Metal allergy and implant failure?
I™m seeking some advice regarding a recent early implant failure. I have a female patient in excellent health and 4 weeks ago I installed a 3x10mm Intra-Lock implant with Ossean surface in #30 site [mandibular right first molar; 46]. The site had been edentulous and healthy for many years. I attained a 35Ncm initial primary stability. Everything went well and the patient was scheduled to return for the insertion of the abutment and crown. The night before (3 weeks after placement) she was scheduled to return she developed swelling and pain and the implant exfoliated. She later claimed that she has an allergy to silver and that is the reason the implant failed. There was no disclosure of allergy during consultation. What should I do? Has anyone had any experience with allergic rejection of any type of implant? What would you suggest for the site and/or any future use of implants for this patient. She had no other local or systemic factors of significance for this procedure.
13 Comments on Metal allergy and implant failure?
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CRS
7/31/2014
Two things jump out at me first four weeks is not enough time for integration. And I don't think there is any silver in an implant. Thus sounds like either, osteocompression especially in an area that has been edentulous many years, bone type? Or infection. Does not matter, I would replace it. Allergies are extremely rare, I would explain that to the patient letting her know the composition of this particular implant. It will be hard to overcome the patient's belief of metal allergy so you could try a different implant type assuring her that there is no silver II it. More importantly, watch the insertion don't overheat of compress the bone and allow enough time undisturbed for osteointegration, with that time frame it is probably loss from compression, operator technique, it can happen no one is perfect. Good luck.
greg steiner
7/31/2014
The patient is not allergic to silver she is allergic to the nickel in the silver. Approximately 5% of females are allergic to nickel. A nickel allergy is very easy to diagnose. The patient will either be wearing no jewelry or only high content gold jewelry. She will not wear clothing where metal contacts the skin such as levis. I can't imagine an implant company putting nickel in their implants but many implants are titanium alloys and I don't know what they are alloyed with and it is possible she is allergic to something in the alloy. I believe Astra implants are pure titanium. If your first implant was an alloy is suggest you try a pure titanium implant and see if that makes the difference. In my many years of doing a few thousand implants I never have experienced a patient where I could not make a titanium implant function so an allergy to titanium does not seem like a possibility. Greg Steiner Steiner Biotechnology
CRS
8/2/2014
Reread your post did you mean to place a 3 mm wide implant in the mandibular molar site and restore it permanently at four weeks?
Mark Montana
8/5/2014
Good call CRS, a 3 mm wide is either a typo or clinical error. If indeed a 3 mm wide was placed, perhaps early failure is a blessing.
Regarding allergy: Silver in practical use is typically alloyed but not with titanium and of course there is not a cross allergenicity between Ti and Ag that I am aware of. If the patient is truly fearful of an allergy to titanium, it is usually pretty easy to get a metal sample from an implant company and tape it to the patient for three days and eval. Also good to observe if your patient wears jewelry or make up; metal oxides in abundance.
I agree with the above post that the simplest explanation is pressure necrosis, overheating or infection; it happens.
ben manzoor
8/5/2014
Hi
could u clarify a couple of points:
1. was it a single piece implant? like milo
2. did u place it flapless?
3. do u hv pre op and post op xrays.
thanks
PJM
8/7/2014
Thank you for the considered comments regarding this case.
The implant placed was a MILO one piece and was selected after consideration of the patients financial position, light occlusal forces, elderly age and desire for a less invasive surgical procedure. Assessment of a cone beam ct was done before selecting the 10mm implant. However, in hindsight and after inspection of the implant in situ I may have been over cautious with respect to the risk to the inferior alveolar nerve and could perhaps have increased the length to 13mm.
With regards to the use of a 3mm diameter implant I was given confidence in selecting this implant as a sound option in the lower molar position after attending an advanced course advocating the use of such implants by a highly regarded educator in this field. It was suggested that it was no longer needed to place two small diameter implants to replace a molar but that the MILO 3mm was a sound option.
After consideration of my procedure and technique I can say that I don't feel that overheating should have been a factor. Osteocompression may have been an influence but if so then how could this have been avoided by following the accepted protocol of advancing the implant with finger driver and ratchet?
Anyhow, I am now left unsure of my confidence in offering this procedure moving forward.
Once again thank you for opinions and advice given.
Tom
8/5/2014
Check the implant composition.
Some implants have some very interesting
combinations. Keystone's Prima contains
5% aluminum and 3% vanadium in addition to
other trace elements. Any of these could be the cause of a reaction.
Remember it is the oxidized later ot
the implant that is integrated. If the oxide is scraped off then
all bets are off. Google titanium allergies. It is out there.
ben manzoor
8/9/2014
considering single piece Malo implant technique including under drilling and using implant to shape the osteotomy. Also flapless technique doesnt let you evaluate the anatomy or residual pathology where cbct was not taken.
Also patient can end up loading single piece implant while healing.
In my opinion mimi implant is sub optimum long term choice in this situation from functional and perio point of view.
Any how failure is likely to be down to compresion necrosis or non healing socket in the area.
Unfortunately no case is straight forward enough or no technique is simple enough to disregard need for optimum planning, training and background knowledge.
CRS
8/10/2014
Would not recommend placement of a 3.0 mm diameter one piece implant in an edentulous molar area. It is too easy for a patient to manipulate the exposed implant and cause micro movement. I would not do it is too small an implant. I agree with Dr manzoor above .
Mark Montana
8/12/2014
I certainly disagree with an educator that would advocate a 3 mm, one-piece implant as a single tooth replacement for a molar. Contrary to my above comments regarding cause of failure, now that I am know it is a one-piece, I speculate that movement of the implant is the most likely cause of failure. These types of implants are hugely dependent on dense cortical bone and are usually restricted to the lower anterior if success is to be predictable.
Dr. Johann Baer
8/12/2014
Dear collegues, we use implants made of zirkondioxyde. We never saw a kind of problems with the immune system. See for example the Zeramex Plus.
Best regards
Dr. Johann Baer, Switzerland.
Ali
8/12/2014
Forget what you were told in that course, burn your notes and take a decent new course in implant before doing anything else. Refer the patient for a new implant or graft and place your new implant after your next course.
Dr Bob
8/12/2014
If the cost of the implant is of a great concern consider the low cost full size implants that have been proven to work well such as:
Implant Direct, MIS, Park Dental, there are others also from about $ 80 - $ 200 some including the healing caps and abutments with no additional cost. I believe that the Milo implant with the separate abutment cost is within the same price range. There are very few times when a cost difference of less than $ 50 for implant and abutment would be the deciding factor for my choice of implant. I use the Milo implant in my practice, but because it is what I want at that site, not because of the cost.
