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Oral Radiology

Case Follow-up: To Implant or Not To Implant: What Role Does Imaging Play?

This case is presented by the University of Toronto, Department of Oral Radiology Residents: Edwin Chang, Sherif El Saraj, Catherine Nolet-Levesque, Daniel Turgeon, Niloufar Amintavakoli, and Trish Lukat.  Pre-operative images provided courtesy of Dr. Milan Madhavji of Canaray | Specialists in Oral Radiology.

You can view the original case here.

Case Follow-Up

Four implants were placed in the anterior mandible. Following implant surgery, the patient experienced persistent pain in the implant area and two of the implants failed in the immediate post-operative period.

Over the course of the following year, the pain progressively worsened in the anterior mandible and the patient was subsequently referred for a follow-up limited field-of-view cone beam CT assessment.

Axial cone beam CT cross-sectional image at the level of the mandibular alveolar process following implant placement

fig1 axial

Rendered panoramic reconstruction from the cone beam CT data set. 

fig2 panoramic

Bucco-lingual cone beam CT cross-sectional images through the anterior mandible. 

fig3 bucco-lingual

1. Why did two of the implants fail?
2. Why is the patient in chronic pain?
3. How has the radiographic appearance in the anterior mandible changed?
4. What do these clinical findings and radiographic features suggest?
5. Based on your deductions, would you have changed the original treatment plan? Why or why not?


  1. Lenny jung February 13, 2013

    There appears to be loss of cortical plate in the anterior mandible as well as a fracture in the alveolar ridge.

  2. Ronn Gibb February 27, 2013

    Based on the evidence and xrays provided above, one cannot answer any of these questions with any certainty. Why did they fail? If they were placed like the implant in quad 4, then they are outside the bone and would fail just like the implant will eventually fail in quad 4.
    The patient is in pain because something is happening in the bone. Is there a fracture? Is the anterior bone cancerous? The xrays are not conclusive diagnostically.
    How has the bone changed? Changed from what? We have no previous radiograph.
    What do the xrays suggest? It would appear that there is a fracture, but in the x section second from right, the dense bone is surrounded by cortical bone. Why is this? Might there be some type of –oma? The axial view shows unusual bone form in the anterior mandible. It might be that the mandible is very close to fracture anterior to the mini-implant.
    In hindsight, a CBCT would have possibly indicated that implants were not the right choice until the question of the bony condition in the anterior alveolar ridge was diagnosed and resolved.
    I would refer this case to an oral surgeon to flap and examine the anterior ridge prior to any further treatment wrt implants.

    1. Nat Podilsky February 27, 2013

      It would be nice to have some before radiographs, especially a previous CBCT.

      There is definitely an abnormality in the anterior mandible. This could be an osteosarcoma, necrosis of the bone or osteomelitis.’

      What is the medical history of the patient? What is the age and sex of the patient? Is the patient on any medications? What was the original reason for loosing the teeth? Any radiographs before treatment?

      In general, more information is required and a referal to an oral surgeon is required.

      1. RadiologyUofT February 27, 2013

        There are pre-op images available on the initial post for this case… please see http://www.jcdablogs.ca/2013/02/07/implantimaging/

  3. Tom Pater February 27, 2013

    1. Who really knows why they failed; these post op images certainly show unhealthy bone now, but before??? 2.The patient is in pain because the anterior mandibular bone is inflamed. 3. Changed from what and when? Useless question. 4. These radiographs suggest osteomyelitic reactions in the mandible and some type of pathological tissue in the mandible. 5. Easy to ask in retrospect; since I do not have any pre op information my answer is a DEFINATE “I do not know”.

    1. Tom Pater February 27, 2013

      Sorry, did not see the pre op link. I remember the case now. The bone looked healthy enough for implant placement before but now it is inflamed, surgical intervention is required. I am still staying with my original treatment plan and would have placed 4 small diameter implants through the radio-opaque mass. It seems this was not done in this case.

  4. raman kohli February 27, 2013

    From the radioleucencies on the occlusal view it appears that the two failed implants were placed either too labial (mesial to the mini-implant) or too lingual (at the midline). By “too” I mean into or beyond the cortical plate. Thus the failure of the implants would not be attributed to any pathology but rather dentist error. Following this reasoning I would expect that the implant in quadrant four will also fail or at the very least not have any bone on the labial aspect.

    The loss of the labial and lingual cortical plates at the sites of the failed implants will likely result in loss of bucco-lingual width and may even compromise these sites such that they no longer accommodate implant placement.

    Seeing that a mini-implant was used I assume that the dentist found the ridge too narrow for a conventional implant. In the mandible, this is evident during the clinical examination, which leads me to how one might have performed this case in hindsight. If during the examination appointment the ridge appears narrow a CBCT is recommended to allow one to determine how much the ridge must be reduced to attain an adequate bucco-lingual width. As well, if I am correct about the location of the failed implants not being within the cortical plates (1.5-2 mm of bone all around the implant required) then it would seem to me that this case was done with minimal flap elevation thus not allowing the dentist to fully visualize the shape of the ridge.

    I would recommend referral to a surgeon either oral or periodontal to rebuild the ridge, check on the remaining implants – and remove if necessary – and biopsy the bone anomaly.

  5. Elaine Orpe February 28, 2013

    Classic cemento-osseous dysplasia with subsequent osteomyelitis. A biopsy is not required to make the diagnosis and the cemento-osseous dysplasia should have been readily identified prior to treatment on the basis of periapical radiographs alone.

    Despite a few comments to the contrary on the pre-operative posting, I believe that the placement of implants is contra-indicated with cemento-osseous dysplasia because of poor vascularity of the affected bone. However, I do have an anecdotal report from an oral and maxillofacial surgeon that he has been able to successfully place implants into affected bone if the cemento-osseous masses are removed and the bone allowed to heal before the placement of the implants. I


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