Implant too close to proximal tooth: recommendations?

Question Is the implant integrated? You could also take a distal shifted periapical or a cone beam to see how close the implant is to the lateral. Why did you not take an immediate post op film to determine the placement so that the implant could be backed out at surgery it would have been a lot easier. Now if it is intgrated you might be better off leaving it and restoring it.

I agree that a cone beam is essential at this point. You might be experiencing radiographic overlap. If you have 1.5 mm distance you are ok. Implants are prosthetically driven with a surgical component, so the argument to distalize placement is questionable. Lesson learned. It seems that there is a particulate allograft previously placed which will remain during the prosthetic phase. All things considered, you may do more harm removing the implant at this point. A custom healing abutment followed by a custom titanium abutment and esthetic crown might work. Don't expect soft-tissue miracles, however.

Close follow up is recommended. Dont touch before any gross problem. Follow up means soft and gentle probing, periapical xray and vitality test of adjacent tooth. If needed just rct.

What's wrong here, everything looks good, there is bone separating the Impl and root at the crestal area and # 7 is asymptomatic... May be be if u take a Distal PA, u will find there is more space b/w Impl and the lateral root. Always place a immediate temporary crown with the anterior implant and make your life easy....if takes more time to make a chair side temporary than the surgery but the results/finess of the soft tissue maturation guides by temp contours are unsurpassable and then px is happy, u r happy, no uncovery surgery needed. Lean the art and principles of making screw retained temporaries. This will make u a better implantologist Sam Jain, DMD Center For Implant Dentistry Fremont, CA

I have to agree with the previous posts that there seems to be bone between your implant and #7. But why was the implant placed so deeply? It appears to be 4-5 mm below the crest?

The only problem here I think is C/R Ratio and possilbe esthetic compromise. sometimes you win the battle but loose the War. Meaning that the impant intergrates but the patient is unhapy with teh ethetic result thus being a failure.

I have a few questions on this. What is the radio opacity coronal to the implant? Secondly, I see a small notch in the crestal bone a few mm mesial to tooth #8 but the actual bone on the mesial seems to be at a physiologic level; could you please elaborate on your statement about trying to bone loss on the mesial of tooth #8. Lastly, what have you told the patient regarding the problem that we are discussing? Thank you. DrT

Frankly i'm amazed at the previous comments. Everyone spoke of proximity to adjacent tooth, no one addressed the prosthetic compromise positioning the fixture there is going to produce. if you are going to place fixtures in the aesthetic zone, they have to be spot on. that little bit of bone loss could have been easily grafted. if i inherited this case, of course i would involve the patient in the decision process, but from the prosthetic perspective, your question about removing grafting and placing a fixture centrally located that will allow for the prosthesis screw to come up through the cingulum is one you should strongly consider.

You are going to have interproximal bone loss 6-10 months after you place the crown, if the interproximal space between implant and #7 is less than 1.5mm (it looks like you used an Astra implant, which is most forgiving in this regard). I wouldn't worry about the apical area much. Overall a poor performance. If the implant is made from pure titanium, explanting wouldn't be easy if he implant has intergrated. If it's made from a strong titanium alloy then you can reverse it without trephination. If you have the interproximal space, just restore it. It the interproximal space in less than 1.5, remove it otherwise you will lose all the bone in #7-8 interproximal space.

It seems to me that the entire science of implants and their restoration is still so new and malleable that many of the concepts that are spoken about as "rules" may not hold up. obviously one should not harm nerves or adjacent teeth but certainly the diameter, the best length and correct placement of the implant are still very arguable. There are people here who swear you should use the largest implant you can get away with and insist that is the gospel truth. Ive always used small diameter implants without any trouble at all Its not even clear that the best implant placement should be restoratively driven and not where the best bone is. In short we should be open minded and listen to everyone's experience as long as we do no harm to adjacent teeth and nerve tissue

Interesting. The first concern is asking other Dentists to diagnose a potential positional issue from your two dimensional xray. I would listen closely to Dr. J's comments, and I agree that a comment like "everything looks good" is potentially misleading. I would like to add, I think it somewhat unprofessional to use this forum to bash other colleagues and or specialists. Finally I would like to say that there are many POTENTIAL issues with the placement of this implant. The esthetic zone is full of potential risks and I encourage dentists early in the learning curve not to frustrate themselves (frustrate is a kind word), or their patients. For those that think the placement of this implant is without concerns I invite you to post the final prosthetic photographs and follow ups. Maybe it will look perfect?

