Deep decay in canine and implant placement: opinions?

I am posting my first case, and I would appreciate your comments.  This is a 71 year old lady who came in years ago, but accepted only crowns on the anterior incisors. Some weeks ago she returned and the canine had deep decay.

I offered her implants and did a 3-D scan.  The surgery and installation went well for the implant in the second premolar site. The canine was a disaster. 

The buccal cortical plate was very thin, so I placed the implant more palatally, and filled the socket with autogenous bone. I decided to place a healing cap and to wait. I then placed an implant in the lateral incisor site intending to place a provisional restoration.  I had minimal space, but I was able to insert a 3.8mm implant and achieved primary stability of 40Ncm.  But because of the thin bucco-lingual cortical  plates I had to place it around 3mm deeper then planned, rather than than chipping off the overhanging thin corticals.  I placed a 3mm healing cap because I did not have a longer one.  It tilted towards the approximal bone of the central incisor.  I then decided to close everything for 3 months. 

In your opinion, where did I go wrong? Would you use some provisional solutions in your practice?
Any advice about when to load those fixtures?

Thank You

16 thoughts on: Deep decay in canine and implant placement: opinions?

  1. Kevin Frawley DDS says:

    First of all, we all have cases we learn from. So posting cases helps everybody. Do you have a CBCT ? Really important, especially with anterior cases. Did you use any kind of guide? Even using a wax-up and doing a suckdown will help greatly. Always take a guide pin shot before you complete your osteotomy, so you can make corrections. Even if you don’t have a CBCT, a PA will still be helpful. When ever things aren’t ideal, it is always safer to graft and come back and place the implant.
    From a treatment planning point of view, I like to take things slowly. I would have removed the bridge, used the canine as a temporary, by doing an endo and post build up. Made a provisional so now you have time to place 3, 5 and 7 implants (premolars with internal sinus lifts) . After healing , make custom abutments on the implants, ext. #6, graft and place provisional bridge on 3, 5, and 7. After 6 heals place implant, etc. This may take longer but you will sleep better and have more consistent results. Hope that helps.
    Take care, Kevin Frawley, Surgical Esthetics

  2. Mike says:

    Would like to know what your restorative plan will be? Fixed removable hybrid? locator Overdenture? you will need custom abutments to correct angulation of #4 and #6 site implants. Its very challenging to place an immediate implant at upper canine site. The socket is so large that to attain primary stability is not easy for inexperienced doctors. I would have grafted and returned a few months later. If you want to place immediate implant placements on large molar or canine sites in the future, there is an implant company out there named Cortex, the implant type is called Saturn Implant. look it up. It has a wing design to increase stability after an extraction. I’m a doctor, zero financial interest in this Israeli implant and I’m not a representative of this system, but have colleagues that have been happy with their results. Let’s see what our other colleagues on here recommend as well. Best of Luck !

  3. Dr Andy says:

    First , I think you did a great work.
    I would wait for the restoration 6 month.
    Regarding the “short “ healing cap you placed ,if you don’t have a longer one, you always can place an abutment.
    Did you thought to use PRF ??
    What are you planning for the final restoration? Would you like to make a long bridge and to come connect tooth 17 with the implants?? I wouldn’t do that.

    • Doriman says:

      “First , I think you did a great work.”
      Can you explain what you thought was great. I’m curious.
      Or have I missed the point? Perhaps you were being kind.

  4. Leo A. says:

    Immediate implant placement has less predictable outcomes, try to stay away from immediates as a beginner. I would have placed 4 implants in the #3, 4,5,7 locations and socket shielded and grafted #6 and provisionalized with an interim partial denture or splinted fixed provisional depending on initial stability. RPD is safer. I would have also ridge split any thin areas and socket lifted where necessary. Lastly I would make sure the angulations are closer to parallel. When in doubt graft and come back in 4-6 months. To summarize my criticism is the following 1) not enough implants 2)wrong implant locations 3)poor angulation. I would have used the existing bridge to make a stent as a guide for your osteotomies. This case will be challenging to restore in the current state. Will this be screw or cement retained? This makes a big difference in design. The primary problem I worry about here after you get through the restorative phase is the patient’s ability to maintain proper hygiene. Please remember treatment planning is everything! Instead, now you have to troubleshoot by working backwards to address problems that didn’t exist before you started. With that said, I would add a 4th implant(free of charge if you have to) in the #3 position and use custom abutments, a good lab and cement retained FPD (make sure you don’t leave any sub-gingival cement behind, there are techniques for this). Do yourself a huge favor when taking your impression splint #6, 7 impression posts together to stabilize them, and if you can get them to draw splint the #3, 4 together. Otherwise you will get distortions and your restoration will never seat properly and you’ll have open margins etc. Good luck.

  5. Mark Sheklian DMD says:

    I will not comment on placement because I don’t place my own implants. I know many doctors place lateral and canine implants next to each other. I always wonder if we really need the lateral site implant. Does it not complicate things. Why not cantelever a lateral? Do placing both lateral and canine , in a case like this add a needed strucural strength? Thanks. Just wondering.

