Bone Resorption Leads to a Difficult Restorative Problem: Did I Have Better Options?

Dr C. , all I can say is scary , too deep for the system ( about 4 mm ) , no need to have perforated the nasal floor. Just place the implant at the correct level and GRAFT the buccal deficiency so that you can have a restorable result and avoid long term issues for the patient . Using synthetic materials you can even increase the vertical height with adjacent teeth. But this a routine everyday situation with buccal bone loss and it would be helpful for you to try to learn a bit about graft (GBR ) techniques to help when you face these issues. Could try and back it out a bit if not integrated and another possible issu is the peri-apical area on the lateral , possibly as a result of the trauma , have you tested the vitality? Peter

Hi Dr D. I think you are going to get a real aesthetic problem with this placement. As Peter said I think you are about 4-5mm too deep. You also have not managed to seat the healing cap due to its flare and this will cause bacterial pumping issues meaning you will possible loose bone to the first thread in the healing phase. I think you have no option in this situation than to try to back the implant out and place another. Do not worry about buccal threads showing in the coronal, you need to graft at the time of placement with a good synthetic and leave to integrate. You need to close in cases like this rather than placing a healing abutment. I would act now, and save yourself a major headache later. The key determinant of success in the aesthetic zone is the correct placement of the implant in both buccolingual and depth terms. If the tissue is not there, you need to put it back either before or during surgery. It also looks as if you have followed the socket to the distal (transport), this might mean you also followed the socket in the buccal direction. This means that you may not have too much buccal plate to play with. I am afraid there are a few too many issues for this to be a successful case in my view. All the best, Mike

I agree with Dr.mike ainsworth.I think big problem in the long time.

Hi ; is the second image just a check radiograph with a direction indicator, i think it is. The first implant is a little deep but sometimes you do have to go a little deep. We are outside teh framework set out by Buser et al but i have sometimes had to place this deep. I find increasing vertical height if ridges very unpredictable. The problem you may have if restoring get a long open tray pick up. Even then if the pick up is unstable get the custom abutement made with a defined margin and the framework for a metalo ceramic crown, with some de-rotational slot on the abutment (note metal margin necessary so the technician has a defined finish lone) Then place some temp bond into the framework and fully seat (have then abutment margin supra gingival to fully confirm this) pick the framework up in an impression and get teh porcelain added to teh crown - note abutment must be fully torqued down into position at this point. Ok so its deep look at the Bicon boys!! Any deep and i would be worried! Just remeber in this situtaion you want the abutment margin reasonablty superficial no deep than 2 mm. Also annual radiographs to chec everything is ok.

Hey, Dr. D., As mentioned above, this situation is pretty much the bread and butter of implant situations and a number of GBR applications could easily solve the Facial bone insufficiency. There is a recent Webcast Replay on the Bicon.com site which shows one solution. You can clean the socket, prep and place an implant of size and position so as to allow an elongated, teardrop shaped collagen membrane to be packed with synthetic graft between the implant and what's left of the Facial bone. This membrane then is folded over the top of the socket over the top of the implant, or over the top of just graft material if you are delaying implant placement. Usually a Colla Plug is tied down with inverted figure 8 suture atop that deeper membrane. This has the great advantage of creating "acres" of nice attached gingival tissue which you can later mold to pleasant aesthetics while also growing a new Facial boney plate and allowing your implant restoration to emerge from deep in the soft tissue while not too deep in the bone tissue. John

Also, a shorter, 4.0 to 4.5 mm would probably avoided the risk of apical plate perforation and nasal floor perforation.

