Straumann ITI with Failing Bone Graft

To Dr. R from Colorado, OsseoNews is offering a great service to dental professionals, by allowing us to discuss freely our problems, and solutions. It would be most helpful for anyone wishing to make a suggestion to you, in that more information from you would be helpful to analyse the total situation of this case....i.e. was this a site of recent extractions? was a membrane used to cover the grafted autogenous bone harvested from the bone trap? were other bone augmentation products incorporated into your graft? was there an antibiotic mixed inot the graft? was there a membrane used? is the patient a smoker? does the patient have good bone density in general? why were the natural teeth lost? what is the age of the patient? We'd love to help you. Please try to supply us with more information, and many of us can then go back to our "cookbooks" and come up with a magic solution and some ideas that we would all learn from. Gerald Rudick dds Montreal

YOu might reenter the site. If the implants still have primary stability, then clean up the site with a ErCr:YSGG laser. I have had succes saving implants with the laser and placing implants into infected sites. THE laser is good to debride infected tissue and clean the surface of the implant.

Interesting problem, in brief 55 yo female, non smoker-'difficult to numb". Tooth #18 , endo failure, removed and replaced with immediate ITI TE wide body with Bio-oss graft, collagen membrane. Peri-operative Amoxicillin. Paresthesia, anesthesia for two days post op. Pan revealed no obvious insult to IAN. Spontaneous recovery, doing well for ensuing 2.5 months. Last week, almost three months post op, sudden return of paresthesia--sensitive to sharp and cotton fiber--Panorex negative, implant firm with no motion or rotation, no pain or increased paresthesia9 Tinnell's sign) with pressure or tapping of implant which is probably intergrating(ed). Placed on antibiotic, palliative treatment. My gut reaction is to remove the implant, but I feel that this will not alter the nerve situation. Any input would be appreciated. Thanks , Richard

in general in this situation it is best to remove the implant and debride the site and regraft. it is too unpredictable to try and get a graft to take over the threads of an implant. even if the implant becomes asymptomatic it will always be compromised. do you really want to have the prosthetics done and then have the problem? take the implant out now and cut your losses.

I agree with the re-entry,debridment and copious irrigation of the site by normal saline and an antibiotic mixture, but I cannot agree with the idea of removing the implant if the primary stability is acceptable.I, personally, prefer to use a large volume of autogenous viable cancellous bone grafts in situations like this or in proximity of the implant threads.It has always worked for me.

As a periodontist who places implants, it there is an early problem, cut the losses(yours, patient, restorative dentist). Remove the implants clean up the site and develope the stie and then come back again to place the implants in good position and bone. A complete failure is better than an integrated implant with bone loss and infection. Yes it can work out, but do you want it to work out or be right? How can we justify our surgical fee and reputation for something that we would disparage others for. If you are the surgical specialist, the worst thing that can happen is the referring dentist has a long term issue because of you. The patient may not mind wasting their time to avoid the surgery, and you may not mind re-doing your less than optimal result, but the referring source may get pissed. Even if they are your friend. do you want them to loose money on your behalf. I have built a significant referral base as being the fixer as sloppy seconds.

As a periodontist, involved in teaching undergraduate students and third year oral surgery residents clinical implant procedures, we have done both, implant repairs during the first month and removal when the problem is noticed early, commonly during the first 30 days. Time has demonstrated to us that it is far more cost effective to remove those implants who show early signs of significant problems, repair the site to the most adequate anatomy for future reentry and second implant. Of those second implants placed in previously failed implant sites, I find that the success rate is higher than that of initial placements.

There are two posts about problems, the one with the infected graft and the one with the recurring paresthesia. In my opinion, if there is a problem with an implant. Remove it, let it heal and then replace it. The paresthesia can resolve if not left too long. I would not graft immediately as there is a higher chance of nerve injury if the graft gets to the nerve inadvertently.

I agree with removal. This is an indication of an early sx failure and to get rid of the implant and regraft later is the safest, most predictable resolution to the problem. I have had one early failure I watched for four months. Everything went away following the 2-3 week post op interval. when I tried to remove the healing collar ( it was a 1 stage I was dead sure of with D2 bone, the whole implant unscrewed leaving the threaded bone there. So I regrafted, waited a year and replaced it. Doing fine at the moment. My problem I firmly believe was the Zometa she had been taking but failed to mention to me until after the second one was there! So I am still sitting on this one, but the 2nd was a 2 stage and it is currently in there like a rock. Not even thinking about trephining that one out until there is a problem. But I wont wait.So take it out. Good advice. Bill

Has anybody ever thought that the delayed sudden onset of the neurosensory disorder may be a separate entity without having anything to do with the sound and firm implant? Let me humbly remind you gentlemen, that sometimes, for example, the first subjective sign of the metastasis of a remote malignant tumor to the jawbone, comes in the form of paresthesia of the lower lip.

An infected bone graft, now thats an interesting case! Put your clinical judgement to good use and decide what is best for your patient. I agree that removal of a dental implant (complete faliure) is better that complaints and problems for yourself and the patient in the future (delayed faliure). I suggest you remove the implant, graft the are with Bio-Oss and natural bone that you can collect from the distal area the mandubular molars or the tuberosity if it is stable enough using a Bone Scraper which is supplied by 3i. Mix the Bio-Oss with the natuaral bone in saline or patients blood that has not been contaminated by saliva and pack firmly. Then seal the bone graft with Bio-Gide. Suture the tissue firmly over that and leave to heal for 3 months! Hope all goes well for you and your patient.

I agree with implant removal in both cases listed above based on information submitted. I have had no experience with cleaning an exposed implant. The technique seems to conflict with principles of sterile technique and those of Dr. Branemark who required meticulous technique. Regarding the case with paresthesia which resolved only to return after 2.5 months, metastasis is a possibility along with other benign neoplasias. However, normal bone remodeling may also produce canal lamina dura resorbtion which encroaches on the NV bundle to produce paresthesia. I have explored two IAN paresthesia cases with a colleague at our local university. Both cases were caused by canal bone encroaching on the nerve. Removal of the incriminating bone produced resolution of the paresthesia.

If the implant has primart stability, I agree with some of the above comments. First and formost you want to remove the infectious process, open the areas remove the grafting material, ( was a membrane used? ) . When I am grafting lateral defects, I feel that it is a good idea to use a resorable membrane over the grafted site to prevent migration of soft tissue. It is also helpful to use teflon coated sutures. They are very bio-compatible. I too use straumann implants and is very happy with the results. Another aspect to look at - was the implant placed subgingival or is the healing cap

IN A FEW DAYS I'LL PUT 6 3.25 BEGO IMPLANTS IN THE MAXILLA WITH NARROW RIDGE.I EXPECT TO HAVE SOME THREADS OF SOME IMPLANTS UNCOVERED.IF I 'LL HAVE SUCCESS IN PRIMARY STABILITY WILL I HAVE SUCCESS IN AUGMENTATION PROCEDURE?

If you drop an implant and it falls down to the floor during the surgery would you pick it up, wash it and place it again? If the answer is NO you should never attempt to wash and graft an infected implant because your operatory floor is by far much more cleaner than the implant that you´re trying to save. If the answer is YES go ahead do it because you are acting in line with your principles.

Which kind of iti implant there was used. I have recently refered two patient an expert because I thought these case were too difficult for me. They placed the sla actives from iti/ straumann, Both fail with grafting with bio-oss. So I have seen some problems with these implants. Maybe more dentist have had some problems with these implants from iti??