Failed Immediate Implant: Feedback on this case?

Authors

The case you see below is a failed immediate implant tooth # 21. I placed the implant after atraumatic extraction in the palatal wall and left sufficient space between the implant and the labial wall and there was no pre-existing infection, rather a split tooth situation.

Everything looked radiographically and clinically fine until the patient returned after having the screw retained temporary in place for 6 weeks (9 months of osseointegration). At this point the lesion you see on the labial appeared. I then had another CT scan done and it appears as though there is little to no labial plate. My plan is to flap and graft the labial area. I think retrieval of the implant would be difficult as it is well integrated elsewhere.

I am not sure with such a graft if I can leave the temporary in place or if I should place a cover screw and let the site close over for optimal graft results? Any feedback on this case would be greatly appreciated.

(click images below for enlarged photos)

Healing Collar 7 Months

![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/06/7-months-healing-e1340888337914.jpg)

Temporary crown 9 month’s

![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/06/temporary-ay-6-weeks-e1340888368410.jpg)

Healing Collar 7 months

![]healing-collar-7-months](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/healing-collar-7-months-e1341352405557.jpg)


![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/07/healing-collar-7-months1-e1341352433774.jpg)

15 Comments on Failed Immediate Implant: Feedback on this case?

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Greg Steiner
6/28/2012
If you left a void between the implant and buccal wall can I assume this area was not grafted? If so you would expect the buccal wall to resorb with no bone forming on the buccal surface of the implant. In that case if you are lucky you will get a fibrous attachment. If you are not lucky as in this case the implant surface will become infected. I would detoxify the implant surface and treat it as a ridge augmentation with a putty graft material containing granules to maintain volume. Greg Steiner Steiner Laboratories
Brent MacDonald
6/29/2012
Hi Greg, Appreciate your comments .These are my thoughts as well.You are correct in your assumption as I have heard that smaller gaps need not be filled however usually I do. What would you suggest to detoxify as I don't have a prohy jet or laser ? Lastly do you think I'd be safe flapping and leaving the screw retained temp intact or should I place a healing cap and allow closure ? Have you had success with this ? I have placed a significant number of anterior immediates without problems yet.Really appreciate your feedback Greg . Brent
Sam Jain DMD
6/29/2012
Can u send some ct x sections Even if the facial bone dissolves away the infections like this b fistula does not happen. Loss of facial bone alone is not the cause of this fistula. DO NOT RAISE a FLAP.
Brent MacDonald
6/30/2012
Sam I am so thankful to have received your feedback.I am going to send you the i cat taken a week or so again. You can see that apart from that little tiny pinpoint fistula the tissue looks wonderful.The patient has no pain. Could the infection be from the old short filled endo on the adjacent central ? I really don't want to flap or remove this implant unless absolutely necessary.I will await your feedback.
Dr. Omar Olalde
6/30/2012
Hello Brent, a post-op infection, usually is presented after few days of the surgery, and not after 9 months. So if this fistula appears after the provisional, much probably is because of that. Take a look and it is very near to the joint provisional-implant. I don't think it is originated from the endo, but you should take a fistulography, and post it. Probably you have a gap or remaining "material" on the neck of the provisional. Don't do a flap or even remove the implant, first diagnose.
David Chan
7/1/2012
Good job Brent. I agreed with Omar. The lesion is most likely caused by the provisional that you put in. Take the prov out,clean the area, modify and smooth the prov. Nobel Replace is not platform switched and bone loss to the first thread can be expected after restoration. There are better implant systems for the anteriors. Have fun and good luck!
Sam Jain
7/1/2012
Remove the temp and look with 6x loupes, may be some debri or open margin, over hang , crack in provisional etc. clean with pgd... I scrub with cotton pallet soaked in clinda and replace the temp and then wait. Sam
Greg Steiner
7/1/2012
Brent I was going on the assumption that the implant surface is infected but as has been posted by others there may be other potential sources for this infection. It is very simple to determine the source of the infection by putting gutta percha in the fistula and taking a radiograph to see where the fistulous track leads you. Also if you can probe the area what is your probing? I use citric acid to detoxify the implant surfaces but I must tell you it is not as predictable as I would like. I am beginning to remove the crown and bury the implant to improve the effectiveness. If you determine the implant surface is infected you have caught it early and there will be bacteria but little or no calculus which improves you potential to detoxify the surface. Greg Steiner Steiner Laboratories
Brent
7/1/2012
Just wanted to say thanks to everyone for their feedback. Greg you asked if there was any pocketing around the implant and there is not. I really feel based on everyone's feedback that indeed given that this complication occurred only after the screw retained temp was placed it is the cause. Had I placed a 7 month photo with the healing collar in place you would see that the soft tissue healing around the implant looks really good and so to does the PA. In fact if there is way to add photos to this case I can do that but not sure how After the initial post ? Anyway I will remove the temporary and see what happens and I expect it will be resoluttion. Thanks again everyone for your input. It's great that we can help one another out through forums like this ! Brent
OsseoNews
7/2/2012
Hi Brent, You can add photos to this case, by just using the Post a Case form, and letting us know you want to add the photo to this case. When filling out the form, please be sure to use the same email you used to post the first batch of case photos. Thanks.
DrT
7/3/2012
I know this is slightly off the presenting issue in this case, but it is relevant to the TOTAL treatment plan of this area. Based on the short clinical crowns of all of the incisors, along with the high lip line, and the compromised restorative status of tooth #8, I think esthetic crown lengthening would have greatly improved your restorative result. Perhaps this was recommended to the patient and this option was rejected. If, on the other hand, this was not done, then I would have to say that your treatment plan was significantly limited and too narrow in its focus. DrT
Brent
7/3/2012
Thanks for your comment Dr T .I did not think this patient wanted to achieve more than returning to where she was before she lost her central.I agree that would be a nice treatment plan although I do have some concerns about the short roots. I appreciate your thoughts. On another note I removed the screw retained temporary today and confirmed that the tiny fistula emerges in soft tissue well above the implant and exits where you see it. Therefore the temp did somehow cause this(possibly from a sharp horizontal angle to accommodate emergence on the temp below the gumline).Thanks to everyone I think this will have a good ending and I think with a well matched final we will end up with a pretty acceptable aesthetic outcome ! I asked osseous new to post a picture with the healig cap in place before that temp went in. Brent
osseonews
7/3/2012
Additional case photos have been posted above. Refresh your page to see the new photos, if you have already viewed this case. Thanks.
Gregori M. Kurtzman, DDS,
7/3/2012
Need to flap and eval what it looks like and how much bone remains on the implant then make the decision if explanting and graft is best or can the exposed implant surface be detox and grafted. it will also depend on the implants surface as some one can detox others not so well. if you determine it can be detox and grafted then I would suggest place a very low profile healing screw not healing abutment place graft then a resorbable membrane and get primary closure (graft will heal better if sealed off from oral cavity verses leaving the temp on and having communication via the sulcus and also micromotion on the temp-implant fixture. Since 8 needs a crown prep that and place a temp crown with cantilver pontic till the graft heals on 9
Dr. Alex Zavyalov
7/4/2012
Check the abutment-implant angulation. Probably, excessive force (difficulties began after crown installation) is the cause of current and future complications.