Non-Osseointegration of maxillary implant: opinions?
I’m a general dentist. Recently my patient presented to me with an implant placed in #3 site. The implant is a Nobel Replace 4.3 x 8mm. I referred patient to a surgeon, whom I know, to have the implant placed, but she went on her own and chose a surgeon from her insurance list. After 4 months of healing, I took an impression with the impression coping torqued to about 10nCM. 3 weeks later as I attempted to torque custom abutment to 30nCM the whole implant started to spin at about 15nCM. Clearly the implant is not osseointegrated. I spoke to the surgeon at that time, and he recommended that I only torque the restorative screw to 10-15 nCM and place the crown. I then called a surgeon whom I know, and he said to not place the crown or it will fail due to lack of osseointegration. Now, 2 months later, the patient went back to the surgeon whom placed the implant. The surgeon told her that I should not tighten the screw anymore because if the implant spins there will be a problem. Those were the patients words. Today, now 6 months after implant placement, I was going to check to see if the implant would allow me to torque crown on to 30nCM, but based on what the patient told me, I am reluctant to touch the implant for fear of taking the blame by the surgeon. Incidentally, I received a fax from the surgeon instructing me to cement the crown with temporary cement and re-evaluate in 3 months. Since I don’t feel right about this whole situation, I am reluctant to even do that. What is your collective opinion of this situation? Would you agree to place the crown temporarily? I told the patient that I will not touch the implant until the surgeon and I come to an agreement on the situation. The patient feels stuck in the middle. All I could do was reassure her that I’m trying to do the right thing. Thanks.
![]This is the only x-ray I have which was taken to assess abutment seating. At 4.5 months post-op. Sorry, no PA](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2014/04/X02706.jpg)This is the only x-ray I have which was taken to assess abutment seating. At 4.5 months post-op. Sorry, no PA
37 Comments on Non-Osseointegration of maxillary implant: opinions?
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Peter Fairbairn
4/28/2014
Sadly has failed , these things happen best to remove and replace a few months later . If it moves with such low torque after this length of time it is best to remove than waste further to and stress to all involved .
Things happen no one has died ...
Richard Hughes, DDS, FAAI
4/29/2014
You can remove all prosthetic components and request the placing surgeon to tighten the implant and give it time. Or as Peter mentioned, remove the implant and start over at a later date.
CRS
4/29/2014
I think the surgeon is giving you the run around. Not integrated is not integrated. I have heard of Dr Hughes technique of sort of recutting the threads by torquing the implant but I think enough time seems to have passed, you could try it but I would have a future plan of removing the implant and just starting over, as Peter says this is not the end of the world and we really don't know why it did not integrate. Now here is my million dollar question, what are people's policies on replacement of non integrated implants which have not yet been restored ? Is there a cost involved? Time frame? I struggle with this since there are many possible scenarios and I don't restore and don't have control over what happens after the healing abutments are placed, I try and send out a safely integrated implant but I feel I could improve . Comments?
Damir Mukhamadiev
4/29/2014
Forget it, The implant will be lost, screw it out with your fingers, send it to your surgeons))). Such things happen at about 2-4% of cases, it depends on 1000 reasons, but nobody knows which is the first one in this case. 1. Screw it out, 2. Reimplant in 4-6 months, 3. Restoration 6 moths later after reimplantation
peter Fairbairn
4/29/2014
Hi CRS , simple always my fault and re-done at no cost to the patient whatever the cause ( even if they are smokers etc ) , less than 1% of the Implants I place so part of the job .
Nice and apologetic to the patient , and re-do , never had another failure on the same patient.
When the referring dentist is restoring I now take an ISQ reading and torque the Implant to test passing the readings on the the dentist .
Regards
Peter
CRS
4/30/2014
I like that thanks for the input. It is a way of qualifying how the implant left your practice. Now a stickier question how do you handle a failed implant down the line either a restorative issue that you did not create, retained cement, retained impression material etc? What I am getting at is a policy on complications that you cannot control. Nobody's perfect, I repair my mistakes but how far do you need to go when other factors are involved?
