OCO Biomedical One-Stage Implant Appears to be Failing: Treatment Options?

Second Option is Better to be followed in this case...

Implants under 4 mm do not perform well centered in soft maxillary bone. Single stage versions fare the worse than two stage, and immediate load versions fare the worst. The even radiolucency could indicate a problem in the preparation and insertion. You have a huge amount of bone in the site. By trimming the Mesial of the tipped molar, room would be adequate for 4.5 or 5.0 mm width placement. By removing the failing implant and waiting for tissue coverage (6-8 weeks is best for tissue maturation), and then proceeding with two stage insertion, you could eliminate many pitfalls and achieve a higher success rate. Using a healing abutment invites the epithelium to invade the weak peripheral bone in this compromised site. A standard two stage, 4-5 mm diameter implant placed in a standard, conservative manner would be your best path.

You don't specify what area was grafted. Six month delays are needed if you are entering a healthy grafted area. Any graft now present must be removed since it obviously is not healthy. If the area is not infected, it may be possible to graft at the time of implant replacement. Did you have a Buccal wall defect? You may need a membrane and total flap coverage.

Also, since a 3.0 mm implant is considerably narrower than the average bicuspid, this implant was doomed from the start if you placed it at the time of bicuspid extraction. That type of implant must be placed in intimate contact over the entire submerged length to be successful. Healthy bone does not just jump across a void.

Thanks John for your comments. The tooth was atraumatically extracted and there was only a one wall defect and grafted with Puros at the time of extraction. Possibly should have waited longer than 3 months, but have not have a problem before this. So I didnt have any worry about bone jumping. It did torque in at 40ncm. I will consider the 2 stage and a wider diameter for its replacement.

Puros is mineralized allograft. It is never resorbed. So what you put in is still there. You have a socket filled with gravel. Not only is the majority of the material you put your implant into inert but because it produces sclerotic bone you have few to no viable osteoblasts to integrate to your implant. If you could place a wider implant and remove the majority of the graft material in the process that would be an acceptable approach however on the mesial coronal portion of the site you have graft material that appears to be poorly integrated and poorly mineralized. I suggest you remove the implant and as much of the graft material as possible and graft with a resorbable graft material that will actually produce bone. Greg Steiner Steiner Laboratories

Thanks Greg- Will keep that in mind, I didnt mention the graft was a mixture of Puros and Dyna Graft D from Keystone.

I'm not sure where anyone gets info ' Any implant under4 mm in diameter doesn't perform well'.. More and more implant manufacturers are coming up with smaller diameter implants. 3mm laserlock implant works just as good as any other in this type of situations. The only thing I've experienced with oco implants ( one stage implants to be more specific ) is that I've seen more bone resorption around them within short amount of time after placement. It could've been something in my technique ( don't want to exclude that possiblitiy there ) but after a few of those that were clearly visible on recalls , I stopped using them. I DO NOT think it's anything to do with 3.0mm diameter as long as occlusion is judiciously adjusted. As far as this case's concerned, I would wait till it heals up and place another one. I wouldn't jump to place larger diameter implant there since you do not know why the first one failed.

Sergio, space and time are short here so complet qualification of an opinion is impossible. Whatever the width of standard threaded implant, they seem to work better in intimate bone contact as opposed to being held up in an open hole with a temporary crown atop. If it had worked, then great, but on the "redo" I feel the patient is entitled to an implant placed ideally and with the fewest weaknesses in technique. So clean out the failed graft and get a complete covering tissue flap. Then place new 2 stage implant in clean, healthy, intimate bone contact and cover to give maximum protection from tissue/bacterial invasion as well as protection from premature loading.

John, like you said, Complete qualification of opinions are impossible due to space and time limit here. I do not disagree on the suggestion that the 'redo' might have to include more traditional approach but I wouldn't imply that it failed because it was one staged surgery. Yes, maxillary bone is known to be softer but OP had 40 Ncm when the implant was placed. I'm sure you know you don't reach that torque in a soft bone if you've placed ample amount of implants. 3mm diameter implants work just fine in a case like this where space is tight in my hands. Like you iterated above, 2 staged surgery might have worked better but we don't know the first implant failed because of that or not.

Placement torque can be a misleading clue as to the amount of healthy circulating bone in contact with the implant. That pressure stimulates resorption which, hopefully, does not take place until new bone is attached elsewhere. I am in the habit of placing Bicon finned implants almost passively, which eliminates the resoptive delay and is immediately invade by Haversian bone.

