Radiolucent lesion and immature bone: Proceed with caution?
Tooth #19 had failed RCT with infection and fistula and large radiolucent lesion. It was extracted and a bone graft with Symbios MTF cortical/cancellous. I waited 5 months and placed an Astra EV 4.8×9 using the Densah osseodensification technique. Patient declined a CBVT prior to implant placement for various reasons. Today, 4 months post-op of implant placement, the patient returnes for impression for restoration. Patient is asymptomatic. Clinically tissue looks healthy and probing depths are within normal limits. Implant has no mobility. However, there is a radiolucent lesion at the apex of the implant plus the bone laterally alongside the implant in the socket areas still appears granular and immature. Would you go ahead and restore the implant at this point? Should I make a temporary crown and load it progressively? Should I just wait? What do you recommend?
15 Comments on Radiolucent lesion and immature bone: Proceed with caution?
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Gregori Kurtzman, DDS, MA
7/13/2017
Did you try taking an Osstell reading to see how integrated it is? I would consider progressive loading on a temp crown. Then check in 4-6 weeks if pt is still asymptomatic and the radiograph looks better then finalize the restoration.
TK
7/15/2017
Just load it as normal protocol, no need temporary
Ralph Alman
7/13/2017
I don't think things are so bad. Certainly, if available, testing the implant with an impedance measuring device is a good idea before restorative measures are undertaken. As far as the radiolucent area at the apex of the implant, I believe it may stem from two different causes. First, I think that the immediate post op film might be a little foreshortened. I think that I can see a thin black line under the apex of the implant which may be what you see now on the film of the impression visit. The other cause may be that in dense, mandibular bone, Densah burs recommend that you make your osteotomy 1mm deeper than the proposed implant. If you were able to do that and not able to completely rachet the implant to the maximum depth of the very dense osteotomy, you might have the reason for the radiolucent area at the apex of the implant. In any case, observation as suggested above by Dr. Kurtzman is a fine idea. I don't think that you have anything to worry about.
CRS
7/13/2017
The lesion did not resolve after the bone graft and was present at implant placement. It's still there. Perhaps a retro peri- implantitis may develop. Long term prognosis poor.
perio d
7/13/2017
I wouldn't worry about this. You can use an Osstell or if you don't have it, do a reverse torque test of the implant by removing the healing abutment and insert the Astra implant driver and torque wrench counter clockwise to about 30 Ncm. Astra recommends the restorative screws be tightened to 25 Ncm. The bone in the x-ray appears perfectly normal under the circumstances to me and with a successful torque test go ahead and restore the implant. The bone to the mesial and distal of the implant within the grafted socket will likely look the same for a long time yet.
mpedds
7/13/2017
I agree with CRS. If you look closely at the trabecular pattern of the bone it appears that a portion of the original lesion is still present. The inter-radicular bone could have been in the way of thorough curettage and placement of graft material. The implant could be fully integrated and appear normal with whatever method you choose to use, however there may be bacteria present which could prove fatal to the implant later. Patient should be advised before proceeding.
Gregori Kurtzman, DDS, MA
7/13/2017
I hear some comments but if this was your patient what would you do?
Brian
7/13/2017
Just a thought... isn't the original radiolucency the result of perforation of the cortical bone? Or, at least, don't they often fail to appear on radiograph until the cortical bone has been perforated? And the area does look less radiolucent after the bone graft and healing, which I would think is a good sign.
If the fistula resolved and the bone graft healed successfully, and the implant is integrated, is it more likely the radiolucency is associated with the apex of the implant or the cortex of the mandible? How does the healing time differ between cortical and trabecular bone?
Martin.
7/14/2017
To me the lesion looks to have improved significantly at the time of implant placement. Even when an area seems to appear completely resolved on radiograph, histologically it may not be so. So for me, a radiograph is just an indicator. I usually place at 8-10 weeks post extraction for lower molars. Almost all look like yours on post-op radiograph with the 'granular' bone appearance. I don't have an Ostell, but rely on torque test at 12 weeks. I never provisionally load molars. So far all have been fine since 2004. As far as I can determine it looks OK.
Aziz Amro
7/14/2017
I think no need to worry
-use Ostell or reverse torque test, if it is Ok, do the prosthetic part.
Follow up
If the radiolucency increase do surgery as apicoectomy.
Alex Zavyalov
7/14/2017
The Osstell device and X ray cannot determine how mature bone is in the all grafted socket. If the patient is an asymptomatic and the tissue clinically looks healthy (probing depths) without implant mobility, I would proceed with making a crown with occlusal rests on molar and premolar.
Barrow Marks
7/14/2017
I am interested in Doctor Zavalovs comment regarding a rest on the premolars and molar attached to the implant restoration. it sounds like an interesting engineering approach do any other doctors have experience with this type of restoration?
Gregori Kurtzman, DDS, MA
7/14/2017
I strongly disagree with that suggestion. As the adjacent teeth have PDL and will move 0.5-1.0mm in a vertical direction under load the rests will allow the natural teeth to depress in the socket slightly but the implant wont so decay will result under the rests. Even if the rests are cemented the tooth will move away and the cement seal will break down.
As I suggested initially, put the patient into a screw retained provisional crown that is slightly out of occlusion, let then function on it and if it remains asymptomatic and the radiograph has either improves in the apical or has not changed then do the final restoration. Dr. Alman had a valid point when comparing the placement radiograph to the impression radiograph the first one is foreshortened so comparing the apical area in both cant give an accurate comparison. When I compare the bone around the implant in both radiographs I see denser bone and disappearance of the demarcation of the socket that was grafted that can be noted in the first radiograph.
TK
7/15/2017
Next time I recommend PRF plug instead of other graft material for socket with infection before
Dr. Gerald Rudick
7/17/2017
I agree with CRS.... the lesion was there at implant placement and did not fully resolve.... it could lead to perimplantitis and the loss of the implant.......
A suggestion would be to restore the implant with a no cost temporary crown and watch it for one year..... if at the end of this time, there are no signs of breakdown, then it would probably be safe to do the final restoration.
