Failing implants in lateral incisors with esthetic problems: Suggestions ?

I have a new male patient who smokes.  He had an implant placed in the maxillary right lateral incisor region (#12) five years ago. The dentist placed a provisional restoration that was never replaced with a final crown. When the patient came to my office he was wearing the same provisional, which he told me had been dislodged and re-cemented many times. It was a total mess. I removed that provisional, cleaned the region and placed a new provisional crown at the same appointment. I even found sutures from 5 years ago underneath the old provisional. The photo shows 15 days after the new provisional.

In this same first appointment he had an implant on the maxillary left lateral incisor (#22) which had been placed 2 months ago in another city. This implant had a provisional restoration that was made at the same appointment when the implant was placed (immediate loading). The patient’s complaint about this implant was that it was loose. When I tried to tighten, the implant rotated out easily and I removed it.

I requested a panoramic x-ray to take a general look and see what was going on. I saw that the remaining implant is probably doomed due to significant bone loss and esthetic issues.  The implant has an external hex. I requested a CT scan but I still don’t have it.

I have work to do on both lateral incisors position. On the right side, it’s possible to see that both canine and central incisors have their soft tissues contours compromised due to the bone loss around the implant. What is the best choice here?

OBS: The remaining roots of tooth #37 were removed already.
OBS 2: Patient has a periapical pathology on #24. Was refered to an endodontist.

Treatment plan options:

1) Remove implant -> Bone Graft and connective tissue graft in the same surgical appointment?
2) Remove implant -> Bone graft, wait and do connective tissue graft at another opportunity?
3) Other

What do you recommend? Can’t wait to see the suggestions.
Thank you

 



16 thoughts on: Failing implants in lateral incisors with esthetic problems: Suggestions ?

  1. FRANK says:

    This patient is a smoker and you have a big order to fill.
    I would suggest extraxting the implant and grafting the area.
    Then two three unit bridges with connective tissue graft if necessary to improve tissue contour.

    The prognosis for extensive treatment, bone and gum grafting, is poor on a smoker.
    Also the dental IQ of this patient is not very high from what I can read.

    Why put him and yourself in trouble. Implants cannot fix every situation.

  2. Dr Jag Bhachu says:

    Extract implant #12, Graft site #12.
    Provisional with adhesive cantilever #13,12
    #23,22, A’s long as occlusion favourable.
    Wait 4-6m CBCT to assess bone at both sites, consider placing implants . Or could always leave adhesive bridges as definitive,
    If you feel unsure about adhesive bridges , could convert to fixed cantilever at both sites. Ensure guidance on canines.

  3. Adibo says:

    Every thing is alarming about this case!
    First of all a patient with 2 temporary restorations should immediately raise the question, WHY?
    Secondly he had a failed implant 22 and another failing 12.
    Thirdly he is a smoker with poor dental awareness.
    This patient is best served with simple reliable dentistry.
    No matter he is not a suitable candidate for implant treatment, just imagine he disappears after you have carried out grafting or placed implants. He may not disappear for good this time but returns to your office when he had ruined your nice work with his neglect.
    I would be very dubious endodontic treatment of 24. It doesn’t look restorable. And again, in a mouth with so many missing teeth, what is the long-term prognosis of this tooth?
    Nothing wrong with keeping the treatment simple until he proves he will look after himself better and your nice work.
    Good Luck!

  4. FES, DMD says:

    Immediate loading an implant, in a smoker, is fraught with complications. I just refuse to do it. If you decide to place another implant, cover it with a resorbable membrane, bury it and say 3 Hail Mary’s. Good luck….

  5. Richard Hughes says:

    I would not be inclined to treat this patient. There are way to many red flags! Smoking, Doctor hopping and prolonged use of provisional restorations.

    You may consider placing the patient on an oral disease control program and evaluate. One can refer to another doctor(s). This is a patient that would have to prove that they are serious about getting with the program. The money and time you invest with this person is not worth it.

  6. Eunice says:

    Perio, Perio, Perio…. first and foremost treat primary disease. The first question I would ask the patient is, ” how do you feel about your teeth – looks, function, ongoing expenses,etc?” You need to “feel him out”. Then let him talk. That may prompt the second question or not… ” how would you feel if you lost a “bunch” ( not a couple) of your upper teeth, or all of your upper teeth ? ” He will tell you what he wants, and that is the most important. If he wants more than you think he really understands, you slow down the process of him getting there and watch. I routinely tell people there is no sense to throw good money after bad… in this case, implants, grafting and all of those high end salvage tx’s are bad for him. Smoking in my office is an automatic NO to implants…. why do I want to provide something, that ,right out of the gate has a 50% chance of failure, and that is IF everything else goes perfectly well. I don’t like failure that much and after 35 years in practice, I like it even less. Just because we can does not mean we should.
    In my experience the mystery is in the history…. smoker, low dental IQ, poor commitment to treatment and follow through. Unfortunately as it was with the previous dentists , it will probably be with you… you are more committed to his problem that he is to it. I don’t think the patient has any ownership of his current dental status. Where I practice in Canada we have very little access to CT services and the Canadian medical system does NOT pay for anything remotely dental, and private insurance companies do not pay for anything other than basic radiographs. Hence, those are the tools we work with.
    For a conservative tx plan, I would :
    1) extract everything that requires anything above and beyond basic dentistry : 14, 13 probably, 12 implant, 11, assess 21 for stability, 24 and 37, and deliver provisional upper and lower partials. If he does not want keep the uppers for whatever reason, then an immediate CUD and lower provisional interim partial to establish a reasonably level occlusion, give him function, improved aesthetics, time to heal, learn and participate in improving his dental health status.
    2) a full hygiene workup and tx every 4 months for a year. This means he has to commit to showing up 3 times in a year for tx , reevaluation, etc. It is essential for any long term success as we define it, that he gain a level of understanding of basic hygiene , proficiency performing it on a daily basis, and a commitment to continue. He has to own his problem.
    After that, who knows….transition to a cast metal partial? or a wait to do an immediate CLD. He is the master of his own destiny, not the dentist. All the best.

  7. Dr T says:

    This patient seems to have a history of never completing treatment at one location. To have an implant placed plus a provisional then getting it re-cemented several times aside from being a smoke etc, is this really some one you want to take on?

  8. Alex Zavyalov says:

    Without restoring the proper posterior mastication function (at least
    with any removable dentures) ) in order not to overload the frontal teeth and the future implant, all your treatment plans will failed soon

  9. Bill M says:

    There doesn’t seem to be a long term plan or did I miss this. You need posterior support ,the occlusal plane needs to be leveled You cant to let this patient function primarily on the front teeth. Need an end point or you may keep spinning your wheels and loose any implants you place

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