MIS implant came out of the socket after 15 days: reasons?
I placed a MIS Seven implant 5x6mm in the region of upper left 2nd molar. I got 35Ncm torque establishing primary stability, then placed the cover screw. Implant was placed using punch incision.The patient was fine after 3 days. Suddenly after 15 days patient sends me a picture saying the implant came out.She is not having any pain or discomfort. Any ideas as to the possible reason for implant failure? Patient is not medically compromised. Why would this implant have failed like this?
46 Comments on MIS implant came out of the socket after 15 days: reasons?
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CRS
2/22/2016
Gravity.
Not recognized dentist
3/27/2016
100% :)
CRS
2/22/2016
Sorry here is my real thought, most likely infection or overheated bone in so short a timespan. I am a bit suspicious with a punch approach there may have not been much buccal plate or a dehiscence that you can't see without a flap.
David Anson
2/23/2016
I agree regarding the buccal plate. With a punch technique, I would only do it with a CBCT scan.
Sbmnath
2/23/2016
Cbct was taken before placement and i had 8mmwidth.
DrT
2/23/2016
It may have been a blessing coming out because it looks like trying to restore that implant would
have been quite the challenge.
Elliot Silber DDS
2/23/2016
Is that the implant or cover screw?
Dennis Flanagan DDS MSc
2/23/2016
There may have been residual bacteria in the bone from the extraction. Was the tooth a failed endo? Scrupulous debridement is crucial if an implant is to be placed in a failed endo site. Try to use a longer implant.
Dennis Flanagan DDS MSc
matthew watson dmd
2/23/2016
Agree with the masses; bad place for punch unless you were the person who grafted the area. Graft it then go back in 6 months with a flap. may want to consider sinus bump and little longer implant? Suggest removal of the 3rd for better restorative. be careful not to torque it too much on placement as you can easily strip the bone. MIS implants are pretty good with light torque and long healing. GOOD LUCK
perioprosth
2/23/2016
my dear friend,
i do not want to be sarcastic, but you as a dentist who would like to place dental implants, must understand that surgical placement of dental implants goes beyond drilling and torquing the implant to 35Ncm. there is a lot more science and knowledge that needs to be acquired and skills to be learnt to take on cases like this particular one.
it is good that you are investigating and trying to learn what could have gone wrong, but asking this question also reveals how much you think you know and IF you should have done it on the first place.
Sbmnath
2/23/2016
Being sarcastic is not ans if u can help me in understanding the failure it is appreciated.
FS DMD
2/23/2016
I agree with the comment about it being a blessing falling out. Even with integration, crown/implant ratio not going to be good. Sinus lift/graft.
Dr. Omar Olalde
2/23/2016
Open a good flap to do the "autopsy", and I'm sure you´ll get a surprise where you placed the implant.
It would be nice if you share some pictures of the site with the full thickness palatal and vestibular flap.
Good luck.
Dr L
2/23/2016
Just a question for the masses: what do you think about placing a 6mm long implant versus some sinus lifting and a longer implant for this case?
Dr. Omar Olalde
2/24/2016
We have to talk about two issues primary and long term stability of the implant.
In this case the primary stability is going to be the same with a 6mm or a 10 mm implant. Our friend wrote he got 35N/cm2
Because if we do a sinus lift with a 10mm or 12mm implant the primary stability will be in the first 6mm of the implant, the other 4mm give us no primary stability, because they will be sorounded by a particulated graft.
In the long term stability it would be better to use the longer implant because the graft would be integrated with the bone, so we would have more mm2 of osseointegrated surface of the implant.
So talking about predictable results and oclusal forces, I would prefer to do a sinus lift and use a longer implant.
In this case I would NOT use a healing screw, I would do this in two stages, trying to avoid the micromovements.
In the other hand he wrote that in the CBT he had 8 mm wide, but he used a 5 mm implant that gives us 3mm of remaining bone, 1.5mm palate and 1.5 mm bucal.
