Mandibular implant placement and shoulder pain?

Did you get medical clearance? Are there any cardiac issues?

Patient did not present with any medical issues prior to the implants being placed. No other medical issues have been found after either. I did have a case where I extracted #15 on a patient (different patient) and she stated that her shoulder pain of 5 years went away after the extraction.

Since you mentioned his pain increased after restoration, I suspect there is a TMJ condition and it's associated with her pterygoid muscles. Many times tensions in TMJ is associated with neck tensions as well. There is an informative clip on U tube which you will find it's link attached below. I hope this will help your patient. https://youtu.be/tGw3J0sMdg8

I suggest you check the tmj, in the panoramic radiography there seems to be a disharmony in the form and height of the condyles, it could be an arthritis in the condyles leading to a temporo mandibular disorder triggered by the insertion of the implants, which could Affect the muscles of the neck and shoulder, check the occlusion of the crowns.

Concur with Dr Shahram. Shoulder and neck pain are almost always associated with TMJ and, more specifically, with bruxism. if your patient's pain increased after restoring the implants it's a sure bet that he's a bruxer, and a heavy one at that. Check the rest of his natural dentition for wear facets and fabricate a lower rigid and smooth nightguard, also known as a MORA or Gelb-type appliance, if you don't want those pretty implants to fail due to bruxism.

The above answers could be correct but the sudden onset straight after insertion – firstly of the implants but subsequently the crowns – would suggest something different. TMJD generally does not have an immediate presentation like you described. The pain sequence does not marry to cardiac issues either – although it should not be discounted. One possibility might be the patient’s head position while in the chair (during treatment). I lie my patients very horizontally in the chair and I know sometimes this causes some musculoskeletal issues due to cervical extension. Given the time frame of onset, this could be a possible cause – however I do not know the position you put your patients in. Perhaps the best thing to do is discuss this matter with a local chiropractor – and as long as he/she does not have an anti-implant stance – then possibly offer your patient a complimentary exam do see if some simple chiropractic treatment can help.

Was the placement under LA or GA? Were mouth props used? Was a cotton wad used for bleeding eg "bite on this" to the semiconscious patient? Was neck movement restricted before or during the procedure? Was the patient lifted from a trolley to an operating table?

I agree with TMJ problems. The patient used the left side to chew before implants were placed - no molars top left. While healing took place she used the right side, inducing contra lateral pain. Consider a bite splint to see if it makes a difference. Also check for occlusal interference with excursions. Good luck. I hope it gets resolved soon.

You (the original poster) wrote that "After I placed the screw retained crowns, he said the shoulder pain has increased." This is your definitive clue that your patient is a bruxer, and has most likely been one for a long time, albeit subclinically. After the restorations were placed he continued to brux on the left, but now more force was transmitted to the muscles because of the presence of the added molars. (And this is not the only aspect of it all, as described by others above.) A complete head and neck muscular examination (and possibly an EMG) will undoubtedly reveal generalized head and neck muscular spasm areas and trigger points. Make sure you examine the pterygoids, the SCM's, the posterior cervicals and the greater trapezius. Fabricate the appliance I described in my first post and do a complete occlusal equilibration, ensuring that the implant crowns have shallower cusps and are inactive in lateral movements. Last but not least, educate the patient about bruxism and don't accept his insistent denials that he doesn't brux -- no one knows when they brux in their sleep. Instruct him to observe himself carefully for daytime clenching and bruxing and if he does it, instruct him to wear the appliance during the daytime also for a few weeks to 2 months. Keep under observation and re-examine the musculature periodically. Inquire about headaches also, specially upon morning wake-up. Follow-up is important. He should be fine with proper management.

I love the open contact on the mesial and the failure to deal with the tipped molar on the distal. After your patient cleans all the food out of those embrasure spaces he likely will have even more shoulder pain.

If the shoulder pain started after the abutments were loaded then TMJ disturbance and pain as a sudden onset can still be considered, but the evidence you have provided suggests the implants were placed first and loaded at a later date. Pain after placement but before loading does not seem due to TMJ disturbance as a result of implant placement. Altogether a different story if a pre existing condition had a trigger. Do correct me if wrong it's my personal interpretation.