Placed immediate Nobel active implant, #9: Reason for failure?

Patient came with #9 fractured at gum line, not infected. Atraumatically removed #9 and placed Nobel 4.3 x 13-mm Active implant with 5 x 5 yellow healing abutment. The root of #9 was also approximately 13 mm. I torqued the implant to 35 Ncm. Facial bone was intact, but thin. Approximately 1.5 mm of dead space between implant and facial bone which I filled in with cortical/cancellous mix of donor bone. I did not put the patient on antibiotics. Gave patient an Essix appliance to wear when necessary. The patient stated he wore it little as it did not fit well. First week looked good. Patient came back three weeks after implant placement; there was pus and bone loss all around #9. Why did this happen?

37 thoughts on: Placed immediate Nobel active implant, #9: Reason for failure?

  1. Lee A Nightingale says:

    Your atraumatic removal has involved raising the labial tissues. A very thin labial plate derives its blood supply from both the PDL of the tooth and the labial periosteum. As an immediate placement we accept the loss of PDL blood supply, as this goes with the tooth. This makes it all the more critical that the labial tissues remain intact and are not compromised. Complete loss of vascularisation has led to loss of bone and failure.

    When immediates go well they can really preserve soft tissue architecture and be a very good treatment modality……when they go wrong they can make quite a mess right in the aesthetic zone. You will have months of pain correcting this, I feel for you. Everyone that places significant numbers of immediate implants has had the odd disaster to deal with.

    Kindest regards


  2. lance says:

    is there any chance that you could have placed the implant more towards the palate? certainly looks like you did a nice job, and is has been my experience that you can preserve architecture by doing that. it may not have been very easy to do that. its a tough case and that is the only thing I see that might have helped. keep trying and let us know what transpires!

  3. CRS says:

    I think that the root fracture involved the pulp allowed bacteria to seed into the bone. I start the patient on Amoxicillin the day before and continue for 5-7 days post op. Grafting the 1.5 may not have been needed. Interesting flap design release incision right over a defect in the middle of the facial plate. Another thing that may have happened is the healing cap may have allowed trauma and additional seeding from the mouth, did not allow the surgical site to close. So two errors may have contributed to this post op complication.

  4. Dr. Shwetha says:

    Sir, may be inadequate primary closure,
    2 . ANTIBIOTICS,not given after grafting hard tissue could be the reasons

  5. rsdds says:

    in my opinion it appears you did everthing right except place the implant into native bone. If instead of 13mm you would have gone 15 or 16mm for immidiate placement things would have turned out differntly . Idon’t replace a 13mm root with a 13mm implant because 35ncm in a hollow socket can go south on you sometimes. I use a cbct for all my implant cases. one last thing antibiotics are mandatory with socket grafting…good luck…

  6. Alex Zavyalov says:

    There is a typical pulp burning/necrosis consequence after aggressive tooth preparation here. The apex area was highly infected because the root canal was not cleaned and filled.

  7. Gregori Kurtzman, DDS, MAGD, FACD, FPFA, FADI, DICOI, DADIA says:

    In cases like this IMHO better to place a low healing screw then a healing abutment and attempt to get primary closure this will ensure that the essix isnt potentially bouncing on the abutment and you are sealing the area to oral bacteria. I would agree that flapping the site did remove the blood supply to the facial plate which was thin but that wouldnt lead to exudate just potential crestal loss of bone as it healed. Also just because we dont see a lesion at the apical doesnt mean bacteria are not there due to the issue with the tooth CYA place on antibiotics as routine

  8. George aoun says:

    Sorry but why are we trusting 13mm implants over 13mm teeth still puzzles me .maybe it’s nature just getting back at us.root canal post and core and a crown would have been a much better choice.implant probably failed due to food impaction around the healing abutment and false primary stability brought by the agressive thread tips slightly engaging the socket walls .

  9. Andrey S says:

    well colleagues…..implantologists.
    with all due respect…… why to remove this tooth which is “fractured at gum line, not infected.” ????
    I believe it was perfectly restorable, unless author have not disclosed some important details.
    As for later situation:
    1. wrong implant size and type chosen – just because it was Nobel ?? It had to be longer, wider, and with less agressive thread.
    2. incision was unecessary – thus extraction could hardly be called atraumatic
    3. not prescribing antibiotics, with grafting (even minimal) – a sure call for trouble

    Overall, nowadays I do fever and fever immediates. I don’t like to play odds and evens anymore.
    ….that’s just my two cents.

