Post-Operative Pain from Implant Case: How Should I Proceed?

Probably due to under-instrumentation. Pain/swelling due to the pressure of implant in the under-prepared osteotomy. Pressure also extending to nose due to proximity to floor of nose. Monitor since symptoms are subsiding through out the week.

Could be a acute flare up of the previous pathology at the peri-apical area , followed the right protocol so hopefully OK . If acute area or any suppuration on tooth removal normally leave a bit longer to heal and currette extensively. Peter

Verry possible there is a perforation on the buccal. If tenderness persists may want to open the area on the buccal and re-evaluate. If so remove and graft.

i can c a lot of radiographic changes around implant as compared to preop....this kind of pain is either out of pressure or infection..and two weeks is little early if u were already waiting,try and open the site...

My guess, based on the immediate severe pain, is impingment of the nasopalatine space & nerve. Perhaps the doctors here can advise on prognosis & treatment.

I may suggest: at first, ask pt to use icebag at the first two days, the second, ibuprofen and tylenol priscriped at the same time, the third, anxious control support and also, the antibiotics may need to disp.

The pre-op radiograph suggests a slight radiolucency at the apex of 8 (possible periapical infection.) In placing the implant to provide proper emergence, your angulation may have resulted in a perforation of the labial plate with some sub-periosteal edema. This coupled with a possible periapical infection and the radiographic suggestion of perforation of the nasal floor - any of which could be responsible for the patient's symptoms. Did you lay a labial flap? Could you visualize the labial plate? Was there resorption which lead you to place the implant more deeply? With hindsight, perhaps block grafting and pediculated C.T. grafting of this site at the time of extraction would have provided a better base for an implant as well as better esthetics to the outcome.

As a patient and pharmacist. I might suggest more open thoughts as to post surgical anti inflamatories. I prefer personally Mobic 15mg TID x 72hrs then tid prn.

Seems to me to be a poor C/R ratio but I am not the restoring dentist or the surgeon. It is funny that you may think you are in bone and have a buccal perforation. After drilling an osteotomy, place a round endedinstrument in the site adn press against the buccal and lingual walls to assure yourself that there is no perforation. The trajectory of the bone could fool you. With the sam instrument press appically to see if you may have perforated the floor of the nose. The floor perforation is not such a big deal but the buccal perforation will possibly cause a failure.Time will tell. Be sure to reassure the patient and if it has to be removed, the sooner the better.

A lot of good reasoning for the problem is listed above. Since the pain and swelling has settled down, I would be inclined to open a full thickness flap and view the labial plate. The natural root was of a smaller diameter than that of the 4.5mm implant, and there may be a perforation. I would try to place particulate grafting material over the perforation ( if it so appears)and try to increase the thickness of the labial bone before considering removing the implant.

I have seen this in patients and the cause is likely underpreparation of the site. What was the final seating torque? Were any grafting materials placed? Was a tap used or needed? You will likely see die back around the implant from the pressure. In addition, if a facial perforation occurred, this can lead to the excessive inflamatory response. Bottom line, I would not open it if you are having resolution. With no emerging healing abutment, you wont be able to follow integration until you uncover. As far as mobic goes, good drug. The debate over NSAID's and bone healing is another topic. Best of luck.

You need to ask your self if there were any operator/ surgeon factors at play.... meaning - did you adequately clean the osteotomy site free of all granulation tissue, seeing you went in after only 2 weeks., - did you over torque -is there any chance of perforation of the naso palatine canal -did you have adequate irrigation etc I think at this stage I would leave alone and watch. I would keep the patient going on antibiotics+ anti inflammatories for another week. I also use a 3 day course of corticosteroids at the time of placement of implant and that usually brings the patient back saying they never needed to take pain relief after day 1. I think if pt cones back in pain or further discomfort, I would take a cone beam x ray taken to assess for any perforations in the naso-palatine canal, labial, palatal etc before making any surgical intervention including exposure. While implant placement is a relatively pain free exercise, these things do happen. only you may have the answer of why it happened though. I would be most interested in finding out how you went with this case so if you don't mind, keep me in formed. My e mail anand.patel@bigpond.com Good luck

On Second thoughts , I think your going back in in 2 weeks and grossly disturbing a granulation tissue plug in the socket may have something to do with the symptoms and swelling. Usually you would wait for 4 weeks to adequate closing and maturation of the gingivae to have a good closure and strength of tissue to help suture.

Third radiograph shows implant touching or perforating the floor of the nasal fossa. I guess you might have achieved more than the required primary torque value. (Compression necrosis..??) Not to worry...implant will be just fine.

Why no pre-op cbct? Anything wrong with#7 ? You might want to get a cbct done now in the event this situation is refered to a lawyer.

hello nice comments all over , i also think the implant could be oversized. but the way ahead ,if symptoms are resolving , i feel let the implant b in place do not open wait for osteointigration, then asses the situation and go for gbr if a perforation is seen during the second stage surgery. prior to loading. all the very best.

From the history, it is likely that the large implant may have forced a section of the lamina dura which is almost as hard as cortical bone and compressed the nerve that used to supply this tooth..... a neuropraxia. The body has great powers of regeneration and healing and can resolve this transient severe pain with time. But do not try this approach on the inferior alveolar because its loss results in numbness of the lip. In the case of the upper incisor area, any numbness is usually inconsequential. The prescription of antibiotics and analgesics is correct and the pathology will be resolved by the body over time. Be patient.

That much pain on the front end is a red flag on several accounts. It may be that backing the implant out a bit might relieve any compression issues, but I'm of the mindset to explant and develop the site. What's a few months for something more predictable long term? It's a front tooth. When you lose one there, it can be incredibly stressful for all concerned. Plus you can almost guarantee a huge challenge to get the site back to where you want it. I posted an anterior failure on Osseonews a few years back. It wasn't fun. Having this trouble, cut bait and reimplant when the biology is more favorable. I don't believe this is one of those situations that will "just work itself out". Just my opinion.

