Placed Implant too Close to the Root: What Should I Do?

Dr. Z. asks:

I have a 34 year old female patient in excellent health. When I placed the implant fixture in #28 site [mandibular right first premolar; 34]. I placed the implant too close to the root of #29 [mandibular right second premolar; 35]. At 4 months post operative, the implant is stable, not mobile, asymptomatic and does not have a sinus tract. The second radiograph was taken at the 4 month post operative visit. #29 is asymptomatic and tests vital. Should I do anything other than to continue to observe the situation? Should I go ahead and restore the implant or should I wait?

Case Photo

41 thoughts on “Placed Implant too Close to the Root: What Should I Do?

  1. This is a very difficult situation that you’re in. These are the questions I have for you:
    1. Did you take radiographs with direction indicators?
    2. Did you take a final radiograph of implant placement?
    If you answered yes then you should have removed the implant immediately and not allow it to integrate. You say 29 is vital, then what is the radiolucency at the apix? Did you get an endo consult? The answer to your question is I would not restore this implant. Even for a board certified periodontist like myself I am not sure what to do when I’m presented with this situation. Needless to say this shouldn’t have happened in the first place. The best I can tell you is to refer this to a specialist and pray.

  2. Hi

    Well you have disturbed lamina dura. it is the reverse process peri-apical radiolucency will be followed by loss of vitality on 29.

    let the patient know the situation(we all know its not easy but its better they hear from you then someone else)
    consider endodontic treatment and hope for the best.
    If conventional endo doesnt work then careful apicectomy and grafting the area might help (depending how far you are from ID canal and mental foramen)

    you donot want to leave area and let it expand as ID canal and possibly mental foramen wont be far.

    any attempt to remove implant will lead to more damage on 29 so pray that endo work and radiolucency disappear and you can load at a later stage.

    if you have to remove implant you are in trouble here as may end up loosing 29.

  3. What would you do of this was your mouth?
    Would you want a restoration made on an implant with that radiographic appearance, which has clearly gotten worse in the time between x-rays.
    Would you want a restoration that would trap food, lead to peri-implantitis and periodontitis of the adjacent teeth?
    This is the line of thinking you need to use when placed with a situation like this. Put yourself in the patient’s situation.
    In all honesty, you are over your head hear my friend. Refer this to a good oms or periodontist and learn from them. Be honest with
    patient. The worst thing that could happen to you here: this patient ends up in another office for a second opinion and the guy slams your treatment.
    Do no harm, tell the truth, and refer to get another set of eyes on it.
    Remember that the treatment is defendable, no one is perfect. But the follow up care, and failure to recognize a problem and refer- this is not defendable.

  4. I don’t believe in bull sh*t like implants are reserved for perio and oms but this seemed like a fairly straight forward case where you had good amount of M-D space. Im sure you looked at B-L width before you selected a size of the implant. I would only leave it alone if the patient is informed of every details in terms of what happened, what could happen in the future if asymptomatic now. This may come as a rude statement but you might want to spend some more time in CE on implants if you weren’t even checking angulation of the implant while placing it..

  5. By the way, to answer your question ‘ should I wait or restore it?’ You see that radiolucency so why the heck would you restore that implant when you know it might have to come out?

  6. Sergio this is BS. GP’s should not be placing implants after a weekend course. If I was this doctor I wouldnt be able to look myself in the mirror. This is the most off angle implant Ive seen. He bagged the tooth and probably hit the nerve and he has the nerve to ask if he should restore this crap.

    You should all be ashamed of pulling punches here. This is malpractice nothing more. We owe it to our patients to provide them with optimum care. Refer your cases, work in a team. No need to make this all about money.

    This doctor caused a disaster for this patient. This patient now needs to have this implant removed and the tooth next to it either root canal or removed and there may be nerve damage her. Taking more CE isnt the answer. This doctor should never place an implant again.

    Lets all get with the program here and elevate our profession. If we cant police ourselves, the lawyers will.