    • Dr. Joe Orti. says:

      Well said, Doctor. There are other options besides implants to restore. But it seems to me that they want us to get hooked on implant placing as a new alternative, but old is most of the time better, because it comes tagged with experience.

  10. mark says:

    my opinion, implant should be placed in more li position ,there should be a gap on the labial to place bone graph,looks to buccal,remove and graph

  11. KG says:

    I see apical lesion on the pre-OP PA. In this case , I would extract and give pt a flipper and let the body to deal with the germs for 6 weeks and gingiva grown over the socket. Then I would implant/graft and close it up for 5 months , not asking for trouble.It’s not implant, it’s the rush.

  12. EMK OMFS says:

    Healing abutment looks more facial than I’d like. I hate the shape of Nobel’s healing abutments, no “natural shape”. A 5x5mm will probably drive the facial gingiva and bone apically. I’d have engaged the nasal bone with the implant. Interesting flap design.

  13. Carlos Boudet, DDS, DICOI says:

    A lot of opinions given above.
    If you look at the pre and postop periapical films, you will see that the apical portion of the implant was placed at the same level as the apex of the root. The osteotomy did not advance several millimeters past the apex of the root to engage this area of bone for stability. An immediate implant in this area would definitely need to be several millimeters longer than the root.
    The other mistake was not burying it. It is a little more work to uncover the implant once it heals, but you are better able to protect it from complications, and you end up with more keratinized tissue to play with when you need to restore it.
    Thanks for posting.
    Good luck!

  14. Guy Nash DDS DICOI says:

    I think the main problem could be that a 5mm healing abutment, no matter how meticulous you are with relieving the pontic on the essix, will always get jostled, bumped and disturbed, whether in function or in simply removing and placing the essix into the mouth. This would cause the implant to fail and infect especially in immediate situation in my opinion.

  15. Marcus says:

    My guess – and this is just a guess – is that the implant was placed without a formal drill osteotomy and was, instead, torqued right into the exo site apex. What happens invariably with Active implants is because of their aggressive wood screw nature, they will take the path of least resistance which is the weak, thin buccal plate in this case. That means the implant almost certainly perforated the buccal plate apically leading to inflammatory resorption and subsequent demise of the implant. I know some Nobel reps won’t even sell Active implants to practitioners who aren’t very experienced. The Active is NOT intended to be a replacement for osteotomies.

    In terms of a flap vs flapless implant placement, there is literature that supports one way is in no way superior to the other. Indeed, I find a conservative papilla-sparing incision allows for straightforward advancement of soft tissue to the collar of the abutment to (hopefully) seal the site from the icky mouth as soon as possible.

    I think there could be some reasonable objection raised in not giving a narrow spectrum antibiotic to cover against bugs in the site – especially in the context of bone grafting. Also, you didn’t mention covering the jump gap graft with anything like a Collaplug with tissue adhesive, membrane or periosteum. Obviously, this potentially welcomes junctional epithelium downgrowth.

    There is literature to justify the placement of a healing abutment at implant placement to help develop the soft tissue so I frankly don’t think that’s a reasonable objection. This is more true since the buccal plate didn’t require extensive grafting and since you didn’t need to perform GBR. I have never seen a better outcome in routine immediate implant placement with the implant buried vs not. In fact, data seems to support better osseointegration results from one-stage vs two-stage procedures(?).

    In terms of depth of placement, I I conquer that the implant could have benefited from deeper placement. The fact that it waste, further makes me think the implant was placed without a formal osteotomy and was just torqued directly into the exo site. In your case the nasal floor looks to be nowhere in sight and that implant could have been a 16 mm easily.

    Ultimately I think there are a few factors influencing this implant’s demise but the most likely, in my humble opinion, would have been fracture of the buccal plate at the apex.

  16. Dr. Gerald Rudick says:

    Like always a lot of good observations are made here…..when looking at the occlusal view of the healing abutment, it appears that the implant is too buccal; most probably the weak buccal plate of made up mostly of “bundle bone” has been destroyed in the extraction. The flap design is incorrect, which would lead to a loss of blood supply.

