Radiolucency apical to implant: danger of implant failure?

Something seems odd on the preop film. What was the extraction like? The post implantation film concerns me.

Is the canine vital? Seems like it is involved as well.

Hi Mike a number of issues here , as Konstantinos says about the canine but also the presence of such a large area at extraction will mean big buccal maybe even palatal defect ( Do you have Scan ). Then site preparation is critical to avoid issues not just a "excavation " prior to graft ( what was used ? ) . I get nervous placing in other Dentists grafts . There is an issue , again did you raise a flap when you placed to assess the bone status ? Peter

Peter glad you posted. You have an excellent point about implanting in other's graft sites. I see this in my practice done by dentists trying to be helpful. Four months is really not enough time for a defect if this size to fill in and I fear the infection is still present and the walled off bacteria have been exposed when the threads were cut during implant placement. This is what an early implantitis looks like. To save it a second surgery will need to be done. I don't trust cbct without clinical correlation and typically when I see this at extraction a large flap needs to be raised the area disinfected and grafted. It is unfortunate and most likely could have been avoided. Posters usually don't want to hear what I advise since it has already been done. I doubt the canine is the issue but it is always easier to look elsewhere. For some reason posters don't appreciate my take so I backed off on this obvious case. .

What do films look like at time of surgery? Was there a lucency at that time? Surgical exploration would be best approach and if necessary remove implant aggressive degranulation, new graft and reevaluate in 4-6mos.

I can't see what all the fuss is about. Your final x-ray shows the ghost outline of the small (about the size of my little finger nail) UR2 apical cyst cavity. It is filling in with new bone and will continue to remodel over the next 6-12 months. UR3 is almost certainly still vital but if you have any doubts a simple ethyl chloride vitality test will give the answer. If it responds it's vital. If it doesn't respond consider root treatment. No need for monthly checkups, tetracycline, amoxicillin, metronidazole, "aggressive curettage" (of what?), hydrogen peroxide, BioOss, allograft, resorbable membrane, CBCT scan - or even erbium laser! Just leave it alone for a couple of months, then go ahead and restore in the normal way.

I too get nervous implanting into another's grafted site. It does look as though #6 is the source of the infection and should of been successfully endodontically treated prior to grafting and implant placement. Also the implant site should of been detoxified. Yes there may be a palatial and or facial defect. I would not use Bio-OSS or any xenografts. They do not resorb. CRS you have mentioned laser use several times. What type of laser would be best for decontamination in a site such as this one? I'm thinking of adding lasers to my practice.

The vitality of the canine should be verified...although the tooth seems caries/restoration free......was it ever traumatized by a fall or punch? Does it test vital? Also, in that very same area, has anyone considered that the lesion could be a Globulomaxillary Cyst?

I'm with John T. Treat the patient, not the x-ray. Once the buccal plate is blown out (as in this case) it will never look the same on the film, regardless of how it is grafted. In absence of clinical problems this is a graft that is doing OK and just looks bad on the x-ray. Give it a month or two and see how pt does clinically. If doing well, restore (I would wait another 4 mo out of an abundance of caution, then strict gradual loading). However, if clinical problems develop THEN treat exactly as described by CRS. I agree with the protocol, but would not be so quick to pull the trigger.

Discontinuity of the lamina dura of the canine is a concern. I agree that pulp testing #6 is step one, please re-post the test result.

Hi Everyone, I've attached recent post op pictures on this case below. These pictures were taken yesterday. The implant was placed last Thursday. Thanks for all your help!.Mike post-op taken 5-5-15 taken 5-5-15. different view

This is a classic retrograde peri-implantitis. There was incomplete debridement of the apical granuloma and placement of an implant into the site creates a huge immunologic response. The only treatment is a type of apicoectomy where the area is opened with an envelope and the pathologic tissue removed. Ideally, an ablative laser allows you to debride circumferentially. I do not graft this with a biomaterial. I find that L-PRF is an outstanding choice to fill the defect and eliminate the inflammatory response. RJM

In reviewing the xrays from December 2015 to May 2015, with the implant in place, I am less concerned with a vitality problem with the canine...there seems to be some bone fill at the apex. I agree with CRS and RJM, that going in with a laser might clean up the area nicely, and L-PRF works very well.... but CRS has her experience with this problem, and using a particulate material will work very well.

It seems there are two problems 1 inserting an implant into a socket grafted with Puros after only 4 months ,means that the implant cannot osteointegrate (puros resorbs after years) and will exfoliate sooner or later. 2there is a retrograde periimplantitis witch has not a predictable mode of treatment,especialy when it deals with grafted Puros. Puros or othet bovine bine is not indicated for ridge preservation because they don't resorb and there is no bone in contact with the implant on most of its surface. I suggest to remove the implant,debride and graft with dfdb .Wait 6 months ,cbct and reevaluate. Then place a new implant.Good luck

Hi, There is no question that bacteria involved in peri-apical pathosis may persist for a long time, some even claim for years in trabecula before it competely resolved. The time between extraction and implant placement is too close considering the size of the lesion to begin with. I would take out the implant. Check the canine. There is a good chance that #6 might be necrotic. Graft it and come back in 6 months. try again. !! It should be fine. Let us know Regards. Farhad.