Malpositioned Implant Fixtures: Any Experience with Using an Electrosurge Unit to Pulse Generate Heat to the Implant/Bone Interface?

Dr. A I've tried it twice on the same patient (trying to remove fractured implants) - with no success, but I've heared of other colleagues that were more succesfull with this method. I now cut a bucal window with piezo and remove the implant bucally - often you can place a new implant at the same procedure and graft as necessary.

I wouldn't generate more heat than necessary. Heat kills bone as you stated. Piezosurgery and patience like dr a said.

Dude seriously u sound like u have done a few implants but electrosurg to remove an implant - it won't work it kills cells will not Have immediate effect to allow removal - simples - trephine out and augment try using a bone ring technique - consent your Pt for loss of canine -

Have you contacted the previous dentist who placed the implants? It sounds like you have high standards for placement and restoration. Why were these placed where they were? Why did that patient leave that dentist (unless they were placed by a specialist who only deals with surgical placement and not restoration? No surgical guide used? Its pretty obvious from your comments that preplanning was not done. Bill

I would strongly advise against overheating the bone to cause bone necrosis in order to remove the implants. It may sound ok in theory, but is it worth the risk, particularly as you want to replace the implants in a different position so you need bone regeneration, not necrosis, to fill in the space of the wrongly positioned implants. I must admit i am a perplexed by Dr Woods comments. He appears more interested in blame than help. Poor positioning can occasionally occur even with the best. i can't see what useful purpose can be gained by trying to blame the previous operator, other than stir up litigation.As a wise man once said, don't criticize a man until you have run a mile in his shoes!

Hi Dr A: Iam surprised that someone is using Steri-Oss implants as I understand that Nobelbiocare bought the company a few years ago. You may be referring to Nobel Replace Select implants. If this is the case I would suggest you check with your local Nobel Rep and ask if they have a retrieval kit that can facilitate the removal of the implants. I had a couple of Nobel Replace Select 3.5mm implants that broke during placement and they weere easily retrieved by using the retrieval kit I mentioned.Mind you these two implants were not integrated but it may work. This retrieval kit is nothing but a screw like attachment that has a reversal thread and therefore engages the inner part of the implant as you apply reverse torque. In regards to the idea of using the electrosurg to generate heat and considering that the implants are in the esthetic zone, I think that is a bad idea. Is too bad that you did not send radiographs or pictures to see the degree of misalignment as some times custom abutments can be used to resolve some critical situations.Hope it helps. Ed

With out radiographs or CT images to aid my decision I would use my pesiotome or sugical length 557 or smaller with copious sterile saline and remove the mesial bone from #10 until you could loosen the implant then back out. As to #8 probably something similar if it is close to an adjacent tooth, D3 bone is not that tough. Trephines work great if you have the space, but it doesn't sound like you do. Use a composite graft let heal 8 - 12 weeks depending on the patient and size of defect and place new implants. I practice in Orlando and have placed and restored implants for 38 years.

You can try to do a segmental osteotomy to repostion the implant with the bone around the implant. It would be similiar to doing Wilcodontics.

Overheating is a bad idea. Please refer this Patient to a Specialist . You are entering a Trouble zone and cases like this should only be resolved within the Prosthodontist& Oral Surgeon team practice. Simply tell Your Patient that these Implants can not be restored by You and He/She needs to see someone else. Both You and the Patient will gain with this approach.

Risk management Dr. A. I do not do things that I could not easily explain to a jury. I have discussed this procedure with young oral surgeons. However, all knowledge has been purely anecdotalal. I am yet to meet a clinician that has attempted this. You have more experience than me, but my specific concern is the thin buccal plate. Heat could leave this necrotic but temporarily intact. That could result in unpredictable and inadequate bone formation. I would rather remove bone and graft the site, I would expect a more predictable result.

to MEU no those were not Replace Select implants, was an other make which were integrated (15 years after placement)and the implants fractured at bone level!

