Note: While this article will focus on implant removal techniques, please reference How to Manage Integrated Implants in the Way of an Arch for a more detailed discussion on management options and theory.
Existing integrated implants in a planned arch are never ideal. That being said, they are almost never as big an issue as many practitioners worry they will be. When I come across integrated implants, I walk myself through the thought process I discuss here. And, if removal is indicated, I proceed by using the techniques outlined below.
There are three primary techniques that I use to remove integrated implants during full-arch surgery.
1. Reverse torque the implant.
Most implant companies offer some type of torque wrench driver adapter that seats into the implant’s internal connection and allows the surgeon to attempt to reverse torque the implant. This essentially allows you to “unscrew” the implant.
Now, while this may sound simple, this technique must also be used with caution. And, you must understand that this will not always be effective.
Sometimes the torque required to remove the integrated implant is too great, and the torque wrench adapter will actually either lose its connection and/or physically break before the implant reverses torque.
The second, and more important reason that caution must be utilized with this technique, is that such great force can be generated that you could either fracture a mandible or cause a significant maxillary or mandibular alveolar process fracture.
For this reason, I am very cautious with this technique (or may elect to avoid it altogether) if removing implants in an atrophic jaw and/or near the mandibular inferior border, maxillary sinus, or engaged with the piriform rim/nasal cavity. I feel these anatomical regions and scenarios carry increased risk of unwanted fractures and the risks often outweigh the benefits. The irony is that while this technique is often atraumatic, when used without caution, it can become significantly traumatic.
This technique sometimes yields better results and/or prevents unwanted fracture propagation when a portion of bone is removed around the implant before reverse torquing the implant.
In my experience, about 30-40% of implants will reverse torque out. Beyond that, they either require some degree of bone removal, or for the reasons listed above, I do not attempt to utilize this technique at all.
I am also aware, as you should be, that there are multiple options for implant removal adapters. I am certain that some are more effective than others, and you may see better or worse results than I report.
2. Utilize a trephine bur drill.
A trephine drill spins in a circular pattern and removes bone around the implant. These drills can be very effective at removing bone circumferentially around the implant without causing significant lateral bone destruction and/or unwanted vertical bone loss.
The implants themselves can then be either elevated and removed with a forcep and/or removed at this point with a reverse torque adapter.
I will caution you that I have had more than one Trephine drill fracture and break, splintering into pieces during its use around an integrated implant. I personally have gone away from using these drills for that reason.
3. Treat the integrated implant like a tooth.
In this scenario, I will utilize a 702 bur to remove bone around the implant. I will do this very aggressively down to the planned reduction line and then with more caution apical to the reduction line as needed. Remember, all the bone down to your reduction line is coming off anyway. Don’t hesitate to simply get that bone out of the way early and make the implant removal easier.
I will then utilize a small elevator to mobilize the implant, elevating in the notch I created with the 702, much like I would a tooth. Then, either a medium rongeur or 150 forceps is used to remove the implant, just like I would a tooth. I find this technique very effective and efficient in removing integrated implants.
During this process, I might also try the implant reverse torque adapter after bone removal is complete. At this point, the implant may simply be removable by reverse torque.
One piece of advice for those of you, like me, who are not restorative doctors:
Request that your restorative colleague remove any implant crowns or abutments in advance of surgery so that, as the surgeon, you have unhindered access to the internal housing of the implant itself.
If you cannot access the implant because an implant crown is in place, you will not be able to reverse torque the implant.
Furthermore, even removing the implant “like a tooth” can be more difficult with the crown in place, as the implant crown will tend to shatter into many small pieces and pose a concern for your airway. And, while it may seem tempting to grab/grip the implant crown like a tooth for removal, this almost always results in fracturing the abutment and screw, making removal of the implant more difficult, as you have again lost access to the internal housing of the implant.
The easiest and most effective pre-op protocol is to ensure your restorative colleague has removed any pre-existing implant crown/components prior to surgery.
Remember that an integrated implant is simply a “slightly more difficult tooth”. Learn to plan your cases with confidence around these pre-operative implants.