Radiolucency around immediately Loaded Nobel Active Implants: Is this normal?
I installed implants in an 82 year old female in excellent health in the following sites: #4, 5 [maxillary right first and second premolars; 15, 14], #12, 13 [maxillary left first and second permolars; 24,25], #19 [mandibular left first molar; 36], #25 [mandibular left central incisor; 41], #30 [mandibular right first molar; 46]. Six of the implants were Nobel Active and one was Nobel Speedy Groovy, and one was Nobel Replace Tapered Groovy. All implants were torqued to 45 Ncm to establish good primary stability. Implants were loaded in one week postoperatively in occlusion. Four weeks post-surgery and 3 weeks post-restoration the panoramic radiograph shows radiolucencies around all the implants. Patient is otherwise asymptomatic . There is no pain or inflammation in the peri-implant tissue and patient is eating well. Do the radiolucencies indicate overloading the occlusion? Do I need to do something at this stage to avoid failure or are radiolucencies a normal finding at the 4 week stage?
OPG after 3 weeks of loading
23 Comments on Radiolucency around immediately Loaded Nobel Active Implants: Is this normal?
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CRS
3/3/2013
The panorex is a little blurry but based on my experience, I don't think these implants are osteo-integrating. Is there any mobility?
CRS
3/5/2013
And to answer your question more directly, no it is not normal.
Robert J. Miller
3/3/2013
I have several questions to pose before making any comments.
1. Were any of these extraction/immediate placement?
2. Was your torque value insertion or final seating torque?
3. Did you do any pre-op medical tests? The bone trebeculation is very fine and this is ususally an indication a thyroid problem. Thyroid deficiency will have a direct effect on bone metabolism.
RJM
MOHIT DHAWAN
3/4/2013
Was the medical evaluation done pre-operatively..?
did u record adequate jaw relations before loading the molars.? are the implants loaded in implant protective occlusion.?
Dadi
3/4/2013
I would take periodical x rays, OPG is not diagnostic enough for this.
ElieVictor
3/4/2013
1st mistake : the implants were loaded too early
2nd mistake : never join a tooth to an implant, the tooth will act as a cantilever
Patient is yet asymptomatic because the implants are not yet moving
I can't understand how a Dr from your experience performed such treatment !
Regards
ElieVictor
yrenn
3/4/2013
I would take PAs to check. Panorex can be misleading. Joining implant with teeth is not a problem. If all clinical signs are fine, these are likely artifacts.
L. Leal
3/5/2013
Please inform me about you theory regarding joining implant crowns with natural teeth. If you have an ankylosed endoed tooth I might understand you but with vital teeth I don't get your point.
Thanks
Richard Hughes, DDS, FAAI
3/5/2013
I don't have a problem with abutting implants with natural teeth, if done correctly. I would not pier abut an implant with a natural tooth, just does not make any sense. I would take caution considering immediate loading in the elderly. The magic age of 50 years, things slow down, bone physiology slows down, bone density decreases.
Yes, PA radiographs are needed, occlusal adjustment, with implant protected occlusion in mind.
I do very little immediate loading. Too many variables to consider.
CRS
3/5/2013
As a practioner who does not restore these comments are very helpful especially in regard to abutting to natural teeth and immediate loading. We are under so much pressure to fix things immediately without regard for allowing biology to take its course. My honest opinion of this case is that this practioner is very bold thinking that an 82 y.o.would tolerate this. The implants are occluding with each other no protected occlusion, no cross arch stabilization. A lot of surgery and restortive was done very quickly which I feel did not benefit the patient. Now the implants are obviously failing and the poster is having an "out of body experience" like what happened? The magical immediate implants with immediate loading do not take into account the healing ability of the human being under all those implants which are not even osteo integrating. I follow cases especially at 6-8weeks when I have found the implants are the most vulnerable changing from initial mechanical stability to osteointegration taking over. Implants are the most stable at placement then osteointegration takes over. These are just biological rules, I didn't make them up, and I try not to sound judgmental sorry if I did. I hope the poster learns from this and the other posters do also. This case is pretty obvious what not to do by a reasonable implantologists or implant surgeon and I think we all have to be honest about this case. Thanks for reading sorry this happened to this patient and practioner.
Viney Aggarwal
3/5/2013
Well, I feel there is nothing wrong in inimmediate Loading in this case as most of Implants are splinted together or with natural tooth, Take a series of Periapical Radiographs at regular intervals to monitor the case . As of now try to balance the occlusion to protect the implants . Do post another Panorax after 3-4 months . We are curious to know the outcome.Best Of Luck
DrT
3/5/2013
It appears from the panorex that there are some significant endo and restorative issues on many of this patient's remaining natural teeth. Should you not have addressed these problems first before you began your implant therapy? I would like to hear your response to this. I think the biggest factor that you have going for you in this case is the patient's age...not because of her excellent healing, but sadly because she may not need her implants for as many years as someone who was in her 40's por 50's.
