Possibly cold welded healing abutment: what to do?

I think you need a special pliers which can holed the neck of the implant firmly ,then you can apply a higher torque in order to remove the healing abutment .I m ready to provide you with this kind of pliers freely, regards

@mazen dukhan. Thank you for the offer but this is a submerged, bone level implant. How do we hold the neck of the implant plus the hex screw slot seems to have slipped now.

What is making me nervous is the timing on all this. At eight weeks post op the implant is still osteo integrating and bone is remodeling. I would have waited at least 12-16 weeks post placement especially since the implant was placed in a eight week still healing extraction site. There are two possibilities here, a stripping of the healing head screw, I don't think the torque is enough to truly "cold weld" or the implant is not fully integrated so the reverse torque is not a good thing. I think the pliers suggestion will allow you to pull the implant out also. If you are an Oral Surgeon are you going to restore this implant? What will tell is over the next few weeks if the implant demonstrates bone loss on the X-rays and becomes loose. If so remove and start over allowing the ideal healing parameters. Good Luck keep us posted.

when i suggest the pliers i mean this is too special for this case it has two sharp edges formed to hold cylindrical body which can holed the implant neck and embraces the healing screw inside without any contact with ,

Happened to me and needed over 120 Ncm reverse torque which removed the Implant ......... sadly and then even after removing it using mole grips to hold it it required about 220 to remove the healing cap .. Life goes on

I suppose CRS is the Oral Surgeon here so I always look forward to hear his opinion on this, and Peter Fairbairn generally has a fairly pragmatic opinion about everything. Well, my policy is generally to wait for 8 weeks in the mandible and 12 weeks in the maxilla; add one or two more months if it is grafted. At site opening, there was good quality bone that I encountered, and had to use tap drill to ensure complete insertion of the implant without too much force. The healing was uneventful. The total wait post implant placement was exactly 9 and a half weeks. I took x rays, verified good clinical healing and then the restorative dentist came in who did a pickup impression coping. He had the healing abutment placed back, and the next time I heard from him was a worrying voice that the healing abutment is not getting off. I went as the maverick surgeon, and soon humbled when despite using the 30 N Biohorizons torque wrench, and then the 70 N anti torque on our implant motor, the abutment wouldn't just budge, and finally the hex screw slot slipped. The patient being an Engineering guy himself realized, and asked about options and I said I will research over the weekend and get back. People have suggested 1. ice application and then trying, 2. a straight slot to engage the regular home driver, 3. using an ultrasonic topic to go around the abutment, 4. Prepare the abutment to put the crown directly, 5. drill a through-and-through hole into the screw where it would somehow fracture and give way. Patient though understanding enough, does not think implant removal would be an option since he will be traveling overseas in a month and half time. CRS do you think, this excessive anti torque application might have started a bone resorption at the crest that we will realize later? @Mazen Dukhan; can I see a picture of your instrument; it will be very interesting to see. If you can post it to the Osseonews admin who can then forward it to me? Thanks.

you can check the pics at the osseonews faceboook page.

Try this: Put a hex driver into the healing abutment with a torque or ratchet wrench. Then use an instrument like a small mallet or the back of an elevator and give the wrench a sharp tap in the counterclockwise direction. This will usually break the seal and free up the healing abutment. This is the safest way to do it since the force is high, but the duration is instantaneous. Much better then sustained high forces. Good luck, Chuck

Dr. Dukhan's primary language (I am assuming) is not english---so I am going to help with the technical part of posting the very elegant design of his device. Its on his facebook page as he mentioned---all you have to do is click on his name and scroll down--you will see the patent, and a few miscellaneous photos--and then the submitted drawing of the device he designed (to the patent office). OR--this link-which will take you to the same place.

I endorse view by Chuck. Tapping is the safest solution to unscrew. In my experience it has proved.

It is almost impossible for a Biohorizon abutment to cold weld to the implant, so the reason that the abutment is difficult to remove is because, overtightening of the abutment, cross threading of parts not properly matching. Placing the cavitron over the healing abutment and then trying to unscrew it may be one of the options. Applying more force may be another solution. The radiograph shows bone loss at the crest, unless it is burnout of the radiograph. I would be also concern of the periapical radiolusency at the mesio buccal root of # 30. Raul

In general, a cold welded connection is released by a combination of moderate rotational force in conjunction with a "withdrawing" sharp tapping force. Not necessarily a strong withdrawing force. I am assuming you have the screw removed and that you are referring to the abutment's having a cold welded connection. Rotational force alone won't release a cold welded connection. That's why it's used on aircraft engines and ship's propellers.

There is research that shows a cold weld is not a real occurrence. I agree that it is probably a cross threading. Dennis

I am the Prosthetic Product Manager for BioHorizons. I would be happy to help you troubleshoot this situation. Please contact me at your earliest convenience. BioHorizons USA 1-888-246-8338

@ Nick Ritchie; dropped an email last friday; there has been no response. Just tried calling the number you have given twice, and after really long waiting, couldn't get to speak to anyone, including the operator!! @ Raul Mena; the relative less density distal to the implant is traces of the socket, which takes typically 6 months to become radiologically indistinguishable. How overtightening one can possibly do with fingers? Is everyone alluding to the fact that we use a fractured screw removal kit? The hex screw slot has slipped now. Will use a scaler tip anyway to impart some vibration.