    Sol

    BTW I am a General Dentist.

  7. The basic principle of implantology is violated by placing this implant in such a manner.When a Dr place an implant immediate observation on pilot drill shows where he is.Why in the first place it was continued as a procedure.Should have changed the angulation from beginning.Even now without waiting any more implant shall be removed.

  8. Dear Colleagues,
    My first assumption is that we all agree that the implant is placed in a very compromised position and that by all international standards of scientific implant dentistry, this implant should not be restored, and eventually removed, since we know that its biomechanical prognosis, once restored, is very questionable, and the potential compromise to the adjacent tooth and vital structures is a reality.
    The best option here for the patient, and for the colleague involved, is to approach this problem with proper troubleshooting protocol …
    Begin by gently and professionally explaining the issue to the patient … the understanding here is that this is a very important step… it will determine how well the rest of this situation will unfold.
    Next, if our colleague feels he or she has the expertise, otherwise refer to a well trained and experienced implantologist, commence proper diagnostic protocol by taking a proper CBCT scan.
    Next, assess the situation, looking at the 3D position of this implant relative to the other vital structures and neighboring tooth, and plan a surgical procedure to involve the explantation.
    How we deal with the explanted site may be a discussion for another day, as there are a number of possibilities depending on the surgeon’s preferences, and depending on the status and prognosis for the neighboring tooth.
    And, let us not forget, the patient should be given the liberty to participate in the evolution of this case … once the options have been explained to her, she will need to consent to a solution.

    Best Wishes.

  9. One more comment,

    To avoid any medico-legal eventualities, personally, I would provide any further treatment for free, even if the treatment goes to other colleagues.

    God Bless

  10. Sol Goldfarb,
    I got a news for you. Periodontists who were trained 15 years ago didn’t learn to place implants in their residency. I know a few OMFS programs that don’t realy include too much of implant placement in their program either. Where then do they learn? Who said this dentist went to a weekend course and placed this malpositioned implant. You are general dentist?
    Lots of time and effort coming from dentists’ part and going to CEs and most important part is you gotta do them. That’s how you learn. I’m not making rationalization on this case. If you read my comment above, I clearly indicated this is a result of lack of education. But YOU NEED to stop generalize general dentists as a whole like some specialists do. I don’t care if you are generalist or not. Some tough love make some poorly prepared dentist on implants realize whether they can contiue or not. Don’t make a statement like ” This dentist should never place implants again ” SO, if your class II restoration fails ( Don’t tell me BS like yours never fail), shoukd you never fill teeth again?
    Make a reasonable argument if you are going to make one.

  11. It would be best at the time of surgery to remove and place the implant in the proper position. Observe # 21 and treat in a proper manner (endo and pros. Let the patient know what happened. It’s not the end of the world. It’s not like removing the wrong lung or leg. I have seen implants properly and improperly placed by specialist and GP’s.

  12. Failures always occur, for the experienced and non-experienced. Firstly, I would pay my respect to Dr. Z for posting a failure case like this,it undoubtly takes some courage to go public with a that. But certainly everybody can learn from it and it´s a very good reminder always to take per-operative xrays.
    Frankly, it is difficult one to solve. Concerning the option of ex-implantation, which in this case demands trephining, would likely damage #21. Maybe it could be possible to trephine a bit and then use the Neo Remover Fixture Kit to remove the implant atraumatically. Afterwards, observe for endo tooth #21.
    Good Luck :-)