If the patient is satisfied with the esthetics at crown temporization & you have not experienced more than physiologic bone remodeling after one year, you can be comfortable. This case is a learning experience in esthetic zone implant placement. Aim for a more idealized placement with grafting, crestal bone spreading, CBCT and surgical guides to avoid future issues.

If there is no sensitivity to the #7 tooth, and the implant is asymptomatic and well integrated, the suggestion of first restoring with a good temporary crown gives you the opportunity to see if both you and the patient are satisfied with the esthetics. To attempt to remove a well integrated implant by trephination, will lead to a permanent disaster, regardless of the graft procedure....the esthetic zone is a very sensitive area, and does not like to be messed around with. A couple of years ago, a collegue from Montreal, Dr. Gilbert Tremblay presented to the AAID and later published a paper on Osseodistraction of Osseointegrated implants, by partially sectioning the bone around the implant, leaving an intact blood supply and orthodontically moving the block section of bone containing the implant into a better position. I have had the experience of placing an implant in what I considered the ideal place at the time of surgery, and was shocked by the final radiograph, when it appeared to be too close to the adjacent tooth....sometimes radiographs can be deceptive ....... only a scan will tell you the real truth. In my humble opinion, I think the patient will accept a well done final crown,even if it is not 100% perfect.... when they think of what they will have to be put through to gain 2 mm......life is not perfect, why do we have to be so hard on ourselves? Gerald Rudick dds Monttreal

I agree with the above contributors; As an OMS and Prosthetic specialist, I have seen, retreated, and reconsulted more similar cases than I care to share or you care to read. I have had my share of surgical misadventures as well. Suffice it to say that adequate training, thorough workup and treatment planning would prevent most of the misadventures I have read about in this blog. In a case like this, I would have planned it with a preop cone beam, and then fabricated a surgical guide by Anatomage or Materialize. This assures proper fixture placement. Our patients pay for and deserve the best. The previous contributor was correct when he said, "in my humble opinion, I think the patient will accept a well done final crown,even if it is not 100% perfect…. when they think of what they will have to be put through to gain 2 mm……life is not perfect, why do we have to be so hard on ourselves?" Life is not perfect and often we can get by by the skin of our teeth, but then one day the luck runs out and the letter from the lawyer arrives, and then it's too late. If we are going to successfully and safely treat implant patients it takes more than a weekend course. Our patients desire no less :-).

Hi folks; I had the chance to study exactly a similar case where the implant not only placed closed to the adjacent tooth but actully hit the root and left a thread mark on the adjacent root. Pt. kept having a lingering pain for weeks, the case ended up remove the implant and the adjacent tooth with a massive bone loss and patient ended up with a flipper. However being asymptomatic on the adjacent tooth is good sign, never the less the location is totally wrong( this is happened with a lot of dentists and it only means that they had a bad day that day). I agree with proceeding with prosthetic part and keep a good eye on the adjacent tooth. Good luck

simple....leave implant...work out the final crown with the temp crown first....and then restore.. Learn that one should take post-op x-rays...and move on... Nothing in life is 100%... except death :)

Dr. Don...I cannot let your so totally distant, completely disimpassioned, objective comment go by without asking...what about the patient???? DrT

Taking verification x-rays early, with the pilot drill or a direction indicator is a must if you want to place your implants in a good position. There is no reason to place the implant in this position. You either did not take verification x-rays, or totally disregarded them. The replacement of a maxillary central with an implant supported crown adjacent to a natural tooth is a predictable but demanding procedure. I would refine my skills mentioned above in the posterior region before attempting such a task. Things you need to consider that are extremely important in this area are soft tissue biotype, tooth shape(square,tapered), gingival exposure, etc... Restoring this implant will definitely be an esthetic compromise. If you place a temporary and find that the patient has no exposure of the gingival third of the crown with an exagerated smile, then the patient might accept the results that you will obtain here. Please know that we have all placed implant in less than ideal positions and have learned from our mistakes, but these are basic techniques in implantology... Thanks for posting and good luck!

