Any Ridge Implant: Suggestions after noticing periapical lesion?

Remove it. The radioluncency is getting close to the sinus. What did the extracted tooth look like? It is not about the implant used this appears to be a retrograde peri-implantitis from bacteria in the bone. This implant appears to be failing.

Yes CRS , looks like a take it out case , maxilla less inclined to an issue with compression , previous pathology as you said...

Wait, slow down Let's look at the x-Ray taken immediAtely after placement and compare it to this one. Are you sure this isn't where you may have over drilled the osteotomy?

The other doctors mention valid points. You either have an infection,avascular necrosis. So, remove, degranulate, detox, decorticitate and graft with an particulate such as OsteoGen. The post insertion PA and knowledge of the patients medical Hx and sex would be helpful..

Looks like you over-drilled the osteotomy. Do you have a post-operative X-ray/Pano? If so, compare and contrast. Another tip for Any-ridge- underdrill the osteomy. For maxillary bone with recent extraction, bone quality is generally very loose. I recommend using linderman drill, then 2.0 implant drill, followed by placement w/3.5 anyridge implant. From my experience, this allows best results as the implant acts as a quasi-spreader.

Thanks for answers to all! It looks that moderator changed my question a little bit. The patient is male, non smoking, good health. The canine was extracted because of periapical lesion and faild endodontic therapy. The implant is placed after almost a year. This x-ray is after 8 weeks of implant placement. I'm pretty sure that I didn't overheated the bone with drilling. Unfortunately, I don't have x-ray immediatley after placement. The torque which produces this implant is very high even if I use cortical drill from surgical kit. We removed the cover screw and the implant seems to be very stable. We tried to rotate it and couldn't do it with fingers. Clinicaly there is no signs of inflammation. The bone seems to be normal on palpation of the area.

Retrograde peri implantitis from original failed root canal. From your post it seems you feel implant is stable. In my opinion once this is placed under occlusal load it will fail. Good luck.

Certainly appears to be a retrograde peri-implantitis. This is one of the most common untoward consequences of placing an implant immediately in an extraction site. Even though the source of infection is gone, unless the complete contents of the apical granuloma is removed, the immunologic response is still present. In contact with an implant apex it will continue to proliferate. There is one very predictable solution; a form of apical surgery utilizing an envelope flap that allows you to completely remove the apical tissue. Then we place a PRF plug in the apical zone. This fibrin matrix plays an anti-infective and anti-inflammatory role, allowing bone to start regrowing. While we do not have large numbers of cases to show using this modality, I can report 100% success in the cases we have treated. If the implant is stable and there is no facial bone loss, you owe it to your patient to have this procedure done, or refer the case to someone who will do it. RJM

When you remove the implant I would advise biopsy of the radiolucent area as it may be actinomycosis. This can happen as a residual problem after extraction of an endodntically treated tooth. It also takes long term antibiotics to resolve.

A radiograph with the original failing tooth may help come to a diagnosis with this case. It definitely isn't the brand of implant that caused this. Been using Anyridge implants for a while and very happy with them and haven't seen this yet even with those that are placed with high torque.

Biopsy??? :)

Consider the worst thing that could happen if this implant is left in place vs. removal. Remove, graft, wait for healing, and then relpace, worst thing, loss of time and the cost of the implant. Leave it in place and have more bone destroyed, perhaps into the sinus with sinus infection and loss of the facial plate. Even if this implant survives to second stage and is then loaded it is likely to fail within a few months. Worst thing, infection with bone loss into the sinus requiring treatment over a much longer time, and an very unhappy patient. The prudent thing to do is to remove and treat the cause of the bone loss as soon as it can be done.

'Amazing to hear of an implant's having been placed with no immediate pre-op, intra-op or post-op x-rays! I have a patient who opted to have a Periodontist put two 10 mm long implants in her resorbed lower 2nd molar site, with subsequent paresthesia... and he wants me to restore the implants... and he says he's taken no x-rays during or since the placement appointment 3 months ago! Of course he sent a CAT Scan taken before placement without any guides... Upon our request for an x-ray of the implants in place, his staff replied that he's such a "gifted" surgeon that he does not need them... Is it not the standard of care to take an immediate pre-op, intra-op (length check,etc.) and post-op radiograph? Even Endodontics uses these 3 x-rays. John

Holy lack of X-rays, Batman! Or should I say Superman? Because this perio guy must have X-ray vision. Or course you take a post op film! For any number of and all reasons! Heed, CRS, John, although you probably have come to that conclusion on your own. This sounds like trouble from A to Z.

Even though I do have X-ray vision I still take an X-ray for documentation!;)

I have a similar patient where implant had a peri apical radiolucency like cyst. Although implant was rotating on tighteing abutment with hand. So do you recommend to perform periapical surgery?

