Max central immediate implant after 4 Months sensitive to torque: feedback?
I placed a 3.7 x 12 mm Zimmer TSV implant in #7 site [maxillary right lateral incisor; 12] in this healthy 40 year old immediately after having removed his horizontally fractured tooth. I did have some concern about the primary stability as it was difficult to engage enough bone apically. However I did achieve adequate primary stability. Patient was not having any problems at 4 months post op. He then presented for restoration of the implant. I attempted to restore but I found even removing the healing cap produced mild pain. I found the same with the impression coping. I did take a periapical radiograph which in my judgement looked normal. Given the only mild pain I decided to put the healing cap back in place and wait another 2 month’s to restore. I have included periapical radiographs of the day of surgery and 4 month’s later. The soft tissue looks good all around. I would really appreciate any feedback you have.
At placement
4 Month’s post op
22 Comments on Max central immediate implant after 4 Months sensitive to torque: feedback?
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peter Fairbairn
11/8/2013
Dear Poster sadly I would remove as I said elsewhere ...... this is not a praying game and even if there is a small improvement in the next two months it will be lost in the future costing you and the patient more time and money.
So take the medicine now.
How do I know , it has happened to me like many others I assume.
Good luck
Peter
CRS
11/8/2013
It may not be intergrated.
Tooraj Moravej
11/9/2013
i do agree with Peter , the implant has not been integrated , so remove it , curette the site , removing all the granulation tissues , wait for 2months and then place another implant
Richard Hughes, DDS, FAAI
11/9/2013
Poster,
The patients pain indicates that Thai implant did not integrate. You should remove the implant, curette the osteotomy and graft the osteotomy with a particulate graft material or curette and place a wider implant.
Remember, when one views a radiograph of an implant, it's difficult to determine if there is integration. This is due to the radioopacity of the facial and lingual plates of bone.
These things happen!
CRS
11/9/2013
You may want to consider grafting the extraction site especially with a fractured tooth in the esthetic area and allow for healing then place the implant. Trying to extract, place and put a healing cap is a lot to manage all at once, you're more talented than I am. Pain is a sign that the implant did not osteointegrate, that is pretty basic . I hope you get that. Good luck just learn from this experience no judgement.
Brent
11/10/2013
I really appreciate everyone's feedback. I will be bringing this patient in this week to remove and graft.
Odd thing is that when he came in last week the tissue looked great and though there was pain the fixture never unwound with the healing collar or the impression coping. I'm sure though that with the actual implant driver it will unwind easily. Anyway thanks again.
Brent
Dr. Anas
11/11/2013
I totally agree with Dr. Peter. Do not waste your time.
Remove it ( I think it will be easily remove) do some curettage and immediately place longer implant.
pickle
11/11/2013
Please do let us know if the implant unwound easily.
sim
11/12/2013
Just had exactly the same.
Pain on removing healing cap at 3 months and when torque applied.....
Booked in this Thursday for removal. Using neobiotech removal kit to remove
Some take... Some don't. Fortunately it doesn't happen often!
greg steiner
11/12/2013
What was the graft material? Greg Steiner Steiner Laboratories
E Mellati
11/12/2013
One thing that I suggest considering is the incisive canal nerve bundles being in contact with the implant. Your pre-op CBCT would be helpful in finding out how close the tooth root was to the incisive foramen and canal. This is a possible phenomenon in central incisor sites and rarely may present such symptomes. Before attempting for explanting, do torque test under LA. If the implant doesn't move even under high torque means that it's integrated. Then you can construct a temp crown and let the patient function for a while to see if there is any pain/tenderness on function or not. If not proceed with the final crown, if yes explant, graft and go for a shorter implant after healing. Re-scanning the area before redoing the implant would be beneficial to ensure you're staying away from nerve bundles in the second go.
Richard Hughes, DDS, FAAI
11/13/2013
Dr Mellati,
You bring up an interesting point. Yes, nerves do grow to implants. This has appeared in the literature several times over the years. This can result is temperature sensitivity about an implant because the implant can act as a temperature sink. So torquing would certainly yield sensitivity if a nerve grew to and wrapped around an implant.
Brent
11/13/2013
Thanks again for everyone's feedback. My patient is coming in tomorrow and my plan is to remove it unless the torque required is excessive in which case I will temporize as the patient has no pain unless it's being torqued and as I mentioned the tissue looks ideal. However I suspect it will wind out easily. I will post my results.
Brent
Dr. Nouman
11/13/2013
Dear Brent,
A few points:
1- Did u notice the gap between the fixture and the socket walls during implant a cement, was it 2mm or more? If yes Did u place any bone then?
2- I've come across scenarios like yours a few times, soft tissue is perfect around the implant but it unwinds on removing the cover screw, so i guess soft tissue health is not a credible marker for ossteointegration.
3- If we see the pre/post radiographs, implant seems to have spun, look at the apical vent in the fixture.
4- After explantation socket needs to be curetted properly as we can see traced of remnant sealer. Either a longer implant or a wider implant can be attempted after thorough excavation.
My 2 cents. All the best :-)
Nouman.
elievictor
11/13/2013
Check if there is trapped tissue btw the implant and the healing abutment. It happens when the HA is not fully engaged.
Dr. Nouman
11/13/2013
Point 1- during implant placement*
Brent
11/14/2013
As expected the implant wound out easily . I placed a graft after curettage and plan to place another implant in 4 months time. The bone was still quite sound all around. Thanks to everyone for their feedback.
Brent
Richard
11/19/2013
How much torque you used to wind out or it was just with fingers?
Brent Macdonald
11/19/2013
Came out with fingers only
Brent
Dr SenGupta
11/20/2013
Dear All
Am I missing something here?
For an extraction and immediate placement ...this is not a well placed implant at all.. and had a very high chance of failure from day one.
Where is the apical bone fixation?
At least 3mm apical to the socket is usually the pre requisite....
That is not difficult to do in what appears to be an intact socket....often placed slightly palatally
It is rarely difficult to achieve torque values of 45N/cm in cases like this.
It has also been placed with a one stage procedure with the tall healing head ....so the temp probably added insult to the already doomed placement.
Sorry ...I see this as poor prognosis from the first day.
Look at the number of threads the implant has engaged in the socket is it 3 ...or 4??
Bruce Smoler, DDS
9/21/2017
Dr Sen Gupta,
Salient points to be sure. It is good to remove rose colored glasses and truly be inspective of cases retrospectively. All too often, I find myself making that decision between good and better. As Misch used to say, "The enemy of good is perfection', but good has to be good and not reasonably adequate. Your assessment is spot on: if only 3 or 4 threads at best, then why not bury as a two staged approach? If one stage, why not cover screw and reduce micro-movement in the oral environment, OR deeper or wider body to engage more of the extraction site walls. All good points and in my view, the central issue to these message boards; to respectfully dissect and offer insight anecdotally to improve the proficiency of the field of endeavor we are all very passionate about... Kudos to you.
greg steiner
11/26/2013
Without a discussion of the type of bone graft used and the biologic capabilities of that graft material you will not understand why this failed. Greg Steiner Steiner Laboratories