But I'm sure those 8mm wide were not uniform from the bottom to the top, neither mesial to distal.
That's why I wrote he better do a flap and take pictures of the bucal plate, I'm sure it is absent.
Why he got a good initial torque? the adherence of the periosteum to the bone some times lies to us, It is common in a flapless surgery.
That's my criteria and experience.
Good luck.
Gregori Kurtzman, DDS, MA
2/23/2016
How long had the site been edentulous? Could have been bacterial contamination or the patient eat on that side and loaded the implant in the early days.
IMHO when using these short implants better to use a 2 stage approach to seal out any bacterial.
When preparing the site did you go to the final drill that matched the diameter of this implant? with the softer bone of the maxilla better to undersize the site and use the implant to osseocompress the bone to improve its quality better use osteotomes after the pilot drill to compress the bone and skip the drills.
Hard to tell in the image but doesnt look like this particular implant has great threads they look very shallow hence less engagement of the bone when placed
himakshu
2/23/2016
Hi
It takes a lot of courage to openly talk about failures and accept criticism and I salute you for this
It looks like a buccal plate blow out as well as an underlying bacterial infection
I wish you well in your future implant journey
Sbmnath
2/23/2016
Thanks
Manjunath
2/23/2016
Cbct was taken before placement and i had 8mm width and 8mm height.i choose not to do sinus lift procdure as there are numerous articles suggesting good outcomes with wide short implants.
Gregori Kurtzman, DDS, MA
2/23/2016
What surgical protocol did you follow? (drill sequence etc)
Dr.J
2/23/2016
Place enough implants the same thing will happen to you sooner or later..Perfect patient, perfect technique, perfect bone, perfect Ncm,..and still an implant can fail. My advice go back in clean it out, let it heal for four months go back in, lay a flap and do sinus lift with longer implant. Remember Eintien's quote: "we still do not know 1000th of one percent of what nature has revealed to us" and that I believe includes placing implants. Keep learning!!
Raul Mena
2/23/2016
This is a response to Perio Prostho
Yes that is a sarcastic response to a colleague that is asking for advice.
I hope that you can have more empathy with your referrals.when they ask you a question.
Raul R. Mena DMD
Diplomate ABOI-ID
Ora-Cranio-Maxillofacial Implantology
Yossi Kowalsky
2/24/2016
Dear Manjunath . Thank you for posting. It is harder to post a failure than a success. I have been placing implants for many years but am no expert , just an experienced GP. I have at least 3 similar cases all posterior maxillae . As you said there was adequate buccal bone so flap or flapless is not the issue . Possibly overheating but its only 7mm so not too likely. Residual infection? I have placed many implants in well cleaned out infected sites, that worked . So ? In other words when they fail we don't really know why. Now to the MIS 7 . It is a very successful implant when placed correctly in 2 stages . (not loaded) . It has an inherent design flaw as the coronal grooves are horizontal not in tune with the apical threads . So if you under prepare your osteotomy the implant will not go in and may in fact start to spin. MIS gives you a final sizing drill. A cover up for this problem . it is actually a counter sink drill that it overcoming this problem . So if you want to immediately load use a different implant. As your case was short maxillary bone this would not be my implant of choice. I also would like to see the implant about 1 mm longer actually engaging the apical cortical bone of the sinus floor. Keep going and be humbled by failures but the only way to totally avoid them is not to try.
sbmnath
2/24/2016
thanx sir
Ivan Dezulovic
3/1/2016
Dr. Kovalsky, interesting thing you said about mis threads. Which implant would you prefer for immediate loading? I recently started implanting and I am using Legacy 3 from Implantdirect. Thank yuo for your answer.
