Implant Placed too Deep: Prosthetic Rehabilitation?

This 40-year old  female patient had a partially impacted palatally placed left maxillary canine.  An atraumatic extraction was done and an immediate Osstem implant 4×15 mm was placed. Required torque was achieved. Now I realize that the implant is too deeply placed. What are the prosthetic implications? What can be done?



47 thoughts on: Implant Placed too Deep: Prosthetic Rehabilitation?

    • Munish Kumar says:

      It’s approximately 3-4 mm below the cervical margin of the adjacent premolar. The buccal bone is thick and intact since the impacted canine was palatally placed. Can cast abutment be of some help after crestal osteoplasty.

      • Ashwath M Gowda says:

        Crestal “osteoplasty” could be, or would be, or it will definitely be an
        INVITATION for a DISASTROUS “AESTHETIC RESULTS”!!!!
        Comments please,

  1. Timothy Carter says:

    Curious as to why the canine was removed, but that is an entirely different discussion. It appears that people on this site are really quick to condemn implants as failures. I would place a healing abutment and let the remodeling begin. I have seen much worse!!

  2. G Allen Herrera, DDS says:

    If placed recently, reverse torque it out and place a new wider 4.3/4.8.

    If osseointegrated, you may cause more damage attempting to remove. In my opinion, pink porcelain is an esthetic failure for a case such as this and will not “solve the issue,” especially if the patient has a high smile line.

    A good option is a custom zirconia abutment with a gingival margin 0.5 subgingival on the facial and 0.5 supragingival on the proximal/palatal for cleansibility. I might plan for a cementable restoration as I would want to torque the abutment in place once and hope to never touch again. The fact that it’s a canine makes me consider screw-retained with the same proposed margins although I’d want to minimize the number of times I screw/unscrew an abutment.

  3. Michael Ramer says:

    I actually am about to restore a case with this issue and the facial margin of the soft tissue is exactly correct compared to the adjacent teeth. Made implant level impression, fabricating custom abutment and placing provisional crown prior to make sure emergence profile is correct before starting finished crown.

  4. Anand says:

    Don’t touch the implant . Take an implant level impression and make a custom abutment or screw retained crown. You will be fine.

  5. Matt Helm DDS says:

    I’ve restored cases like this before. No sweat. I would not remove this implant if torque was achieved and especially if it’s already well on its way to osteointegration. Implant level impression, custom zirconia abutment, a well fabricated temp to ensure the emergence profile is good and establish proper contours/esthetics prior to fabrication of permanent crown, preferably zirconia also.

  6. Asja Celebic says:

    THE RESTORATION ON THIS IMPLANT WILL HAVE A HIGH GINGIVAL MARGIN AND THE CROWN WILL BE TOO LONG. IF THE SMILE LINE IS NOT HIGH AND IF GINGIVA IS NOT VISIBLE, NO SERIOUS PROBLEM.

  7. Shorty Doc says:

    Is this film immediately after placement or after integration? How deep is the platform relative to the adjacent teeth CEJ’s? Prosthetically, I think being a little too deep is better than too shallow. But, it will be difficult to get the gingiva looking nice here because of the bone levels. An impacted canine often leaves big bony defects so the implant may show through the gingiva if you didn’t verify facial bone thickness or graft. Your patient is young AND female so unless she has a very low smile line and a thick biotype you may end up having difficulty satisfying her esthetic needs here. At minimum, make a custom healing abutment and temp crown. Be patient to develop good gingival and crown contours before fabricating the final crown.

  8. Dale Gerke - BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    I have seen a few cases like this. I inherited these cases from another prosthodontist. You have asked about the prosthetic implications … so this is my experience.
    It is likely the gingival height of the crown will be unacceptable. Further the depth of the pocket is likely to be very deep. As well, maintenance will most likely be difficult. The aesthetic quality is very likely to be compromised and it is entirely likely your patient (especially a 40 year old female) will be most unhappy with the eventual result. From a medico-legal point of view, I suspect it would be difficult for you to defend the placement positioning (it would be easier to defend if you had done CADCAM analysis and used a surgical guide – not sure whether this was the case).
    Perhaps more importantly, my experience has been that once a restoration has been placed, there will probably be an extreme loss of alveolar bone to the adjacent teeth. One case I had to deal with had about 50% bone loss and consequent gingival recession which created issues with aesthetics, sensitivity and longevity. For good reason the patient was very unhappy. I think you can already see this happening in your case.
    Unfortunately solving the problem is not easy. As some have mentioned, if you can unscrew the implant then that would be best and then reposition at a later time (after healing). The radiograph appears to show this might be possible.
    If the implant is integrated then I recommend you refer to a very good oral surgeon and get an opinion as to what can be done. In my cases, unfortunately there were no surgical options (the cure would have been worse than the problem). However, in my opinion, you are obliged to explore the options.

