No Primary Stability: Suggestions?

I personally think that if you are placing implants, you should be able to answer these questions...that being said: Primary stability is the best indicator of successful integration. You could re-orient, if you have enough bone and it's in a good restorative position. You could go deeper, if you don't go through the sinus. you could go wider, if you don't tag the other teeth and the other fixture. You could graft, but see my first point. You could put a membrane, but some people don't.

I would suggest a surgical course.... having said that, yo should re orient and drill to go deeper and obtain primary stability with a longer implant, hopefully with bicortical stabilization, while keeping a good restorative emergence profile.

Yes

you can go deeper with smaller diameter drill than the implant with bone and membrane.

Were you doing an immediate implant? If not, was there a miscalculation of ridge width and implant diameter? Deeper is possible as suggested above, but in the second premolar region you may have the sinus floor in close proximity. If the patient is not in a rush and you want the best result, graft the second site with a membrane to form a buccal wall, let the bone heal for 4-5 months, and then have another try. Once you have one complication, you sometimes run into more trouble trying to fix that complication immediately.

i really like dr FGS suggestion,if you feel insecure graft it and wait 4 or 5 months and try a narrow implant,if you have more experience you can change the direction of the osteotomy and put a longer implant you can always graft.No hesitate to ask any question or feel intimitated,all question are important if there is any doubt.Implantology is the future for surgeon,periodontist,prothodontist and like or not the specialist ,GENERAL DENTIST, there is alot that we have to learn and we learn by our mistake,just because you do implants does not mean you know it all.

Its good to have excellent primary stability. If you don't achieve primary stability it doest mean that the implant wont integrate. If you don't load this implant and you have minimum primary stability ( I am talking that you can rotate this implant by hand) there is still high chance that implant will integrate. If you have perforation as you stated you must graft the area. Its hard to say without seeing actual case and the anatomy of the bone. If your angulation is incorrect and you perforated the buccal plate then you must remove the implant, place in correct angulation and graft the defect. If your angulation is correct and you perforated buccal plate due to insufficient buccal bone then you must just graft the area. But you shouldn't worry too much about excellent primary stability as long as you have some minimum stability. I did experienced that and never had problem. I don't care if any one will say no to that.

Its amazing to see such diversities in opinions to one particular problem and they all stem from experience. Great learning, which is why I'm such a fan of this site. Anyways, heres my opinion... when in doubt there is no doubt that somethings not right!....When its all about the end result, id rather have augmented my buccal bone by a nice graft, waited a few months to see an ideal osteotomy site and then placed my implant on a second exposure getting that oh so important primary stability. Whats the hurry?....If the patients in a hurry then tell him to get this done from some place else. And patients almost always understand after a nice chat and cup o tea. But if you want to take the risk then go deeper and palatal if you can. Off the record, you should have seen this coming before unless you were flapless or going immediate extraction.

Can someone answer the original question, as I would like to know also. Consider the following; an osteotomy of 5 or 6 mm is prepared to "x" length in a healed site then a smaller say 4mm implant is placed to the appropriate length so there is NO primary stability. Primary closure with a submerged technique is used. Would this immplant integrate? Would this not be like almost all immediate cases, where there is a gap between the implant and the bone (the "jumping distance"). Why wouldn't we expect a clot that would eventually populate with bone and allow for integration. Is an immediate implant significantly different to the above hypothetical scenario especially when submerged and not loaded? What are everyones thoughts? Thanks Andrew.

Dear, surgical stent/template is the answer to your complication, it is important to work on a paper before you attempt to place the implant. A little pre-op effort saves you from worries. Its better to remove the implant, re-orientate the angle, do osteotomy and place it agian, fill the previous perforation with bone graft and suture it tension free.

andrew, that's not quite the original question, but it is similar...i've done that a couple times for whatever reason[once my assistant put the drills back in the wrong sequence]and it didn't work too hot.the take home lesson was, always save the autogenous bone shards in the flutes of the drill bit while you're doing the osteotomy.this you can mix w/ a little corticle chips and if you're using a tapered implant you'll probably get the last few threads of the apex to bite.pack the buccal side prior to implant placement and add a few grains at a time as you're seating it.all in all you should just graft the site and try again later if you've got the time.

Dr. H, If I understand you, no this would not be like an immediate. I get good primary stability, or I graft and come back. Choosing an implant with aggressive threads is key to achieving that stability. Having said that, an implant with NO primary stability can integrate. It's just that the risks are higher and in most cases there is no good reason to take that risk.

Almost like an immediate - not exactly like an immediate - the difference being that in an immediate there is 3-4mm of the implant in bone giving primary stability and the other 10 mm or so in no contact with bone - but does not the coronal part eventually become integrated and "contribute" to the overall stability. So why can this happen with in the hypothetical scenario I outlined? Do you think it is because the implant is bouncing around too much in the osteotomy? Just trying to provoke ideas and thoughts etc. its just a hypothetical scenario. Thanks for everyones comments/time Andrew.