Dr. A It's hard to believe that the distance between the implant and the 23 is 0.5 mm because the morphological anatomy of the canine would obstruct the introduction of the implant, so that distance quite possibly not be real. Recommend CT to verify the distance and remember that you can restore the implant if there is a minimum distance of 1.5 mm between tooth and implant, you can use cad / cam for the abutment to be more predictable. Before implant extraction verify measurements. Good luck

Dear Doctors, I would like to thank you all for your responses. I realize that the concept of success with electrosurgical alteration of bone quality is not a concept that seems to be embraced by any respondents. It seems that there is no research available for this modality. I found that the comments by IK most interesting. I have been placing, restoring and surgically modifying sites for ideal placement of implants since the mid 1980's. My practise is restricted to the placement and restoration of dental implants. It was, infact, the failure of OMFS to provide the results that I requested, that prompted me 25 years ago, to commit my focus on dental implant training for the last 25 years. I now find that I spend some of my time bailing out the OMFS in our area that have not had any training in prosthetics. Some dentists fail to realize that it is not the bone availability that governs the case but the prosthetics. If one does not understand the prosthetic and esthetic requirements, they are want to fall by the wayside in being able to provide a solution for the patient. And, in fact, it is the patient who is the most important. They do not want implants. They want teeth. My origional question was lost in some of the responses. "My question revolves around the consideration of using electrosurgery to pulse generate heat to the implant/bone interface. If I could weaken the integration enough to have woven bone instead of lamellar bone surround the implant, I would have a more predictable way of spinning out the implant." By this, I mean, could we alter the bone from organized lamellar bone to woven bone over time by altering the environment through heat generation, that would result, again, over time, with the easier removal of the implant. It is not about frying the bone. We heat the bone at every turn of the osteotomy bur, but with, for most part, limited negative effect, if we are prudent. Research shows that heating the bone to 47 degrees centigrade for one minute will result in necrosis of the cells affected by that heat transfer. We know that stress beyond a certain limit can change the bone remodeling rate from its normal of 40% per year to 500+% per year in the maxilla and mandible. This rate change, of such a large degree, replaces mature lamellar bone around implants with softer, less organized woven bone. If this could be accomplished predictably, it would seem that we would have a much easier time of spinning out the affected implant. If there is no predictable way of doing this, then I am resigned to the more traditional ways of removal or case redesign. Maybe this could be a research study that could benefit the field as we have seen the difficulty of removing broken implants or malpositioned implants with the old school approach.

Dear Dr. A., I'm bound to agree with you , but given that I am a neophyte in this area, it is with reservation that I am posting my response. Think of your electrosurge device as a blow torch. If one is unable to REGULATE the amount of heat, one ends-up melting down the festoons; worse ruin the entire wax up. However, given the right setting, in the hands of an EFFICIENT worker, it can do wonders for the prosthesis. It is inevitable that a degree of ALTERATION or DESTRUCTION has to be affected in order to disengage the implant. Whether it is with the use of trepine bur, piezo device, or electosurge, the aim is to MINIMIZE the damage as much as possible. You seem to be the type to be very efficient and cautious. I would say, why not try it? Of course I'm sure you'll know to begin with a posterior, non critical case. When the time comes, I would like to try it myself knowing that if heat generated is minimal, the body will be able to recover and heal itself. Warmest regards...

Dear Dr A. the problem in making bone necrosis is that you cannot gain immediate results, and you cant guiss where it stops, considering that you only have 0.5 mm of bone in some places. in your shoes i would make an envelop bony flap using piezo or sagittal saw. once the cortical block is removed, implants are easily extracted and the buccal block is screwed back in position after grafting implants sockets.

Hi Dr. A I feel the responses are all good and trying to be helpful. You do need to look at this treatment from several points of view and each view has great validity. The fact is that once treatment is started, you are responsible. You are experienced, I am an experienced GP like you. We know that three things can happen: 1. it goes well according to plan. 2. it goes badly and 3. it gets worse. I would jump into this more aggresively if these were your implants, but they are not. Advise and consent and treatment plan and charge for the worse case scenario. Probably removal of implants, bone, block bone, PRF/PRP , alloderm?, advancing flap, tension free primary closure. Get a CT, Diagnostic wax up, this is a new case so please treat it as that. Go for the predictable. Many short cuts are very unpredictable. Healing in the esthetic maxillary zone is, for me, the most difficult and unpredictable. It isn't your problem and don't make it your problem. We as dentists often get into more upsets trying to "help someone out" with limited treatment. I have sat on a large state peer review council and have seen results and issues. It is never who is right or wrong, it is about the thought process to the treatment result and how informed the patient is via written information and signature. Just my opinions Sincerey Leonard

Dear Dr. A: I just read your March 3 post. I feel that all the responses arent missing the point. If you want to do a clinical experiment, then that is your choice. The fact is that if it doesnt work and there is further loss of buccal bone, a large defect that now has to be treated, you have added a minimum of one year of treatment and possibly more. Patients finding this out after the fact are very litigious and unhappy. You and the previous treating dentist will be brought into this. It happens to specialists and GPs alike. We are not alone. Just my opinon as a fellow clinician. Sincerely Leoanrd

Dear Dr A It is clear that not even one of the Doctors agree with You to alter bone quality with the aid of an electro surgical device. It is also true that few OMFS do not place Implants as good as a GP like yourself. Lets leave scientific ideas in hands of colleagues with specialist or PHD degrees. In Denmark we refer cases like this to our Dental School where We have a great team to help the Patients. I am sure You can find the same/similar in your area. I would also be grateful if Dr Mehdi Jafari would write his views about this issue . I have been reading all his posts in Osseonews and they are very scientific and up to date. I also agree with the post of Dream dds.

