Radiolucency apical to implant: danger of implant failure?

I have an unusual case (at least it is for me). Healthy older lady fractured #7 [maxillary right lateral incisor; 12] at the gum line, unrestorable. Tooth was removed by my associate atraumatically back in Dec 2014. He placed Puros graft and collagen membrane. It was allowed to heal for 4 months. I saw patient recently and ordered a CBCT of #7 for implant planning. #7 site appeared normal on CBCT with some radiolucency apical to area #7. Placed implant, then had a post-op PA taken of #7, and this is what I found (see pic below). I went back and obtained the pre-op xrays of #7 and the lesion today appears to be smaller and healing. Any danger of implant failure? Implant was placed today and Pt. currently on amoxicillin 500mg. Everyone’s feedback is appreciated.

Taken Dec 2014
Taken Dec 2014
Taken Feb 2015
Taken Feb 2015
another view,taken Feb 2015
another view,taken Feb 2015
Taken today
Taken today

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26 thoughts on “Radiolucency apical to implant: danger of implant failure?

    1. CRS,

      According to my associate, the extraction was non complicated, he “excavated ” and placed bone graft. I consulted with my endodontist, he suspects #6 may not be vital, but will need to perform pulp vitality tests to confirm.
      thank you

  1. 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

    1. Peter,

      I did perform a flap, there was no buccal defect, other than a buccal concavity. So I was able to have direct visual access prior to and during implant placement. On The CT scan, there was no perforation on palatal nor buccal. Very thick palatal cortical plate. When I did slice on CT, did see some radiolucency but figured it was bone graft still maturing in that area. Primary stability of implant was achieved and did not feel a “drop” while drilling prior to implant placement. I changed patient’s antibiotic to include Metronidazole 500mg and Amoxicilling 500mg. She is coming on Monday to check vitality of #6. My plan is evaluate her every month to see that it is healing properly. Once(and hopefully lesion clears) then plan to restore.

  2. 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.
    .

    1. Thank you CRS for your input! I prefer to swallow my pride and hear the brutal honesty. I wont be helping others again. Would rather extract myself.
      Can you please elaborate a little more on the need for a second surgery to save the implant. If the canine #6 is vital, do you honestly feel that having patient on both antibiotics will clear this? Thank you

      1. Glad to help, if this implant is well integrated and non mobile this is what I would do: raise a buccal flap either at the mucogingival junction or better yet at the gingival crest, aggressively curette the area, I use a Nd-Yag laser to disenfect but an erbium laser works well. Hydrogen peroxide will work along with tetracycline on the root surface for 2 min to decontaminate. Graft with Bio-OSS, resorbable membrane primary closure. Inform the patient it is 50:50 success rate to treat this localized osteomyelitis. Start the patient on Amoxicillin the day before. You can also mix some allograft with the Bio-OSS. The localized debridement is necessary due to the poor blood supply in the area. Since it was caught early and the crestal bone looks good. Next time remove the pathology and disenfect, allow for adequate healing then place implant. I see this often. Good luck it should be okay.

        1. I read your surgical note, bone graft does not have enough calcium in it to show on a film until minimun of four months. There is not always a perforation and the tip off is a lack of trabecular pattern. Sometimes grafts need to be redone if the area has residual infection and poor blood supply bottom line opening this up will be a sure way to know what is happening. If there is some bone debriding the area will be helpful. I find that many dentists rely too much on X-rays and antibiotics. Also you can graft the con cavity and place a small ct graft for esthetics and a nice result. Definitely evaluate the canine to rule out a contributory factor. Now you are talking like a surgeon!

          1. Thanks CRS,

            I dont own a laser, but I will perform second surgery to debride and detoxify area well, and then graft with bioss and allograft.

            Thank you all again. Ill keep everyone posted on progress…
            Mike

  3. 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.

  4. 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.

    1. Hi John, Thank you for your valuable input. What you stated is what my endodontist also said. There are different opinions on ways to treat(or not treat) these cases. Thats what makes this dental site and message board wesome!

  5. 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.

  6. 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?

  7. 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.

  8. 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.

    1. Hi everyone, wanted to give all of you an update on this case. Saw patient yesterday. She reported having pus drainage over the weekend(implant placed last Thursday) with swelling. When I saw her yesterday there was no sign of swelling or drainage. It must have subsided. I recommended that she continue taking Amoxicillin 500mg for an additional week. I did pulp vitality test of 5,6 and 8. Response was normal to cold test and percussion test. I took new xray from different angles, and on one xray, theres a shadow of bone in the background forming, and from another angle looks just as what I posted. Like George F. pointed out, it looks bad on one xray but not as much on another. I will try to post the recent xrays, but may have to start a new thread. OSseo News doesnt allow attachment of pics to comments.

      1. We certainly do allow you to post photos to comments. To post more photos, simply use the “Post a Case” link above in the menu, use the same title as this case, and provide the same contact information for the case, for verification purposes. Also, you can let us know you want it posted in the comments.

      2. Pus means that soon after implantation or grafting is evidence of infection. This is best rectified with laser disenfection. Nd-yag for surgical applications. I think this implant will be a problem I would remove it and refer to someone experienced managing bone infections. This is a localized chronic osteomyelitis and the measures you have used likely will not rectify it. Sorry.

  9. 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

    post-op taken 5-5-15

    taken 5-5-15. different view
    taken 5-5-15. different view

  10. 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

  11. 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.

  12. 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

  13. 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.

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