Severe Pain after Implants in mandibular anterior region: reasons?

The panoramic x-ray gives you a two-dimensional picture of a three dimensional structure. If the angulation of the implants is such that the apical portion has perforated the lingual, they might be irritating some muscle attachments in this area. If the patient is still in pain I would consider taking a CBCT . Good luck!

I agree with Carlos get a ct scan there is something unusual going on here. This area is a low risk placement if you are not to the lingual. However some patients require codeine for pain control if you under medicate the patent will not be comfortable. It is bone pain and once it gets ahead of the patient hard to control, not a practice builder! But this seems unusual.

this zone is usullay bone type 1 or 2 some time when the drilling is very hard it makes burnning bone wich can bring later a strong pain and somtimes the implant will not be oseointegrated however ct scan is recomanded to see all the dimesiones of the bone and better to place slim implants in this zone

I agree with all colleagues who put comment that CBCT will help a lot. but i think you must have done it before installing implant due to anatomical features. Anyhow, if new CT shows well placement of implants, I suggest you to put your patient in a combination antibiotic therapy like Amoxi+Metro and keep observation for another a month as i think it may be the initiation of retrograde implantitis. Good Luck

I disagree, retrograde implantitis is usually painless and one week post op is too soon. There is either lingual placement that would show on a ct, inadequate pain medication for this patient most likely or some type of neuropathy which I doubt. Antibiotics in this case for a month is not prudent without a diagnosis. Since the implants are not osteointrgrated they may need to be removed if the pain continues. One question is the patient wearing any type of prosthesis over the implants? This could be a source of pain. Welcome to the world of surgery it is about diagnosis prior to guessing at a therapy and trying to sound smart.

All of the prior comments are valid. My questions are: how was the osteotomy prepared? Did you tap the site? Did you prepare the osteotomy in an appropriate manner for D-1 bone. If under prepared and over torqued, you may have a vascular necrosis. This could be a cause of the pain! Is there any exposure of bone at the incision line.

Can you palpate the threads facial or lingual through the tissue? What is your assessment of the patient's pain tolerance? Do you detect inflammation? Have you considered steroid dosepak? just checking. kw

Could be also be neuropathy of the incisal branch of the IAN, it happens sometimes. Typically a burning continous pain, sometimes worsened by temp change and wind (meteorotropism) and dysesthesia of the chin region. More throbbing pain would indicate inflammation. This is theory. Hard to make a decision here. CBCT is indeed very useful in this case. If the implant tip is 'touching' the branch, or if there is a perforation of the lingual, better remove it. If not, wait and see. It happens and usually the pain wears off in a few weeks.

Dear all, Interesting comments already. I have seen this before and even it is not a common complication but it very well can happen. All of these cases have one thing in common, and that is the distance of the mental foramen to the surgical site. However, anatomically it is believed that there are extensions of the nerve to the midline and the pressure from the implant or the injury to the nerve is the cause of the pain that otherwise cannot be explained. Anti-inflammatory medications (Steriods) may have some effect. However, I do not see any indication to keep putting the patient on different antibiotic treatment when there is no sign of symptom of infection present. If the condition is not improving then the only way to deal with it is to have the implants removed. Preferably using Piezoelectric instead of a trephine bur. Let us know what happens. It would be great case report specially after taking the CBCT. Farhad.

I think "Gary omfs" is most likely correct. I have seen this a few times ...also often evident during implant placement and you have to top up the local anaesthetic...typically if the incisors were recently extracted thus having incisive nerve remnants Exposure thru the lingual, is a point well taken ,and can often be palpated ,although it may not necessarily cause pain. I would check for implant mobility right away...post op pain on implants is generally not a good sign. What is the temporisation method here? Is that squashing the wound? Pain can only be from the periostium or directly from neural tissue in a case like this.I don't really see how necrosis would cause pain here

i believe as colleagues said its mostly a 3d problem and if a 3d image is useless then we can start thinking of nerves and n.endings...