Implant Encroached on Periodontal Ligament Space: Should I Back it Out?

Ideally it is best to remove this implant and reposition at time of surgery. It is still early in the process so it is favorable for you and the patient to reposition. There will be some prosthetic challenges because of the lack of parrallelism with implant#29. Also, risk of loss of vitality for#28 if occlusal load is transferred to this implant at this trajectory. Best option to remove reposition and graft any defects.

I agree that due to the lack of parallelism you may have difficulty restoring this case as is. At the very minimum the removal and re-positioning of your implant in #29 is required. Why did you choose to use such narrow and short fixtures in this area?

The lack of parrellesism is not an issue. Trimmed stock abutments or custom abutments will sort this out. Standard stuff for a decent technician. I would not remove anything ... Although I would have taken it out at the time of surgery. Did you use a stent ? Unless you can screw this out easily I would monitor vitality of the natural tooth

If you have not already done so I would take a few more periapical radiographs at different angles and you may find there is actually more space between the implant and the tooth. If there is contact then you should remove the implant. If no contact leave it and monitor. Greg Steiner

I agree with Dr.AI,I would not remove implant and monitor vitality of the natural tooth.

Agree with Greg take another angle and it may look better , but leave now , but always take pilot radiographs . Wider and Longer ? not necessary and dictated by the width and shape of the mandible , although 20 years ago it was always the longest and biggest the better we now know that is not so . If you have a block of wood the bigger the screw the weaker the remaining wood , and in over 20 years I have not had an implant break even a 3.5 in a Molar site. Another thing here is the implant in the 5 area could have had better placement to avoid a possible loop at the mental foramen. Peter

Please consider that a periapical radiograph is a two-dimensional image. So it is likely that the implant is not as close as it appears. I would leave it.

Even the implant has not the correct position I don't think you have a problem with osseointegration or with the vitality of the tooth, as Doctors say above take radiographs with a mesio and disto angulation and monitor vitality each three months. Good luck, I'm sure it won't happen again.

Peter, Unlike you, I have seen multiple 3.5mm fixtures (nobel) fracture in 1st molar sites... I am not saying it happens every time, but what I am saying is that given enough BL and MD width, a 3.5mm is not the first choice. Based on this PA it looks like the larger implants were placed more mesial? Perhaps the original post author can enlighten us on his implant size selection criteria?

YES!!!! Do it before the implant integrates.

The appearance of second molar to first bicuspid areas in one periapical x-ray indicates this is an off angled shot and there is likely more space than indicated. If an implant is near the lamina dura, but not through it, and if it was placed with little force, and if it is a design allowing vertical and horizontal circulation in the area, it is doubtful you'll have much of a problem. As above mentioned, these angular variations are well within acceptable limits. Many implant systems over the years have suggested varying angles are more resistant to off angle forces than a row in perfect unison. Also, while a few small diameters here and there might be OK, greater support would be attained with some wider/shorter implants. John

I subscribe to the 2D vs. 3D positioning considerations. The teeth are always more bucally situated with a very thin cortical plate in the area in discussion (apical third), while the implants - because of the patern of bone resorbtion in this area and the implantologist's quest to place them in the center of the ridge - are always placed lingual to adjacent teeth. Outside of these considerations, the operator knows best whether the PDL was violated based on angulation and tactile feel.

Dr. H, I agree with Dr Steiner and others in that a single peri-apical X-ray cannot be used to judge proximity to the premolar's PDL. Please take a couple more peri-apical views and you may find that the PDL has not been invaded at all. In the case that it is, maybe just unscrew it out 1 or 1.5 mm and that should spare the premolar. Or remove completely and reposition it more distally. However, in the rare case that the root surface has been nicked, then external resorption (now called ICR) of the root surface is a possibility in the near future. Not easy to deal with at that depth. On another note, it appears from the angulation of the implants that you are attempting a tripoding effect for maximum load-bearing capacity, which is the right thing to do, when doing joined crowns. By the way, the zirconia crown on the posterior molar looks sexy!

I will leave the comments above to suffice for your options. Usually when this type of alinement issues occur it is because of the use of a short insertion device requiring you reach over the mesial tooth to prepare the osteotomy to depth. Use a longer device or an extender so you don't have to angle in such a manner. Also, prepare first osteotomy at the correct angle using the teeth or stent (I don't use one in these areas between teeth ever..) and then insert a pin that gives you that angle and parallel each other osteotomy with this and these problems will not happen. It is very easy. The short implants are not ideal but will work. The prosthetics are not difficult with these angles, just that it would be so much easier if they were parallel. Do not remove the implant for if you change one, you might as well change the middle one as well. Check the radiograph first as mentioned above. Learn to be creative with your prosthetics and it will serve you well.

