Acute infection just before final fit of prosthesis on multiple implants: how aggresively should I treat?
I have a 69 year old female patient in good health. She is a non-smoker. She came to see me due to failure of her implanted supported fixed prothesis. She had 5 Astra 3.0 implants placed over 5 years ago and all appeared healthy and osseointegrated. However the design of the fixed bridge was poor with uneven contacts and subsequent fractured screws. Implants had been placed in #6,7,10,11,13 sites [maxillary right canine, lateral incisor and maxillary left lateral incisor, canine and second premolar; 13, 12, 22, 23, 25]. I have gone through all the stages of making a hybrid bar overdenture and 2 days before final fit she presented with severe swelling and pus draining from the implant in #11 site. The implant itself still appears to be solid but there is an obvious buccal defect. I have curretted the area, irrigated, used topical and sytemic antibiotics and will be reviewing her in a week. My dilemma is what should I do next? If this implant fails I can still use the overdenture on the other 4 remaining implants. However if the infection spreads to the adjacent implant, she could lose the potential to use the overdenture.Given the risk should I be more proactive in treating the infection? My plan is to attach the uniabutments and bar at the next visit and monitor. I am worried this may not be an aggresive enough approach. Any thoughts?
(click images to enlarge)
PA at time of presentation with acute infection draining from most mesial implant
bar of overdenture on 5 Uni abutments ready to fit
15 Comments on Acute infection just before final fit of prosthesis on multiple implants: how aggresively should I treat?
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Dr. Charles Sutera III
6/6/2013
I think you have handled this case excellent at this point. It appears the implant has some portion of the apex in the maxillary sinus. Therefore the etiology of the infection could either be derived from the sinus or the oral cavity. I would prescribe a systemic antibiotic (eg Pen VK, Clindamycin, or Keflex), and Peridex 0.12% take home rinse QID. The area should be curettaged with irrigation and topical antibiotic (eg. minocycline) as you have done. At one week, I would evaluate for healing, evaluate periodontal probing measurements, and determine the implant prognosis. Depending on the evaluation of pocketing, the implant may either require only monitoring, a bone graft, or may need to be explanted to prevent future sequella. Regardless, of what you decide, I would suggest planning to delay insert of the prosthesis for several more weeks to ensure the implant health is stable. It would save you and the patient a potential headache in spending the time delivering a great prosthesis only to have to remove it to access an ailing implant during a possible walk-in emergency type visit.
CRS
6/6/2013
Is the implant in the floor of the nose? Can't tell on the pa do you have a panorex?
Peter Fairbairn
6/7/2013
Yes this is in the floor of the nose and this can happen when using "bi-cortical fixation" in this area often years later as in this case . I have seen other cases of this with infection from an Implant plced like this .
Best to maybe think of removal using Neobiotech kit and using the other 4 Implants which should be sufficient .
Maybe this approach is best as Abiotics will merely treat the symptoms and no the cause.
Regards
Peter
Dr. Alex Zavyalov
6/7/2013
Any overdenture bar is usually placed according to the alveolar ridge center to lower lever forces, but this one is vestibular shifted (where the bone is itself thinner) and the implants will be predisposed to overloading.
ttmillerjr
6/7/2013
I think you need to be more aggressive in determining what the cause of the infection is. You probably need to open a flap and eval. Also, is that a tooth behind the bar on the left? Will the partial have rests on the remaining teeth? I do have concerns about the design of the bar too. Besides the bar being more facial than ideal, my concern is that the axis of rotation should be parallel to the Hader clips. According to Misch, "An overdenture with no prosthesis movement is basically a fixed prosthesis" That's paraphrasing, but see Misch, Contemporary implant dentistry page 298. The way your bar is designed will make your prosthesis basically fixed, and if you loose #11.......