  9. Dobs OMFS says:

    Agree with Dr. Gerke. Take the implant out. Graft if necessary. Revisit clinical and diagnostic imaging after healing. Consider guided surgery that is prosthetically driven. Sometimes doing everything in one sitting can lead to periodontal and aesthetic disasters. The long term periodontal problems and aesthetic problems in an individual expected to live into her 80″s are unacceptable in the present environment. Pink porcelain does not solve peri-implantitis.

  10. Ed Dergosits D.D.S. says:

    I would remove the implant ASAP and replace it with a shorter and wider implant that is placed about 4 mm shallower. A photograph would be very useful. Maintaining an implant that is placed this deep presents many negative obstacles.. It will be simple to correct the problem.

  11. Dr. Gerald Rudick says:

    You have not indicated how long ago this implant was placed…… if it is less than two months ago, then you could probably reverse torque it and bring it down to an acceptable level, and then leave it undisturbed until osseointegration takes place .
    I have seen a case like this corrected by good friend in Montreal, Dr. Gilbert Tremblay, that he presented at an AAID meeting a number of years ago, where he used a piezo cutting blade, and cut the bone around the implant in all dimensions, and moved the whole unit down, and stabilized it by bonding the integrated implant in the bone to the adjacent teeth for stability…..left it for a number of months… and there was no damage to the adjacent tissues.

    • Ed Dergosits says:

      I am glad for the patient that nothing serious happened when the implant was released with a block section with a fancy piezo saw and re positioned. I personally am very much not impressed that any dentist would do such a procedure when an implant can be removed with reverse torque and a wrench. Contrary to circuit lectures implants can be removed with a torque wrench with counter clockwise forces applied even if they have been “integrated” for more than a year.

  12. RB says:

    If restored successfully, the future problems of food impaction, gingival inflammation and recessions will be unavoidable even in good function. This will necessitate future removal of implant . Alternately if patient opposes the removal of the implant due to extensive bone damage during the procedure , then you can leave it intact, let it be buried and place a conventional bridge.

  13. Mark Barr says:

    take it out if not integrated
    graft and start over, why complicate the pts long term with rationalizations. it only stirs litigation or patient loss when we skirt the issues of less than acceptable placement. the final crown will be way to buccal and this depth will lead to periio issues ….
    Dentistry is one of the hardest of professions to be perfect in; but we can work and play in the zone of excellence.
    just sayin

    • Ed Dergosits says:

      Mark how can you determine from the very limited information given that this implant is placed too far buccally and too deep?

  14. Sajjad A.Khan D.D.S,B.D.S,M.I.C.O.I says:

    Check >the distance of anticipated gingival margin with platform
    >lip line during smiling,eating eg.biting a hamburger
    >if patient has reasonable cosmetic expectation
    Then decide depending on the above information if need to remove the implant ,bone graft etc
    If possible leave it alone with proper soft tissue support and cosmetic illusion with pink porcelain outcome will be pretty good.

  15. Vinoth says:

    If you have the gingival labial margin in right level with respect to adjacent teeth, placing an immediate temporary will prevent gingival recession and maintain the level. The problem with deep placements is that even a slight change of position will reflect as an interference for components extending from the implant, necessitating use of customised abutments. The real problem is non availability of angulated impression copings in most systems!!! Try finding abutment Manufacturers who may probably have a component for making impression that is angulated as well. Dibay.com; Implanet.com etc….

    • Ashwath Gowda says:

      The real problem is non availability of angulated impression copings in most systems!!!
      It would be hard to even imagine that,
      how an “angulated impression copings” be capable of producing,
      a “logically & technically” or even “theoretically derivable” convincing results.
      Like to hear
      amgdds

  16. Munish Kumar says:

    Thank you All for kind suggestions. For a further help, the implant was placed after immediate extraction of palatally impacted canine through socket, this X-ray is immediate post op. Buccal bone is thick, & intact. The implant collar is 3-4 mm below cervical margin of 1st premolar. I am thinking of osteoplasty of buccal margin after two months of remodeling, then wait for another month before temporary restoration. The final restoration is planned after six months by then the soft and hard tissue would remodel further. Suggestions are welcomed in order to help me and the patient. In gratitude 🙏🏻 🙏🏻