John, you are right about torque value that could be misleading but that's the only clue at the time of placement whether the implant is in the solid bone or not. I place bicon implants once in a while too and you tap it in, not drive it in. It means many times bocin implants ARE passive fit in an osteotomy, hence their recommendation of not using t for immediate loading tx. Again, not because of how many stages it requires for a surgery. Anytime an implant fails, textbook explanation could be given with confidence but that many times still doesn't explain a particular case why an implant didn't survive. You sound like a knowledgable dentist and I'm just stating no one knows exactly why the first implant failed in this case. I've had implant failures with bone loss around it when it was 2 staged. That shouldn't happen but it does every once in a while. When I use one piece implants or one stage surgery, I rarely see bone loss and a subsequent failure.That doesn't mean one stage surgery is better. If I don't get enough torque driving the implant in, then I do in 2 stages. Simple as that.

Sergio, yes, I see what you are saying. Several factors of this case could have contributed: Maybe not enough circulation thru that graft, maybe a previous chronic perio infection, maybe the problem was slower healing palatial defect, maybe too large a gap at emergence...

you should;ve placed a longer implant so as to engage the cortical bone at the floor of the sinus by allowing the tip of the implant to penetrate the sinus by 1-2mm . now for this particular case remove this failing implant and use a wider and longer implant and make sure its tip just penetrate the sinus floor ,wait for 6 months and then proceed with 2stage procedure. good luck

Very simple, micromovement during osteointegration. Next time bury the implant let it osteointegrate first.

Did you raise a flap? Sometimes there is not enough buccal plate and you can't determine without a flap.

It's quite obvious the grafted area has not healed well at time of implant placement. Look at the drill guide which is paralled to both molar and premolar. Now look at the position of the implant. Why the two don't match? The reason is the cortical bone of the original socket is still present which guided your drills when preparing the site. The implant never engaged any bone other than the grafted bone, probably D4 or D3 at best. Put this on top of a restored implant, no matter if out of occlusion, you are getting yourself in trouble. I would question the implant's primary stability at the original causative problem. As most guys have already said, remove the implant, degranulate the area, make it bleed! In terms of bone graft, I have done may sections of 4 months using PUROS and found nice viable bone with some graft particles remaining. I trust this graft more than I would trust your choice of implant and implant position. You need to engage native bone.

I like your alignment and size. I place a lot of OCO and they are good, solid implants. When working with a one piece implant many factors can prevent osseointegration, In your case micro motion caused it , not the implant or technique. I don't recommend immediate function but gradual. Always splint for 2 month and take it out of occlusion. Please remove the implant, let it heal, take a ct to make sure you have buccal support and place next time(about 4 month) a 2 component implant, place the healing cap and let it osseointegrate without any preventing force. I design medical devices and developed a technique called the bubble technique and the rate success of one piece implants went from 80% to 97%. We give seminars and specialize on immediate loading implants with high success techniques we have developed. A new all in one sinus lift will come to the market that will revolutionarize the way you do sinus lifts and many new implant devices are been developed. Take a peek at our dental secrets seminars.

If you have enough bone try to place a wider two stages implant and allow 6 months to heal, if not pack with bone graft and do the implant placement 3 months later

Some things never change. The implant is too narrow and you loaded it early. Now you have added a half a year of treatment, to a very simple case. Bv

I time to time do get referral for such failed implant one piece implant cases due fibrous encapsulation. there can be several factors from medical history to socket grafting. It about the vitality of bone and ability to place implant without pressure necrosis as usually these one piece implant manufacturers recommend to use 2.0 mm drill and then torque the implant in. I have successfully treated these type of cases by: 1. remove the implant and debride the osteotomy with curettes. 2. wait 3-6 months 3. place 2 piece implant. I have used Straumann SLAactive for these types of cases. But I am sure this is personal preference any surface will do. hope it helps