Those are the cases to refer. I agree with the above...this will be tough to manage over time.

dear collegue dr.d alredy put the implant.. i think it is better now to discuss the second step not to tell him it was better to do this or that>> forget evrything now and let speak about the restorative step>> dear dr.d . it is not difficult at all>> but also it is not easy>> see i ve documented the same case like this and i manage it like that: the second restorative stage should start wityh long healing collar(either buy it from the company or use the abutment + cap over it as healing collar>> my favorite system is implant direct system where you can find the implant+impresion transfer+abutment+healing collar+plastic cap>>in the same pakage) so use the abutment and cap over it as a healing collar and then after 10 days contenue the normal procedure of restoration >> just if you can do the crown as screw retaintive not a cemented type to avoid entraption of cement deeplly under the gum >> good luck and keep in contact

When a natural tooth is avulsed due to trauma, very often there is damage to the socket, specifically the thin labial plate. As much as we prefer closed procedures so as not disturb the blood supply to the periosteum and less invasive for the patient, it is sometimes a better idea to have a look and see what has happened to the foundation for the future implant. The esthetic zone can be a very tricky area to work with, and a damaged labial plate can lead to drastic recession to the adjacent teeth. Next time, after opening a flap,and if there is labial plate damage that occurred, then it would be wiser to do a bone graft using a titanium mesh to increase the vertical height in order for the graft to grow up against, and uncover 4-6 months later. When you have restored the bone to an acceptable height, then place an implant. A crown that is excessively longer than its neighbor is not attractive, even with a pink porcelain covering.. so if the patient is willing, take out the implant, and start again....both you and the patient will be more satisfied with the end result.

Dr. Rudick gave you very good advise. The correct way to handle this is to do the site development first, then place the implant. This gives you a second chance to improve the bone and soft tissue if you see that the site is still deficient after the first grafting attempt. Some of my colleagues would attempt to do immediate placement and graft at the same time, but they would have to agree that delayed placement here is more predictable especially when dealing with a single maxillary incisor making it look identical to the adjacent central without pink porcelain. Also like Peter said, watch the adjacent teeth for periapical lesions, they can cause your implant to fail. Good luck!

All I can say here is WTF. If you have just placed it(I pray this is the case) you had better back it out ASAP!!! You will get IP bone loss and have an esthetic nightmare if you could restore it in the first place if you leave it like this. I hope you have a low lip line patient that cares more for function than esthetics. I would have placed the implant where you had your initial pilot drill x-ray platform and grafted at this point with primary closure. Now, you probably can not get apical stability when you remove the implant so you most likely will need to remove, graft (not replace the implant right now) allow for healing, and place the implant later. Are you a GP or specialist? This is crazy. Tell the patient what is going on and pray they do not sue. Refer to a specialist if you can not handle this. I just do not know what goes through one's mind when doing stuff like this. Good luck

The implant is deeper and implant crown is long,and without aesthetic.the company osstem ask if the have in their system abutments straight multi unit abutment with those can make an extension of platform and the implant crown shorter,do it connective tissue graft, bone graft,whether to keep the implant. But remember you are esthetic zone some negative point in that case:periapical pathology in adjacent teeth,implant deeper,soft tissue, bone loss, for better esthetic remove implant and do the case again .

Dr. C, I would preform both at the same surgery time. I´d do the expansion, place the implant and graft que buccal bone with Bio-Oss, cover it all with a thick colagen membrane and close everything. I´d even preform a conjuntive tissue graft do gain thickness and protect my bone graft.

One more aspect is I noticed you have not been able to fully sea tthe healing cap due to the depth , this may be catastrophic for the surrounding bone due the bacterial issues at this level . I think you may need to proactive here to prevent a bad senario. Regards Peter

When we're learning to place implants there can be a strong temptation to take every opportunity to place an implant. It appears that you jumped into this one. Implants are just another treatment option that we have in our bag, they need to be part of an overall treatment plan like anything else. If a tooth needs a root canal and crown, one wouldn't put the crown on first then do the root canal. Same thing here, you have to plan before you place. You really have created a potential nightmare. I agree with those that advised to take the implant out and create a suitable site. The abscess on the lateral is another potential complication, I have a cbct and it can be surprising to see the actual extent of some lesions. It's not too late to correct things, of course it will be easier if the implant hasn't integrated yet.