Lucency in path of proposed implant: recommendations?
I have a new patient who had implants installed in #21, 20 sites [mandibular left first and second premolars; 34, 35] by another dentist. He also extracted #22 [mandibular left canine; 33]. The patient presented to me about 2 months post extraction with the radiolucency which has not changed in 10 months. She is asymptomatic, there is minimal pocket dept and the implants are not mobile. She states that she had a pinpoint parulus which resolved very quickly. I have not witnessed this. She has been on courses of antibiotics. Would you go in, debride the area and graft to improve the angulation of the crestal bone, risking further damage to compromised implant? Or would you recommend removal of the implant on #21 which was not done too long ago? Would anyone throw caution to the wind and just place an implant here in #22 site?
(click images to enlarge)
Pre-extraction x-ray
6 month post extraction
10 months post-extraction
11 Comments on Lucency in path of proposed implant: recommendations?
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Leal
2/15/2013
If the patient is asymptomatic, if there is no purulence, no pathologic pocket depth, no bleeding, no compromised aesthetic situation, no bone lost since the patient has been within your arms, no near bone possible to do augmentation... then this is the typical wait and see situation. I wouldn't touch it and transmit to the patient the need to do proper hygiene. Control this radiographically. If the bone loss continues then you can think and act aggressively.
There is a little bit of Gutta sealant nearby the implant. Probably no issue.... might be an issue...
CRS
2/15/2013
Could be retrograde periimplantitis from the failed root canal, I would proceed with caution. Is there a palpable bony defect on the buccal? This can be treated like an apicoectomy, open. curette and graft.
Robert J. Miller
2/17/2013
This is the apical granuloma from the extracted tooth that was not debrided at the time of surgery. These granulomas tend not to resolve even though the tooth has been extracted. This is because inflammatory infiltrates are self perpetuating and may, over time, increase in size. If the lesion becomes active, it will probably vent up the apex of the implant producing the classic retrograde peri-implantitis. Treatment is exactly as CRS proscribes; open flap curretage and removal of embedded tissue on the apex of the implant. The instrument that we use for this procedure is an ablative hard tissue Erbium based laser.
RJM
peterdent66@aol.com
2/18/2013
CRS Again said it all best to treat or this could be an issue as Robert said , happened to me once even though less obvious site.
Peter
Doc Laz
2/19/2013
It is unfortunate to have to come after mediocre work. I would remove the implant and, graft it and let it heal. Every time you try to get away with something, you end up burned and giving away a lot of free dentistry. Carefully explain to the patient that the implant will likely fail sooner than later. It should be removed and replaced. Don't put her on any more antibiotics - lest you be the one responsible for the C dificile or pseudomembranous colitis. You could place the implant at the canine and remove the other one at the same time. Definitely use a cone beam so you know where to place. I would suggest a guide. Look at the whole bite and occlusal scheme and what is the best big picture for this patient. Maybe you should be setting up for a full lower implant supported prosthesis.
stevem
2/20/2013
If there are no signs or symptoms of a problem, leave it alone and it has a chance of resolving on its own. It seems to look better in the latest x-ray compared to the earlier films. If it develops swelling, pocketing or discomfort then enter surgically for possible treatment or removal.
Peter Fairbairn
2/21/2013
Problem with that Steven is then it will possibly be too late an the implant may be lost .
Richard Hughes, DDS, FAAI
2/21/2013
I agree that an apical curettage, detox and graft with OsteoGen. If you do this, it will resolve nicely.
Several years ago, the JOI had an article about placing implants in the sites of failed Endo.
stevem
2/21/2013
My rationale for leaving it alone are: 1. it may be fine, 2. if its not fine, the predictability for a successful surgical resolution is low, 3. if over a period of weeks/months it becomes infected or breaks down, you're probably better to remove it and start over. If, over the period of observation it remains free of problems, then enter the site to place implant # 22 together with bone grafting as needed.
CRS
2/22/2013
I agree with Drs. Fairbairn and Hughes you don't have anything to lose treating a retrograde implantitis and you will save the implant. The pathology needs to be addressed. It still has to be removed when the implant fails or when you place a second implant. I see this with endontically treated teeth also if the lesion is present over 6-9 months it is not going to resolve on its own and need be treated. I don't see the value in waiting. It is a simple and straightforward procedure, you are not near the canal. I think is it a predictable procedure.
Baker Vinci
2/27/2013
Please scan the patient. If there was a paruli, then there was, or is an infection. You will not know until they are off of the antibiotics, for a period of time. "Throwing caution to the wind", is not the answer. Bv