@AAslamOMS: The short answer here? Choose your own option #4 AAslamOMS! It is the best, and easiest solution to your dillema, by far (to solve the problem for the patient, as well as for yourself, from a patient management standpoint). And here is why and a few other points to consider: Simply prep the healing abutment and crown it. That was option #4 in your list of possiblities. Make sure you don't over-taper! Prep the healing abutment with just a minimal taper to enhance the mechanical retention of the crown. If the healing abutment is too short and you're concerned you may not have sufficient retention, you can obtain additional retention and stability by also prepping out the hex-hole in the healing cap's head slightly conically toward the surface (as if to receive a cast post) and have the metal coping of the final crown cast with an integral internal post, like in a Richmond crown. The hex is already stripped anyway, you cannot do it any more harm. If the resulting abutment (the prepared healing cap) is too short, and you still have retention/stability concerns, cement the crown with a self-cure resin, With weak retention the crown will still be easily removable for maintenance. You should also add a couple of longitudinal (vertical) grooves in your preparation (of the healing cap) to also add a bit more mechanical retention and anti-rotation to the crown. You may think those vertical grooves are insignificant, but every little bit helps. (Remember that it is the sum of the details that create the final result.) Take the impression like you would for any other crown prep. Make sure the emergence profile of the final crown has no height of contour right at the gingiva, which would retain food and traumatize the gingiva, possibly causing slow coronal bone loss or peri-implantitis over time. This detail is even more important if you are unable to create any sort of chamfer or shoulder at the gingival margin of the preparation. It is imperative that the final crown should taper smoothly coronally from the free gingival margin. The placement of the natural (anatomical) buccal and lingual heights of contour to direct the food bolus away from the gingiva is also imperative, but it must not be done in such a way as to cause an excessive undercut in the gigival 1/3 of the crown. Considering the patient's short travelling time frame, this is your best, most efficient, and least head-ache prone solution, Considering the implant is still fresh and, as per the x-ray, bone has not fully healed around it's head, specially in the distal, all other solutions would disturb the implant excessively. Applying ultrasound may work but it may also damage implant stability long term. I see it as too risky, specially in such fresh implants. Likewise the solution with the counter-holding pliers involves applying a gread deal of force on the implant, which is also very risky. Even with the special pliers that would counter-hold the implant as you try to unscrew the frozen healing cap, it is humanly impossible to avoid applying excessive force to that implant, in one direction or another at some point during the procedure. Do yourself the favor and prep the healing cap for a crown, and save yourself AND the patient the unnecessary additional sweat. Two months is way too early to disturb this implant in any other way, which is only about 75% in solid bone, at best, and only 50% on the distal. I would not have restored prior to 12 weeks. I have seen this situation before, and have witnessed other's attempts which resulted in disaster (removal of the implant or its failure in just a few months time). I personally have solved it as described above, and it was by far the best and least risky solution of all. Best of all, it worked out very well. Remember that one of our mottos is to do no harm. Preparing the healing abutment for a crown does no harm to the implant, or the patient.

Dear AAslamOMS How about the radiolusency at the apex of # 30 mesial root? Raul

@Raul Mena; the 46 is asymptomatic and didn't notice the radiolucency before in other radiographs. Will investigate it though. @Matt Helm; thank you very much for a very detailed explanation and least risky solution suggestion.

@AAslamOMS: You are quite welcome! Glad you liked it. It is indeed the least risky, easiest, and kindest solution by far. I am always for erring on the side of kindness. I also omitted to mention that if the implant collar (or even any of the implant threads) protrudes from the gingiva, you can ALSO gain additional crown length by preparing the part that protrudes with a diamond and copious water cooling. You don't need to prep much, just enough to elimnate the implant's threads (if any are showing) and create a taper. Any mm you gain in the length of this crown will aid retention and stability. You have nothing to lose if you prep the collar (or even part of the implant) because since the healing cap is so frozen you'll never be able to place a proper abutment on this implant anyway. Use the tricks I described -- the post prep in the healing cap and vertical prep grooves -- to add retention and you'll be just fine! Had you tried any of the other alternatives you would most certainly jeopardize the implant, maybe even yanked it out, because even though it may have looked submerged clinically at the time of placement, radiographically it is not. I especially don't like the distal, where radiographically only 50% of the implant is in solid bone. That means bone is a long way off from truly forming, specially on the distal, and that's IF it will ever fully form all the way up to the implant collar..I especially dislike the counter-plier solution as being too traumatic and risky. Once an implant is placed, it should be forced or torqued as little as possible. I don't know how this healing cap was placed or who placed it, but as a point of safety, I always prefer placing healing caps and abutments BY HAND. You can never go wrong with your finger feel. Using the handpeice can cause cross-threading, which is what I believe happened in this case. Good luck and let me know how it works out!

Thank you everyone; got lucky today, and it came out quite easily today after a lapse of about ten days. Had seriously started to think about asking the restorative colleague to do a healing abutment preparation to directly receive a crown. However, thought should give it one serious try. Tried the regular scaler (Cavitron) gently in an anti clockwise direction twice for about 4-5 minutes each. Then the restorative dentist had the slot through the healing abutment deepened adequately, and when the flat head home use screw driver was inserted, it came out with almost no force. Guess the scaler had done the trick already and it just needed a little bypass mechanism to derotate through a regular screw driver. Have put the picture on the facebook picture here at @ Raul Mena; the adjacent first molar tip is all clear. No endo/perio on x ray.

What r the chances of the implant re-osseointegrated after it is loosened during healing cap removal and implant immediately placed back in the socket? a colleague had encountered similar situation n told me that he had loosened the implant during healing cap removal but implant was quickly placed back. he gave it time n eventually the implant osseointegrated, n he restored the tooth.

From Senior Wien you have problem to lose healing caps. Spray coldspray on a cottonpellet and hold it on The CAP for 5 seconds. Now you can unscrew the CAP. Regards Olle

it has happened to many. I have tried simple technique of tapping the healing abutment with back to mirror handle (exactly when bottle cape does not open one tape it all around gently with spoon before opening). It breaks the cold weld bond. Generally it works.