Too late for healing caps for implants?

I have a patient who had 3 implants installed in the maxillary arch and 6 implants installed in the mandibular arch. Three implants in the maxillary arch were not given healing caps.  One implant in the mandibular arch does not not have a healing cap.    Is it critical for the healing process to have the internal surface of the implant sealed with a healing cap?  It is now ten days after the operation, is it too late to put healing caps on?  Should I just leave as is and onserve the healing?

The implants were not placed on the same level.
The implants were not placed on the same level.

38 thoughts on “Too late for healing caps for implants?

  1. HMM says:

    All the lower implants have multi-Units placed! The will be no problem with them…

    The upper, leave them as they are, while osteointegration occurs. Betwen wekk 1 and 3, the bonding strenght to the bone is at its lower level, so they should not be disturbed.

    • jane says:

      I notice there is a sinus lifting on the left side, can anyone tell if there is any sinus lifting on the right side (with one implant) from the X-ray?

    • CRS says:

      Actually it is six weeks when mechanical stability is substituted for osteointegration. The healing caps should have been placed at surgery or within 7-10days when the error was discovered. There are a lot of perio involved teeth and bacteria, food and debris will find their way to the internal threads. Jane you seem concerned that a sinus lift was done on the left at you the poster? Anyway there is no reason to tilt those mandibular implants when the bone seems adequate, the placement in this case are just bizarre. Implant placement should be restoratively driven. This is substandard work.

  2. Paolo Rossetti says:

    Years ago, when I started with implant dentistry, It happened to me twice with bone level implants. No adverse reaction occurred. When the time came to uncover the implants, I could observe some soft tissue ingrowth in the hollow of the fixture.

  3. CRS says:

    I’m sorry but I see a large radio-opaque mass in the right sinus which appears to be slightly distal to the implants. Don’t get the tilted implants on the bottom. What is the restorative plan? I think the lack of healing heads are the least of your concerns.I don’t get the implant placement was there a plan?

      • Richard Hughes, DDS, FAAID, FAAIP, DABOI says:

        Just look at the tilted implants! There is no need to tilt.
        Use eight or nine implants in the mandible and fabricate a nice fixed case with segmented bridges.
        The radioopaque or radiodense material in the sinus probably will not turnover and make bone.
        There are no cover screws on some of the implants.
        Teeth five through eleven are questionable!

        • Peter Fairbairn says:

          Hi Richard said it all , NO prosthetic plan whatsoever! even the Implant in the UL7 area ? why because the was a little bone there but nothing planned to occlude with it on the lower…
          Even 6 Implants in 3 bridges is a good solution on the mandible
          BUt this is a mess .

          • Richard Hughes, DDS, FAAID, FAAIP, DABOI says:

            Peter, well said. What a mess!
            I would remove the tilted implants and place 5 to 6 more implants in proper locations with socket grafting. But first determine V&C with occlusal rims, fabricate a lower denture to evaluate the vertical.

            The patient deserves better than this. We all make mistakes. Fortunately this is fixable.

            I would like to see PAs of the maxillary teeth.

  4. Tooraj Moravej says:

    first of all the concept of all on four has been ruined totally , in all on 4 concept of dr malo the posterior implants are tilted and the anterior implants are straight ,if you wanted to place 6 implants then you had enough vertical bone to place all the six implants in parallel position in the region of first molars , first premolars and canines and provide the patient with a FPD i feel you have to reposition the tilted implants as early as possible to prevent any problem arising at the time of prosthetic restoration, what kind of bone substitute you have used for the sinus lift?

  5. John T says:

    When I was a lad my old Mum would every now and then make a cake with all the bits and pieces lying around in the kitchen cupboard. We used to call it “Run Round the Larder Cake”. Somehow it came to mind when I saw this x-ray. I suspect the surgeon was having a stock clearance and – Voila! – a “Run Round the Surgery” case.

    PS. Sometimes the cake worked and sometimes it didn’t.

  6. naser says:

    what is the treat. plan here .in the mandible you have enough space and hight to insert 8 parallel implants and construct a FPD on them . i can see cover screws in the upper implants though it should be your least worry here.

    • jane says:

      it is gonna be a full arch all on six. Do you think FPD works better here? It’s been 18 days since the surgery. Part of the gum is till little red and has minor swelling, is it normal? one implant on the bottom has no healing crew. Is it ok to leave it like that?

  7. CRS says:

    Jane if I were you, I would be cautious restoring this case. When it goes south it will be ugly and the last person touching it will get burned. An implant case is only good as its treatment plan and placement of the implants. I still don’t get the tipping and the asymmetric placements and I don’t think you understand what’s going on, if you accept this case beware. If you are the restoring dds it is customary for you to determine where and how the implants are placed according to the prosthetic plan, it is restorative driven surgery not the other way around. Good luck.

  8. Cliff Leachman says:

    I hope this is the last case you sent to this fellow.
    I get a bead of sweat down my back just looking at it.
    Thanx for posting, great for learning!

  9. michaelwjohnson dds, ms says:

    looks like the patient got hit with an implant shotgun! First, remove all the mandibular implants. The concept of all on four or all on six is to fabricate a hybrid restoration with a metal platform and denture teeth processed to the frame. This restoration requires at least 15mm between the mandibular ridge and the opposing dentition. Even with ceramometal you need 8-10mm of interarch space. There isn’t enough interarch space for any restoration. Remove the implants. DO NOT GRAFT THE SOCKETS. That is a fallacy. Only graft when you want to keep the ridge height. In this case, remove 10-15mm of alveolus to create room for your restorative material then replace the implants according to a restorative game plan. Either 4-5 and a hybrid or 6-8 and a fixed bridge. My rule of thumb: if you’re new to the implant game you need three players, surgeon, restoring dentist and lab. Two out of the three need to know what they’re doing to help the novice stay out of trouble. This goes for novice surgeons and lab techs too. They should work with an experienced prosthodontist. In this case, it looks like none of the three new what they were doing which is a shame since the patient loses.

