Implant with lingual cortex perforation: Explant or wait for osseointegration ?

Reverse torque it out immediately.

Well, this is unfortunate, it's always better in the mandible to start from the buccal and to maintain the lingual bone. It's relatively simple to augment out to the labial. One has to be very careful in the lingual region. It is relatively easy to hit the lingual artery and to get into a very dangerous situation. When in a Maxillo-Facial residency in Great Britain we had a patient come in with a lingual bleed which developed following a traumatic extraction of a mandibular molar. By the time she came to the Emergency Room she was severely swollen in the sub-lingual region and was having respiratory distress. It was necessary to perform an Emergency tracheotomy. In this situation, it would be sensible to remove the implant and allow the region to heal. Later, it should be possible to come back and place another in a more suitable manner. It's very easy to slip off the crest of a ridge with a starter drill. It is much simpler and safer when done with a surgical guide. Good luck with this, you will always remember this case.

Take it out right away!!! This is one area you must not play with.

Remove the implant and start over. You may need to ramp down.

You have some very good advice......remove it and let the area heal?....go back in six months ? and redo the osteotomy in the correct angulation ?...….however.....from my own personal experience I will tell you what happened to me in a similar situation about 40 years ago......working in the same area......using a press fit Calcitek implant, after the osteotomy was completed, no abnormal bleeding, everything normal,...…. I tapped the implant in place, and on the final tapping…… the implant disappeared.....I took an xray and found the implant sitting at the base of the mandible, lying horizontal next to the roots of the adjacent teeth........I panicked and called Calcitek to speak with one of their experts who told me......make a small incision on the lingual side of the osteotomy, push the soft tissue away from bone and with a dull small instrument, feel the implant and gently bring it to the surface.....now gently put the implant back into the osteotomy, with no tapping, just a gentle push until it is at the desired depth.....and leave it alone...….guess what!!! We let the implant become integrated into the bone, waited six months, placed a crown on it ...and for the next 25 years......….this restored implant functioned very well and lasted without any problems for the rest of her life.... forty years ago CT Scans did not exist, there would be no one to pass junction......and it worked...….. so now you have different scenerios from experienced dentists....the choice is up to you......and best of luck to you and your patient......If I can locate the chart, as the patient passed away and we usually disgard the files of deceased patients...…..but I remember her name.....if I can find the documentation, I will certainly post it...... ..

Hello Doctor: I feel everyone's response was very gentle on you. I assume you are a GP and I am a GP. I also teach implant procedures to Dentists, mostly GPs. Specialists don't like to look too harsh in advice to us GPs but this is a time when you need to see where your training needs to be redirected. I am giving you advice I wish I was given when I started 30 years ago with implantology. I feel you need to take some basic courses starting with treatment planning and use of CBCT, mounted casts and surgical guides whether model base or CAD/CAM. Next would be a combination didactic and hands on patient course, maybe AAID or ICOI sanctioned.. Only after 2 years should you commit a patient to your service. The area you are treating here has no apparent protocol. The patient is in harms way here and so are you. If you don't realize it, you never made it through crestal bone into trabecular. Now, a perforation on osteotomy is not a major issue if the doctor knows how to feel the drill from the lingual and understand anatomy and the mylohyoid fossa. A reasonable perforation would be 8mm inferior to where you are. That would be in trabecular bone and out lingual cortical bone. You are not in bone. For a new but skilled implant user, there would be a surgical guide (implants are crown down, not implant up) and a lance drill would be used; if not a lance, then a 2 round surgical to make the initial perf through crest, then a pilot drill 3/4 down and an XRAY of a directional finder. Adjust, and finish osteotomy. Understand torque values, bone density, the term Bone Compression Necrosis and whether to close flap or place healing abutment. Please take this as constructive criticism from your peer. Sincerely Leonard

The implant is under the periosteum not in cortical bone, remove it.

I have to agree the implant is under the periosteum, please be very carefull when removing it. You dont want to damage the lingual artery or the lingual nerve, it is nice that the periosteun is protecting the nerve and the artery. Don't wait for an infection or for granulation tissue to form around the implant. The versa bur is not a magic wand, may as well throw it away and use the burs that come with the implant company kit.

That’s a very dangerous area to be in. Bone graft it or let it heal by self and then attempt another implant and a better angulation.

You need to consider doing your implants guided. There are courses out there where you make your own guides, or companies who will make them for you. This could have ended really badly for you and the patient. The sooner you get that out, the better. Graft and let it heal and start over.

yeah.. you wont forget this case’ you’re lucky not done more posterior. if nothing was done, it would fall out eventually. i’d hate for neighboring dentist to see this patient as a second opinion though.

