Dysesthesia that comes and goes after dental implant?
The lower left first molar had been missing for some time. A Nobel Biocare implant was placed into the site in November of 2017. The bone was type 4. There were no problems immediately post-op. There was no dysesthesia on day 1 or 2 post-op. On day 3 post-op she began to feel some dysesthesia with pins and needles feeling of the area innervated by the inferior alveolar nerve. She was given ibuprofen to take at that time.
The dysesthesia was gone when she presented for an impression for the implant restoration in March of 2018. A screw retained crown was placed a few weeks later. 2-3 weeks after the crown placement the dysesthesia returned. The screw retained crown was removed and a healing cuff was placed and the patient had immediate relief.
After some month symptoms returned and upon probing suppuration was found. In December of 2018 the healing cuff was removed, full thickness flaps raised and cratering was evident around the implant. All granulation tissue was removed, the implant surface was decontaminated and the site grafted and the implant buried. Normal healing occurred over the next few months. She had discomfort from time to time and took ibuprofen for the pain. Three days ago she stopped taking ibuprofen and the dysesthesia returned (pins and needle feeling). A periapical x-ray was taken and no signs of infection were evident. The soft tissue over the implant had no redness, swelling or fistulas.
Do any of you have any thoughts on what could be causing the dysesthesia that comes and goes? Your help would be appreciated!
23 Comments on Dysesthesia that comes and goes after dental implant?
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Peter Hunt
6/20/2019
I expect that both you and the patient are wanting to get this situation resolved. By your description this implant developed some symptoms of Peri-Implantitis, quite soon after the insertion. It was more evident later when you opened the region up, degranulated and grafted.
This can be very difficult to eradicate once established. So perhaps it's time to change direction. It might be better to open flap again and to counter-torque the implant out. The region should be de-granulated. augmented, closed and allowed to heal. Hopefully the symptoms will resolve and then you may decide to give it one more try.
It's best to be frank with the patient and to involve them in the decision process. I am sure we all wish you the very best in getting this difficult situation resolved.
Dr. Gerald Rudick
6/20/2019
Peter Hunt, above, has given you good advice...… you have decorticated and grafted the area, but there appears to be perimplatitis around the implant, as is evidenced in the radiolucency around the implant, and the reduction of the crest of the ridge..... it may not be that simple to reverse torque it to remove, because it is very well anchored...good luck, I hope the problem gets solved.
Dennis Flanagan DDS MSc
6/20/2019
The implant is very close to the mandibular canal and may be causing a compression inflammatory reaction.
If the pt is diabetic or pre-diabetic there may be porphyrin breakdown yeieding ferric ions that can cause a neuropathy.
rrodds
6/20/2019
I forgot to post the most recent x-ray done yesterday.
mark simpson
6/20/2019
Look a little closer at your CT on the second molar. Perhaps the root canal is an issue
Randy
6/20/2019
It seems to me that if the dysesthesia along the distribution of the inferior alveolar occurred after placement of the implant, then the implant is putting pressure on the nerve and should be removed.
Robert
6/20/2019
You didn't give the symptoms of the dysesthesia. Altered sensation, burning, or soft tissue edema?
RRO
6/20/2019
"pins and needles" type of feeling when anesthesia begins to wear off.
Dok
6/20/2019
Be very careful here. Removing the implant could take some periapical bone along with it further exacerbated any nerve damage. Evaluating adjacent teeth ( to be thorough ) is a good idea. You really should have a solid idea about the etiology before deciding on a course of action. 2nd/3rd opinions with local guys ( preferably an oral surgeon/periodontist and an endodontist ). The patient will understand that you are acting in their best interest by being careful, cautious and thorough.
miguel
6/20/2019
i agree with 2nd and 3rd opinions, the sooner the better. who would cover those fees? how do you explain that to patient is what i’m asking. im sure we’ve all been as close or closer to nerve than you-with no nerve disturbances. decadron 4mg IM in area? was the occlusion high?
Sean Rayment
6/20/2019
Your problem is #18 IMHO. Likely fractured with PARL associated with both roots. I may not load #19 until symptoms improve but patient may need another implant in second molar position.
William
6/20/2019
As the dysesthesia started first on day 3, likely there was some damage already from the start. Possible cause could be related to the implant drills usually 1 mm longer than actual implant length compounded by the type IV bone and the knowledge that in 8% of cases the superior border of the mandibular canal does not have a dense cortical margin. Pain is “additive” so current issues with either the peri-implantitis or adjacent teeth brings back the original complaint.