DrT
Dr G
3/5/2013
Looks like they are all failing. Very atypical radiograph. Honestly I think you've made 2 errors.
1. Immediate loading in an elderly female
2. Using Nobel speedy groovy- major history of immediate implant failures.
Recheck the patient in 3-4 weeks for micro mobility. And good luck!
KPM, DMD
3/5/2013
I'd like to comment only on the practice of splinting natural teeth and implants. My question would be, why not? All things being equal, that is, proper technique and planning has been done regarding placement and subsequent immediate loading, what harm can come to the implant from the natural tooth? Especially if occlusion has been taken into account. I can see if a severely mobile tooth is splinted to an implant and a satisfactory initial stability has not been achieved and the tooth actually mobilizes the implant. However, I cannot see a natural tooth being harmed by being splinted to either a sufficiently stable implant or, certainly, a thoroughly integrated one. On the contrary, would not a mobile tooth benefit from being splinted to a solid implant?
CRS
3/5/2013
An implant is not a tooth no PDL no micromovement it is anklylosed to the bone. However I do not restore implants so it is not reasonable for me to have a personal opinion. Misch's book states that implants can be splinted to natural teeth if grafting is not an option. Other clinicians have posted this with success but with careful consideration to the occlusion.. I still feel it is a plan B, but I am far from an expert!!!! Does a natural PDL require a physiologic amount of movement to keep it healthy?
Lharrison
3/5/2013
I have tried splinting implants with natural teeth and the type of cement to use was always an issue for me. It was such an issue I quit doing it. Maybe you can shed some light on that subject for me. Thanks
Grw
3/5/2013
Implants can be splinted to natural teeth if needed. I am not sure there was a need for splinting #19(lower left first molar). I have implants splinted to teeth that have been in function with no problems for over 15 years. That being said I understand that it is preferable not to splint to natural teeth.
Dr. Bill Woods
3/5/2013
I have a hard time seeing some of those torqued to 45ncm. The bone doesn't give me the impression that it is dense enough. Could have been. Were these immediate extraction sites? Was there bone grafting before implant surgery? Was there a study to see bone density? Was there a waxup of the case prior to surgery? Too many variables. The age of the patient is a consideration, especially since you have splinted to natural teeth. No stress breaker to even allow for that. I would have opted not to splint. I just think this case wasn't thought through well. One implant here or there is ok? Maybe, but you have to look at everything . Here you needed time for those to osseointegrate. Maybeceven more than 4 months. Just my opinion. I know immediate load is great for business but sucks when things go south. We are too quick to do something too fast and just rely on the body at any age to take over and make things good. We aren't made that way. This is the practice of dentistry. We need to be studying every situation to come out on top. We all have failures and they are instructive. See where this case goes, then alter your treatment planning to prevent this in the future. Thoreau once said something like "The cost of a thing is the amount of life that must be exchanged for it". Pretty timeless and appropriate in every facet of life, including implants.
Cliff Leachman
3/5/2013
Thanx for posting, there's already been enough said. I just wanted to thank you for your bravery. I always learn more from mistakes versus pristine cases done by super specialists. Having said that, I have to agree the fires should have been put out first before your implants were placed especially at 45 N/cm. Keep us posted! Cheers
KPM, DMD
3/6/2013
With regards to the question on what cement to use for splinting implants and teeth, I have to say that I treat this situation as I would any other cementation and it has not resulted in any issues to speak of. I am currently using GC Fuji for the bulk of cementations and Monocem for non metal situations. That said, I do have to admit that I am not a strong proponent of splinting implants to implants, in general. That is, unless I am asking, say, 2 implants to "do the work" of 2+ teeth due to drifting, etc. Where I will routinely splint teeth and implants is in a extended fixed bridge situation. I have found this to result in very stable situations. Recently, I have taken to restoring these cases with something other than PFM/PFG, however, as if you're dealing with moderately mobile teeth, the torquing stress can fracture porcelain coverage.
SF
3/6/2013
Start by reading Carl Misch-
Contemporary Implant Dentistry
You can be a good mechanic but without sound evidence based principles trouble will abound
Staying out is better and you will avoid these problems
We cannot let the patient drive the science
Dr. Alex Zavyalov
3/9/2013
I approve this prosthetic treatment plan to join implants to natural teeth. There are plenty of pseudo scientific literature sources in dental implantology which have a pure theoretical approach.
Richard Hughes, DDS, FAAI
3/9/2013
Again, implants can be abutted to natural teeth. Keep the spans short, do not abut a span with the implant in the middle, employ copings on the natural teeth. Cement the copings with a glass ionomer cement and the bridge with zinc phosphate. Always ans I mean always the principles of implant protected occlusion.
The literature does show intrusion but never gives a clear explanation for the reason. There is a major perio text that quotes studies that nothing adverse happens when implants and natural teeth are abutted. I would not abut to mobile teeth and I would not pier abut to natural teeth.
I have 22 years and scads of cases to back this up.