Immediate implant failure: thoughts?

Going to be difficult for anyone to provide decent feedback, without better photos of the case. If you can get them, please upload to the comments section.

Agreed, will be difficult to answer, but i have two thoughts. 1) even though you curetted, you may not have completely cleaned the socket. 2) imo, when placing immediates, i would place it more apical for a few reasons. A) most implants are going to lose a mm of bone regardless, yiu appear at the crest. B) most extracted sites will lose a mm of bone, so now, for me you are 2 mm more crestal then I’d prefer. C) I like to have 3-4 mm of bone apical to the socket. Just some thoughts

i have never removed an implant because the patient complained of pain. Patients say the dandest things, sometimes just because they think there should be NO pain., that is our culture now-a-days. Next time, Pre-op with dexamethosone, post op nsaid, ice pack and talk them down explaining of course it is going to hurt and that you are there for them with a smile. i doubt this is a dry socket, again, never seen it under those conditions. Go deeper as you have plenty of room to place a Biohorizons 3.8 x 15 along the mesial wall of the sinus.

Whole host of factors could have contributed to failure. What confirmed to you clinically implant needed to be removed? How was original tooth fractured? Was buccal wall intact? What antibiotics were prescribed post op? Is patient a smoker? Was patient compliant with post op instructions? How is patient’s hygiene? Did patient rinse too hard? Patients are usually happy and relieved after implant surgery. When I have a patient in pain a few days after implant placement it’s usually gingival irritation (poor hygiene vs unstable suture) or infection within bone graft and implant (approaching failure). Even with infection, irrigation and stronger abx may save the case as long as symptoms subside quickly. You need a cone scan to assess what went wrong and plan ahead for your next case. Doesn’t happen often so this should be a good case to learn from. Please utilize CBCT. You wouldn’t want any surgeon touching your body with outdated technology. If technology is limited, there are plenty of mobile cone scan companies who will do it for you. Thanks for posting.

I agree with many of the others...Possible that the site was not curetted properly? Also, definitely grab more apical virgin bone...it you have it, use it. Did you graft any gaps that were present post implant placement. Also, did you have to prep the site post exo?? Are your burs old? They really need to be changed often. Also, especially with an immediate implant, the patient needs to be on Post-op antibiotics. Also, did you have a CT scan??? Those look like PA's from film??? I personally do NOT place an implant without a CT. To me it is standard of care. You really need to give us more info with regard to this case. Just not enough here. If you removed, I hope you grafted with FDBA and will now allow this to sit and regenerate. Time at this point is key. Neil Zachs DMD, MS Periodontist, Canyon Ridge

Immediate implant placement is one of the most difficult things to do and not as easy as dropping titanium into a hole where a tooth used to be. If only symptom was pain, then maybe the implant was fine. You know when it’s failing that close to surgery, there will be exudate, swelling, severe inflammation, sometimes regional lymph node involvement, etc. There is not enough information. It looks like the surgery was performed flapless and unguided even though you stated bone graft and primary closure. Primary closure would have meant you reflected full thickness flap, released and advanced buccal aspect to palatal. Based on the X-ray I’m assuming a lot of things. Fracture of infected or healthy tooth? At the tip of a chronically cracked/infected tooth you will usually find some mushy infected nasty granulation tissue that if not properly curettage from socket will result in post op infection. If I didn’t have a CBCT and this patient came in I would flap totally to see entire buccal plate and look for any perforations, especially if there was a draining fistula clinically. Extract, curettage completely and drill past the apex of previous root to ensure apex of implant grabs into healthy native bone for improved primary stability. I would place the implant 0.5-1.0mm sub-crestal to alveolar bone on the buccal (palatal if buccal plate missing) and try to get close to that sinus wall as other doctor mentioned. Flapping totally will also give visual confirmation that threads of implant are not fenestrated through buccal plate. If buccal defect, then release periosteum ensuring you can get TENSION-FREE closure all the way to palatal tissue. Then secure resorbable long lasting membrane extending 3mm past buccal defect securely to periosteum. I would trim the membrane prior to placement to ensure it does not touch the root surfaces of the adjacent teeth and tucks at least 3mm past alveolar bone on the palate under periosteum of palatal tissue. Once membrane is secure, I place hydrated allograft where needed, cover bone graft with membrane and tuck the other end under the space made previously under the periosteum of palatal flap and suture it to the palatal flap. Then move released flap and get primary closure with chromic gut (2-3) interrupted and Then place one horizontal mattress suture with non-resorbable PTFE to take tension off the incision line. I Put pt on strong dose of antibiotics immediately and chlorhexidine rinse every 12hrs starting 24 hrs after surgery. If no buccal defect and I get primary stability of 35Ncm or more, then allograft the gap, no membrane, place tissue shaping trans-mucosal healing cap, put pt on antibiotics and chlorhexidine and move on with life. Also, bone over-heating can occur during drilling osteotomy if not using copious irrigation or drilling too fast. Also, Never forget that the implant can not survive in the same position as the natural root. “The bone sets the tone, the issue is the tissue and YOUR FATE IS IN THE BUCCAL PLATE!” -Carl Misch I suggest you get two books and read them if you Want to Successfully place implants. Also, get some better x-ray equipment, and join an implant organization like the ICOI Or SPEAR Study Club to learn from the best in the business. The two books: 1.) Misch’s Contemporary Implant Dentistry by Randolph Resnik 2.) Zero Bone Loss Concepts by Thomas Linkevicius I hope this helps you and anyone else who reads this. I know it’s a long read and people will surely disagree with some things mentioned, and with good reason I’m sure. This is just what works for me in my hands. Thank you Dr. Tim Gutierrez Katy, Texas

A few questions regarding technique: 1-What were your RPM's during Osteotomy prep? 2-What irritant did you use? 3-What was the condition of buccal plate after extraction? 4-What post op meds were prescribed? It appears technique was proper and implant placement excellent. What was your reasoning for explant?

I’m sorry but why was the implant removed if the patient c/o severe pain? Wondering what caused the pain is your thought Is pain after implant placement not a normal thing? When unsure why did you end up with an aggressive approach to remove the implant rather than prescribing some analgesia?Did you put him on a course of Antibiotics considering it was immediate placement ? Bone compression in maxilla? What was your final torque?