Angulated implant: best way to proceed?

I am wondering how we can restore this implant in the #12 site. There was an error and case ended up with an implant that is angulated towards #13.  The implant is an Alpha Bio SPI 3.3.  I am concerned if the misangulation will adversely affect the placement of a healing abutment.  I am also concerned if the  misangulation will make getting the impression difficult. It should also be mentioned, that there was a PFM crown on #13, but it was removed a year ago. Should preparation of the tooth provide a better access for transfer positioning? Or should I use an angulated abutment for making the impression?  Will that give me more space to manage the misangulation?  Thoughts on how should I proceed with this case?

34 thoughts on “Angulated implant: best way to proceed?

  1. Frank Avason says:

    How the heck did the surgeon get this angulation so far off? Is it palatal to the adjacent teeth or has significant movement of the premolar occurred? Even with significant preparation of #13, good luck trying to impress this one. Of course, every implant placed in the wrong heals….. You might want to send this one back to the surgeon, as I would not want to make this my problem (and it will become yours if you accept this result as a positive one…..). Good luck.

    • Dr Bob says:

      I agree with you Mark. Perhaps a platform switch to a smaller diameter angled abutment, and preparation of the abutment with carbide burs in the mouth, in addition to the movement of the adjacent tooth to the distal as you suggested would be a solution. A routine C&B impression of the implant abutment could then be done. If there is no real need for an implant level impression why make things more difficult..

  2. Gregori Kurtzman, DDS, MAGD, FACD, FPFA, DICOI, DADIA says:

    Two options really since the current situation will make getting an implant impression difficult due to #13

    1. remove the implant and start over at a proper angulation
    2. ortho short term to distalize 13-15 then when sufficient space present take implant impression, place a custom abutment and crown and then remove the ortho and 12 will keep it in place as cant drift mesially.

    I dont think crowning 13 (looks like very little prep was done on it for the prior crown) will create enough space to get an impression head into 12. Possible that 13-15 drifted forward as the implant was integrating.

      • Dr. Rana Oral says:

        Implant removing with removing sets doesn’t need any bone loss. Also safe for inserting new implant at the same time flapless.

  3. Dr. Mohamed Elnadi says:

    Hello Dr.

    I would first try to take an impression using open tray. If the impression coping does not go in I sometimes prep the coping to make it fit. If that doesn’t work then I would place an Angled abutment and prep it in the moth and take a regular crown impression with retraction cord. I would not remove an integrated implant if I can restore it.

  4. Dr. Mohamed Elnadi says:

    I just would like to add that this is a 2d image. If the surgeon was able to use a driver to drive this implant in I am pretty sure there will be a path for the impression coping. Please do not judge placement on a 2D image. Go ahead Dr. and uncover this implant and see what is the angulation for yourself.

  5. Herman COMLEKCI says:

    I do agree with all the options the other clinicians presented.
    Experience will tell you , yes you can restore these difficult cases spending significant chair time but it’s always wiser to remove the implant and start over with a longer and wider, properly placed implant. If you restore the present situation it will most likely come back to haunt you.

  6. Dr. Mohamed Elnadi says:

    Another tip for you dr. Is You can also prep the healing abutment to make it fit. I have placed and restored many Angled implants and research showed that up to 45 degree will have the same prognosis as a straight implant. My only concern here would be the decay on 11 :). Go ahead dr. Don’t be afraid to uncover the implant and restore it. Do not let the 2d image scare you. I am sure there will be a path for the impression coping because most of us use an implant driver to drive the implant in and you can’t get the implant in at this direction because the handpiece or the driver will hit #13.

  7. Dr. Mohamed Elnadi says:

    In a perfect world I am sure this surgeon would have placed a much bigger and longer implant. Unfortunately we do not live in a perfect world. Without a 3D image or bone sounding I can not really judge that. What I can tell you is most likely this was the best implant that he can fit in that situation. I have faith that most of us know what we are doing. You can try to remove that and would never be able to place another implant there again with out a lot of work. I would try to restore it first. If that comes back in a few years then I would deal with it then.

  8. scmdds says:

    Removing an implant and starting over is rarely easy and if there is another way, such as orthodontic re-positioning, I would certainly select this over removal.