1. Just like the opinion of the buddies, you don't need to remove the implant even there is no primary stability. Grafting the perforation properly would result in success, unless you guaranteed an immediate restoration. 2. It's a matter of assessment and experience if you committed to perforation in such kind of scenario. If primary stability is in doubt before you place your implant, you may consider to re-orient in order to achieve >180 degree wrap-around. Alternatively, you may consider implant system like Bicon, that may totally neglect primary stability with good result.

primary stability can be achieved by placing the next bigger dia implant ,in the same osteotomy site,at the same time,and perforation can be repaired by a graft.

Dear Dr KG, I am presuming from your opening line that you were placing Implants in edentulous , post-extraction, healed sites (Delayed implant placement) in the Maxillary Premolar regions. There are several DEXA scan -based studies that have reviewed the continued de-mineralization that progressively carries on following tooth loss in the alveolar ridges. This contributes to a qualitative depreciation of bone residual to the loss of the tooth in the area. Most hypotheses, point to the lack of "osteo-stimulation" in the area of tooth loss as being the primary pathophysiology!This demineralization gets progressively severe from anterior to posterior maxilla, leaving the Premolar and Molar regions more severely devoid of mineral content (Ref:Devlin H, Horner K, Ledgerton D. A comparison of maxillary and mandibular bone densities. J Prosthet Dent. 1998) This along with the observations of HomLay wang et al(Wang, H. L., K. Kiyonobu, Neiva RF. "Socket augmentation: rationale and technique." Implant Dent, 2004) that over 40% of bone volume is depriciated in the first 11 months to 18 months following tooth loss, just fortifies the belief that the residual alveolar ridge is usually deficient to start with almost all the time. To get back to the case you are talking about, the poorer mineral content in the 2nd premolar region may have been the reason why you did not get adequate Primary Stability upon placement of the Implant. To answer your next query -"...Whether you should have re-drilled the osteotomy>...?" redrilling would have done nothing for the Primary stability of your implant. In fact several implant systems are known to have clear drilling protocols for soft and dense bone; that have implant osteotomies for soft bone decidedly 'under-drilled' so as to accomplish the desired diameter-differential between the Implant and OSteotomy, that would bring about Primary Stability. The other thing is Prosthetically, once you have planned that a particular Implant diameter is the chosen one for the situation (based on the wax-up, emergence profile, contacts etc), deviating from it by opting for the next diameter would change your outcome. Likewise, redirecting the implant by changing the direction of the osteotomy because you did not get primary stability, would entail loss of optimal Axial inclination of the Implant as this would then lead to sub-optimal loading and may even lead to bone loss from abnormally transferred occlusal loads over time! In the face of the knowledge that Maxillary bone is even otherwise presumed to be composed of larger trabeculae with larger "marrow-spaces" thereby making it "Soft" bone in comparision with the Mandible, it would be prudent to assume that upon evaluation of the recipient site in the premolar sites, you may have been able to assess the relative poor density in the area. This would have led you to simple Bone expansion procedures (Such as those accomplished using Osteotomes rather than drills for implant placement). This would have had two-fold benefit in this case - 1) you would have ended up compacting (condensing) the recipient bone thereby converting the bone type from D3 or D4 to a more acceptable D2 quality. - 2) there would have been a certain amount of clinical repositioning of the buccal plate achieved by the use of the expansion osteotomes that would have restored the original contours of the region more or less! Hence, it may have been necessary to leave out drills entirely, and this would probably have ensured Primary stability for your implants in both sites. The question of augmentation of the perforated buccal wall with a bone-substitute, would be inconsequential if you did not get Primary Stability to start with. If however, you had a minimum Stability of around 20 Ncm at least, then bone substitutes (in the situation, preferrably a slow resorbing alloplast (HA, B-TCP, CaSo4, Bio-Ceramics)would have been appropriate. There is divided opinion amongst the fraternity on the usage of a Barrier membrane over the graft around an implant. In the situation that we are discussing it may be prudent to do away with the membrane as you already have good vertical height of native bone and are using the bone substitute to augment the deficit and not to reconstruct a large bone defect. Membrane (Collagen) are great for selective tissue healing (GBR), however,the disadvantages of a membrane, include cutting off the blood supply to the healing area from the overlying connective tissue. So, if you have a fairly intact Mucoperiosteum, it may not be a bad idea to go without a membrane. Good soft-tissue handling (including planned incisions, gentle tissue flap elevation and retraction, apprpriate release incisions when necesssary, all help acheive primary closure, which would be critical to the success of such a procedure. The use of a suturing technique that would allow optimal tissue apposition without strangulation of tissue flaps, as well the choice of a suture material that facilitates healing with minimal tissue response (Teflon -PTFE or Monofilamentous PGLA ) would also have a bearing on the healing processes. Cheers Jeevan MDS, Fellow & Diplomate ICOI