Patient experiencing pain after removing cement underneath crown: treatment?
I recently delivered two single cemented implant crowns. Radiographs clearly showed cement underneath the crown margin, so I decided to remove them using a Cavitron [ultrasonic vibrations to loosen cement under crowns]. I guess I cleaned it too aggressively because patient experienced extreme post-operative pain. I prescribed Motrin 600 mg but the pain was not relieved, so I decided to remove the crowns which reduced the pain around the implants but the patient still had moderate pain when opening the mouth. No pain on percussion done on the implants nor palpation around the implants. Any thoughts about the cause and treatment? What should I do now?
9 Comments on Patient experiencing pain after removing cement underneath crown: treatment?
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CRS
7/9/2013
Remember an implant is not a tooth, there is no junctional attachment just a long epithelial attachment. A cavitron was probably overkill when a titanium scaler and some patience would have been fine. You may have stripped the attachment, I would recommend replacing the heading heads nd letting it reform. Tylenol #3 will help. Next time try the implant analogue technique of placing cement to prevent excess. It has been posted in osseonews and dental xp. But very importantly you were very wise to take X-rays nd remove the cement that is how implants fail. I'm sure other posters will give techniques to cement. I recommend screw retained whenever possible it should be the first option. Good luck and thanks for reading!
sharon
7/9/2013
Hi CRS;thank you for the info..where in osseonews is the analogue technique for cementing an implant crown? I do agree though screw retained is better! Thank you!
CRS
7/9/2013
Sure, you can google dental implant cement technique, there is a PDF file from wadhwani and pineyr Journal of Prosthetic Dent 2009,102,57-58 titled Technique for controlling the cement for implant crown. It uses blue mouse and Teflon tape to make an analogue out of the mouth to control cement. I also heard it discussed extensively at the last AAID meeting by several practitioners. Good stuff!
Zvi Fudim
7/9/2013
I disagree about screw retained approach since the disadvantages of screw retained crown are greater then the advantages. Firstly the screw retained fixtures are cast and polished what reduces the accuracy and has a huge impact on the seal between the abutment and the implant. Secondly a poor fit leads to the screw loosening. Thirdly in case of multi unit frameworks there is no control over the passive fit what results excessive para-axial forces on the implants. A simple and a predictable solution is to use the G-Cuff as a cement barrier when cementing the crowns. It is a small plastic ring that is placed on the abutment before the abutment is screwed to the implant and removed after the cement is set preventing the cement from going apically. I call it the G-Cuff "Cement Fighter".
Good luck
CRS
7/9/2013
if the crown is made properly and the implant placed correctly many of these things will not occur the screw just makes the restoration retrievable. The implant crown is not susceptible to caries and the crown margin should not be too far sub gingival for hygiene. Many the problems are eliminated if he site is prepared properly and the implant placed with the final restoration in mind. I think we have a tendency to cement since that's how crowns were originally placed in dental school. Cement in the sulcus will cause the implant to fail, period. An implant is not a tooth.
Zvi Fudim
7/10/2013
The seal between the abutment and the implant is a problem. Screws always smells even after couple of days. The fact that a screw retained crown is retrievable is very good but it is not enough to compensate the other problems of the screw retained crowns. Historically the first two piece implants were designed for screw retention then people realized that they cannot achieve precession with UCLA abutments switched to cement retained but recently due to cement perimplantitis returned to the screw retention. Since the G-Cuff solves the problem of cement I would strongly recommend giving a second chance to the cement retained crowns. I've found a YouTube videos about the G-Cuff please check them out.
JS
7/10/2013
Zvi,
Your comment about the poor fit of screw retained implant crowns doesn't make sense. The UCLA type abutment is made with a gold casting abutment that is beautifully machined by the implant manufacturer to fit as precisely into the implant as any stock abutment. These gold casting abutments have a plastic burnout sleeve that the technician waxes to provide proper emergence etc. But the wax and plastic burnout sleeve are well separated from the part that is machined to fit the implant and therefore won't affect the fit.
Zvi Fudim
7/10/2013
The gold abutment is made of two parts as you said the gold and the plastic. the technician waxes the abutment then he invests it. the next step is a wax lost technique when the cylinder with the invested part placed in the furnace at 1600 F (890C) and the wax and the plastic ring are burned out. At that point the gold ring oxidized and becomes almost black. when the part is taken out from the cylinder after the casting it should be sand blasted finished with abrasive instruments and polished. That's when the accuracy of the abutment is practically vanishes. A milled abutment has also some tolerance but here we are talking about 2.5 microns ( 1 tau ). In that case to minimize the impact of the tolerance I would recommend implant with tapered platform.
mwjohnson dds, ms
7/10/2013
You didn't specify what abutment style you used. It is imperative to have either a cad/cam abutment (atlantis abutment) or custom abutment made so the finish line is no more than 1mm subgingival. This makes cleaning the cement a snap. Also, I use a radio opaque cement like tempbond. The temporary cements are much easier to clean than a resin type material.
Yes, I suspect the cavitron was a little much. I never recommend sonicare around implants either due to the more fragile nature of the attachment and never recommend going subgingival on a healthy implant with a scaler or probe. Is the patient sonicaring the implant crowns? That could be causing the increased sensitivity. Otherwise, I agree with replacing the healing abutment, letting the tissues heal, then replacing the abutment and crown.
