Questionable position of implant: recommendations?

I installed an implant in #31 site [madibular right second molar'47].  The implant is not centered in the mesiodistal space between #32 and 30 [mandibular right third and first molars; 48, 46].  The implant is too far to the distal and too close to #32 and too far from #30.  When I insert the crown, it will have almost a cantilever on the mesial which may increase the occlusal force on the implant.  Also the implant has been placed too far above the alveolar crest.  It should have been placed deeper.  What do you recommend I do at this point?

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33 thoughts on “Questionable position of implant: recommendations?

  1. For salvaging the implant, maybe use a laser to disinfect/sterilize the implant surface that is above the crest of bone,pack more bone and extract #32 ?
    Otherwise , since you don’t like the placement of the implant anyway, remove it and place another one more subcrestal?

  2. An occlusal rest from the future crown is a palliative option to decrease cantilever moment.

  3. hey, its not the end of the world. you have a good amount of bone distal, just make sure the crown has the contact point centred axially over the implant and the mesial cusps of the crown are completely out of function. If you are worried then raise a flap, and with huge amounts of cooling, polish smooth the coronal threads and then tie it back up to heal before restoring it (or if you are skilled and familiar with modern grafting techniques you can get bone back around the implant) hope this helps. all the best, mike.

    • Here is the reason why to start over, fortunately you are at a good stopping point since the crown as not been placed. Having that many threads exposed in a bony defect will be a future headache for the next 2 years until the implant fails. It may not look that bad now but it will really look bad after the crown is placed. The restorative cannot make up for a poor foundation. The point being the heroics suggested above are used on an implant which has been restored and functioning for several years not something that is a poor result from the get go. This edentulous space appears wider and there is not a lot of bone from the crest, I don’t know what it looked like prior. Now even if by some miracle bone can be grown with a no walled defect the placement is still poor. Remove it and fix it now vs nursing this thing along, I give you permission based on all the reasons you stated in your first post. Next time take a film at placement and simply back it out, place a simple graft and start over, it happens, it’s part of surgery. I would also advise using a surgical stent to line this unusual space up. Perhaps two small implants? Now please understand that I am very impressed with you posting this it shows good judgement and wanting to do the right thing. You know the rationale, if the removal is a problem work with a colleague who can help you, I do it there’s no shame in that and your patient will appreciate it. I know this may sound harsh but in the long run it is the best vs taking Mike’s advice and going down that compromised path and hoping it will work.

        • I had this happen to me and the cantilevered crown caused loss of the implant, I’m redoing it, so I being honest with you! I got burned since the referring doc didn’t send a stent and I tried to eyeball it! In this case the extra time and expense with a new crown could have been avoided. Good luck it happens.

  4. Hello Pranav, Even I faced this problem. Eventhough I try to place it at the centre, the osteotomy invariably goes into one of the sockets, either mesial or distal. Implant seems to have osseointegrated. All the best for prosthetic part. Keep posted.

      • Hello Pranav, I am not that experienced to comment whether to remove the implant or not, but I have seen many impantologists boasting of success with even such implants. I think, you can just go ahead with bone graft and cover the exposed threads and hope for the best. I am also eagerly waiting for few more comments regarding retaining the implant and getting a fair prosthetic outcome.

  5. Implant is too distal. But it is at the correct level. If you had placed it at the bone level it would be incorrect. However there has been loss of Bone height. This should’ve been corrected previously or at implant placement.
    Gold standard is take it out, graft and try restore height if possible.
    Or accept the compromised situation, place crown with axial stop and mesial cantilever out of occlusion. Be aware mesial food trap.

  6. Backing out the implant and place more mesial in an idealized position by using a guide. You may have to place a particulate graft and let it turn over prior to replacing the implant.

    Yes you can go a little deeper.

    The comments about cantilevers are correct.

    You can try to gain more height with grafting/GBR.

    • Dr Hughes I have a question in these odd shaped molar spaces is it acceptable to place a molar implant with an open cleansable inter proximal contact to avoid a cantilever in a non esthetic area as a last resort. The implant is not going to drift like a natural tooth and if it is distal to a natural tooth that tooth is not going to drift distally. Could this be used to avoid the traumatic occlusion of a cantilever? Some patients have open contacts with their natural teeth Any thoughts?

    • looks like it is at the crest and no threads are exposed. although it is placed to distal let it heal have a custom abutment made from atlantis, fabricate a cementable crown with good contacts

  7. dear pranav pl. let me know
    1) when you placed this implant?
    2) have you done bone grafting at that time?
    3) why did you place this implant like this…..too mesial/some threads above the crestal bone?
    4) how many threads are above the crestal bone, seems 2-3?
    4)how much space is there… distal 46 to mesial 48 crown to crown?

    • Hi Vijay,
      i placed this implant last sunday, i.e. on 13th.
      to tell you all that no thread was exposed and this IOPA was taken immediately after implant placement.
      i am still wondering how come this radiolucency is there around the crest..maybe due to overexposure???
      I’ve read all the comments and have decided to remove the implant.
      Hope patient understands.

  8. I would approach this issue with two implants and two separate crowns. This way the contacts are closed. Also consider reshaping any inter proximal contacts on the natural teeth.
    CRS, I hope this answers your question. This should reduce the cantilevers from a large crown.

  9. @ Pranav..
    If you have placed it just a week ago…then the best option is to remove and place it again…

  10. Nice little challenge…I would remove it (torque it out) and immediately place a same diameter yet shorter implant to the same depth (no bone drilling needed). At the same appointment, I would place a 2.9mm diameter mini hybrid implant on the mesial corresponding to a “mesial root” and design a single crown on both implants with an accessible “furcation” bucal to lingual. After all, lower molars do have two roots!

    • I agree to you .There appears to be enough space mesial to implant, so instead of removing this implant , we can place a small diameter single piece implant at later date( ie during restorative phase).

  11. I agree with CRS comment in restoring and leaving a large contact with the first molar (2 to 3mm) to avoid the cantilever effect. After all we are facing a situation where compromise is probably the best option.

    I am not favorable to a vertical bone augmentation in this case because we it s unpredictable and , even if successful it may not survive with the distal position of the implant.

  12. hi
    I think it will be very difficult to remove and place another implant immediately because primary stability will not achieved after removing and placing implant same time in this case. so it is better to remove, graft, wait, place implant sequence.
    otherwise wait 2-3 months and do as following.
    1) Do enamaloplasty on mesial side of 48
    2) a little bit slicing on distal side of 46
    3) keep out of occulusion distal side of 48

    removing implant….placing another….two implant…
    most of the time pt will not agree and extra money…. another surgery…etc
    good luck

  13. This may be contrary to some but this case can be restored with a three unit bridge.
    One does not have to worry about placement, vertical bone height or cantilevers.
    The patient will be restored in an expedient fashion.
    Placing and restoring an implant in the second molar area can be difficult due to lack of access.

    • Sounds logical but I would be concerned with the high placement, not covered with bone, and hygiene. If this fails in the future it will need to be removed from under a bridge. It is a tough call. Perhaps removing the third molar and restoring with a cleanseable contact at the first molar. I still would remove and place it better if possible.

  14. Thread exposure plus cantilever increases the risk of implant body fracture. Determine whether the patient actually needs a second molar implant and if they do, remove this one and replace closer to the first molar.

  15. 1- Remove it and position in ideal Position more anterior (closer to 1st molar)to prevent Cantilever.
    2- How much (mm) is space between this implant and Distal of 1st molar. if there is 8 or more than 8 mm it is possible to insert another implant (3.1 or 3.3 or 4mm) and make two crown and No cantilever

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