    A longer, narrower implant, directed to the palate could have been placed, and prior to the placement, a particulate graft prepared with PRF exudates of Vitreonectin and Fibronectin could have been placed into the socket prior to screwing in the implant, which would have only a cover screw closing, and a Fibrin plug could have been used to close the wound.

    It is not the end of the world, with a little time undisturbed, a graft can be done, a new , narrower,longer implant can be placed in5-6 months, and left buried for an addition 4 months..

  17. Dr. Vipul G Shukla says:

    Dr. Carlos Boudet hit it on the head! I agree with both his points, although I have done anterior immediates with a healing abutment from Day One, and they worked out fine. I use MIS Seven line of implants most of the time.
    Besides the vertical releasing incision at middle of the socket, and avoiding peri-operative antibiotics, I think the main issue here is that the implant moved during it’s initial healing period, and that is the key thing here. If you are going for an immediate, take it past the socket apex into solid bone at least 25% more and give it good rigidity.
    Last possible scenario (and don’t take it as an insult please) is that the instruments were not sterile or somehow the technique was compromised or the patient is somehow immuno-compromised or uncontrolled diabetic.
    Don’t take it personally, shit happens!
    Now, Rx Amoxicillin or Clindamycin for a week, and go back in, see if the graft is green or if implant is mobile, if just the graft is infected and implant feels solid, then remove graft, clean a bit and graft again in a new blood clot.(fresh blood will have the systemic antibiotics in it)
    If the implant is moving, then explant, socket graft with fresh autogenous in a new clot and wait three months.
    Instead of an Essix, try a flipper with an ovate pontic denture tooth. Much better aesthetic results.
    Good Luck!

  18. Manny says:

    Many have said to use antibiotics with grafts and implants. Could someone provide any references that support this? Thanks in advance.

    • Gregori Kurtzman, DDS, MAGD, FACD, FPFA, FADI, DICOI, DADIA says:

      The philosophy behind this which is well accepted is that the mouth is full of bacteria and since we can not prevent some from getting into the site that is receiving an implant or graft the antibiotic helps prevent bacterial growth in that area until the body is able to manage the site via its immune response.

      is there a reason your against antibiotic use in these cases?

      • Manny says:

        While I personally don’t use them in my cases, I would never criticize someone for choosing to do so. In residency we were trained to use antibiotics with all implant, bone grafting, and soft tissue allograft cases. Of course, I always questioned the scientific basis for such a stance and have never found a single study to support prophylactic antibiotic coverage aside from the claims of CYA, or everyone else does it so you have to do so as well. Since stopping, I have noticed absolutely no difference in my outcomes and quite frankly I am not surprised since I fail to see the need from a biological standpoint. With no disrespect to you Dr. Kurtzman, the mouth is definitely full of bacteria but the innate healing potential of the human body (in systemically healthy individuals) is often underestimated, in my humble opinion. We as clinicians want to tinker and place biomaterials, biologic agents etc. to aid in healing when patients would heal just fine without them. I do use antibiotics in cases where infection is present, or when placing an implant into a site that has a history of failed endodontic treatment (not evidence based, just my own theory).
        To answer your question, I choose to not use them due to possible undocumented patient allergies, MDR strains from overprescribing of antibiotics, and most importantly, that I just don’t see them as being necessary in the majority of cases. I always keep an open mind and enjoy hearing other clinician’s perspectives though.

  19. Alex Zavyalov says:

    Moreover, the adjacent tooth has the same problem – infection in the apex area due to the burned pulp and necrosis as the result of it. You can see it on the X ray. This makes the prognosis of any implant insertion inevitably bad.

    • Dr Gilani says:

      I don’t see any apical lesion at any other tooth on the radiographs. In doubt operator can do vitality test on the adjacent teeth.
      I also suggest to fabricate an occlusal guard as the worn facets indicate parafunctions.

  20. BJohnnDDS says:

    Noel Active has a very aggressive thread which actually pinches the bone between the threads. You can push the implant side against your bare finger and rotate it and it will engage and stick there. Great retention, good implant, great company.
    Perhaps the osteotomy was not complete and there was excessive pressure when the implant was bottomed out. The bone between the threads on the distal appear resorbed. It seems possible that pressure necrosis may be a factor.
    An envelope flap may have helped with vascularity.
    Thank for your post! It is helpful to review these cases as we can all learn from them.

