Adjacent tooth to implant is in contact to root: how to proceed?

My patient returned from a specialist who placed an implant in the upper right lateral incisor site. She reports that he took no radiographs. She now has considerable pain in the adjacent canine that isn’t improving. I took radiographs and found the implant in contact with the root of the canine.  

My questions:
1. Is it acceptable not to take radiographs at the placement of an implant? I have other specialists doing this also. This is not how I was trained. Have I missed an update on placement techniques?
2. As the restoring dentist surely I can’t restore this. Should I call the surgeon and ask him to explain?
3. What is the likely timeframe of irreversible damage to the canine? Can this be salvaged, if the implant is removed asap. It has been in situ for 7 days.
All input and advice appreciated.

You May Like

15 thoughts on “Adjacent tooth to implant is in contact to root: how to proceed?

  1. Sorry, I can understand ur frustrations but I think the implant needs to be removed. 7 days still allows u to torque the implant out. Graft the site with either FDBA or auto bone with PRF. PRF would be important as it contains lots of growth factors & cells that are crucial for periodontal regeneration of the canine. Observe the canine for: 1. Vitality 2. Cessation of symptoms. If both are achieved, the canine is salvageable. Observe the radiograph for any root fracture of the canine too – the apical one third especially. If there is, canine removal is necessary. There’s another additional reason for explantation – the angle of the implant is non-parallel & the prosthodontics would be too challenging. Bcos the m-d width of the lateral incisor crown would be too broad. But the main bummer is the symptomatic canine that dictates that this won’t even work @ 1st instance. I shan’t comment on the rest of the points uve raised – valid as they are – cos to do so would be speculation & hence non-objective & unfair to the surgeon. I wasn’t there afterall 🙂 good luck. Patient management is key here, not a witch hunt that can inadvertently be triggered with the wrong choice of words.

  2. Are you sure it is in contact? It could be lingual or buccal to the canine. I would suggest the specialist spring for a cbct scan. Ive placed about 7,000 implants and have had this occur a couple of times in the lateral position even with radiographic guidance. Interestingly enough both of mine were asymptomatic and were eventually successfully restored. If it is indeed in contact your best bet would still be removal as outlined by Jawdoc. Up to 4 weeks removal is very simple (mainly osteoclastic activity) after that osseointegration begins in earnest and removal becomes more difficult. Love to see an xray by the way.

      1. Hi
        Actually the current radiograph wasn’t the original one that was posted – which I had based my original comment on. May be helpful is all available radiographs be available for a more balanced & complete presentation of the case 🙂
        Cheers

        1. @JawDoc:
          There was no radiograph posted along with the actual question when it originally appeared. The case image was only posted later, when it was received. I believe that it’s possible you may have originally saw a thumbnail, generic, stock photo on a listing page, and mistaken this stock photo placeholder as the actual case image. If so, we apologize for the confusion.

          Stock images are just placeholders, and are never shown on the actual page with the question. They are simply just placeholders for the listing page, when there is no image uploaded at the time a question is submitted.

          We are very sorry for the confusion. We will obviously have to change our generic stock photo to avoid this confusion in the future! Apologize about that. Anyway, the case image is at the top of the page now, along with the question.

  3. Why would you want to touch it? Refer back to os and let him deal with it. As soon as you touch it you just inherited the problem. Of course the treatment is to remove immediately and graft but I would leave this explanation to the person that placed it, oh and get a new os to refer to!

  4. What leads you to believe this is touching the canine? While I’m sure that seems obvious without a CBCT it is impossible to assume. With that said the placement should have been done better. And if a 2mm guide post radiograph had been taken it would have never happened.

  5. “1. Is it acceptable not to take radiographs at the placement of an implant? I have other specialists doing this also. This is not how I was trained. Have I missed an update on placement techniques?”

    Let me update you about reports from patients, They malinger.

    “2. As the restoring dentist surely I can’t restore this. Should I call the surgeon and ask him to explain?”

    Duh? Of course you should. Why fear professional to professional communication about a mutual patient? Did you refer the patient?

    “3. What is the likely timeframe of irreversible damage to the canine? Can this be salvaged, if the implant is removed asap. It has been in situ for 7 days.
    All input and advice appreciated.”