I would examine the teeth in that quadrant first followed by probing the implant aggressively under local anaesthesia followed by gaining access through the screw channel and attempt to firstly reverse torque the implant manually (<<20 N/Cm) .
Hope my input helps . All the best. But he upfront with the patient and say that you are trying to help establish and solve her problem. In my opinion do not charge her as money usually upsets the patient.
Dr Kamil
6/21/2019
Compression of IAN is most likely
Recommended 2-3 mm is a safe distance
From the x-ray the distance seems less than 1.26mm
Suggest to remove, leave for a while & replace with shorter implant
tom
6/21/2019
check premolar.
Ed Dergosits DDS
6/21/2019
The implant was initailly placed way too deep. I do not think there is impingement on the IAN but it would seem impossible to have a healthy peri implant complex. Reverse torque the implant. The site is now significantly compromised due to crestal bone loss. I doubt that can be corrected. I would consider a very carefully and competently restoration with a 3 unit fixed bridge. The radiograph from yesterday makes things look better than they are in terms of crestal bone level due to poor vertical angulation of the beam. Things sometimes turn south.
Dr Will Johnson
6/21/2019
The safest process for your patient seems to be to remove Any structure causing any possibility of any symptoms. Once absent all the hardware and symptoms you and the patient have a whole new array of options. The first rule is always to do no harm.
Don Callan
6/21/2019
With all the problems, it would be my suggestion to remove the implant either let it heal or bone graft it and start over. A three unit bridge in this case may be the best treatment after removal of the implant.
DrG
6/21/2019
As a periodontist who testified as an expert witness for many malpractice cases I can tell you exactly what happened . All drills have a 1-2mm triangular extension at the tip. So if you are placing a 8mm Nobel or biomet you are drilling to 10mm. This is the reasoning behind the 2mm safety zone from the nerve for implant placement. The cross sectional image that measures 1.26 confirms you probably entered the canal when you were preparing the osteotomy. My guess is there was very little damage to the canal this the intermittent parasthesia. My advice is to carefully with an implant removal kit back this out. Let it heal for 3-6 months, make sure the symptoms are gone and then place a 8mm implant. A failing endo on a molar won’t elicit these symptoms, however swelling adjacent to the mental foramen will, so if the premolar is necrotic I’d suspect that could be a contributing factor. Step one definitely should be a pulp test on the premolars anterior to this implant.
RRO
6/21/2019
In my 27 years of placing and restoring implants I have seen cases which have had immediate post-op paresthesia , all of which resolved in a few days or up to two month. But I have never seen a case that has no paresthesia or dysesthesia for 2 days post op and then begin on day three and then comes and goes over a long period of time. When she presented recently, she complained of excessive cold sensitivity to the adjacent premolar. Not finding decay or a fracture I focused on the long standing implant problem. I think your advice excellent. I will suggest that an endodontist evaluate the adjacent teeth and lacking problems there I will discuss removal of the implant with her.
Angelo Zammit
8/29/2021
Sir I have this problem and it seems to get worse when it's swollen. I got this done Aug 2018 and I've been numb ever since and I begged my dentist to remove the post. All he did was back it out 3mm which did nothing at all to stop the dysesthesia. I am wondering if I have this post removed surgically, will it stop? [email protected] please contact me.
Dr Kamil
6/22/2019
Agree with DrG
Every dentist/Dental surgeon faces unusual case and with problems, no matter how experienced we are.
The important point how to deal & treat the preop problem If & when happens.
DrBead
6/23/2019
DrG: Thx for your post. Having other folks look at your problematic cases often gives you different set of eyes looking at it. I think it is unlikely that the implant is causing paresthesia due to compression or injury to the iAN. I do think the implant may still have a problem with it........see arrows on the film. The implant is also quite deep in position, which will be an oral hygiene issue. I would tend to remove the implant. I suspect that something may be going on with #20 as appears to have disruption of the PDL/laimina dura at the apex and is in close proximity to the IAN.........so if there is apical disease there it might explain the intermittent paresthesia. Endodontic evaluation is definitely indicated. Keep us posted on what you learn in terms of etiology.....thus we all learn from the case.
DrBead
6/23/2019
Sorry, tried to upload a copy of your recent PAXR with arrows pointing to radiolucency around upper aspect of implant and at apex of #20 but would not allow me to do so.