Its normal and possible lingual cortical perforation specially after the distal root of the lower first molar or in area of 7 and 8 ,but this its better addapted or uses in mono cortical implant

Dr, all the comments are valid, the bulk of your implant is not in bone. You were blessed that the lingual perforation caused no sublingual hemorrhagic complication which could easily be disastrous. Another point is the restoration of a buccal pointing mandibular implant could be challenging as well. I will carefully reverse torque out this implant and graft. Goodluck

I agree with most of these opinions regarding removal of the implant. I think that is imperative. However since we are both general dentists I think it would be a good idea to ask a friendly oral surgeon to give you a hand. I don’t think you will be criticized. It takes a lot other responsibility off of you if something should go wrong and protects the patient. I do think it will be an easy procedure to accomplish but it never hurts to ask a person with more experience for help. That is one of the first things Carl Misch taught me 30 years ago.

I think you did your osteotomy right but inserted the fixture between the lingual cortical plate and periosteum, and then grafted the osteotomy site.

Thank you dear colleagues for your time and valuable opinions.I intend to explant now ,graft and implant at a later date.Regards

This is a perfect case why one should not do flapless surgery without a LOT of experience, guide or no guide!!

Explant immediately......if not done at the earliest.......this is not only done for the patient’s best interest but to also avoid very serious medico-legal ramifications

My colleague gave you right decision please note that if by any chance you be successful, you will not be done the prosthetic work as it will drop in immediate complications

It would be moot to repeat what everyone has already said, i.e.: explant ASAP, get training before further placing implants AND, closely monitor this patient! I've already posted a long comment outlining the egregious mistakes made here, the gross oversight of details, and total lack of experience that led to the cascade of unfortunate events which generated this gross failure. I had also included, among other things, the requisite criticism that I truly feel our colleague really needs to hear -- for his own sake, first and foremost! Alas, presumably, the site moderators didn't see fit to publish my critical post, because it was, well, critical -- even though it was well within the norms of civility and professionalism. However, in restricting said critical speech -- 1st Amendment anyone? -- the moderators are not only stifling debate but, are also making themselves guilty of censure and are missing a very crucial, indeed essential point: Aside from open discussion and sharing experience, one of the purposes of this board is to have the opportunity to openly admit mistakes in a safe environment -- and read our peers' honest opinions -- without fear of legal consequence. That also means sometimes hearing criticism, stern as it may be! For, let's not forget, that some of the best and durable lessons we learned were born of stern criticism levied at us by our educators. Let's also remember that sometimes, someone really needs stern, vigorous criticism, because it's the only thing standing between them and the next blunder! Our esteemed colleague really needed that criticism, because if no one tells him how utterly wrong he went, how will he ever know? And this speaks not only to this particular case, but to our colleague's limited experience as well as his overall attitude and approach, which also appear lacking, and bordering on light-hearted. If no one attracts his attention sternly enough to make a bulb go off, and make him take a step back to re-evaluate himself, HOW in the world will he ever know that he needs to do so?!? He may feel slighted for a moment but then, as reason sets in, he will rethink and ask himself the serious questions which will inevitably lead him to definitive self-improvement as a professional! And isn't that the other purpose of this board -- to improve ourselves and to foster same in others? Improvement sometimes has a cost in pride. But better a momentarily stunted pride than a dead patient and a multi-million dollar lawsuit OR, worse yet, a whole career curtailed. This WAS one of those very rare cases within that possible realm, IMHO! Sadly this case doesn't just border on malpractice, it is malpractice, and it's much better for our colleague to hear it from us here, than from plaintiff's attorney! Saying otherwise is not doing our colleague any favors! Worst of all, by failing to alert him to the potential severity of the situation, we are preventing him from taking the immediate and clear steps necessary to safeguard his patient and himself. In a sense, we become complicit in his errors and their consequences. N'èst pas? I therefore encourage all of you, my esteemed colleagues whom I respect and whose insightful posts I appreciate, to follow my suit! "If you see something, say something" should apply here as well, not only to 'suspicious packages'! Gross, truly egregious errors must be called out by name, especially if they endanger a patient's life even if only 1%. That is our Hippocratic oath! Speaking frankly isn't a crime, but a red alert to a colleague that he/she needs to take a step back and thoroughly re-evaluate the situation. So please pardon the cliché, but as Shakespeare famously said "a rose by any other name is still called a flower"! In our profession that "flower" can have dire -- even deadly -- consequences! And to the moderators, I encourage you to let criticism stand, when it's decidedly called for! There are very rare instances when one serious lapse can cost a life, or a whole career. I highly doubt you wish to make yourselves complicit to a potential disaster! Further, and with sincere all due respect, I highly doubt that you are sufficiently professionally qualified to stand in judgement of such clinical issues! Cheers!

Unfortunate occurrence but we all have been through this. Always remove it, there should not be a question as “ Can I get away with it.” If it doesn’t fail soon it will fail after loading.

A nice way to avoid this is to push back the lingual tissue and use a perioprobe to feel the lingual bone contour. That helps you direct your drill (esp free hand) so it bisects both buccal and lingual plates. Note too, that cortical bone is not very conducive to generating a bone graft. You need vascularity.