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Pain on Torquing Down Abutment?

posted in Abutments, advice

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Anon. asks:

I have a healthy young female, nonsmoker, placed a 4.1×12mm parallel, threaded implant into edentulous #3 area which had previously been grafted at time of extraction (PepGen, 6mos prior).

Her follow-up was not regular due to cancellations but she appeared to keep the dental implant reasonably clean when she did make it to her post-ops. Gingiva was healthy and probing circumferentially showed 3mm depths without any evidence of hemorrhage, suppuration or implant mobility.

But when I torqued down the abutment to 35Ncm, the patient experienced a sharp pain that radiated superiorly. There was no evidence of implant mobility, no hemorrhage, no pain on palpation of the buccal and lingual cortical plates adjacent to the implant fixture, no abnormal findings in the overlying mucosa. Should I suspect a fracture of buccal plate? I really cannot find anything wrong. Any thoughts?

11 Responses to “ Pain on Torquing Down Abutment? ”

• JOnathan Abenaim October 2nd, 2007

  
  

  was her gingiva in the way?? did the abutment spin when you torqued it?

• Andrew Browar October 2nd, 2007

  
  

  Differential diagnosis would be a/ soft tissue impingement from the abutment - or - b/ the implant did not fully integrate.

  In either case, I would wait about 4-6 weeks, remove the abutment, clean it up and reinstall it with the torque device.

  If it was soft tissue impingement - then disassembling it allow you to remove any necrotic crushed tissue. If it goes in without the pain recurring - you are good to go.

  If it was that the implant was not fully integrated but healthy. It will likely do well 6 weeks out. And if you torque it without recurrence of the pain - you are good to go.

  It the fixture is not integrated because of inflammation/ failure then you’ll know. Time to make some new donuts!

  Good Luck

• Dr. Ben Eby October 2nd, 2007

  
  

  PepGen as a graft material does works in time, most of the time. 6 months is a minimum. After a six month waiting period, there were a couple of cases I used PepGen with PRP and found it to be brittle and needing more time to turn into a solid base for loading a crown.

• jerry Drury October 2nd, 2007

  
  

  Pain on torquing could be soft tissue imingement but more likely not sufficient bone to implant contact to withstand the force without pain. You can wait a couple of months and try again or live with less torque. Some bone quality is so poor that you may never be able to torque fully.

• zeinou October 3rd, 2007

  
  

  This looks like the case of implant not fully integrated….so leave it for 2 or 3 months and check again and avoid torquing to 35 or you need to wait a real 6 months time or put a provisional one for 6 months
  This problem will not occur with implants with internal conique connection with wide threads
  like the ankylos; you required to torque it less!!!!

• Kass Nourishad October 3rd, 2007

  
  

  The complication is minor. Question. You recall at the placement of the Implant, you oriented the flat surface of the abutment to a desired position.
  When you torqed the abutment, did that position change? If No, its a soft tissue impingment. If Yes, The Implant is not ready to be loaded. You may load it with acrylic temp for patient satissfaction, and splint the temp to the adjacent tooth, and waith another couple of months.

• Robert J. Miller October 5th, 2007

  
  

  The previous comments are all on the mark. However, one important aspect has been left out of the conversation. The choice of graft material will also affect integration. Anorganic bovine materials, like PepGen 15, will remain in situ for extended periods of time (sometimes not resorbing at all). Bone to implant contact is directly related to the percentage of host bone available. If there is a significant amount of graft remaining, there will be no integration where graft comes in contact with the implant. Low BIC can can result in microfracture when torqing the abutment to the implat body. Place a long term provisional on the implant and evaluate over time. If there is no moboity or pain over an extended period of time, and no crestal bone loss, you have a decent chance to complete the restoration. DO NOT rush this case. It will tell you where you need to go.

• Dr. Mehdi Jafari October 5th, 2007

  
  

  I wonder that this clinical features “(the patient experienced a sharp pain that radiated superiorly and There was no evidence of implant mobility, no hemorrhage, no pain on palpation of the buccal and lingual cortical plates adjacent to the implant fixture, no abnormal findings in the overlying mucosa)” brings about the possibility and/or probability of a vertcal crack or fracture that may have happened within the fixture body.35cm torque force is not that high, but some certain platform designs make implants more prone to these kind of vertical or even oblique fracture/cracks.

• Dr P.P. October 17th, 2007

  
  

  Pain when torquing the abutment is more an issue of implant mobility or not enough BIC to go through this torque force.
  Placing an acrilic crown with no oclusal contacts will help in final decision. If after 3 months nothing happens then you can go to final restoration but with less torque.
  Graft material and time is also an issue. Allways wait 8-9 months when grafting with bovine substitutes to place the implant. Then another 6 months to let the implant heal. After this time normally you are in a safe zone.
  Good luck.
  P.P.

• daren rosen November 19th, 2007

  
  

  Soft tissue between the abutment and the fixture should cause pain as the abutment is inserted - even before the torque is applied. I would probably bet that there is no osseous integration in this case. (Did you try removing the implant by turnning it in a counter-clockwise direction?)
  I noted that most of the commenters would wait and give the implant more time to integrate, yet if this was my case I would probably remove the fixture and either replace it with a wider one at the same time (plan A) or wait and repeat the surgery after the area heals (plan B). I have found that if an implant is not stable after several weeks, regardless of the upper or lower jaw, chances are it will never be..

• rajdeep October 25th, 2008

  
  

  i placed a abutment which was not seated and tightened it till 35ncm
  how do i unscrew this

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