Is there a fracture in implant fixture?

It looks like you already have bone loss below the first thread on an implant that is too small to carry molar occlusal loads. Consider explantation, graft, re-implant with a larger diameter implant (6mm+). This will also provide a large platform surface for abutment stability. You can spend a lot of time and effort with unpredictable outcomes by trying to retain an implant on the way down. Restore the molar with a crown too.

To be honest, from what you have described, I think you should refer the case ASAP. You do not have the right driver, you are not sure how the crown or abutment has been attached, you cannot remove the crown and abutment, you are not sure if the implant is fractured, you do not know why there is pain and presumably not sure if the pain is from the implant site or adjacent teeth, and you say that removing the crown is a nightmare for you. There are a few indications here that you would be best to refer. All of the above is significant but my concerns are the next steps: removing the crown, properly identifying the problem, and if necessary – removing the implant and then doing whatever is required to replace the implant. In moving to a final conclusion, there will be the required work up in regards to identifying surrounding anatomical structures – eg IAN, bone width etc. I am concerned that the surgical aspects will be considerably more difficult than removing the crown and identifying the cause of pain, which you have admitted is a problem for you. Hence my suggestion to refer.

Dr Gerke is 100% correct. This is an ailing and failing implant. With just a PA we cannot fully diagnose not give opinions. What is the width of bone in this area? It does need explantation and grafting but if this is a nightmare or you don’t have a way to remove the crown and “reverse torque” it out, you could do more damage to remaining bone which will lead to much more jnvasive GTR. If you refer, you may wish to go in and watch to increase your comfort level.

With little information, you cannot expect to get answers to your questions.....this is a serious game...… refer the matter to people who are more experienced...this is how you will learn....and good luck

Cut the crown off ( chop it up ) until only the metal abutment remains in sight. Take a narrow diamond flame-shaped bur and hole out the inside of the abutment ( be careful not to hit the screw head ) as large as you can to make room for the screw driver/torque wrench. That should leave a thin outer shell of the abutment and a large access hole to work in. Try again to remove the screw with the screw driver or with a screw remove tool ( buy a screw removal kit from Salvin if you don't already have one ). Temporize the implant screw hole and refer to an O.S. for implant evaluation.

Is this implant a Nobel Active? Please confirm.

Verify the implant make to insure proper driver size. Verify screw hole clean of debris. Possible screw separation. Worse case, spilt the crown off. If verified that implant is fractured, no point in being neat about it.

Agree with posters above, especially Dr. Gerke, I think this case is beyond the expertise of a beginner/intermediate level practitioner. Refer it out to a more experienced colleague. It appears to be a NobelActive implant or maybe MIS SEVEN series, with aggressive engaging thread design, both awesome products for immediate placement indications. But only in the right hands. Based on that poorly angled peri-apical X-ray provided, I think the crown is too wide/large for the implant diameter selected. Being a first molar, expect heavy chewing load here. The broken mesial on the molar behind no doubt contributes to a food trap and further complicates the scenario. A Bitewing X-ray is more useful here. You did not mention if you checked if the occlusion on this implant-borne crown is ideal or heavy? Did the alleged fracture of the implant cause the crown to become loose? Does it move during function? Are you sure the implant is the cause of all pain here, and not all the food accumulating between this crown and the broken/decayed second molar distal to it? By the way, I don't think it is wise to open into a screw channel without verifying if the tools you have are accurate. Lastly, expect a piece of sterile cotton or PTFE tape or condensed gutta percha or a temporary filling at the base of that abutment channel. The restoring dentist hopefully did that to protect the screw head from overzealous diamond burs that have no reason entering that abutment channel without the requisite information.

Removing the cemented crown on an implant is not that difficult that you should worry about it. Explain to the patient that the crown and the implant will need to be removed but that first you need to make him or her comfortable. 1- make an access hole large enough that you can see and access the screw head. The screw head is always blocked by some material usually teflon tape. 2-Use the correct driver to remove the crown/abutment complex and check that the implant is indeed fractured. If it is, you have verified your diagnosis. Sometimes excess cement will be seen in the area. 3- Refer to remove the implant and replace it with a wider one if possible. You still get to restore the new implant and you have a happy patient. Good luck

How do you know there is a fracture on the distal side? This is probably a 0.50" (1.20 mm) screw, which may be stripped. Many reverse engaging screw removers exist to remove stripped screws. Alternatively, you can drill the entire head of the screw away and the crown will come loose, leaving the threaded portion of the screw behind, which can be slowly teased in a counterclockwise fashion with a slow speed running in reverse or the tip of an explorer. If the implant is indeed fractured, you will not easily remove it by inserting driver tip and reversing it out. Maybe you'll get lucky. Alternatively, you can use an implant remover kit (Hiossen, Neobiotech) which will help make this much simpler. Lastly, you can use a very skinny surgical bur to drill at least 180 degrees of the bone around the implant, trying to "ride the implant to within 2 or 3 mm of the apex. Try to spare the buccal plate, and focus any any other wall, unless you know you will have to sacrifice the buccal plate due to thin bone, or danger to the other walls. Then, elevate the implant and remove it with forceps. Keep in mind, more bone may need to be removed if the implant will not move. One the implant is out, please consider placing an implant right away instead of coming back at a later date, in order to spare the patient the hassle and pain of enduring a separate procedure. Also, in these circumstances with crater type resorption, I find tissue level (polished collar) implants to be the simplest to place and maintain. Hope this helps!

Sometimes focusing on a tree we fail to see the forest. The inadequately restored molar behind the implant may be cracked thus eliciting pain when chewing. In addition, behind the rct tooth is a molar with an oblitered canal system and the appearance of a widened pdl. It would be wise to check both teeth out before proceeding further. It is also not uncommon on a Nobel to see some bone loss around that top thread. You didn’t mention checking mobility either for the implant crown or adjacent teeth. Cutting the crown off and retrieving the abutment shouldn’t be any different than cutting on off on any other tooth. My hope is that the pain is coming from one of the adjacent teeth.