Implant placed too subcrestally: advice?

Please provide a better radiograph. It is not possible to see the platform level accurately. Having said this, as best I can make out, the position looks reasonable but I might change that opinion when I see a better radiograph (a simple PA would be adequate).

You may compromise longevity of structure leaving it as such. Easier, and better prognosis to back out at follow-up visit, use a 0.5mm or greater larger diameter, and 3mm longer implant, I would advise with L-PRF, and your done quickly, knowing your implant and restoration have a better long term prognosis. Remove healing cap, back out implant with driver/mount used to put in, fill void with L-PRF membranes, and replace with larger implant. If tissue not ideal, probably not from having surgery done last week, I would add a few layers of PRF, underneath PTFE membrane for 4wks. Please follow up. Thanks for sharing

I agree back it out yo he crest. Don’t worry about stability

Although not mentioned, was 29 grafted? You mentioned ‘simple new case’. If wanted simple; socket preservation and implants in 4-5mo. Answering your last question; yes, use new graft preferably mixed with biological activators.

From what I can see in these difficult to read xrays, tooth #46 did not need to be extracted, it required endodontics, a post and a crown. There is a huge lesion where #45 was, and for sure this needed to be grafted...…..providing the healing of the regeneration procedure was successful, then an implant could be placed for #45. Dental implants are not a substitute for teeth that can be restored.

These fine surgeons said it all.

As stated above. The molar should never have been extracted and the premolar also could have been saved by an endodontist. The implant should be removed grafted and replaced accurately with restorative driven placement.

Thank you doctors for your input. I guess my goal will be to take the implant out and to put a longer and wider one. I know that unwinding the same implant just a little won't do much, as I reached ~20N just at the last rotations of placement However, this leads to other questions: -what happens with the old graft if I leave it? -could I get good results grafting 45t a week after the extraction? (At the time of extraction I didn't have a membrane to cover the socket.) As for the 46t extraction I agree with you. However it was treated with Russian Red and retreatment+post+crown would have cost her more than the implant + the crown (I live in the area where the retreatment with the microscope is quite expensive and finding a good endodontist is not easy).

Dear Colleague I do not understand why the patient had panoramic X-ray each time. The diagnostic information is limited and compromised by the patient not having removed her earrings. Also a larger dose of radiation than necessary was received. Also in the uk we have to report on the whole x ray not just the area of interest. A well positioned and correctly exposed pa would have much more diagnostic value.

I agree with Dr. Marcus above; you should be taking PAs in this kind of situation and doing so with no metal interfering (earrings.) It's a shame to shoot that much radiation at the skull and brain, only to obtain poor diagnostic quality. I am not trying to scold just saying you should consider this in the future.

Beside the fact that PA are much better and much less xray exposure, you should take a PA before you do the temp abutment flowable HA. Implant is too deep. Suggestion is to remove it and graft both 45 and 46. Actual situation is missing 47 and now 45 with huge bone defect, immediat implant 46. Let say 46 was in a good position. Then what is the tx plan ? I am puzzled by the steeps so far. This is a simple case if planing is good, like having material to perfom graft 45, and maybe 46, then come back and place implants in good bone, easier to have good 3D placement. Why the need to follow the actual trend on immediat molar implant+custom HA ? How is the patient getting better care ? Thanks

What is the treatment plan with a single implant placed too deep in 46? Will there be another Implant in 45 too? And later 47?

Doctor. Yes what is the treatment plan Do you intend on a 13mm cantilever (8mm bicuspid & 5mm half of molar). To be very gentle , take out implant. Graft. Get a treatment plan patient accepts and pays

Why remove 2 teeth and only place one implant? If you are planning to cantilever off this molar implant or bridge to the natural tooth, I have to strongly advise against it. We have learned from the past it is less predictable to cantilever implants or attach implants to natural teeth via fixed bridge. I don’t see any graft material in the extracted pre molar site, unless it’s demineralized bone. If you want to keep the same implant, just remove healing cap & reverse implant until platform is only 1.0-2.0mm sub-crestal, place flat cover screw, resorbable membrane and release flap to cover membrane and allow healing by primary intention. Put pt back on antibiotics starting 1 day prior to revision surgery. If you feel you need to completely remove the implant, then graft the osteotomy and premolar ext site, membrane, complete flap closure, place two implants on completely healed ridge no more than 2.0mm subcrestal. Also be sure to completely curettage every single speck of infected soft tissue within the bony defect in premolar site. If you’re concerned you left some behind, then remove implant, all the graft material, curettage thoroughly and use round but on bone drill to remove every bit of granulation tissue, and flush thoroughly with sterile saline. Place allograft, membrane, release flap and cover membrane completely, let heal 4 months. Then place two implants, one premolar and one molar, restore individuality or splinted for added strength. The implant should unscrew out from osteotomy with ease if you placed it 1-2 weeks ago. If you wait until after it osseointegrates, then you will have to trephine the implant out!! No way do you want to have to do that On immediate non-splinted molar implant placement it’s less predictable to place implant, graft, and transmucosal healing cap from the start. This can be done more predictably in the anterior area where forces are different. If I immediately place implant with an insertion torque value less than 30Ncm and not splinted to another implant, then I like to place flat cover screw, any necessary bone graft material (allograft - mineralized cortical/cancellous mix), resorbable-membrane and cover all graft material and let heal for 4 months before 2nd stage implant uncovering surgery. This also allows me to manipulate the keratinized tissue to ensure keratinized tissue on the buccal when I uncover 4 months later. Don’t cut away any of the valuable tissue unless you really don’t need it. Avoid tissue punching unless you have tissue for days. After uncovering implants, tissue shaping healing caps can be placed followed by custom abutment and crowns. Screw retained is the best for retrieve-ability and not having issues with implant failure due to excess cement. If you plan to use stock abutments (don’t advise this), then no tissue shaping healing caps needed. Custom abutments with cement or screw-retained crowns are always the best way to go. Costs more, but allows for more control of inadequacies unidentified at time of implant placement. Screw-retained unless screw-vent compromises esthetics in the anterior! (Nobel fixed this issue with a screw that can be torqued at a 30 degree angle.... it’s called the “Omni-grip” Hope this helps and I wish you the very best on the case.

Sadly, I see a lot of poorly planned and executed implants (restorations) I am unsure if this is due in part to lack of understanding or simply inadequate training. Dental implants offer a good solution (but not the only solution) to replacement of hopeless or missing teeth. Unfortunately the definition of hopeless seems to be too wide. I understand blogs like this are supposed to be helpful top our profession, but when i see standards that are so low - we should all call them out and perhaps suggest further training before our patients are irreversibly damaged and implants are considered a "bad" choice by ur patients.