      • michaelwjohnson dds, ms says:

        I agree, grafting sockets is beneficial when you want to keep the bone height. However, when dealing with an edentulated patient and the restorative plan is to fabricate a fixed hybrid type of restoration then interarch space is vitally important. We do not want to keep the bone height so an alveolectomy is needed which essentially will obliterate the sockets. I am against charging the patient for bone grafting procedures when they are not needed. Yes, it’s a free country but let’s make sure we are keeping the patients best interest in mind when we decide treatment. Not every socket needs a graft. There’s plenty of literature that states when the facial plate is at least 1.5mm wide bone grafting is not necessary, especially in the posterior regions.

        • Richard Hughes, DDS, FAAID, FAAIP, DABOi says:

          I agree. I graft the socket and place the implant at the same time. I usually don’t charge. I just want to keep the epithelial tissue out. I do not trust bone jumping the gap. I’ve been burned before.

          As per the modified Ante’s Law. It is at least a start to properly engineer a case. It works, Remember the Law of Beams!
          I do not want to short change the patient.

          I just do not buy into all on four.

  10. Dean Licenblat says:

    I agree that the whole surgery hasnt been entirely thought out and is definitely not prosthetically driven.
    It seems that it has been planned as a modified All-On-4 (with 6 implants) this is very rarely indicated unless there is very little bone or thin ridges.
    At lease 2 of the multi-unit abutments are incorrectly seated and the top looks exactly like what John T said – clearance sale.
    It will most likely work with a great lab and good prosthetic work but be sure to radiograph & photograph & document everything in explicit detail.
    Great learning tool

  11. Zaki Kanaan says:

    It looks like the surgeon attempted an All-on-4 set up in the mandible and decided to place 2 more for luck behind them! All-n-6 is fine but not in this configuration. Not well planned at all. As Peter said, a mess!

  12. Tuss says:

    Healing abutments are the least of your problems.
    Check you multiuints are seated – LR tilted looks like its not down.
    You may have vertical issues and space for a framework – did the surgeon reduce the mandidular ridge to get you space or just put in implants.
    The surgeons given you a headache with the upper left third molar site implant – why did you want an there in the first place??
    Lower left terminal implants will be a hygiene issue when framework and teeth go on.
    Antes law is an aniquated conecpt with no real place in implant dentistry.
    I thnik reviewing your basic treatment planning and case work ups would be help for you and finding a surgeon who would mentor you.

  13. John T says:

    Has anyone yet worked out what the radiopaque “thing” in the right antrum is?

    Sorry for the facetious comment earlier but in fact it should be possible to build up some bridgework on the lower implants, given a bit of ingenuity by the technician – who deserves a Christmas bonus if he succeeds.

    My only concern is with the two left fixtures. Their platforms are almost touching and there’s definitely going to be a hygiene maintenance issue here. Might be wise to remove one of them.

    Incidentally the original posting asked what to do about missing cover screws/healing caps. Obviously although the surgeon had lots of spare implants at the back of his drawer he had under-ordered the covers. However, I suspect he’s not the first one to forget to put on a cover screw. In fact I know he isn’t because I’ve done it! Usually doesn’t cause any harm. If the fixture is buried the gingiva will heal very nicely anyway. If it’s exposed it will tend to collect food in the screw hole but you can irrigate it out and place a cover screw at the next appointment.

    Musn’t forget that appointment with the Alzheimers clinic.

  14. Dr. Nitin Sharma says:

    I don’t want to comment on implant and their placement, because I just want to ignore the radiograph. The question is, what if there’s nothing covering the internal hex of Implant….
    The worst you, will face at times when Bone covers the entire Implant and at times the cover screws. Imagine the bone is grown, think about removing it now.
    Even if it’s 21 day’s clear it up flush with lot of saline and think to consider putting the cover screws in place. They come free, don’t worry you can store it after you replace it with abutment…. Just kidding
    All the best

  15. CR Tooth says:

    Hi everybody,

    Unfortunately this case demonstrates why not everyone should be allowed to place implants. The patient ultimately suffers and the practice of implant dentistry is smeared. Too many things to criticize in only a 2 dimensional image, let alone a series of transaxials with a radio-opaque prosthetic plan in place. Advice: If you placed these implants, cease and desist immediately without further comprehensive and tested training thorugh a reputable program. Then refund in full the patients money and refer to a colleague that is willing to take this case on and make it right. You will be eating a bit of crow, but that is a small price to pay compared to the alternatives. If you are thinking about restoring, read the posts and learn from those of us that do this full time. Proceed very cautiously and get lots of opinions with those in your referral area with expertise in full mouth implant rehabs.
    Thanks for the post as it demonstrates the unfortunate ugly side to implant dentistry run amuck.

  16. uzman haq says:

    at least the lowers can be fixed by replacing the implants. Im more concerned with that radioopaque mess in the right antrum

  17. Sherri says:

    What was the restorative plan here? Why tilt the mandibular implants and then place implants behind them. The idea of tilted implants is to increase the AP spread. Also, has anyone addressed this patients overall periodontal condition?
    I’m perplexed


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