  21. Marcus says:

    Antibiotic use at dental implant placement.

    Veitz-Keenan A, et al. Evid Based Dent. 2015.
    Show full citation
    DATA SOURCES: Cochrane Oral Health Groups Trial Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID and EMBASE via OVID. Databases were searched with no language or date restrictions.

    STUDY SELECTION: Two authors independently reviewed the titles and the abstracts for inclusion. Disagreements were resolved by discussion. If needed, a third author was consulted. Included were randomised clinical trials with a follow-up of at least three months which evaluated the use of prophylactic antibiotic compared to no antibiotic or a placebo and examined different antibiotics of different doses and durations in patients undergoing dental implant placement. The outcomes were implant failure (considered as implant mobility, removal of implant due to bone loss or infection) and prosthesis failure (prosthesis could not be placed).

    DATA EXTRACTION AND SYNTHESIS: Standard Cochrane methodology procedures were followed. Risk of bias was completed independently and in duplicate by two review authors. Results were expressed as risk ratios (RRs) using a random-effects model for dichotomous outcomes with 95% confidence intervals (CI). The statistical unit was the participant and not the prosthesis or implant. Heterogeneity including both clinical and methodological factors was investigated.

    RESULTS: Six randomised clinical trials with 1162 participants were identified for the review. Three trials compared 2 g of preoperative amoxicillin versus placebo (927 participants). One trial compared 3 g of preoperative amoxicillin versus placebo (55 participants). Another trial compared 1 g of preoperative amoxicillin plus 500 mg four times a day for two days versus no antibiotic (80 participants). An additional trial compared four groups: (1) 2 g of preoperative amoxicillin; (2) 2 g of preoperative amoxicillin plus 1 g twice a day for seven days; (3) 1 g of postoperative amoxicillin twice a day for seven days and (4) no antibiotics (100 participants). The overall body of the evidence was considered moderate.The meta-analysis of the six trials showed a statistically significant higher number of implant failures in the group not receiving antibiotics, RR= 0.33 (95% CI; 0.16 to 0.67) P = 0.0002.The number needed to treat for one additional benefit outcome (NNTB) to prevent one person having an implant failure is 25 (95% CI; 14 to 100) based on an implant failure of 6% in participants not receiving antibiotics.There was borderline statistical significance for prosthesis failures (RR= 0.44 (95%CI; 0.19 to 1.00) with no statistically significant differences for infections or adverse events. No conclusive information for the different durations of antibiotics could be determined.

    CONCLUSIONS: There is statistically significant evidence suggesting that a single dose of 2 g or 3 g of amoxicillin given orally is beneficial in reducing dental implant failure in ordinary conditions. No significant adverse events were reported. It is still unknown whether post-operative antibiotics are beneficial and which antibiotic is more effective.

  22. Dennis Flanagan DDS MSc says:

    There were probably residual vegetating bacteria from #9 and/or infection from #10. I would advise getting a CBCT to rule out #10 as the culprit. Thorough debridement is crucial for immediate placement, or delayed too for that matter. Vegetative bacteria can colonize an implant quickly. Dennis Flanagan DDS MSc

  23. J. De Backer says:

    In my opinion this case has two points of discussion. The first is the angulation of the implant position with probably is a little bit too buccaal. To avoid such a position you can use a suture wire arround the neighbour teeth so you can prepare inner this surface. If you’re not familiar with this technique you can use a surgical guide so you’re obligated to follow the right direction. Personally I should used a surgical guide and placed the NobelActive implant longer 15 mm and more to the buccal. The bucal gap I should have filled it with a mix of PRF chips and bone grafting material. Finnally I would have placed the temporary crown while different layers of PRF were placed arround the temporary abutment before screwing the temporary crown. This gives a perfect obturation of all what was placed in the alveolus and a perfect closure of the wound.
    Secondly a prescription of Azithromycine before and after the surgical intervention gives the best healing capacity if we may believe the litterature.