nina king
6/8/2013
Thank you very much for your comments. The overdenture does have some extension and support from the palatal tissues but yes it will be basically a fixed prosthesis as there is very little movement.... hence my concerns. The trouble of course when redoing cases that have failed prosthetically previously is making a decision about wether it is valuable to replace all existing implants in order to facilitate a more ideal palatal position on the bar.In this case i have accepted the position. Thanks very much again
naser
6/8/2013
this implant prognosis is bad ,there is apical infection which may be originated from the incisive foramin and few threads are exposed coronally . my suggestion is to sacrifice this ailing implant and use the other 4 and redesign the baroverdenture
CRS
6/8/2013
It is difficult to give advice with so little information what do the other implants and bone look like. Speculating on the history five year failure , implants encroaching on anatomical limits narrow implants and a failed prosthesis I would re-evaluate and start over. Trying to quick fix or use the compromised implants that are there will get you in trouble. The fractured screws are indicative of a poor planning, poor placement and poor prosthesis design which you will be repeating and not really helping the patient. It will just fail faster. Trying to resign on a poor foundation will most likely give the same result. Talk to a prostodontist this is a complex case.
TOBooth
6/10/2013
Why over complicate? remove the failed implant. Are these 3.0mm ??? look like 3.5 astra, plus they cannot be that old astra only started using the profiled implant 2-3 years ago .
Obviously you cannot place loactors on 3.0mm because they do not make them!!!
However why not place more implants and go fixed again?
If you loose 11 the span cross arch is too big!!!!
David Broughton
6/11/2013
My comments are those of a technician, with 26 years experience working with many implant systems.
I don't question the clinical comments already made. Mine are based on the practical aspect of now providing the best solution for the patient!
If the fixture @ 23 is compromised, then remove, and work with the remainder.
Here in the UK, we have an engineering company called Renishaw. They have approached the dental/implant scene with a fresh pair of eyes; Engineer's eyes!
They can produce a custom made bridge using a sintered chrome frame for Astra, (Nobel,Straumann, Biomat3i; others will follow soon) that will fit to a degree of accuracy that defies manual technical skills! As passive as it is possible to achieve.
Your technician would need to construct a framework in resin, fitted to the fixtures with temporary cylinders, and supply to Renishaw. They will provide the most accurate framework in sintered cobalt chrome imaginable, for either ceramic or acrylic restoration. After sintering, the process is to machine the interface with the respective implant system.
I urge you to try this system.
PS I have no financial connections with Renishaw!! But I do use their know-how!
David Broughton
Baker Vinci
6/12/2013
This is exactly why cbct imaging will be standard of care. Had you scanned this patient at the first visit, you would have saved you and your patient an invaluable amount of resources and time. If you are going to embark on a career of implant dentistry you need to at least have access to this technology. You are not going to be able to save an old infected fixture. It is not infected because it is in the nose. A ct scanner is huge addition to our everyday armamentarium. It is a very cost effective tool, that sells dentistry and saves you and the patient from unnecessary procedures. Bv
Nina K
6/13/2013
Thank you for your comments about the CT scan. It is always difficult to give a full history of a complicated case in a short space. I however " inherited" these implants and as registered Prosthodontist I did refer the case onto my surgical colleague before deciding on a definitive plan of action. We did do a CT scan ( as well as conventional PAN) and all implants seemed sound so we decided to progress. These are indeed 3.5 Astra implants and a system which I know very well indeed. I appreciate all the feedback/opinions and whole heartedly agree with the general consensus of preplanning in detail. However a lot of time was dedicated to assessing and planning this case before proceeding but as we all know sometimes we have unexpected failures and it is more helpful for me to discuss future options and treatment. From the CT scan we considered initially the placement of more implants but my surgeon advised me this would be an extremely complicated task due to a severe lack of bone.
Edward Dergosits
6/13/2013
I would remove the imploant in site #11 and refabricate a bar that does not create a lever effect. You probably could simply remove the implant and use the same bar but the position of the bar is not "ideal". Ed
Baker Vinci
6/14/2013
Sorry, didn't see any mention of a scan. I'm confused as to how you didn't see the early stages of the infection before you fabricated the prosthesis. Implants typically don't get infected overnight ! Bv
Dr.Nami Ben Otman
10/1/2013
you should take panorama x-ray to evaluate overall, regarding upper left position 25
it seems to be inside sinus, no supporting bone, should be removed and use membrane + agument by bone TCP +pedical flap to close any cummincation, re-evaluate case and new treatment planning for the case may increase no. of implant, which type of prosthetic FPD OR FRD