Do not worry. You should not remove the implant. Do a follow up visits 1,3,6 and 12 months to evaluate any changes with the adjacent tooth. Signs and symptoms to evaluate: change in crown color, tooth mobility, pain to percussion or mastication, radiological changes.

Nice margins on the cerec on the molar. I wouldnt worry too much. If the implant had damaged the tooth or space the appearance would normally be more obvious. Probably just 2D overlap. Monitor + more rads. If you're really worried remove it. No point losing sleep. Tell the patient straight what's going on too.

I agree with many of the comments. If you choose to leave it follow the patient carefully for symptoms. It is not impossible for infringement on the PDL to encourage an abscess to form which puts bone and the other implants at risk. Peters suggestion of pilot radiographs will really be helpful.

Tyler ,cool name ( named my son same ) , sorry forgot about those tri-lobe boys , yep many of those seened to have fractured , possibly they were placed without lining the lobe buccaly thus exposing a weekness to co-axial forces. Peter

Worry not,review radiographs taken from different angles,monitor symptoms and check vitality of the tooth and then decide action plan.

Pode ficar tranquilo, mesmo se houve contato será apenas de uma rosca do implante, nada acontecerá, nem com o implante que irá osseointegrar e com o dente que não perderá a vitalidade. O paralelismo dos implantes me parecem bastante razoáveis.

I am of the same opinion shared by others in that you should leave the implant as is and monitor the area radiographically. More than likely, you'll see normal development and the tooth that appears affected by the implant will remain vital. As far as lack of parallelism, no big deal here as there are several prosthetic solutions eg. custom abutments and bridge, cresco bridge,etc. Hope it helps

Yuo have to get implant out , because mal position of implant

i will leave it and monitor vitality of 4 parallism is not an issue at all as all designs gave you a problem solutions

we have implants 'touching' the PDL all the time: osteosynthesis screws, bone anchors, distractors, IMF screws. It has never been an issue.

Never back out an implant unless it begs you to!...In this particular situation if the patient doesnt have symptoms associated with the tooth in front then just forget about it. If you're gonna disturb the healing cascade now with the kind intention of rectifying a problem which probably isnt a problem then you might end up worse. 2D pictures can be quite misleading at times. Keep in touch with the patient and try to have them more parallel and slightly distant next time. Its all good.

difficult to say with this view whether the fixture has encroached on PDLof 28. why not try CBCT?? Even if it is positive keep observing for vitality of 28 and other symptoms... good luck

How long has it been in there? I`d take more periapicals and see how much space there actually is.... If its been more than a week Id just leave it...if its damaged the root already taking it out wont really help.

i think the radigraph again for the are from another angulation mau show that the implant is not invading the pdl , if the patient asympotmatic and pain free i will leave it , i have same in som patient but when i take another x ray,u might see that the implant is not engaging and irt is more lingually so the xray touch it finally .

I always critisize my work and I think we all do. It will be fine. Now go to sleep. Ha!

please do not remove the implant. monitor the vitality of the adjacent tooth. implants are not parellel but can be managed with the help of angulated abutments or custom abutments

the cbvt tomograghy is the best for evaluation even the tip of root may be convex! .by pa ,there is no correct Dx. so the radioghrapy dosnot too important .it,s better too control the sign and symptoms.if threr is nothing ,leave the implant for 6 to7 month,then start the proth.

Do not remove it!! the angulation o the Xray sometimes could be dedeptive as well>Nevertheless worse comes to worse you might need to endo that tooth but your implant will osseointegrate! Cheers.

I don't see a problem with this case. Lack of parallelalism but you can prep wide abutments to draw with one another. cuspid may require rct if it starts to get sore but other than that this case looks like a few that i've done with long term success. I would've used a wider implant in #30 you dropped the ball there

My opinion, leave it alone, you can never be sure 100% with PA's how close your implant is to adjacent teeth. Check the vitality in few months and follow up if patient is having any discomfort immediately after the surgery.

A good number of the doctors gave good advice (take more PA's at different angles, monitor for endo changes), give it time. The chances are, nothing will happen!