  13. First of all, to call “this implant failed or a failure” may not be appropriate in descriptive terms of understanding the situation as it presents now.
    Discussion:
    1. It is open for “possible corrections” without removing it. Although the consequences of such heroic “corrective procedures” as also suggested by other posters could be un-predictable.
    2. This implant, as it stands, is not in a “congeneal relation with it’s apical envirnment” for it’s (implant’s) survival. Restoring this implant with an “acceptable” and a comparitively easily maintainable restoration is not really a “challenge”.
    Personal observations:
    A. Orientation of implant is not acceptable even for or from a “beginner’s” point of view or an expert.
    B. Looking at the radiographs, the apical radioluscency in “the apical region” when the implant was placed was from the “mental foramen”. There is/was no pathological lesion.
    C. In case of there being no other complications in terms of symptoms or any other post operative radio-graphic findings… the implant could be restored.
    D. Apex of the implant seems to be located a one half way into the mandibular canal or being lateral.
    This is the way it was placed.
    Look what happened!
    “At 4 months post operative, the implant is stable, not mobile, asymptomatic and does not have a sinus tract. The second radiograph was taken at the 4 month post operative visit. #29 is asymptomatic and tests vital. Should I do anything other than to continue to observe the situation? Should I go ahead and restore the implant or should I wait?”

    Case Photo

    E. If the author thinks that #29 tested “vital”, there may be a need for re-testing and or improving the testing technique.
    F. The possibility of implant’s apex impinging and or even severing the vascular supply to #29 at the time of implant placement is affirmative. No restorations or any other lesions attributable to necrosis of pulp.
    G. The implant did not produce the apical lesion directly, but the iatrogenic, devitalized pulp of #29… contrary to clinical observation (says it is vital) is responsible for the apical lesion. Ref: Line F.
    H. There may not be a manifestation of a fistula as early as in four months… it could be(is) too soon for this to happen … especially considering the (otherwise) perfectly healthy pre-operative field.
    I. There are two options to correct and or to treat this situation.
    a. Endodontic treatment on #29… having confirmed “non vital”
    b. Wait, watch and observe the resolution of apical lesion.
    c. Apical lesion “resolved” as anticipated… Restore the implant with a restoration that fully satisfies every single requirement as demanded for proper maintenance and function.
    d. Apical lesion persists or enlarges… remove the implant diligently curette the socket and allow for healing to complete.
    e. Removal of this implant, so decided, could be easily achieved using an “implant removal tool”
    f. Trephining may not be necessary
    g. Suggesting two implants, considering the mesio-distal width of space could serve the best.
    Summary:
    i.Implant procedure not the “implant” is creating or has created the apical lesion.
    ii. Functional integrity of #29 seems “un-affected”
    iii. Need to treat apical lesion appears “inevitable”
    iv. Which means root canal treatment on #29
    v. Upon implant maintaining it’s healthy but “ugly” posture… restore it.
    vi. If replacing/re-positioning the implant two implants carrying two splinted bicuspids “cemented” is (seems)appropriate.
    Open for comments
    amgdds

  14. One possibility here is to extract the tooth, trephine the implant (risk of nerve injury), graft the ridge and then place two implants.

  15. Dear Colleague Gowda,

    With all due respect, I vehemently disagree with much of your observations and your advice by all international scientific standards and consensus.
    The implant should be removed, it would have a very poor prognosis once restored … it is severely angled distally, the recent literature is very clear on this, read Lan et al, IJOMI, 2010.

    Respectfully, thank you for sharing

  16. The Situation is not ideal but it can be solved I like to keep things simple and try to look at things long term. I think to solve the problem you need to
    1. Remove the implant.
    2. Monitor #29 for 4-6 months
    3. Place implant again but with a surgical guide they are very helpful.

  17. I agree with many of the comments and disagree with others. I disagree with the statement the only OMS & Periodontists place implants! That comes from the OLD noble rules years ago that they only sold to OMS & Periodontists. As an ” Implantologist” of 29 years, (yes, a residency in implants, a residency in facial trauma at an inner city hospital, and a partnership in an established implant practice, of not to mention the 2 fellowships in implants,and yes I’m a GP), WHAT THE HELL was this guy thinking! This is a lawsuit waiting to be served! What kind of training did this joker have? I do agree that the weekend wonder guys should NOT be placing implants! I would remove the implant, endo #29, wait 4-6 months and then send the patient to somebody who can do this simple case made difficult by lack of training and experience. You do not need a stent here! If you can drill a hole straight and vertical then sell you implant kit on E-bay!!!