    Hey Implant Guy, What does Implant Direct have to do with this case?

  9. Kevan wong says:

    Remove and replace the implant not wider diameter but longer. Extra apical bone will give primary stability. Do not accept the present as it will have a 20yr legacy of poor implantology with your name on it.

  10. RU says:

    Have you evaluated the case clinically? I would not decide on a treatment plan until you check the implant in the mouth. It looks bad in the pano but you may be surprised to find that it is not as bad as the radiograph shows.
    I would use an angle abutment.

  11. Elijah Arrington III says:

    I dont think its integrated yet. Open a flap, remove partially and reangle. Set drill to reverse up 105 Ncm. If it is integrated, obviously you can place a 17degree or 30 degree abutment and take impression via closed tray, or like everyone else is saying just prep an abutment. Don’t be in a hurry. Hope this helps….

  12. Jar says:

    Since there was a way to place the implant than there must be a way to deal with it short of removing it. Placing a crown on 13 would overall be an easier task from a patient point of view than to start over again. A custom abutment will solve the problem. Cannot envision a possibility of the implant drifting after implantation.

  13. AB Periodontist says:

    Options you can try in this case:
    1. Root canal treatment of the second premolar and crown preparation so as to facilitate space for impression and prosthesis of the implant. If the implants is integrated, I won’t recommend removing it.

    2. Like mentioned in above comments, orthodontic distalization of premolars and molars till sufficient space is available.

  14. uttom k shet says:

    1. Try to avoid using healing abutment and use prosthetic abutment (angular) during second surgery. At the same time, take the abutment level impression for making temporary crown. After completion of soft tissue healing, you can repeat the same impression taking procedure to make the final crown.
    2. removing this implant and retreat the patient involve with many issue to manage.
    best of luck.

  15. Diti says:

    I think that the implant is tipped vestibular as the surgeon tried to take advantage of the pallatal bone , also seems that is more radiollucent apical so that will be a problem with a longer implant.Overall you should try to uncover the implant and see for yourself how bad is it ,for me that looks restorable .

  16. dr. R Walton says:

    This is unfortunate.Definitely the placement angulation was poor but I’m interested in knowing if this was worsened by the patients failure to have the implant restored in a timely manor leading to mesial migration of 13 to 15. If there was adequate space at the time of implant placement then the simplest treatment would be to place a split acrylic space regainer. To get maximum space I would disk the mesial of 14 and make sure the acrylic engages the mesial of 13 but does not engage between 13 and 14.

    If this is the surgeon’s fault, I would have him replace the implant!

    I would offer both options to the patient.

    Also this case demonstrates the need for a temp crown when the restoration might be delayed. A good learning experience.

    Glad to answer any questions you might have

  17. TK Diplomate, ABOI says:

    the most simple way is to remove the #12 implant and place at right angulation, don’t create 2nd problem by touching other teeth as more problems create further

  18. mark says:

    removing the implant is all well and good but you are missing the fact that #13 has drifted forward. Move it back into position and then see where you are. My eye tells me an angulated abutment may solve the problem . If I’m wrong then remove the implant. Removing the implant is not going to solve the open contact!

  19. Dr.D says:

    Hello,

    This implant is totally restorable. It was inserted and torqued, so this means it is also possible to place an impression coping and take an impression. The angulation may look bad on the OPG, but I am sure it will look better on a CBCT scan.
    Some tips regarding the procedure you are about to perform:
    – Try taking an open-tray impression. If you cannot insert the impression coping, try doing it with a long angulated abutment (sit the abutment in the implant in a position that fits, take a close-tray impression, remove the abutment and and give it to the lab. They will then screw a lab analog and place the abutment back in the impression and make the cast.)
    – You can even do a screw-retained restoration using Dynamic abutment solution.

    I have done many cases like this, it can be a real pain in the a** but it is doable..

    Best reagrds
    D

  20. Dr.B says:

    What? No one suggests removing #13 and placing a 2nd implant?

    Just Kidding!!!!

    I agree with the above that theremust be a way to connect a coping because the handpiece was able to place the implant in the first place.

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