    • Dr. Oliver Scheiter says:

      Dear Munish Kumar,
      This seems like a good plan.
      I must say Iam truly embarrassed by my colleagues comments. With nothing more than a fairly distorted periapical non of us can judge this case. With nothing more to go on than 3-4mm below cej of adjacent pm ( which is perfect by the way) and a stable buccal plate (who thinks that is a problem?) no one should pretend to know what this patient needs, let alone recommend drastic measures.
      The fair and helpful advice to you can only be not to get confused by all the comments. And maybe you would want to document that case a little better. Post intraoral photos and a panoramic. Provide more visual information on the case and I am sure you’ll find good advice provided by experienced colleagues on this site

  17. JJ says:

    If a healing abutment is placed, you will get a good idea of what can be achieved prosthetically. It also gives you the needed support for your gingival tissue from the start. I think your problem at uncovering will most likely be to remove excess bone without damaging the implant… place your healing abutment and then do you selection of abutment whether it is a transfer or castable abutment.

    • Mark says:

      Perhaps the angle of the radiograph makes the placement appear deeper than it actually is Try a bitewing and see hiw it looks

  18. Dok says:

    Deeply placed implants can create deep periodontal pockets that are virtually impossible to
    clean and maintain. Deep pockets and a predisposition for periodontal disease ( especially a past history of periodontitis ) are a poor combination and risk this complication. Restore, cross your fingers and hope for the best.

  19. kent hamilton says:

    don’t remove, its not too deep
    a custom abutment will correct the problem
    I think you will find that it will be okay
    The head of the implant should be AT LEAST 3mm apical to adjacent CEJ.

    Your fine

  20. Dr. Tim Hart says:

    I agree with everybody who recommends a custom milled abutment. You probably will be fine.
    Removing the implant has serious implications for the aesthetics of #10 (actually #10’s eventual free gingival margin position may be in trouble even with leaving the implant in, also).

    Once you successfully restore with the custom abutment approach, I would have a discussion with her about the future. Mention the possibility of deterioration of the aesthetics. I would plant the seed that if that happens, you would have more control over the aesthetics if you buried the implant and provided a fixed bridge. If you are so inclined, maybe also indicating you would credit her her implant investment if you had to go that direction.

    • Ed Dergosits D.D.S. says:

      Restoring this implant while telling the patient to expect future problems will confuse and raise lack of confidence. It sounds like you do not think that restoring this implant that is likely placed too deep will be successful. If I was the patient and my dentist was preparing me for failure I would lose confidence in the proposed treatment. At this stage it would be simple to reverse torque the implant and avoid all the likely disappointments and future damage to the site and adjacent teeth..

  21. Dr. Luis A. Alicea says:

    The angulation of the x-ray sometime give a wrong judge. I recommend to remeasure the distance of the cervical gum area of the canine to the implant and compare with the area of other canine. Make sure your future implant restauración follow the gum tissue scallop. If your implant was place 3 -4 mm, you are safe . However if the implant was dipper, removed the dental implant with the implant removal tool (Neobiotech or DDS Gadget) specially in Maxilla is very easy to remove the dental implant with minimum damage. The problem is not now, it is the future. The adjacent teeth will be lost half of the bone support and the attach gingival will be lost too. A good combination for damage the esthetic zone. It is difficult to reestablish the nature, but after remove the dental implant I do most of the times a bone graft with PRF or bone healing enhancer and pedicle palatal soft tissue graft. I am dealing everyday with unhappy patients and If you are not happy with the dental implant position, not expect to your patient be happy in the future with the outcome. All the best with the case.

    • Abdullah says:

      I agree with these comments. If the implant head level is within 4mm from the gingival margin, you will be okay and should proceed with restoring the implant using a custom abutment and regular crown procedures.

    • Ed Dergosits DDS says:

      Luis I agree that the implant should be removed if it has been placed too deep. One does not need a dedicated implant removal kit to reverse torque an implant that has been placed less than 3 months prior. Simply attach the driver to the torque wrench and back it out. Using a trephine causes unnecessary removal of bone and significant morbidity.

  22. Ajay Kashi, DDS, PhD says:

    If already osseointegrated you should be able to take an implant level impression, get a custom abutment fabricated and form the gingival contour before finalizing it with a crown. There are options available today where custom abutments can be fabricated much precisely for situations such as these. Good luck!

  23. Dr Andy says:

    just make a screw finial crown. Try not to use a cemented crown. , it will be very difficult to clean the cement . Pick a good lab. And go ahead.
    It’s ok – far from disaster !!!

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