Poor Primary Stability: How should I manage this?
I installed an implant in #19 site [mandibular left first molar; 36] 1-day prior. Â I was not able to achieve primary stability and even had some lateral movement of the implant. Â The implant was also placed close to the adjacent tooth. Â I placed a Bio-Oss graft on the mesial of the osteotomy site. What are the chances of this implant achieving osseointegration in the long run? Â How long will it take to achieve osseointegration? Â Should I anticipate any problems with the implant being close to the adjacent tooth? Â Should I tell the patient there is a good chance that the implant may fail?
(click to enlarge photo)
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25 Comments on Poor Primary Stability: How should I manage this?
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Bruce Burgess
6/20/2012
Your chances of initial osseointegration are reduced due to poor primary stability. The implant is too close to the adjacent tooth so in the long run you will have bone loss around the tooth and the implant. You are in a difficult prosthetic position due to the placement. I also think the implant is too short, but others would probably disagree. In summary - 3 1/2 strikes against. Not a great short or long term prognosis. Remove and place properly. You may even want to slick the posterior molar and place two implants. Would depend on the occlusion which we can't see from this radiograph. Sorry to be the bearer of bad news. Thanks for posting.
Sb oms
6/20/2012
I have seen so several posts recently of beginners ending up with horrible results that could have been so easily fixed with a wax up and guide and a single pilot drill x-ray.
What the heck, who is teaching these people?
Basics people, come on.
Regarding poor primary stability:
1. Know your implant system, you obviously over drilled here.
You should have different protocols for different density bone.
2. You need to develop tactile sensation for the bone quality. Watch the flutes of your drill. With your smaller diameter drills- Are there bone chips coming out, or just bloody slurry. This will help you determine the density, and therefor the appropriate drill protocol.
OMS resident
6/21/2012
I'm sorry, but this is probably a gonner... Is this case done under the supervision of a periodontist as well??
--
6/26/2012
No, I was at a OMFS course. Why else do you think this was messed up?
--
6/26/2012
This is the comments from the post that your refer to that was "supposedly" covered by a periodontist supervising. See below. Hope you learn something more in your residency than being a d**che bag. Good luck.
jon June 19, 2012 at 10:48 pm | Permalink | Reply
W, I have to call some BS on this. If you were under the direct supervision of the periodontist why did you not remove the implant and replace at the time of surgery (i.e. why is the patient coming back for you to do this a week later?). It sounds as though the periodontist was not right there when it was placed but maybe you are in a class where you bring in your case and then present it. I am not sure but I can not imagine someone experienced in implants such as a periodontist who is educating allowing you to leave the implant as is after he “just told you†to remove it. Sounds like there was not direct supervision to me but I may be wrong. Everyone has mistakes like this at times but I would really like to know the circumstances of the placement (i.e. if the periodontist was right there when placed and what was said when you did not do as he recommended with the patient in the chair).
W June 20, 2012 at 3:07 am | Permalink | Reply
Hi jon
There was misintepretation by the editor that periodontist was present at the surgery. I wrote i had help with about 10 cases mentored before this case had happened. I did this case with no supervision. Sorry if i didn’t correct this before.
OMS resident
7/4/2012
Haha.. Nice one:-) Sorry if I stepped on your toes. Be a big boy and see the humor in it!
tomobooth
6/21/2012
Right how can you tell from a 2d radiograph that an implant is too close to adjacent teeth, just ignore comments above.
yes guides are helpful for beginners.
Leave this implant alone!!!!! don't remove it my opinion it will be fine and will not affect the adjacent tooth it looks to be circa 2mm away so just ok . Expose moving lingual tiisue buccally. Tell the patient to avoid eating in that raea just because it doesnt have primary stability doesnt mean it will not work if its a good implant-mainstream one.
Take more courses learn why you didnt get primary stabilitty over prep/ in relation to type of bone.
Make a screw retained crown for this patient and monitor with pa rads annually.
I think sometimes peoeple have to be very critical i wouldnt be too worried about this one.
Do not tell the patient they will get bone loss around the adjacent teeth because its too close because i dont think she will.
Dr Chan
6/21/2012
I am wondering if the patient on this post is the same as the one in the previous post? Although good primary stability is ideal, it does not mean that the implant will fail if the stability is poor.
Leal
6/21/2012
When this happens you can just remove the implant get a bone chip (even do it with a tungsten bur with the turbine with GOOD irrigation) place it in the osteotomy site (mesial or distal, whatever) and insert the implant as long as you have buccal, lingual bone, blood and initial stability. This frequently occurs on the posterior maxilla or mandible in old women.
Feeling lateral movement when the implant is placed is just not acceptable, period.