Dear Doc, Thanks for sharing this case, 1. if you didnt have any wall perforations may i suggest not grafting with allograft just natural healing of the socket, if you do graft wait 4-6 months. in the x-ray there seems to be unresorbed bone right next to the guide pin. A longer wait would have been good. 2. With the apical thread engaging native bone and the platform of the implant being pushed against the crestal bone, torque values can tend to give a high value 35+N-cm, and if its self tapping it will tend to give such values. with such implant designs should be careful with immediate non-functional loading. 3. I take it you were well within bone. no perforations of cortical plates. best guide is a second dip (loss of resistance which tactile sensation of your hand holding the contrangle gives you)if you opted for flapless. If you didnt you'd see it visually. Possible solution: If 1. The smile line is low and lip line is too. 2. Your implant is Self advancing/tapping. 3. No exhudate, mucositis, peri-implantitis, around the implant, 4. Remove the temporary prosthesis. 5. Rinse with CHX 0.12% or take a cotton pellet dip in 2%Citric acid dab the juction between soft tissue and the fixture througly. 6. After local anesthetic in the area 7. Advance the implant further into bone(Self tapping implant will move into bone)as you have 2-3mm of bone in radiograph. 8. Torque with your finger will approach 15N-cm Max. if you encounter this leave as is without prosthesis. 9. Recall in 1 week to observe mobility/infection If stable reacall in 1 month. 10. Antibiotic cover for a week and 2 weeks CHX mouth rinse Morn/Eve. 11. If you still find mobility after setp 9 Remove implant after a week and Follow your above mentioned protocol. Best of luck. God bless

Hi all I haven't read all but according to the X-ray a failed osseointegration occured due to overloading occlusal forces. you can notice the complete radiolucency around the implant. in such case i would go in two direction first. Remove the older implant do good curetage with irrigation place wider implant, bone augmentation if necessary and wait few months till complete osseintegration then go for prostheic loading or remove older implant, do bone augmentation to prevent bone resorption wait 4 months then place new implant, ensure primary stability and avoid immediate load this will ensure success.

You started the case perfectly, but you are 1 or 2 diameters shy. Let the implant integrate and you have a great case. Bv

It is possible that the bone was compressed and became necrotis. 40 ncm sounds high ustual range is 15-25. Tkae it out graft with cortical-cancellous demineralized bone wait 12-16 weeks. Bury the implant 4.0 is fine let it integrate then uncover Don't repeat the same process. also lay a flap so that you can see the buccal plate!

If 35 ncm is the most commonly suggested seating value, how can 40ncms be too much? I sure hope you are wrong. Biohorizons suggest that it is safe to approach 70 ncm. Bv

Dr, As a user of the OCO system I have been very impressed with immediate placement/immediate load casesISI} that saved me and the patient's a lot of time and expense. I have also seen this type of failure a few times-not the implant's fault, I believe. Since you obtained very good initial stability(40 Ncm in maxilla with a 3mm diameter is amazing} If you ask the company reps. if you can use this size implant for that application they will say yes but "should you" can be answered by reading posts. It could have worked but if you are going to that much trouble and expense why not maximize chances for success? Use a two-piece{TSI\ERI\Engage} implant-not loaded,then wait. If patient insists on a tooth immediately you should be able to successfully place/restore a one-piece implant{ISI} of a larger diameter when you remove the 3X12 ISI. I would go another 2mm to floor of nose and make sure temporary way out of occlusion. Also, splinting temporary to adjacent teeth can help but they must have no mobility and not in heavy contact in excursion. There is a possibility that you followed the OCO company recommendation of flapless surgery you inadvertently placed too far buccally and when the patient pushed against temporary with their tongue during sleep/swallowing they were able to "jiggle" it enough to prevent osseointegration. Keep to palatal with osteotomy. A good approach, in the maxilla especially, is to place a TSI and if everything is favorable then go ahead and place one-piece abutment which converts implant to ISI so you can restore immediately. If not sure all factors positive then place cover screw and wait. You can bond a pontic/flipper into space if you have to.

I agree with many of the comments. 3 Months is early to place an implant into grafted bone especially the maxilla. Two stage would have been a better choice or waiting 6 months before placing a one piece. Immediate load of this small implant in grafted bone was likely to fail in my opinion. Others have suggested bonding the temp to the adjacent teeth. This is a very bad idea from what I have read. All natural teeth move in function. If you bond an immediate implant to adjacent teeth micromovement is guaranteed and the implant will not integrate. At this point I would remove the implant, currete the heck out of the socket, and determine if there is a buccal plate. If there is and the remaining diameter of the osteotomy will engage most of the walls I would let the site heal without additional grafting and place a larger diameter implant with a two stage manner. Choose an implant with a conical connection like Astra, Ankylos, Anyridge, or Hiossen. These implants eliminate the micromovement at the I/A interface that is associated with crestal bone loss.

Dr Ed, it's not a bad idea to fixate an implantnt by bonding to the adjacent teeth. Yes there is micro movement by the teeth. You also have a very small level of micro movement in the bone. I have done this several times with great results. You will need a significant ammount of bonding material (composite) or use acrylic.