If you haven’t performed a “remove & replace”, you haven’t cut enough arches.
Removing a failed implant, and replacing a new implant to maintain a loaded prosthetic, is simply part of full-arch surgery. This technique is truly a skill in and of itself.
I had the blessing (and curse) when I began my full-arch journey of working at an AOX center that had been open for nearly 20 years. That’s thousands of full-arch patients that were being managed by this practice.
As such, a normal part of my week consisted of 1-2 remove & replace cases, many of whom had implants placed years prior. I learned quickly how to rescue a failing All-On-X case.
Today, I want to share with you 3 of the 6 reasons “Why I Avoid Replacing an Implant at a Failed Osteotomy Site”. I will cover the additional 3 reasons as part of future content.
Why I Avoid Replacing an Implant at a Failed Osteotomy Site
1. A failed implant site often presents with an acute infection – or a chronic inflammatory reaction.
An acute purulent infection at an implant site is a fairly obvious contraindication to replacing an implant at that same site. The infection needs to be managed prior to placing another foreign body (implant or graft) in that area.
However, what’s not often clear is when there is a more chronic inflammatory reaction and granulomatous tissue (without purulence) at the failed implant site. Should we or should we not use this site?
I will be honest, I have on rare occasions re-used this site when I have absolutely no other option. This is in the absence of acute infection. And, curettage and copious irrigation are carried out to remove any granulomatous tissue. But, I try to avoid this practice at all costs.
In my experience, when there are signs of a chronic inflammatory reaction – it’s more predictable to look at a new implant site. And that’s exactly what I do.
2. Reusing the same site requires increasing the implant osteotomy diameter.
*IF I have to re-use the same site, I always clean out the failed osteotomy via curettage and irrigation. Then, I also increase the osteotomy diameter by stepping-up to a larger drill. My hope is that this helps remove any surrounding inflammatory cells in the bony walls of the osteotomy.
However, the necessity to increase the osteotomy diameter may not be an option for all patients given their surrounding bone availability. This is especially true with more difficult atrophic cases, that ironically, may have a higher tendency toward failure.
Therefore, due to increased osteotomy size demands, I attempt to avoid the habit of reusing the failed osteotomy site.
3. Due to the history of implant failure, if the same osteotomy is reused, I will often opt to bury the implant.
In this scenario, I feel burying the implant provides more predictable healing (Well… it at least it makes me sleep better at night).
However, when I go down this treatment path, I still have to find an additional implant site to maintain the patient in a loaded prosthetic.
As a result, I almost always end up simply moving forward with the “new” implant site that will allow the patient to remain in a loaded prosthetic and I avoid the “buried” implant site altogether.
Performing effective “remove & replace” surgery is an art of its own.
There could be a whole lecture written on this topic.
Therefore, this is not meant to be a comprehensive guide to replacing a failed AOX implant, but rather a glimpse into the thought process of whether we should or shouldn’t re-use the same failed osteotomy site.
Happy removing and replacing.
And if you think this article isn’t for you – well… you’re time is coming 🙂
Matthew Krieger DMD
P.S. When I discuss a “remove and replace” – the failed implant is being removed and the new implant is being replaced at the same surgery. If you delay the “replacement” portion of the surgery, using a failed site does not necessarily carry the same risk as the infection and/or inflammatory infiltrate has likely subsided.
“Failure is awesome. Failure means you tried something, you tested it, and you learned some things. Failure gives you the tools to move forward.”
Leah Busque
Q & A with Dr. K
“Why don’t you use an OptraGate retractor? I feel it’s a better retractor and more comfortable for patients.” |
An OptraGate is without a doubt more comfortable for patients. However, all of my AOX patients are in a true general anesthetic state, so they are not aware of the retractor during surgery.
My preference for the Orringer retractor stems from the fact that it is easier for my assistants to optimize the surgical field view for me.
They are able to manipulate the lower metal bar on the Orringer and control the patient’s upper and lower lips as well as their cheeks.
This allows the surgical team to enhance my field of view depending on where I am working in the mouth.
I have tried other lip retractors and have found that this aspect is not as effective. Hence, my preference for the Orringer retractor.