Dr. Dezulovic
Srood Al-hakeem
2/24/2016
From the radiograph 2 points indicate that the extraction was done for long time ago, first of them is the sinus floor and the second one is the mesial and distal migration of second molar and second premolar respectively. In such cases to ensure better success it's better to try sinus lift even with open technique if necessary. When a lift is done much enough length will obtained for an implant, as such length used and showed in the photo will be so prone to failure after restoration with coronal part and prosthesis placement. Being an old extraction site support the point of insufficient buccopalatal thickness of the alveolar bone in this area which eventually may lead to a dehiscence which will appear through only a flap or a CBCT.
Dr Nehal Sheth
2/24/2016
This may be due to lack of buccal bone. I doubt about overheating as it is posterio maxilla. I think u havent put healing cap so the wound might be open and contaminate it...
Best of luck next time
Alex Zavyalov
2/24/2016
One of the reasons of the failure may be a lack of fibroblast pseudopodia focal adhesion (vinculin protein deficiency) to the implant surface. Probably fibronectin/fibrin/collagen chain did not work well.
sbmnath
2/25/2016
Thank you all for your comments.I am still not able to find out reason for failure.overheating may not be the reason because i used physiodispencer with saline irrigation and length of the (Preparation)implant was only 6mm.The tooth was extracted 6 months before the placement, socket was fully healed (Residual infection?).Buccal plate was intact as i checked before placing the implant.Drill sequence i followed according to mis surgical kit instruction.
OMSurgeon
2/25/2016
Based on my personal experience (OMFS and orthopedics), this is my (educated) guess:
Avascular necrosis of the osteotomy site -> fibrous healing -> implant looseing -> implant loss
Avascular necrosis in implant surgery can be caused by overheating of bone during osteotomy or high compression forces upon insertion (underpreparation).
Regarding the dimension of the chosen implant: Too short and too wide. In a molar site like this, a diameter of approx. 5 mm (+/-) and a lenght of at least 10 mm would be considered more appropriate. Good luck!
sbmnath
2/25/2016
please let me know high compression means how much.how many newtons.thanx
Gregori Kurtzman, DDS, MA
3/1/2016
I can see compressive force causing failure in the denser bone of the mandible but since the maxillary bone expands easily its not likely a problem there
SAAD BOJI
2/25/2016
Hi, for me implant with 6mm length is not to fix any were in the mouth especially in upper posterior area. It's too short implant and have very small area for osseo-integration!!.
Raul Mena
2/25/2016
I have been placing short implants for over 20 years with an extremely high success rate. Both Quantum and Bicon have excellent track records with short implants.
The miss implant failed before loading, so it does not have any thing to do with the implant length.
No one has mentioned that sometimes if implants are placed flapless the soft tissue is dragged into the osteotomy by the implant threads. The soft tissue then invaginates and grows into the threads preventing the implant to osseointegrate.
dr Sunil
2/25/2016
Hello
Failures are two types one is surgical and second one is prosthetic failure. Looks to be surgical failure because of bone over heating try chilling the saline bottle before use for irrigation.
Alex Zavyalov
2/26/2016
This case is a cell-to-cell biochemical communication failure. It can't be limited to tissue component discussion only.
Geoff
3/1/2016
Pack a day smoker ?
Faisal moeen
3/2/2016
Hello peeps!
The term primary stability is soo far from the truth. Implants with the same fixture diameter and lengths can have different primary stabilities based on variations in thread pitch, groove depths, even surface topographies and most importantly host bone variables. It's a term that should ideally be replaced by "fixation force" since the compressive stresses transferred onto the walls of the prepared osteotomy by a tightly placed metal insert actually defines its true state of mechanical stability. A 35Ncm for a MIS would mean different for a 35Ncm of a Biohorizons placed in the same site.
Also a 35Ncm for this particular implant also means nothing. A parallel walled, short implant with an apex looking like that could be biting un homogenously into any one or two places giving you that 35Ncm, making you feel happy. There would be lots of empty spaces between the implant and bone that you can't see inside. Hence in my opinion wrong selection of implant is the primary reason.