  18. Get a CBCT. It’s the only way to know for sure if the implant actually violated the adjacent tooth root or not. Angulation can be off not only in a mesial-distal direction but in a buccal-lingual direction as well. You could get lucky and have it be off in a buccal-lingual direction and miss the adjacent tooth. In this case, back out the implant, graft, take more CE or use guided surgery. If the adjacent tooth has been violated, then I’d still suggest removal of the implant. Endo would most likely become necessary and keep your fingers crossed that it doesn’t turn out needing extraction. The earlier you try to remove the implant the easier it will be. Implant Direct has some implant removal tools that may work well for you. It’s not a good situation, but the wait and see approach only turns out worse.

  19. Leaving the main topic of discussion alone, I will move appart and disagree with Dr Gowda regarding that there is enough mesio-distal space for two implants. This would make the already complicated situation, even worse…there is no space to consider placing two implants, unless you extract #31 as well, (#30 is missing as you all know). Carefull case study would prevent the majority of these complication….Use of Scientific basis, and then rationalization…

  20. Given the awful angulation, is it also possible that the lingual plate is perforated as well. Given the history and the symptoms you described, the apex has a big problem and should not be stored. This is sure fire lawsuit if the patient is to go for it. The Best thing is to do the right thing from now on so if it gets to a court you won’t look too bad. For now you have committed “Malpractice”, and from this point on you will also commit “negligence” too. That implant should be removed and placed at the right location and and angulation (what the hell were you thinking when you were placing it). If your implant is a titanium alloy you should be able to put a torch wrench and reverse it out even if it is integrated. If it’s pure titanium then you need to dig it out and be very careful not to damage the nerve/other tooth etc.
    Given your poor choice of initial location, you have plenty of room distally to start a new osteotomy. This is bad, real bad but you can rescue it by saying to the patient that there may be an infection that will jeopardize the long term success of the case and we need to start over.

  21. Dear Dr. Z.,
    Thank you for sharing this case. There are many good points that have already been made. I’ll try to address things from a somewhat different perspective.

    This case will break down and cause problems at some point. The earlier these are addressed, the better for all. The longer you wait, the more challenging the problems are likely to be.

    Try to forget about this for a couple of days then think through things logically. The main issue to decide is whether you feel comfortable carrying this through to a satisfactory conclusion on your own which would likely be removal of the implant and endo or extraction of #28. If the answer is yes, then get a CT scan ASAP so you can determine where you are in 3 dimensions. I would not touch anything without a scan, you are already uncomfortably close to the mental foramen. A trephine may or may not be the answer for implant removal. If you placed the implant to the facial, you may already have a dehiscesce and may be able to deliver the implant facially and avoid the nerve altogether. With ridge augmentation, you may be able to recover enough bone for another implant.

    If you do not feel comfortable doing everything to completion, including the potential complications, then contact a periodontist or oral surgeon that you have a good working relationship with and ask for their evaluation and assistance.

    Whatever you do, don’t dig a deeper hole for yourself. You have taken the right step by asking questions. Decide if you want to complete this on your own.

    Good luck,

    PC

  22. Tell the patient the implant is too close to the tooth and has affected its health. The implant needs to be removed. Hopefully you can just reverse torque it out under LA put some graft material to fill the void and extirpate the 3. I would then have a colleague redo the implant and the endo and pay their fees. Two mistakes won’t be forgiven and you already have the pressure on you about the wrong doings of this case, so redoing it yourself may be difficult. Sometimes we can panic in a case or a patient makes us do something we end up regretting. If you get the implant out and save the other tooth you are ok.

