Impression for a fixed restoration in malpositioned implants?

Bury the middle implant and make a bridge.

Open tray is more accurate than closed tray. I cannot tell by the PA if the impression transfers will overlap or hit themselves. This would be a good case to scan intraorally since you could scan one site and then scan the other and merge the scans. There might be some short closed tray impression transfers (we don't make them) but maybe someone else does however I sense they still may hit one another. The other issue you will run into is after the impression is the restoration. I can help you there with this - Aurum Angled screw channel ti base -

remove or bury the middle implant and remove #23 (3-2) since it's weakened. Then, as above, make a 4 unit bridge re using the implant at the #26 (4-2) site.

I know the angles on the pano might play games, but does it look like they might loose #23 as well? Are the implants really that close together? If so, a number of problems besides taking the impression will come into play. Does anyone else question the old saying , “ I have to restore these now”? I say you have to find a better surgeon. 🤓

The position of the implants should be assessed in 3-d. Before impression, best to make sure they are restorable, in proper position, and have adequate bone support. If uncertain about any of these, then I recommend a waxup for your desired occlusion, a duplicate in radiographic guide and CBCT to check every thing. Restoring questionable implants is not a good service for the patient. If not perfect , then it is easier to explant using reverse torque and re-do case following digital planning.

It is often ignored the fact that implants are prostheses with a surgical component. Therefore, implant planning should be from the crown to the root. Guided implant surgery should have been used in this case

This is like one of those old photos of a bunch of people stuffed into a phone booth. The two new implants are really close and of a design that loses bone around the collar. I’d prefer removing both and placing one in the 23 site, restore with a bridge to the #26 implant.

How long ago was the sx? Can they be backed out? Without any blame, explain the very compromised position and anticipated problems. Based purely on a 2D pano my guess would be ext/graft the now hopeless #23, bury implant #25. Then make FPD #23(distal pontic)-24i-25p-26i. Again, difficult without seeing the 3D parallelism and interferences. Can you discuss this with the OS? Seems he should kick in for any complications considering if the pt goes to the dental board he is toast.

The only comment one could make is that dentistry should continue to be paid by the peace and in due time every walking tooth will have a crown and every vacant space will have as many implants as the space can accommodate during placement. Gastroenterologists should learn from dentist and charge by the inch or centimeter dealing with intestines. Poor cardiologists are left only with one heart, nephrologists with only two kidneys.

Remove all three, graft and later place 3 - 2.6X15 implants with a fixed splint. The anterior mandible does better with narrow diameter implant, these three will probably sustain peri-implantitis.

I humbly thank all for the valuable suggestions. When I was asked for restorations on these implants I was equally angry about non planning of this case and now I have to sweat....anyways let's c how it goes...thank u again.

Did you not provide your surgeon with a surgical guide?? Implant dentistry is a team sport. The restorative provider has an obligation to provide a surgical guide derived from the final position of the crowns, to the surgeon, prior to surgery. If the surgeon opts to free hand it, and makes a mistake with positioning or alignment, then you should indeed, find someone else to team up with. However, if you didnt do a wax up of the final restorations and provide such guide, you are as much at fault here, as your surgical colleague.

FES ....would like to clarify that I am involved at very late stage in this case and only because now after placement it has become too difficult to restore.other wise the surgeon does restorative work by himself.This patient is not at my practice I am just the consulting Prosthodontist (too late) ....

I would obtain a CBCT first. I'm doubtful that there is sufficient facial and perhaps lingual bone. I agree with evaluation of #23. Perform a diagnostic wax up. Remove said implants, graft, revisit with 3.0 or 3.2 mm wide implants (2) single stage root forms and fabricate a 3 to 4 unit FPD, depending on the prognosis of #23.

Patient has ongoing periodontal disease and is losing teeth, and we continue placing implants? Lower right side implant and unrestored lower left implant don't seem to have opposing teeth. When are we going to stop the case, remove those poorly placed implants in the anterior of the mandible and have a comprehensive treatment plan with the patient?