  24. greg steiner says:

    Many dentists extract teeth with no antibiotic coverage and have few problems. The reason is because the nidus of infection was the tooth and when the tooth is removed the infection now becomes a surface infection with no place for the bacteria to hide and the immune system can now resolve the infection. However when you place a graft (or implant) those bacteria as still isolated and likely colonizing the new material just like the tooth that needed to removed giving the bacteria a new place to hide from the immune system. Being in the bone graft business I am called upon to explain why a graft or an implant has failed. My first question is if the patient was placed on antibiotics. I would say 90% of the time no antibiotics were used. We strongly advise our customers use antibiotics with our products. Greg Steiner Steiner Biotechnology

    • Manny says:

      After reading my post I need to clarify one point. I was referring to placing a patient on a 5-10 day course of antibiotics post-operatively. There is limited evidence that using antibiotics peri-operatively can be beneficial with the only study I am aware of being the Veitz-Keenan study that Marcus posted above. And they also concluded in that study that it is unknown if post-op antibiotics provide a benefit.

      I am aware of at least 2 studies that showed no benefit to antibiotics, aside from a subjective perception of decreased post-op pain in the antibiotic group in one of those studies. Not trying to be a “dental cowboy” as someone suggested above (interestingly enough while providing no evidence whatsoever to support his/her claim). I’m pretty sure a scientist like Alexander Fleming would be doing “a back flip in his grave” over someone providing personal opinion as scientific evidence.

    • Manny says:

      Dr. Steiner, thank you for your comment. What is the antibiotic recommendation for your customers when utilizing your products? Is it peri-operative and/or post-operative coverage? How many days and which drugs/dosing? Are you not seeing many failures when antibiotics are used and only when they are not used? Thank you in advance for any advice you can provide.

  25. BigGoogootz says:

    Placed too labial; do not follow root.
    Blood supply compromised by deep labial incision(why there?),
    Better to place immediates below level of bone(esp facial) and close with barrier and bone..
    Healing abutments that have tight contact with surrounding tissue are actual healing abutments; those that do not are plaque traps.
    Immediate placement without antibiotic prophylaxis is biologic Russian roulette.

    ” I always questioned the scientific basis for such a stance and have never found a single study to support prophylactic antibiotic coverage aside from the claims of CYA”

    Really? Alexander Fleming just did a back flip in his grave. Don’t be a dental cowboy.

    • Manny says:

      After reading my post I need to clarify one point. I was referring to placing a patient on a 5-10 day course of antibiotics post-operatively. There is limited evidence that using antibiotics peri-operatively can be beneficial with the only study I am aware of being the Veitz-Keenan study that Marcus posted above. And they also concluded in that study that it is unknown if post-op antibiotics provide a benefit.

      I am aware of at least 2 studies that showed no benefit to antibiotics, aside from a subjective perception of decreased post-op pain in the antibiotic group in one of those studies. Not trying to be a “dental cowboy” as someone suggested above (interestingly enough while providing no evidence whatsoever to support his/her claim). I’m pretty sure a scientist like Alexander Fleming would be doing “a back flip in his grave” over someone providing personal opinion as scientific evidence.

  26. Dr. Gerald Rudick says:

    I agree with Greg Steiner…always place some antibiotic powder into your bone graft. In our office we prefer to mix a small quantity of Metronidazol powder into the particulate biomaterials, as they are being wetted.It is especially helpful when working in the sinus area.

    Dr. Joseph Choukroun has an excellent presentation showing how gas bubbles are being produced from anaerobic bacteria in the sinus, which actively form voids in a graft…which would not occur if Metronidazole were used .

  27. Bill says:

    Did you take a preop conebeam? Appears to me there is a PA lesion and it is apparent on several of the xrays. There is your nidus. The PDL had the infection limited in space With the extraction the infection could just travel up the screw you placed The implant is too wide for the site and has been guided by the palatal cribiform plate during placement. Therefore , the placement has been moved to the buccal. If you had a post op conebeam you might find a perforation at the apex and your buccal bone may not be as thick as you think. Your PAs look good and placement is good in the dimensions that they show
    Buccal incision-I don’t get what that was for- suspect that broke down also. I don’t think antibiotics would have rescued this implant. Pus at 3 weeks is pretty significant. It may have been a blessing to loose this implant because had or if you restore this you will be loosing the facial bone in 3 years. Take it out-,clean and wait until soft tissue heals over site- come back then and re-evaluate your next step. Give the body time to clean out this mess before you graft That part takes only 3-5 days. If you wait for the soft tissue to cover then you will be able to get primary closure on your nest step. Smaller implant ,minimum 2mm facial bone – better 3- 4 MM but tough to get. You will need more skills coming back due to the possible destruction from the infection JMHO

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