  23. Oh dear we have really missed a point here
    Mistakes happen guys and that’s why this person has been honest enough to post a x ray – if your practicing implant dentistry who ever you classify yourself as omfs perio os gdP I don’t Care mistakes happen – can we give positive adivise and guidance here not Throw egos around this at the end of the day it’s a human being – admit and inform and offer choices to them such as Endo and wait and see xla and replace with another implant free of charge etc and learn from a mistake

  24. First of all ,I think that you are just a beginner, so you need to take somemore classes in implantology.
    eventhough some experts might even get close to some teeth with tilted or curved roots.
    in this case the iatrogenic mistake is obvious.
    the best advise is to explain everything to the patient honestly. tell her that the implant is at the proximity of the neighboring tooth. eventhough that the particular tooth is vital, but due to apical radiolucency, the rct is mandatory, then watch the result after 3 months, if the radiolucency becomes smaller ,then proceed with loadin the implant.
    if it gets worths, a delicate apicectomy is required.
    do not worry it will be solved.
    but for the next implantation, pls try to make a surgical stent, and get an x-ray from the first pilot drilling, to be safe, and not to be disappointed.

  25. Ac, I agree mistakes do happen. But this is beyond a simple mistake, I will not sit here and say that in 30 years I have not placed an implant too close to a tooth. If you have done enough cases you have done this at times. But considering the angulation, the resuls, only an inexperienced practioner would continue to place that implant. He has at this stage proformed malpractice, and I hope him well in removing himself from this situation with his skin on. I’m sorry, but in the real world we are held to a standard that is set by our peers. This case ,as much as we should be kind to Dr. Z, is below the standard of care we have set for ourselves, therefore he should not have started this case or if he realized it was going south during the surgery then do the RIGHT thing and bail out before you can’t.

  26. To colleagues who submit questions:

    It would be a courteous practice for colleagues who submit cases for commentary to give some feedback as to their thoughts regarding the advice given.

    Thank You

  27. I come across one suggestion recommending an “APICIECTOMY” if the apical lesion persists.
    IT IS GOING TO PERSIST, UNLESS THE CAUSE BE REMOVED>
    Attempting an apicoectomy in this situation could lead to an even greater disaster, even for an expert endodontist because,
    i. The most complex spatial orientation of extremely delicate anatomical structures.
    mental foramen and it’s contents.
    ii. Apex of the implant (riding over the vascular bundle)… I hope that sectioning the implant is not being considered…if the answer is “yes”, Q is WHY?
    iii. Morphological(surface contour) configueration of the superior wall of the lesion may not allow for a thorough and satisfactory instrumentation(curettage).
    iv. Unless a thorough debridement of the apex of the implant(thresds) is also achieved (not practical), the the purpose of the surgical procedure may (will) stand defeated.
    DISCUSSIONS:
    A. Apex of the implant “ENTERED” in to a “perfectly healthY” zone to begin with.
    B. Pre-op & pos-op radiographic appearances suggest that the apical lesion is a CONSEQUENT DEVELOPMENT upon invading and (let me say possible)”OCCLUDING” of the VASCULAR BUNDLE that once nurished the tooth(#28).
    c. This tooth at it’s current stage HAS TO BE NON-VITAL… two reasons/three!
    i. Implant, per operator is NOW INTEGRATED.
    ii. Presence of infection at placement, would not have allowed regionally selective integration! Body of implant integrated but not the “APEX”.
    iii. No dead pulpal tissue in the implant(Joke)!
    D. So, the strangulated dead (anachoretic infection) pulp tissue is the SOURCE for creating this lesion.
    E. A SUCCESSFUL root canal treatment on this (yet to be) CONFIRMED NON-VITAL tooth HAS to either allow COMPLETE RESOLUTION or the ARREST the SPREAD of LESION.
    F. Upon finding the tooth VITAL, if at all,and if ever…
    G. REMOVAL of the implant for NO JUSTIFIABLE REASON could be a PREFFERABLE approach to the problem.
    H. Rather than a HEROIC surgical intervention(apicoectomy) with a much GREATER POTENTIALS for even worst complications…
    i. Dammage to vascular supply to #28.
    ii. Dammage to mental/mandibular nerves
    iii. If the apical lesion refuses to respond after apical surgery… THEN WHAT NEXT?
    CONCLUSION:
    1. REMOVAL of implant will not resolve apical lesion… because it created the situation and is now sitting absolutely INERT and maintaining it’s own UGLY POSITION and POSTURE.
    2. Tooth #28 is NON-VITAL. Ref: point B.
    3. Endodontic treatment of #28 is necessary to eliminate the cause and source of infection that created the lesion. Ref: point D.
    4. PER AUTHOR’S statement IMPLANT IS INTEGRATED! so is the NEED TO CONSIDER keeping it and restore it upon apical repair.
    5. Source of infection removed(endo), lesion resolved restore the PISA TOWER (much worse) any way!
    6. Source of infection removed (endo),lesion UN-RESOLVED… suspect “integrity of Rct”.
    7. I like to chalenge the forum to offer A SINGLE LOGICAL/SCIENTIFIC REASON for removing this “DECLARED INTEGRATED” implant FOR THE SOLE/EXCLUSIVE PURPOSE of “TREATING THE (associated)APICAL LESION”.
    8. If implant is removed, it may still require Rct. on #28 for it’s(#28) survival.
    9. Other affirmative/salient/imminent reasons for removal of this “AWCKWARD” implant are being duely recognised and “ACKNOWLEDGED”.
    10. Application of Laser beams over the implant apex is a possibility if there ba a need to it.
    amgdds

