. Dennis Nimchuk's comment. Have you tried accell sold by Keystone Has BMP

dr.Vaziri and dr.Chow comments are quite right in my view, i agree on it.

I agree with Dr.vaziri comments except placing a wide diameter implant at this site.Placing an implant 3-4mm apical to a fresh socket without any pressure to crestal bone with using a root form implant is the safest way to avoid pressure necrosis and getting a good primery stability.At this circumstances nver use bio-oss and placing an allograft material is the best option .

hello, we are not here to fight each other,i as a dentist with more than 20 years of experience in implantology,bilieve that Dr.Vaziri,s comment is correct.if we are looking for an alternative,then there are some more options,but in this particular case ,a agree with Dr.vaziri except using a wider fixture.

Can you please translate Dr Vaziri's comments ?

u all understand what dr vaziri wants to point out but some of u are too busy to read carefully.i personally dont graft with any material, remove all the granulation tissue and immediatly place longer implant.INFLAMMATION IS A PRODUCTIVE amd positive PROSEDURE in my oppinion once started and after the causative factor removed.