Unusual pain after implants: treatment plan?

1. Remove implant prothesis. 2. Wait 7 to 10 days and observe symptoms. 3. If symptoms disappear. Reduce occlusion on prosthesis. Retry. 4. If symptoms do not disappear. Remove implant in #12. Observe for 4 to 6 weeks. 5. If symptoms improve you may consider to place again. And try new prosthesis. 6. If symptoms remain, tell patient #12 is not viable spot for placement. Then section off current prosthesis and use remainder for 13-15. Do a cantilever bridge for 11-12. Canine appears suitable abutment.

It sounds like atypical facial pain or trigeminal neuralgia. I would refer her to a neurologist or pain clinic a course of tegretol may improve symptoms. The physician will most likely obtain a MRI or CT to rule out central origin. Could also be " supra- tentorial" does not seem to be of dental origin. Good luck.

definitely neuralgia, not provoked by treatment but augmented by it. try Lyrica or any of the gabapentins. also ramped dosis of b complex vitamins

Remove the bridge and observe if there is pain. If there is no pain without the bridge, then you have a failing implant. It may not show radiographically because it is in early failure stage.

Suggest you infiltrate a few drops of articaine into papilla at B and again at lingual aspect of 11-12 when she has this pain. Any change? (Give it about 60 sec). If not, go half way up the distance to the apex between tooth and implant and deliver about 1/8 carp of articaine. Any change? (2 min). If not, go to apex and deliver another 1/8 carp. Any change? You are trying to determine the exact location of whatever is causing this problem. It is entirely possible that none of these infilts will make any difference. If any of them do make a difference, ask yourself what can be done at that site to minimize any stimulus that would activate sensory neurons at that site. This pt clearly has a trigeminal neuralgia and you will handle it with referral (let the neurologist prescribe the meds, many of them come with significant side effects and you are not in a position to manage them), and/or local treatment to reduce sensory input if meds fail. Unfortunately, it is quite likely that removal of the implant (or anything else you do locally) will not reverse the neuralgia, so if patient insists on this treatment be sure they sign a consent that states this "no guarantee of symptom relief) in writing. Finally, understand (and make sure pt understands) that although this condition occurred in close temporal proximity to the treatment you delivered, the underlying cause is a neurological problem that may well have occurred anyway. There are a great many patients out there with trigeminal neuralgia exactly as you described who have not had implants. You (both) fell into something that neither you nor anyone else could see coming, and while you are sincerely sorry for the problems that pt is experiencing it is not a dental problem and therefore it will not have a dental solution. Exception will be case in which removal of sensory input from that site stops the trigger. Consider removal of prosthesis, removal of abutment, replace cover screw, fill in intaglio surface of implant with temp resin to reduce food impaction and get close to the ridge (but don't touch it). Maybe by getting that implant out of the prosthesis you will reduce stimulation of that trigger area enough to provide some relief (?)

it could be from the implant being close to the canine and as a result inability of the patient to clean the area. Reflect a flap between 11 and 12and curette the area. Let it heal and figure out a way that the patient will be able to clean the space between 11 and 12

Sounds like atypical facial pain. Affects women more than men post 45 years old. Pain travels from one site to the other after treatment. Usually present during awake hours. She needs assessment by a neuro specialist. Good luck.

The above comments on facial neuralgias sound very possible especially if #11 checks out ok. The placement of the implants and surrounding tissues look ok to me so possibly you are dealing with something that will not show radiographically. The Neurological Consult would definitely be in order. Don't get the wrong idea about me but have you also considered the patient might have a bad case of "buyers remorse" and might be wanting to justify a refund and to keep all the work at the same time?? I bring this up because it happened to me about 7 yrs ago and to say the least it was a totally appalling experience!

What about the condition of the opposing dentition ? Any possibility of referred pain on that side? Occlusion can bring that about from the lower arch as well. Pathology? Try anesthetising lower as well. You may possibly discover something there as well. Thanks for the post. Great insight from GTF. I'll definitely keep those ideas in mind. Bill

Pain began before the implants were restored. I would consider a fracture of tooth #11. Try to stimulate pain response with percussion and biting on rubber. Try administering a local anesthetic when the patient presents with pain. Having placed implants for 27 years I have seen intermittent pain more often with natural teeth rather than with implants.

this is for sure... facial pain .atypical facial pain.... check neurology. and get some B complex , and let her rest for 1 week . don't remove the prosthesis . and she should take strong pain killer for few days. stay away from chocolates , nuts and Coffe take care

There is usually a dramatic drop off in the buccal plate just Distal to the cuspids, yet the implant diameter appears to match the cuspid width. There could be some cortical plate perforation about 2/3 to 3/4 of the implant length. Also, the 2nd bi implant has radiolucent area just before, thru, and just after sinus penetration. Of course, viewing the film so tiny and in this fashion could be the cause. You should at least rule out these possible simple contributors.

Just relax, check the occlusion first. TN has its typical features. To me all Implants looks good in position. Have you confirmed the occlusion and lateral movement of the jaw. Have you tried any lignocain gel on the soft tissue, did it relieved the problem... No Than did the pain vanish after injectable... No.. Than u May think to decide its psychosomatic and needs a referral. To me there is some issues with occlusion either with your anterior most implant or the posterior most implant. Pls update

Alternative Option: A course of cortico-steroid (e.g. Medrol Pak, possibly in conjunction with an internist/endocrinologist); and an occlusal guard.

I understand that the patient was symptom free prior to implant placement. Was a neurology consult obtained prior to going ahead and restoring with "bearable" pain? Was there ever a pain free time? I think you be in a grey area of causation and need to speak with the neurologist prior to having the patient evaluated. In my experience dental implants are not painful unless something is wrong, infection, trauma, neuroma. Also the rare probability of a central origin needs to be ruled out. I would stop pursuing the dental etiology since this seems to have been ruled out. My other thought a neuroma from the original surgery, was it a lateral sinus lift? Trying all these things posted without a diagnosis could do more harm than good. Lastly you may want to contact your insurance carrier.

Can we see the preop photo and the existing teeth? Sometimes existing granulation tissue can seal itself off and not resorb. I have seen implants placed directly on graulated sites causing unobvious pain.

Oh and great implant placement btw. Well done.

Answer may be in pts history. How she lost her teeth in first place. May it was a case of regional odontalgia- atypical facial pain which cause her to loose teeth in first place. If she had a history where she had root canals and no pain relief leading to subsequent extractions . Then u need a neurologist.

I have ex planted the fixture a few week after publishing this post using a trephine bur.there wasn't any sign of inflammation,granulation tissue,bony plate fracture..and surprisingly all symptoms disappeared immediately.

How can we give an opinion without a proper PA radiograph? I can't see the apex of the RC Treatment and barely the apex of the adjacent implant. Raul

Did the bridge fit passive ?