Dear sir, Thank you so much for your kind regards "et je vous remercie".I have been using this technique during the past three decades, just to remove the implants, but never for the correction of their position in the alveolus or changing their axis.I, personally, do not see any justification in keeping the fixture still in the bone after it being electro-cauterized.

Dear Dr. Mehdi Jafari, Thank you for your response. Could you tell me please what setting you use for your electrosurge? Is it a cut or coagulation setting? Is it a pulsed current? How long do you typically make contact with the implant? How many weeks do you wait before spinning out the implant? I had heard through the grape vine that this was possible. It is great to talk to someone who has had the experience with this technique. What do you see are the risks/rewards? What are the problems that you have encountered? How do you minimize or eliminate these problems?

Sir, My electro-surgical unit is a very old model of U.S. made Coltene-Whaldent but it is still working.First I keep the surrounding soft tissues detached from the metallic fixture.Then, I keep touching the fixture for five seconds after the machine has been regulated for an energy delivery of 40 Joules and on a coagulation mode.My cases,however,have been very few,but I have never confronted any frustrating situation so far(Merci Dieu).

Dear Dr. A., Quantum theory had been presented over a hundred years ago, yet there are only some who are able to comprehend QUANTUM MECHANICS as they apply in the field of medicine/dentistry. To be able to understand biological processes in the MICROPHYSICAL level, well enough to consider inducing IONIZATION; initiate electron transfer in order to re-arrange molecular configurations by conducting electrical current is considered "revolutionary" because many still think in terms of CLASSICAL PHYSICS. It is but natural to meet opposition with this concept, as you already found out. Hats off to you for presenting your theory, and for finding CONFIRMATION to your idea! Dr Jafari, Thank you for providing an enlightenment in this direction. Thirty years--- the concept is not so revolutionary afterall. Cheers...

An article describing the technique and case reports on the use of electrosurgery for implant removal was published by Serge Szmukler-Moncler. I do not think Dr. Szmukler-Moncler would mind any questions. If you would like his e-mail, please drop me a line at [email protected]

Dear Dr. A this technique has been published before in a case series by an Italian dentist in private practice. The idea is to deliver very small amount of current to the implants so the osseintegration is lost and not to overheat or necrose the bone. The idea has merit. The settings they used do not translate to the electrosurge units used in the US but it was a 1 second pulse delivered a couple of times without anesthesia so the patient can tell if too much current was being applied. The implants were reversed out two weeks following the initial treatment with minimal reported adverse effects. Sorry I can't be more help but please let me know if you try it. The comments on this site are mostly off the subject... what ashame

Dear colleagues, I started using this technique to remove the implants with wrong angulations which had been placed by then totally inexperienced ME during late 80s and early 90s.However I don't see any point in "who did it first" but in if it is working or not.If it can be a useful method to help our patients and it helps our colleagues to ameliorate their services, then I have added my note to the symphony of human race progress, even though,no name of me is mentioned.

Dear Dr. in distress, I have removed few partially and fully osseointegrated implants. I have never used the electrosurge, but have heard anectdotal uses of it to cause bone necrosis to cause deosseointegration. May I suggest another theory? How about don't remove any implant? Is it possible to segement the alveolar bone and move that segement orthodontically just enough to place the implant in a position sufficient for restoration..sort of like "Wilkodontics" or orthodontic distraction osteogenesis? I know it sounds far out. I have never tried this. I have only read one report of it being done. However, with a team approach, it might be worth a shot with a lot of informed consent by the patient if the other options seem too invase. Good luck.

I am not experienced in the technique utilizing radio surge (electro-surg) units to remove integrated implants. I did however hear of the technique while attending a week long course in Berne Switzerland (Dr. Daniel Buser headed up the course for Straumann / ITI institute). I got the impression it was how they handled the removal of integrated implants in lieu of other methods. This was 5 years ago and I could be totally wrong but their "camp" may be a good resource for citations or techniques/SOP's.