Always raise a flap. Your cbct ain't as good as your vision of the buccal bone. Ask patient not to eat from that site, be gentle with rinsing, don't even sleep on that side.
Don't worry about the failure, happens to all of us.
Best wishes
Faisal Moeen.
yasser
3/2/2016
totally agree.
from my little experience in short implants.
when it comes to short implant go for Astra or Bicon.
with all my respect to the other implant systems.
Yossi Kowalsky
3/2/2016
Ivan, hello. It was actually Dr Niznick who pointed out that the threads of implants pitch cant change or they will spin snd not go in, In soft bone I use an aggressive threaded implant . Alpha bio - SPI or Adin Tourag or Nobel Active . In strong bone I prefer a less active implant Alpha bio DFI , Adin Swell or in between bone Nobel Speedy groovy. I almost always immediately load
Claire
3/13/2016
AnyRidge is perfect for those indications as well, add to that Xpeed surface tx advancement and voila a perfect combination.
isabella
3/2/2016
Hi. Two things- you should engage the cortical plate, the sinus floor. one,two mm longer implants would be better. more aggressive threads as well since the medullar bone in this region is on average very soft. bone to implant contact- nobody can actually calculate this, more cancels bone, bigger marrow spaces, less bone-implant contact. Following the drilling protocol is like a following a recipe, but none of the sites for implant placement are the same. Tactile feel is v. important- you should change the drilling protocol according to that.
Another thing is host- medical history, underlying systemic problems ( diabetes, medications, etc.). Sometimes you can overseen them more often is impossible.
learn from your mistakes and good luck.
DrAB
3/3/2016
As pointed out by someone in the thread, if you had the desired primary stability, and good asepctic precautions; the only cause that could have caused this is improper closure of the site. Since you describe to have used a tissue pundh for placement, my guess is the site was not closed and the area got contaminated. Further leading to the implant popping out(if I may say that).
How did you close the site?
It might have been a good idea to close the side with the wide platform sulcus/ginigival former.
If it was not closed imagine a 5 mm dia hole in the gingiva catching all possible debris/food!
DrAB
3/4/2016
As pointed out by someone in the thread, if you had the desired primary stability, and good aseptic precautions; the only cause that could have caused this is improper closure of the site. Since you describe to have used a tissue punch for placement, my guess is the site was not closed and the area got contaminated. Further leading to the implant popping out(if I may say that).
How did you close the site?
It might have been a good idea to close the site with the wide platform sulcus/ginigival former.
If it was not closed imagine a 5 mm dia hole in the gingiva catching all possible debris/food
**an edited version of the last post. sorry for the typo errorsDr
BigGoogootz
3/6/2016
Punch is risky without healing abutment.
The post op image has not soft tissue over the implant and the is no healing abutment on exfoliated implant.
Also, the contour of the remaining soft tissue over the implant hints at invagination of gingiva during placement. The punch may have been too small. So, your first move may have lead to the failure; compounded by leaving the implant exposed to the oral cavity with necrosing ring of of impinged gingiva. These factors would probably give the results as you described; especially since it was a short fatty..
Peter
2/26/2018
It is impossible to determine biologic reasons, there are so many, however, we need to look at the most obvious of problems. The posterior maxilla, in general has the poorest quality of bone, second, you stated that on CBCT you had 8mm of width. You violated the rule of 2's, you needed minimum 2mm buccal plate and 2mm palatal plate. A 5mm implant diameter would require a minimum of 9mm of width. Additionally, flapless when you don't have enough real estate is a blind procedure, not recommended. Also, 5x6 is not enough surface area to have proper amount of bone to implant contact, again, in particular regarding the posterior maxilla. I believe you would have had a better chance with a 5x10 and bumping up the sinus via a crestal approach and having the patient on antibiotics 2 days prior to procedure to minimize bacterial influence .