Peter Fairbairn
5/2/2014
Sorry CRS missed this one ...... generally do it again grudgingly for free even if the restoring dentist is clearly at fault ...
Had a case a few years ago where the lower right 7 was restored by a referring Dentist and after 2 years it "came out " , when the patient came to see me he said it was the best day for many years due to the relief when it came out as that was all he could bite on for the last 2 years !!!
Yep I did it again for free......
Peter
Bob Cohen
4/29/2014
I agree with those that say to take the implant out and, after assessment of the bone post-removal, have a surgeon replace an implant for your patient. I would say that the lack of osseointegration and the compromised interface of implant to bone would not improve over time without a new rejuvenation of the osseous site for the implant. Hopefully, removal and time will allow for a successful next one.
Tomas R.
4/29/2014
Explain to your patient the whole risks about dental implants, unfortunately he or she has this scenario. Send your patient to the surgeon, he must remove the implant an do the guarantee process with Nobel Biocare too, it's free the replacement of a new implant, no matter if the size is different. Then, do the prosthetic rehab at the time and that's it. Don't forget to take several x-Ray, always will be better having a lots of documents and data to support your diagnosis and treatments. Good luck!
Diizii
4/29/2014
I think the implant is lost. Does she feel some pain while you are screwing, unscrewing?
If I understood well, months have passed after you noticed problem. Don't waste time. Screw it out, wait and place new implant.
We always do new implant at no cost to the patient. In almost all cases you get new implant from Nobel, so we are covered for that.
Mark Montana
4/29/2014
It happens, especially in the poster maxilla. My disappointment is with the surgeon's response and seeming avoidance of responsibility. Reads like both the surgeon and the implant are spinning. Remove and retry.
Lyle
4/29/2014
If "her" surgeon told you to under-torque the abutment, simply send her back to the surgeon and ask him/her to refer your patient to a restoring doctor that they work with. Your patient did go on her own to this surgeon. Sometimes it is better to cut your losses.
Rand
4/29/2014
This is great advice. Who wants to be caught in the middle. Like in the game of tag the last one who touches the patient is "it."
sherry
6/5/2018
could not agree more, surgeon who implanted it is ultimately responsible. He's passing the buck, dont let him. Poor patient looking for help. Many of you COULD help her, but its the responsibility of the attending. He's looking for a way out. SHAME ON HIM. Hold his feet to the fire. If he cannot handle this, he shouldn't be doing it, and resign.
LuÃz Jesús
4/30/2014
Tighten the components with your hands without the help of torque wrench. If you rotate the implant is lost. Explain to the patient that osteoointegrou not, unfortunately, you do not know the cause but as others have said this and not end of the world. Do it again, but with a real surgeon. Written notice of the surgeon, not rely on what the patient says. Remove the implant curette, to take full granulation tissue Store, suture, waiting another four months post implant, plus six months, put the tooth.
sherry
6/5/2018
then it would be your fault Luiz Jesus, IF you rotate the implant and lose it, YOU BOUGHT IT MISTER. Dont you know about medico-legal ramifications of such an action. PASS.
Dr.Bochlogyros
4/30/2014
Classic case of a failure of the implant in the upper Jaw due mostly to the length of it.If we take ISQ values on regular bases before proceeding to prosthetic rehab.we wont face such problems .An X-Ray showing the apex of the implant would help .
Richard Hughes, DDS, FAAI
4/30/2014
Length is not an issue in this case. The implant site was over prepared or the biologic aspect of integration is an issue or the trabecular bone was not dense enough.
The 100% solution is removal and try later. One can try to hand tighten to obtain primary stability and try to load later. The enemy is soft tissue ingrowth.
If removal is the option then grind out the internal aspect of the osteotomy and place OsteoGen and an immediate implant or just place the OsteoGen and let it turn over. Implant later. These are all viable options. You learn to figure these things out when you place implants a lot of implants on a regular basis.
Sherry
6/5/2018
Richard, how do you know these things unless you have been involved with the patients care directly and have seen her X-rays and chart? You cant ASSUME what's happened like you just did. I cant believe what I just read. NOT ETHICAL.