  28. I can`t believe most of the comments in this site. If you don`t know, this is the place to discuss this kind of cases and learn from other colleagues experiences. I respect Dr. Z´s courage to show this case to us. So, what´s the porpouse to only show perfect cases…?? In that case a prefer to read a book… Of course this is an ugly case, with a lot of mistakes, starting with an horrible planification, but the problem is done and now we need to help our colleague to take the best option instead jugde him as some of you did.
    I think you have to explain what is happening to your patient, make him part of the solution. Take a CT Scan and then measure the real damage. Try to take out this unrestorable implant. Graft the site, control 29 over the time. If its necessary, you will have to make the endodontic treatment. Then, over 3 months, put another implant USING SURGICAL GUIDE THROUGH CT SCANN PLANIFICATION. If you think you are not able to do these, refer the case to an expert. For the future…. the difference between an expert and a begginer is THE ABILITY TO PLANNING your next move and to know HOW TO FIX THE COMPLICATIONS at time….
    Good Luck

  29. Dear Colleagues.

    Sorry for my silence, but I am waiting for results too. Frankly speaking, I’m not pleased with this implantation. I am prostodontist and this patient was referred to me for further restoration. Your tips have been shown to surgeon. Her choise – endodontic treatment of 20 tooth and monitoring of the lesion. She has explained to patient what will happen and refer him to endodontist. By the way, pulp of 20 tooth was vital. After two weeks of endodontic treatment patient have no complaints.

    I’ll appreciate your advices.

    Thank you.

  30. “By the way, pulp of 20 tooth was vital. After two weeks of endodontic treatment patient have no complaints.”

    WHY IN THE WHOLE WIDE WORLD was endodontics was performed on a “CONFIRMED VITAL”(per author) tooth?

    The answer to this question being…
    Vitality test results were WRONG!…False possitive.
    Because, the symptoms went away…”After two weeks of endodontic treatment patient have no complaints.”
    If the symptoms have disappeared, allowing SUFFICIENT TIME for the APICAL LESION to CONTAIN and to gradually
    RESOLVE without surgical intervention may make sense.
    amgdds

  31. The purpose of OsseoNews.com is to promote interactive, interprofessional education for clinicians anywhere in the world. We believe that the best learning experiences come from our failures, not our successes.

    Perfect cases, which are available for viewing in many other publications and websites, do little to expand one’s knowledge, whether one has placed thousands of implants or only one. This is why our case section is devoted to problematic cases.

    Furthermore, as the number of implants placed worldwide grows over time, inevitably the absolute number of failed implant cases will also grow, even if the failure rate remains low. The numbers suggest that at some point we will all face failure. We believe that having a free, unbridled, and yet respectful forum for any clinician to examine and to discuss implant cases, which have not been successful, is an invaluable tool both for beginners and experts alike.