Patient will no doubt lose papilla on Distal, however is it better to remove, graft, replace with ct guided with or without immediate temp? Depends on smile line, age and gender, bio type of gingiva, patient psychology and socioeconomics as well as expectation. All you can do is inform, lower the bar for the expectations and let the patient decide.

It is much too deep and you could have avoided the mesial bone loss on #9 and still have angled the apex of the implant toward the mesial of #9. Good luck with restoring and I suspect you will lose bone IP 7-8 and have papilla loss when you uncover and restore.

Leave it alone ! will be fine..

You should take a ct to have a better idea where you placed this implant, I think you are more worry about the lateral incisor and the damage you could cause to it . To avoid damage to adjacent anatomical structures ct. Now trying to remove this implant will be more damage, and we are talking about reparing with a block bone graft. Try to imaging restoring this implant versus taking it out. If you decide to resotore it you should start now with a temporary giving the emerging profile,consider the bone defect you have at mesial of number 9 At this point what I recommend is a ct to get a better idea I think this implant was placed towards lingual. The path of insertion is another issue, you need to placed an abutment and see if you will have the alternative to restore it most important emerging profile you need to play with the abutment and the temporary .

Hello Don't think of removing the implant. I think you should start with a custom abutment and give a temporary crown for few weeks before replacing it with a permanent crown and also keep rechecking the patient at regular intervals in future also.

This might happen with any dentist ,once no harm to the neighbouring tooth no pain on percoution ,go ahead using angulated abutment and put the crown

Sorry if this has been said already, but why are you asking the question now? Any comments about position, cej approximation, or crown: root ratio are useless based on this radiograph. I'm also sorry for suggesting that if you can't place the implant, then you shouldn't explant the fixture. No patient deserves that.

Actually i am asking a question not related to this topic.I tried to ask this question in Q & A section but i was not able to upload it.But i think this site is the perfect platform to ask this.I am a PG student.I like to know that the bone formation in sinus lift technique is due to the osteogenic potential of periosteum or from where osteoblast are coming? if i am wrrong please ignore this.

CBCT guided surgery for standard implants in the ethetic zone, both depth and trajectory can be adressed pre-op. free hand placement in trajectory sensitive areas may be a thing of the past. good luck moving forward.

Carlos Boudet says it all , take check x-rays , and yes the angle it is taken is critical. Most cases I have seen like this is because of Technology and CBCT stents used where the Dentist feels secure . Always assume you do not know and check to confirm. Peter

I would like to see a panoramic radiograph or CBCT before making a judgement.

Explain situatation to patient,determining correct thickness and position of bone ,Place temporary crown and monitoring the case.Result can be see after loading and decision depends on result of oseointegration or any sign in relation to 7.

I had a case, the problem was that if she present discomfort, do opt for orthodontics to parallelize the pieces and make room for the tooth! now she has a year with her bridge

please make sure that apically implant is well surrounded by bone, you can use cone beam and clinical palpation in apical part of implant area as there is an angle problem in premaxillary area.

Can't see how a cone beam CT will do anything at this point, other than expose patient to unnecessary radiation. Do you really need further confirmation that angulation wasn't perfect? It happens. Explant not a good option, in fact, contraindicated if #7 asymptomatic. That's the key point here. Custom abutment with temp crown first, as suggested. Other than with potential papilla issues, will be fine. Learn something from the case on how to minimize incorrect angulation issues in the future, as suggested here. We all have our "learning cases".