Implants in compromised position: How do I restore this?

Two implants have been placed to replace #2,3 around 6 months ago. Implants are obviously in compromised position and angulation. Is it possible to splint them and restore? Please share any option you would have for the successful restoration of this case.


16 Comments on Implants in compromised position: How do I restore this?

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Steve Hurst
2/26/2019
Due to the vertical and mesial cantilever on #3, I would splint and consider leaving a large mesial open contact of 3mm for easy cleansibility. Good luck with this one, thanks for posting.
Joseph Kim, DDS, JD
2/26/2019
#2 is not deep enough, and #3 appears to have no bone around the apical 2/3 of the fixture. I would remove, elevate the sinus, and redo just #3.
Dr Dale Gerke, BDS, BScDe
2/26/2019
The radiograph does not show enough detail for an accurate assessment but I would think the #2 is not viable long term (and would seem difficult to restore in a reasonable occlusal plane). Whether you leave or remove it needs to be decided by you. In reality there is no functional requirement for #2 implant, so I would probably not be looking to replace it. #3 seems adequate but I cannot see enough detail to say whether there is enough bone support. You would need to decide this (presumably with a CT scan). If there is good support then you have a decision to make about restoration. Whether you leave a gap or not depends a little on what would suit the patient best. Certainly one large unit restoration will be hard to clean and as such not desirable. However, I think a cantilever crown and small pontic is worth considering, with special emphasis on the design to allow for easy maintenance.
Mark
2/26/2019
Boy that's a tough one. If that came to me I would do as was already said and restore only the #3 implant. It would be very hard for the patient to maintain a two unit splint. I would have to see more but I might try a single crown built out to mesial to contact tooth 4. Def screw retained.
Gregori M Kurtzman DDS
2/26/2019
#2 is predominately not within bone crestally and I would explant it. Since no lower 2nd molar I would not replace the implant at #2. With regards #3 take a closed tray impression (with the angulation wont be able to do open tray) have a custom abutment made, insert it then take an impression to have the crown made.
Timothy C Carter
2/26/2019
Assuming it is stable just restore #3 and leave #2 as is. Other than the distance from the adjacent tooth #3 is not in bad angulation. There should be no problem with simply restoring #3 as is and leave #2 asleep.
Carlos Boudet, DDS,DICOI
2/26/2019
I think this is a case that has not been planned the way any case should. If orthodontics is indicated, and it is, I would complete the orthodontic therapy before placing my implants unless they were needed for anchorage, and in this case they obviously were placed without a prosthetic plan in mind, and before the fixed appliance therapy was finished. Other things to consider are probable sinus pathology in the contralateral side to the implants, and endodontic therapy that probably needs retreatment in #30. As an exercise, you could restore the implant in the area of #3 with questionable long term prognosis, but the most distal implant appears unusable. Good luck.
Peter Kwon
2/26/2019
I would leave #2 alone as is and restore #3 with a screw retained crown. Close mesial contact and teach the patient to floss under the crown like a pontic. Inform the patient the crown may come loose over time, which will require the screw to be replaced.
Pankaj Narkhede DDS MDS F
2/26/2019
Need CBCT. But, if implants stable & integrated / healthy in whatever amount of bone it is in. With appropriate consent from patient. Use temporary abutments or angulated abutments - make screw retained crowns in PMMA / composite- like we did for transistional loading. I would prefer seperate crowns so that you know if any is failing. Then observe. This is less expensive & will not hit you back with malpractice.
Andris Bigestans
2/27/2019
Take them out ....
Peker Sandalli
2/27/2019
I think the short and wide implant has been inserted to get extra money from patient on the third molar tooth region. Because there is no wisdom tooth at the opposite side. The treatment plan should be: 1- Remove the short implant 2- Make a bridge between next implant and first molar tooth.
Timothy C Carter
2/27/2019
I completed my perio residency in 2007 and I trained along side with prosth residents. We were taught to manage complicated and/or compromised situations. Since that time my CE has been primarily annual perio meetings, journals, and topic specific lectures. I have noticed a trend, especially by those posting on this site, to remove and replace any implant deemed less than ideal. As I thumb through the multiple "throw away" journals I can't help but notice the advertisements by the implant manufacturers and the "training courses" they offer. I can only assume that they are driving this train and teaching profit through the remove and replace approach. In this particular case there appears, based on the information provided, to be very little compromise with the #3 fixture while the #1/#2 just needs to be left alone and put to sleep. The process of removing an otherwise stable implant is still a surgery with inherent risks. Maybe I am just too conservative but a simple approach would seem to satisfy the needs of this patient. I we take time to evaluate patients with implants in function, regardless of who placed the implants (us vs. another dentist), we will noticed a lot of well functioning compromised implants. I guess what I am proposing is to at least consider a simple approach and avoid over complicating manageable situations.
Dr. Moe
2/27/2019
Timothy, Agreed 100%. I wouldn't remove the implant, just let it sleep. Why cause more pain to the patient? Also, I had a similar situation where and O.S. placed #18 with No intra-occlusal space. When I informed patient, the crown will have metal occlusion, Pt balked. I told her to just go back to O.S. and have him bury the implant. She was very happy, I am sure she would have not been happy, if 1) we weren't going to do the crown and then 2) More surgery just to fix a "mistake"? Really?
oralsurgeryjj
3/12/2019
I beg to differ.................. It would be very very rare, but there are slightest chances that some careless and young and hot blooded dentists could picks up such kinda spot in the panorex and audaciously tell the patients "something's wrong with your implant." It had happened once in a while in my country, which had sometimes lead into dirty lawsuits. I believe there will be nobody who carelessly babble about other collegue's clinical result without careful hearing in the united states . So...in my country........I would prefer to leave no evidence in my patient mouth, if it is gonna work as sorta "timebomb." Besides, #2 has transmucosal portion and it cannot sleep....it will put its eye wide open intraorally and may cause infection on sinus area and sometimes delayed plunging to ocean of sinus if not cleaned properly everyday. And #3 is too distally placed so it might cause constant mechanical problems since occlusal load will be concentrated to mesial molar area. Distally angulated single implant with margin 11 mm away from the center like #3 will cause good trouble......not to mention of hardship of putting driver into the mouth when patient have not too good mouth opening...
Greg Kammeyer, DDS, MS, D
3/4/2019
I agree to leave #2. When restoring #3 I agree w Dr Gerke: build a proper tooth contour with a small, non-occluding pontic. Was the original plan to place an implant at #31? Certainly there is not much bone to implant contact on #2 for that restorative plan.
Hex888
4/1/2019
proper placement of implant fixtures will bring success to the restorative crown. Improper placement of fixtures will certainly result in failure and complications once the restorative crowns will be done. Also If another implant dentist reviews this case , it would be hard to justify Do take them out... or send back to Doctor who placed them to deal with it

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