    Thank you for your understanding, questions, problem cases, and continued support.

  32. OMS are the worst people to place implants in my humble opinion. They are detached from the prosthetic side of implantology, nor do they even care actually. We will never have a truly prosthetic driven implant system as a result.

    Back to the question. The loading question will come into play once it is in function. No offence, but take care of #29 before dealing with the implant.

  33. OMS and periodontists place just as mny bad implants as GP. This is a bad placement. Right now the dentist wants some advice as to course of treatment not lectures on what he did wrong! If you place the implants you should be able to deal with the complications. If you refer out you will lose control of the case and the patient. I am not sure prayer is the answer here…we are talking about a tooth not a life. Bury the implant, do not restore! Perform endo on #29 and follow closely. If the tooth continues to be symptomatic after endo consider apico with graft.

  34. To Osseonews,

    In response to your June 16 commentary …

    Our failures can certainly be learning experiences, but failures are not necessarily the “best” learning experiences.
    Both failures and successes can teach as equally effectively … they are two different entities.
    That being said, I would like to entertain the concepts of “failure” and “success” on only one playing field … competence, science and evidence-based practice.
    Thus, when incompetence is behind a particular case, then we need to redefine “success” or “failure” in this alternate playing field.

    Respectfully,

    Dr Mario Marcone
    Montreal, Canada

  35. as i can c,and what i,followed from previous discussions,lot has already been said,its lot to do with basics,more importantly,angle of handpiece,often people use wrist to place implants,that will gve ths picture for righthanded person on left side,incorrect operator position,vision,accessiblity,poor grip have added to pitfalls..implants survival is miraculous….but that does not justify improper approach….corelating clinical signs and symtoms,radiological data and pateint pyschology,action has to be initiated…lets understand…intention must not have been bad,but approach is…lets help positively…

  36. After you placed the implant you should take x-ray and check angulation. You shouldn’t leve implant that engled. When you saw that you should remove this implant and reposition and then control vitality of tooth #29.
    I don’t know if you want to restore this or remove this implant and place again.
    I always thing that if I place incorrectly and that patient will see another dentist what would other dentist say about me when he see that.

    If this this not a matter to you then you can order custom abutment and restore that.

    If you can talk to a patient and your patient will be able to understand you then remove and re-implant again. I think that will be the best, otherwise you will always have this in your head and you will always think and hope that nothing happens. i don’t thing its worth it. Good luck

  37. Guys, it would better if v could bail out the doc.from this situation, refer to OMFS… think like a surgeon…doc violated the basic rule of safe zone so create it..
    Moreover i dont think so its 1st premolar site, see the M-D space and observe crown of molar in 1st X-ray..(luks 1st molar)anyways.

    1.do endo & apicetomy of 2nd premolar
    2. as well clear all granulation from apex of implant and make sure that now apex of 2nd premolar is 2mm away from implant..can consider autogenous bone grafting too.
    3.Nerve reposition if implant is too close to it. (rule is 2mm away frm nerve,create it)
    4.Place one more smaller size implant in the mesial space and restore as one unit.

    …surgery is an armed savage trying to achieve by force…what a thinker will do by strategy….

  38. All I can say is that sh*t happens. Most likely in the early days of practicing or too much confidence mixed. And if Dr. Z asked for help I think we should unite efforts so that he can solve this problem. First of all the pilot drill radiograph is of utmost importance so that direction and osteotomy depth can be observed. So I believe this will never happen again.
    I would use an implant retriever to remove the implant, remove granulation tissue and endo + Ca(OH)2 changed every month untill that radiolucent image disappers (the apicectomy is VERY dangerous as you have to consider the mental nerve, alveolar nerve, mental foramina and the anterior ansa can be damaged).
    You have space for a second and a third premolar 3,5/3,75mm/3,8mm implants.

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