  6. Dale Gerke - BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    All the previous comments are excellent. While we all have to start somewhere, as professionals we also have a responsibility to the patient. With this in mind, more initial planning would have been better (and indeed in all cases).
    This was an ideal case for preliminary CAD/CAM diagnosis and preplanned surgical guide. That would have solved your problems before the event. You could have also planned how you were going to make temporary restorations. The above suggestion about using the canine was a good one. However if you have previous models (with all teeth in place) then you can place some wax (about 2 mm) in the palate, duplicate it, make a suck down and then use whatever temporary resin use have in your surgery to construct a quick partial denture (basically like the old “spoon” dentures) and that will get you and the patient out of trouble for a month or two.
    In this case, if you had sectioned the bridge and prepared a temporary part denture prior to surgery, then you could have placed implants in the edentulous areas and used the part denture until healing had occurred. Then sort out whatever you wanted to do with the canine (and either add to the part denture or construct a provisional bridge on the then integrated implants or not implanted the canine position at all).
    In regards to the position of the implants, you probably could have made them more parallel, but I have seen worse situations. You really need to know how you want to restore (bridge, denture, single units?). At least one abutment will need to be redirectional and the easiest thing to do is get the implant rep to call on you with a catalogue of the abutments they have and see is there are any “off the shelf” abutments that will suit (sometimes this is easier done talking to the lab with a model – after fixture impressions). Alternatively you might be able to get something tailor made (milled). As such you might want to use a very good lab (one that specialises in implants). It might cost a little more but they will have the experience to help you.
    For a first attempt this was not too bad, but learn from the issues you now face and next time plan ahead for all stages that are required so that you have them all ready to go (or at least thought through so you are ready to deal with each stage).

  7. mwjdds,ms says:

    As in previous posts, the treatment planning and execution were not particularly well done. I am assuming you planned a crown and bridge restoratation replacing 3-7. The planning should have gone like this:
    1) how many implants to retain this bridge?
    2) what positions? Not only tooth numbers but vertical and horizontal positioning as well.
    3) how should I handle the extraction and implantation of #6? (extract, graft, delayed placement vs. immediate placement)
    4) how will I provisionalize?
    5) will I provisionalize the implants or go straight from healing abutments to final restoration?
    6) what is the final restoration? screw retained or cement? What material?

    Once you answer some questions then you have a better understanding of what is needed. Have the final plan in mind before you ever start a treatment plan. In this instance, implants should have been positioned at sites 3, 5 and 6. Cantilever #7. It is very difficult to place side by side implants and restore them esthetically. I always cantilever #7 from #6. Next, make a surgical guide to help position the implants in all three axes (vertical, horizontal and mesio/distal). Place the implants, bone grafting as needed. Then restore after integration.

    This is a fairly complex implant situation and maybe one you shouldn’t have done without doing some easier cases first. Use an experienced surgeon to help you in these difficult cases. This will be difficult to restore due to the uneven implant positions, possible too palatal locations and what are you going to do about #3?

  8. Dok says:

    If these implants are completely stable do the following:
    Custom abutments on all the implants to create parallel path of insertion for a 4 unit bridge. Replace the crown on #2 at the same time the prosthetic bridge is made to close any space that may be left distal to the bridge. Easy peasy.

  9. Dok says:

    How in the heck does the patient clean under such a bridge, especially with a deeply placed implant in the tooth # 6 position ? Easy answer. Utilize an irrigating brush tip ( interproximal brush with an irrigating function ). It irrigates and brushes at the same time…… below, between and around implant prosthesis blowing out all the debri , delivering your choice of irrigant and mechanically brushing at the same time. Did I mention the ability to target the irrigant flow at any flow rate you desire. Well yes it does that to.

    • Matt Helm D.D.S. says:

      Dok, can you give at least one commercial name for such an irrigating interproximal brush? Is it in the Water Pick line? Thanks.

  10. Dorian Hatchuel says:

    There are 7 habits to highly effective people. See the book by Stephen Covey.
    Habit one: Be proactive. (Consider all aspects and plan ahead).
    Habit two: Start with the end in mind. (Have a goal).
    Habit three: Put first things first (prioritize).

    In Short, its all in the planning.
    I’m not going to make practical suggestions how to treat your case other than to say put those 3 habits into play and you will find all your answers. Find a mentor too.
    Best wishes.

  11. Dr. Cz Zoltán says:

    First of all I feel very pleased, that in such a short time I have got this many feedback, some of them positive, some of them also to take notes.
    I try to answer later under the comments uniquely.
    In general I have to say, due to some misspelling there is an error. It is the first case I post here, but not my first implant ever. With no experience that would be too hard in my opinion, although it is my first canine case.
    I did not made a guide, I measured the ct, when the bridge was in, to come out with the implant at 1.5.
    Maybe I am a bit too surgical point of view, but being parallel is less a thing to me rather than respect periimplant bone requirements. I keep 1.5mm around fixture and 3mm between each one. I thought angulated abutments and multiunits supposed to correct bad bone anatomy. Are You more about parallelism, even doing extra grafts and more expenses?

    I used cortex brand and achieved nice primary stability, I was confused only about the big dehiscence I was filling up autogenously. I have a fear of grafting, than hanging out a healing cap is n the same place.
    I really appreciate comments on provisionals, I will definitely take study impressions in future.
    Deep implant position shall not be a big pain, I hope I’ll get gingival attachment. But upon impressions I’d thank any advice on an ideal impression material (commercial name, which You use) for open tray.

  12. Richard Hughes, DDS says:

    It’s best to start these cases with a classic work up. Mounted cast, diagnostic was up. A lot can be observed from these basic steps. A suck down is a good guide . Always evaluate the inter arch space and the inter span space. Strive for an idealized occlusion.

    That said this case was poorly executed. Sorry.
    As is now, this case has potential for litigation.

    The other doctors have made excellent suggestions.

  13. Greg Kammeyer, DDS, MS, DABOI says:

    For me the missing piece that has been addressed minimally in the above posts is that the posterior part of the mouth bears the most force, hence the most implant support is needed there. Does she wear a lower partial denture? What occlusal scheme will you use to help her keep her teeth? Best of luck.

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