I have had 2 cases with pain after surgery. Patients usually remark that the post op was so much easier than they expected. I put them on antibiotics and the discomfort went away. I lost both implants. I agree to get the implant out sooner than later. I had a lot of bone loss.

I used to place Ankylos Implants. In theory a brilliant system, but in practice in my hands, my patients suffered severe pain, bone loss and early loss of the implants. If you look at the post op PA, there appears to be a radiolucency developing along the mesial axial wall of the implant. I have had colleagues who complain of similar outcomes. I had a very similar case six months ago, the patient walked into my surgery with the implant in his hand! There was massive loss of hard tissue. A bone graft and a Bicon implant six months later has resulted in a beautiful restoration. Just my humble opinion. J

All the thoughts are great. You may try a Medrol Dose Pack.

I think surgical technique is to blame for this. Either too little irrigation during the osteotomy or too much torque at the end causing pressure necrosis. I think it is placed correctly though. Just wait it out. And yes, I would use a bottle-shaped healing abutment for tissue guidance. Just my thoughts. Good Luck!

Just a few little notes, I tried early (4 weeks) a few times and found that the patient experienced alot more post op pain. So i stopped pretty pronto. Not a big fan, I would much rather do an immediate in certain cases or delayed 8-12 weeks and just accept that I will often need to graft. As you went into effectively an unhealed socket, the most likely complication, will be a perforation of the buccal plate from labial transport of the osteotomy. In these cases you often do not have quite as much room as the size of the socket would suggest. I would possibly think about down sizing to an A (3.5mm) implant in the future. You will engage the osteotomy in the palatal apical 1/3 with this not the buccal plate, and leave a void which you can either fill or not, place a flared regular healing abutment and purse-string 6/0 proline. (as an immediate) The implant appears to be a bit deep even for an ankylos, you may want to use a longer implant placing 1mm below the lateral crest, and graft in cases like this in the future. Ankylos implants have a few nuances which are different from the norm, but well worth the effort. (btw, I cant remember the last time I used anything other than an A (3.5mm) ankylos, implant (certainly not the last couple of hundred anyhoo i think I have one going out of date in the cupboard...I should have a look!) After all that, I think you should be fine with this case, just being a bit picky, the patient will most likely recover fine. (try to use the 1 abutment 1 time theory at the end just to cover yourself and prevent any bone loss) All the best, Mike

just i want to share u my exp. about controlling pain after surgery i think it is better to start with a voltarin 75ml im injection in the first day of the surgery. i did this routinly in addition to the NSAID ( BRUFEN TAB.)+ANTIBIOTICS+GENGIGEL GEL which contain hialoronic acid that help in collagen fibers formation> this is my protocol don't remove the implant >> just fellowup the case and observe the pain disappearance thanks alot best wishes

Pain could be becasue of pressure on nassal floor or previous infection. If the pain continue then remove the implant and place later again.

hello every one pain could be from pulpitis from adjacent teeth

Fair comments all around. You will generally have adverse reactions when replacing a root canal filled tooth. In spite of what endodontists might say, some endodonticall filled roots have a tendency to develop areas of focal osseus necrosis . If that tooth is removed and not enough time is allowed for the body to heal that area before placing whatever implant,you will illicit a lot of pain and inflammation because of release of toxins. You might be lucky and ,by performing your "placement-osteotomy" , unknowingly curettaged the bone It should heal but with more than normal pain. Give it a little time before explanting it. A general approach is a painful implant after 3weeks is an implant you`re losing.Read all you can about cavitations or NICO lesions and you will understand why when you lose an implant a few weeks after placement,you are surprized when you place an implant in the same position a couple of months later, it integrates without incident. Hope this helps

A lot of good ideas. I agree with mike stanley if there's no inflamation but severe pain i might think of a peripheral neuropathy: give implant one more chance. 1. infiltrate a small portion of anesthesia next to the imlpant site - if the pain reduse 2. infiltrate 1mg anestheic solution + 1mg Dexamethasone If u have reduction of pain try same proscedure one week later if not .....follow instruction written above

In regards to pain control after implant surgery.....if you know what you are doing, the patient shouldn't feel "pain" after the first two days. My full arch patients report only minor discomfort after the first 48 hrs. Rarely are they in pain after that or even take pain meds after the first day. I'm the one who usually fucked up when the patients are still in pain on the second day..... Stage 2 though....pains a bitch

I agree that the sight is under prepared, and implant is probably too short. Perforating the base of the nose or buccal plate Is most likely not the cause of your problem. If I had to quess , I would suggest that by not performing the complete osteotomy past the apices of the removed tooth, you could have sealed in an infection. Was the tooth symptomatic before it's removal? Why wasn't it restored( via apico). As an omfs , I want to place as many Implants as the next guy , but nothing replaces a natural tooth better than what was there. In my hands , Tylenol is useless and practically all NSAIDs have about the same efficacy . Dont be afraid to use a narcotic if needed. Keep the patient comfortable! I agree with waiting a bit, if you had better than average seating torque, your patient may have a chance. Obviously check adjacent teeth. B. Vinci /omfs

My personal observation is that there is never ever any pain post implantation! That is a rule. And to violate the rule the commonest reason is buccal plate perforation by putting an oversized implant or the buccal movement of the ostetotomy and eventually the implant. Secondly if the Periosteum has been torn somehow. Thirdly encroachment of neighbouring PDL or nerve. Buccal cortical plate tear with periosteum damage ranks topmost.