H.Barghash
6/22/2012
primary stability is a key for success osseointegration and for those who recommend to leave the implant I advise them to read a bout physiology of bone healing , you never graft an implant unless you have primary stability, this implant well hold by fibrous tissue which you well discovered during either impression or initial loading and both the doctor and the patient well be disappointed
Greg Steiner
6/23/2012
H Barghash I don't understand your rational for never grafting an implant that lacks primary stability? As a proof of principal I have floated implants is bone graft material with no bone contact and achieved integration. If you want to see such a case go to our Socket Graft Putty web page and scroll to the bottom to view the case. Greg Steiner Steiner Laboratories
H.Barghash
6/24/2012
G steiner
your comment means primary stability is not essential for osseointegration. so if you have cases like that I like to see it published
Robert J. Miller
6/25/2012
With regard to the positioning of the implant, I have no issues with the limited amount of information gleaned from this periapical film.The issue here is primary stability. Not one poster seems to want to comment on the huge radiolucency surrounding the apical half of this implant. Whether this was an extraction/immediate placement, extraction/graft/delayed placement, or extraction/no graft/placement,there is no excuse for placing an implant into pathology. THIS is the most likely reason for lack of primary stability.
RJM
naswe
6/25/2012
I think the implant is fine once u do not do emmediate loading leave it burried for at least 3-4 monthes till osseointigration is achieved , u could have placed a wider and longer implant instead for bitter primery stability, why always some colleagues are so critical
to some nondisasterous situation.
naswe
6/25/2012
primary stability is very essential in immediate loading cases but in delayed loading is good to achieve it but not very essential
Greg Steiner
6/25/2012
H.Barghash
The need for primary stability to achieve integration is valid if you are not using a bone graft or you are using traditional bone grafting materials such as autografts, allografts or xenografts because fibroblasts reach the surface of the implant before osteoblasts resulting in fibrous encapsulation of the implant surface. With our graft materials osteoblasts are the first cells to reach the implant surface and integration occurs. If you Google Socket Graft Putty and scroll to the end of the page you will see a well documented case where complete integration occurred with no bone contact. We published this case not to encourage dentists to float their implants is graft material but to establish that when using our material in bony defects around immediate implants you can get bone fill and integration to the grafted area. Greg Steiner Steiner Laboratories
DrT
6/26/2012
Is lack of primary stability really the issue in this case?? The poor positioning of the implant would seem to me to be the more obvious problem. In this instance, the lack of primary stability will work in your favor in that you can remove this fixture easily, which is what I strongly recommend ASAP.
CRS
6/26/2012
You'll know at exposure if you have a fibrous union vs osteointegration. Just forewarn the patient, if it doesn't integrate, just remove it and do it over. Wait about 8-12 weeks.
vong hak
11/7/2017
How can i know fibrous intergration of implant side?
dr. dan
6/27/2012
Take it out, graft, and so it again the right way
pranav sharma
6/27/2012
as there is little lateral movement,as you said so it can be removed with some ease.my suggestion remove it and replace it with a wider diameter implant.leaving it like this will also cause prosthetic complications.remember patient has to eat from the prosthesis and not the implant.do a proper waxup.take CBCT.Make a surgical stent and then place.take into consideration the bone morphology and then select your implant.
Regards
cerecer
6/27/2012
I feel this obsession with the implant angulation to be silly. Clearly when the fellow was doing his osteotomy he probably was intuitively choosing what appeared to him to be a good angle restoratively. And if you look closely at the pa you will see he was following the angulation of the adjacent premolar and although it appears close to the neighboring tooth there is still a nice margin of bone.
Implants should be placed where there is the most bone to encase it and prevent movement. We can always deal with the restorative using angled abutments or prepped abutments.
If you start thinking of the abutment supported crown more like a pontic and less like a tooth you will never have to worry about restorative. Take a fresh view of things..keep your mind open to other ideas....
Think about it..
If you can restore a molar a with a mini implant...and people do...than the whole idea of super large implants has just become obsolete. If you can restore a dentition on four implants than clearly its not the long axis thats important but the solidity of the fixture.
DrT
6/27/2012
To all of the posters who are offering various suggestions on how to restore this implant, I just want to ask you one question: "Would you want this in YOUR mouth??"
cerecer
6/27/2012
sure..if it is shown to integrate well...
I dont really see a problem with the restoration of the abutment..you may have a problem that there was no initial stability and it will fail for that but that is
an entirely different problem than the final restoration.
I would venture to say that the beginner implantologist probably drilled the osteotomy in the most intuitive location restoratively..regardless what this p.a. shows
Baker vinci
6/29/2012
Cercer, seems to get the " big picture ". Nice seeing some new blood. Bv.
Vinci Oral Facial surg. Baton rouge La.