Hi Dany ............ er no ! if rotating just rotate it out and place in the bin... "Peri apical surgery" as such is only viable with integrated Implants.. Monish Bhola at Detroit Mercy has done some long term work on this type of surgery which is very interesting. Does no one use Osstell ? Peter

You can not judge this after 8 weeks. Compare PAs before and after placement with 8 weeks after. 2 scenarios 1- either overpreped (it will be ok)2- left over granulation tissue(it will be OK too) I am positive this will osseointegrate fine . Wait and take another PA after 4-6 months before loading. Even if this is a herd, the bacteria have no substrate to survive. Implants have no canals! No apical lesion for implant unless there is an intraoral access for germs.

I believe that the bacteria do quite well surviving on the blood in the marrow spaces once the area is seeded. I like the posts on the peri implant surgery I would use the nd- yag to kill the pathogens. Could someone please post the article references? You are correct that a failing root canal does continue to seed the area but this is a different pathological process. I would still recommend removal since this is early in the game vs chasing a compromised implant.

Thanks to all again! I would like to say that the doctor whose patient this is, has all neccesary x-rays before implant placement. I didn't post them at first, and now can't attach them after question was posted. The truth is that we don't have immidiate post-op x-ray and I really don't know where we made lapse(probably because at that tme it was lot of work). To clarify my earlier post. The tooth was extracted in january 2013. and implant was placed in november 2013. So it is not immidiate post extraction implant placement. The immidiate pre-op x-ray doesn't show anything suspect. I'll try to somehow post the image. I am also aware that this has nothing with AnyRidge implants, but patient has already 3 Astra Tech implants for years without anything like this. My first suspicion was also that this is retrograde periimplantitis, but I couldn't bealive that it can happen 10 months after extraction. We tried to rotate the implant with driver and fingers but it is very stable. Probably, it would be necessary to use a lot of force to unscrew the implant. The thing is that I can only suggest the colegue what to do, becuase it is his patient. The patient works on international ship and he must leave the country for 6 months and doesn't want any more operations. I'll post update if somebody is interested when he returns.

It is very simple the bacteria are walled off in the bone and are quiescent. When the implant osteotomies are drilled the bone is opened up, new blood supply, a nice blood clot, and the process starts. So my new protocol as an oral surgeon removing old failing endo teeth is to use the nd-yag laser with correct wavelength to kill pigmented bacteria several mm below the bone surface with proper measured joule energy. Probable second dose at implant placement just to be sure. This cannot be done with any other laser especially a diode which just melts the tissue, I graft at the same time use a laser generated clot and obtain primary closure if there is not a vestibular issue. I also inspect the buccal plate and modify the graft appropriately. It is sort of like having the right antibiotic in this case the right laser. And no I do not work for Millenium just use the correct laser for the problem, I've been burned( no pun intended) on these cases by well meaning referring dentists who like to do their own extractions and grafts which I have to redo and the patient pays for twice. On the other hand I am intrigued with Peter's success with the calcium type grafting products in my hands I have gotten poor results and have shifted to all human products including PRGF, no bovine thrombin, and human chorionic membranes. I still like Teflon however. This is an interesting problem since the implant bed looks great then starts to break down before uncovering for restoration. I do see the pattern also when an implant is placed near an old endo tooth. We have come a long way with endo now with microscopes and I am old enough to remember periapical surgery so I am suspect with older Root canals or ones not done under a microscope. Thanks for reading my ramblings it is a snowy January!

Hi Richard , your initial post states that it was 8 weeks from extraction to placement , now it is extraction in Jan 2013 and placemnet in Nov 2013 .... so not quite 8 weeks . We are trying to help and need the correct case details initially ... Hi CRS , yes after 10 years with certain alloplast we appear to have a real game changer developed which is very exciting . I have had an animal study published in the new Implant Dentistry on the concepts ... Regards Peter

Hi! Thanks. The problem is that moderator probably didn't understand my first question (due to lack of my knowlage of english) and modified it very much. So, the real case information is said in reply posts. For now, patient had to go outside the country and I doesn't have any news. When he returns we will make new x-ray and see what happens and try to remove the implant. The problem is that we can't use trephine burs for removal because there is just thin bone which covers the implant buccaly (about 1-1.5 mm) and we will loose that with trephine. Maybe will try with torque wrench. Best regards!

Need to radiographically follow the progression ( or lack thereof ) of this lesion. Does the original radiograph show this area ? If there are no symptoms ( no spontaneous pain, NO PAIN TO PALPATION, no exudate, no mobility ) leave it a while longer.... 2- 3 months. If a change in size ( increase ) or symptoms develope during that time, treat it as described above with lateral window access and debridement/regeneration. Of course if the lesion appears to get smaller just continue to watch it. Surgical scars and open sockets generally take longer than 8 wks to heal as do most periapical lesion that are in a phase of healing.

as an aside the lack of pre extraction, peri implant and other radiographs (ie CBCT) is quite telling. Again, cuttingcorners in simple cases--and this is a simple one--always compromises results in the most inopportune ways.