    You need a CT. By the PA, there is as much evidence that the implant is in the root of the canine as there is evidence that the canine root is fused to the premolar. The correct placement of the implant will be way palatal to the root of the canine and could have overlap on a simple PA of that angulation. Get a CT before you do any thing.

    My mom always told me that you are judged by the company you keep. I see a busted up central and a missing lateral. Was the canine under the protection of the tooth fairy?

    Seriously, your PA does not have the apex of the tooth in question and the angulation may have overlapped the root of the lateral if present.

  6. 1) On the balance of probability the implant needs to be removed. But remember in days of evidence based dentistry you still have no evidence to suggest there are trouble ahead in the implant site and the implant needs to be removed. There is a small possibility that it could integrate.

    2) You and the patient won’t loose anything (if she is not in major discomfort) to wait a few weeks/months and see how it develops. Take perioapical X-rays on a month intervals maybe up to 2-3 months. If the implant is too close you will see sign of rapid bone lost between the implant and the adjacent tooth. Once you see the bone lost then you have the evidence in hand that the implant is failing. Then send the x-ray to the surgeon.

    3) CBCT is giving a good indication for the exact position of the implant to the adjacent tooth but bear in mind the radiation dosage of a scan. You are probably better of to stick to perioapical x-rays for the moment. But try to take them in different angles and maybe even an occlusal radiograph becomes handy as well. I think with some good intra orals X-rays taken after a few months you would get a very good understanding about the implant site and you most likely do not need to take a CBCT.

    4) The implant site was a upper lateral incisor. The space is very limited and taking X-rays during implant placement specially in such narrow site is highly recommended.

    5) If the patient is planned to have an immediate implant crown placement (because of aesthetic reasons) then do not make the crown yet. You can fill the gap by an acid retained bridge (or even single tooth denture).

  7. Likely the PDL of the canine was injured by site preparation, and the injury is ongoing because functional movements of the canine within the PDL are like walking around with a splinter in your foot. This is just guesswork until you have either a CBCT image or a series of PAs taken at slightly different angles to clarify the position of the implant relative to the root. Small FOV CBCT radiation exposure is trivial (maybe 200 microSv at most) and I would not hesitate for one second based on concern in that area. I have a hunch that a surgeon will have to remove the implant, graft the site, and then replace the implant (I would give it 6 months to heal before going back in). Next time, the surgeon must use a surgical guide fabricated using CBCT information and current models. You don’t always need to do this, but why risk a placement problem on the second pass? Original surgeon absorbs ALL of this (no cost to the patient) or they go to court (not a hard decision for most; if the surgeon has a problem with that then replace the surgeon and document carefully because there will be attorneys). Real question is whether patient will allow the same surgeon to take another run at the case… that could go either way. I personally would not let that surgeon do the case again unless they have experience with (and agree to use) a surgical guide on the second pass. One adverse outcome does not make you a bad surgeon, but you do need to show good faith and good risk management going forward (or no deal). Good luck…

  8. My questions:
    1. Is it acceptable not to take radiographs at the placement of an implant? I have other specialists doing this also. This is not how I was trained. Have I missed an update on placement techniques?

    It is not standard of care to not take radiographs during or at the least after placement of an implant. radiograph would have told him he was contacting the adjacent tooth, ideally he should have placed the pilot drill back in the initial osteotomy and take a radiograph to check its placement in relation to adjacent teeth this would have caught the issue at the beginning and he could have adjusted the osteotomy accordingly

    2. As the restoring dentist surely I can’t restore this. Should I call the surgeon and ask him to explain?

    I would contact the surgeon and inform him that the implant is non restorable as placed and is causing pain to the cuspid that its contacting and the implant needs to be removed and site grafted for later proper implant placement. and ask to see his/her final radiograph, if they say they dont have one then ask why didnt they take one and find another specialist to work with in the future

    3. What is the likely timeframe of irreversible damage to the canine? Can this be salvaged, if the implant is removed asap. It has been in situ for 7 days.

    Explant it ASAP to minimize issues

  9. 1. I would like to review a truly diagnostic radiograph
    2. I believe the implant will integrate and that their will be no long term effect on the adjacent root
    3. with a good lab and a custom abutment the fixture should be able to be cosmetically and functionally restored

Leave a Comment:

Comment Guidelines: Be Yourself. Be Respectful. Add Value. For more details, read our comment guidelines. Though we require an email to comment, we will NEVER publish your email.
Required fields are marked *