Implant placed in non ideal angle: Can it be restored with a customized abutment?

Dear Doc This case is very challanging from esthetic point of veiw especially if the pt has high smile line, i would take more time planing the case, CBCT would be very helpfull. For this case custom (titanium) abutment will be my choice. Good luck

It is not the angulation itself, which is usually manageable. The actual problem is that the implant platform is too far buccal. This may cause soft tissue recession and may result in a prosthetic crown that is too long (and/or exposure of the abutment in the long term). How to manage this? Assuming that the implant is fully integrated and you do not consider to remove it, you may want to place an angulated abutment and prepare it, so that the emergency profile is as little buccal as possible. The abutment screw must have a short head and, despite its shortness, it may happen that it is slightly involved in the preparation. A knife-edge preparation of the abutment helps during the temporization, because it allows you to adjust the temporary crown margin in case of soft tissue recession. Once the soft tissue is stabilized, you may consider preparing a shallow shoulder on the buccal side of the abutment (avoid the palatal side, because it weakens the abutment that will end up to be very thin- this will turn to be especially true if you use a standard 30 degrees abutment instead of a custom-made). During the uncovering of the implant you may want to make the soft tissue thicker, by grafting some connective tissue. In this case avoid vertical incisions and try some kind of envelope tecnique. Luckily the soft tissue looks thick, which is helpful, but take your time anyway before finalizing. Regards Paolo Rossetti - Milano

If you do not have enough bone to place an implant in an ideal position, you should always do ridge augmenntation first. You have created a difficult prosthetic problem for yourself and the esthetic outcome of the treatment is compromised at best. As soft tissue recession is almost a certainty, I would use zirconia custom abutment to prevent the metal from showing. Good luck.

hard to tell since no final image is here to show placement position of the plateform or angle. This will also be affected esthetically by the lip line low lip line shouldnt be an issue but may need some pink porcelain. with a higher lip line the pt needs to be aware of this possibility. Another option is remove the implant before it integrates and graft the site to get it more ideal then place another implant in a few months after graft healing

The crowns cosmetically failed and if I had seen bony difficulty as mentioned, I would’ve remade them with a cantilever only.

It can be done, but is going to be far from ideal. You will get a long, long tooth. Hard to fix and probably following the rule " every implant that is placed away from ideal possition, integrates" thus the problem. Maybe a ceremic abutment and crown but its not going to be very nice.

How are you addressing the osseous fenestration on the lateral?

Place the implants where you want them and use angles you like and graft this computer guide world is a bit worrying Peter

You don't have a picture showing the final location of the implant. Like Dr. Rossetti said, the angulation can be managed, but the result will depend on the position of the prosthetic table of the implant. A CBCT scan for treatment planning would have revealed the problem and allowed you to consider grafting for site development prior to surgery, or plan to place the implant in the right place and graft around it. The days of "putting the implant where the bone is" are gone.

One may consider a vital segmented osteotomy as per Hilt Tatum's methods. Remember prior planing prevents poor performance!

You could of burried the implant deeper, so the platform would be in the proper position. You may have some soft tissue issues later by placing the implant deeper. Sometimes you have to play the cards that are delt to you.

As a compromise use an angulated(12/24°) Southern Implants(www.souternimplants.com) implant placed palatally and angulated to the incisal edge of the 22-bone sets the tone...rather redo with ridge augmentation first.

it is obvious from the direction of implant insertion that you well need angulated abutment and I wonder that most of the comments worried about esthetic without mention the occlusion problem as you work at the site of canine .so implant diameter is issue and also the implant length and it looks from the situation that you have a narrow diameter? careful adjustment of occlusion lateral guidance is important which should be group guidance avoiding the canine totally

Gents, thanks for your comments they are most welcome. To provide further background, there was loss of the buccal plate due to a chronic infection resulting from a failed RCT and crown fracture despite a gentle extraction with a piezo unit. On extraction of the tooth, I noted the significant loss of buccal plate already and curretted the site and placed a graft. I followed this 16 weeks later with a CBCT. Despite regaining some bone volume, from the CBCT and surgical guide I knew that there was going to be an angle issue. I decided not to graft again - From your comments this may have been the incorrect choice in retrospect. Thanks for your thoughts I will post a restored picture later this year.

Whatever the guide or problem, it is always valuable to visualize a line from the long axis of the implant, thru the desired emergent area, ad up to the center of a line drawn between the contacts of the adjacent teeth. Doing that after the first pilot test drill would have shown you the problem while ther was still time to correct the angular ion.

Don't know the implant diameter. If it is wide enough then platform switching and a custom cast abutment using a UCLA pattern may be of help. This can be tried with an implant level impression with soft gingiva pour. Wax up to the UCLA offers unlimited shapes, is inexpensive, and can be used to evaluate other options.

You can do, a osteotomy technique to correct implant angulation & gingival biotype After raising a buccal flap ,perform two releasing osteotomy on mesial & distal of implant & another horizontally 2 mm. apically from apical of it without violation to lingual periosteum.the best method is pizosurgery.then dislocate the bulk to proper position .after 2 -3 month you have a fixture with normal position & a thick buccal gingival .

If someone is going to perform an osteotomy, the flap design has to be completely different than the one used at placement . Why is the mucosa so traumatized before elevation of the flap, in your pictures? Bv. Vinci Oral/Facial Surgery. Baton Rouge, La.

Why not perform an osteotome technique to expand the bone, thus improving the chances for an esthetic result. You may want to address the slight frena. One of Roberts STR implants may address this issue.

Bury it and do a three unit bridge. Tell the patient that the implant will preserve the bone. The case should have been grafted first, you can't fix this,and if you remove the implant you will cause a large defect.

Patient smile line might save you. soft tissue recession will be inevitable. What has happened has happened. I would recommend CAD/CAM abutment eventually. I hope you have buried the implant. If you have placed straight healing abutment you must be seeing recession already. If implant is buried. I would recommend to place a two piece healing abutment after customising it by removing the buccal bulk of the abutment. Most manufacturer may not have that option. The other option can be to make chair side provisional from the essix retainer. You can monitor the soft tissue stability on your provisional before going to final. It will also tell you if pink porcelain is needed. I hope making sense.

You can restore this 2,3 with UCLA screw or cement retained crown. For cement retained, gum ceramic will be used. so gum shade must be taken. For screw retained crown you may have to fill screw hole with gum composite. How cosmetic pleasing depend on the level of the ceramist. If the patient doesn't have gummy smile then "god save the king". I have rescued quite a few like this case in the past. Not anymore due to ethic reason. may I ask what brand and implant system you used for this case?