Jaime
4/30/2014
I had a " similar case " . On removing the healing cap , the implant joined the turns .
I tightened the implant against the cortical of the sinus with force . Left to integrate for 3 months . It´s been 3 years since and it´s fine . It must be done immediately with bleeding . No blood - no healing . Also no delay time !
Alex Zavyalov
4/30/2014
If you took the case for restoration it means you were sure that the implant had been integrated. It's hard to believe that the presented X ray is "the only X ray" you have. In other words you began the case without proper diagnostics. Why do not you show any current X ray?
CRS
4/30/2014
I just was reminded of something. I had a restoring doctor leave impression material in the sulcus. If the implant was truly integrated when the impression coping was placed then this could explain the change. We need to see a complete periapical to assess if the implant is integrated. Just a thought.
Dan
4/30/2014
As I said in my post. I only torque impression copings to about 15. It was at delivery that I finally torqued to 35. A PA is not diagnostic to show/not show osseointegration. I count in the oral surgeon to give the go ahead before restoring. For 15 years it's worked out perfectly until this particular case/surgeon. This isn't my first time to the rodeo. You don't truly know if it's integrated until you torque something down onto the implant or torque the implant itself. An x-ray isn't the answer to everything my friend. Wondering if you're the surgeon??
CRS
5/1/2014
Such a defensive and accusatory response to a simple request for a periapical film. And yes quite often lack of osteointegration can be picked up on a film. Perhaps next time you will torque the implant appropriately at impression to be sure prior to ordering an expensive custom abutment. Please try and remember that the advice is trying to help you regardless of how many rodeos you have been to. And in my experience things can happen like impression material or cement in the sulcus, but in most cases an implant needs to be checked clinically for osteointegration, since we can't do that on a blog, asking for a film is reasonable. At my rodeo I take a film just prior to exposure, then verbally advise the patient that I don't know if the implant is integrated until I check it clinically when I place the healing head, that is the moment of truth.
Dan
5/1/2014
CRS, You're right. I will start torquing impression coping to 35 at impression appointment. My defensive comments were directed at the post prior to yours. I Didn't appreciate the accusatory tone that he couldn't believe that the x-ray I had was "the only x-ray" and that by having that x-ray would've made everything clear. I will get a PA of this case and post it. Thanks. Didn't mean to offend you.
CRS
5/1/2014
No worries and in this case you are right I can't tell much on the periapicals. You know what to do, sorry that the surgeon is such a d*ck!
Dan
5/1/2014
I saw patient today and took these 2 PA's. The surgeon said he torqued to 35 and implant was stable. When I went to verify 35, pt felt pain at 30-35 as she did at surgeons. When I attempted to remove custom abutment (I had to because the abutment was in a different rotational orientation today) the abutment spun while still seated into implant. No need to beat this dead horse. I remain convinced that this is a lost cause. Thank you all for your input.
Richard Hughes, DDS, FAAI
5/2/2014
If you have a spinner at this stage, then remove the implant. I would start over and also perform an uplift to obtain more bone in the vertical dimension. Graft the site then revisit in 5-6 months. We have beat this topic to death.
Gerald Rudick
5/2/2014
Dear Poster,
All the comments above are very valid and well taken. With the submission of the last two xrays.... we are given a host of information that was not available at the onset.
You are not to blame for this scenario or its outcome. The surgeon should have realized that this implant was too small to take the potential load it would have eventually been exposed to, in an area where the bone quality is D3.
There is plenty of room to place a 5 x 13mm implant using the Summer's technique to gain additional length and width. The choice of implant should be one with more aggressive threads to increase bone-implant contact.
A suggested way to install the implant would be to use Osseotomes, to compress and compact the bone without removing any by drilling.......don't be so hard on yourself.....this is the surgeon's responsibility, to redo the case pro bono.......all that is lost for the patient in this case is a delay until the crown is placed..... and I would advise placing a temporary plastic crown at first and watching the situation for a few months before the impression is taken for the definitive crown.
Gerald Rudick dds Montreal AF AAID ; F,D,M ICOI
Carlos Fernando.
5/4/2014
Dear colleague,
In my opinion you should not touch the implant before 6 months, specially in a zone near the tuberosity since the bone is not the best there. Also, you should ask for the surgery report to the surgeon when you can check the final torque at the insertion time. Sometimes you got to wait more than usual, some cases are extraordinary. But for how I see things right now, I would contact someone who can measure the osseointegration with the Ostell Device. If the value indicates is osseointegrated, you are good to go, if it's just a bit below the osseointegration value, wait a couple of months more and if the value is way too below osseointegration value, start over again. Although i believe you shouldn't touch the implant in the first place before the 6 months healing period, you have on your side that the patient did not follow your indication and choose a surgeon by her own.
Tell us what happened in the end.
dan
5/5/2014
Hi this is the original poster,
The surgeon saw the patient again and said the implant was stable. I saw her 2 hours later and spun the implant as I tried to reverse the abutment screw. I contacted the surgeon to tell him. He replied that he recommended the patient get a second opinion from a prosthodontist whom he knows. I spoke to the patient, and she was considering seeing that prosthodontist. I suggested another as a 3rd opinion, whom I know, if she desired. If either 2nd or 3rd opinion says to go ahead and restore, I will let them restore it, and unfortunately I would dismiss the patient to avoid being blamed for who knows what later. When the implant does fail, they may claim that I didn't check the occlusion frequently and I'm to blame. Who knows, so I will get out of the way of this situation all together. Thanks again for everyone's comments.
CRS
5/6/2014
Very very wise, you are done with these non-compliant people and have the responsibility shifted since the patient was appropriately referred. I had a similar case I almost got caught in when the patient ended up in my chair for complications on implants I did not place. The restoring doctor and implant placing doctor both reassured me that the five implants were not failing and I did not know how to read an X-ray and the implants were perfectly fine. She canceled her removal appointment thankfully. Later all the implants failed and were removed. I am grateful and relieved night not to be involved! Sometimes it is best to walk away when people don't comply!
Mircea
5/6/2014
Why do you need Osstel for a certified spinner? Leave it alone and revisit after 3-4 month.Miracles happen.Good luck!
Robert Wolanski
5/7/2014
Just following the comments. I would be careful not to hope for a "miracle". It is a spinner that, as was pointed out earlier, has the enemy of fibrous ingrowth. The predictability of a miracle does not serve your patients best interests given the risk of infection and bone loss which is inevitable. Yhere is some great advice here about how to procede. To maximise the odds in your favour and the patients, explant, graft(site and sinus separately if not experienced),wait 6-9 months and place an implant that is better suited to the location and occlusl load requirements.
greg steiner
5/8/2014
The implant did not fail. The bone failed. This site was grafted with a nonbiocompatible material and because of poor vitality of the mineralized tissue integration did not occur. You will likely have the same problem with the next implant due to the presence of this material. If a larger implant is wedged into this material it could support the implant for a few years but likely fail again. You are lucky to not be involved and if it was me I would send this patient to the surgeons prosthodontist for the restoration so he can redo it when it fails. Greg Steiner Steiner Laboratories
DR Saad yasin
5/9/2014
This Implant is failed.
you can remove the abutment and with a ratchet try to screw the implant and see if you will have primary stability then screw the cover and wait for 2-3 months and reexamine the implant for osseoitegration.
Or you can remove the implant and do curatage of the implant bed and wash it with saline and then put a wider implant to have better primary stability and wait for 2-3 months and then do the prosthetic phase.
Manosteel
5/1/2017
This implant is a looser and has failed to integrate. You should be able to torque your abutment screws to 35ncm even 40! I place and restore my own implants. I took a LOT of courses and Carl Mische's surgical and prosthetic programs. Although Carl is no longer with us I believe Randy Resnick has the program along with Temple U faculty. Still highly recommended. I would remove the implant graft the sight and place another implant 4 mos later. Also it sounds to me like this Oral Surgeon is jacking you around and I wouldn't tolerate it! Get rid of this guy and get someone else! O.S.'s are a dime a dozen and there is one out there who will work out better for you with out shifting blame or throwing you under the bus!
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