Metal showing after implant treatment and dark gingiva #7: advice?

The crown looks very nice and a connective tissue graft on the labial should take care of the metal show thru. Question is there labial plate on the implant I can't see it on the CT? If there isn't you may want to place an onlay bone graft also any perio defect on the labial? Anyway CT graft should fix it

I don't want to cause any disturbance but see how the gingiva seems a liitle "dusky" above the metal, the bone sounding is a great idea. If the CT graft is done as an open procedure then you can add bone but tunneling the graft is more conservative. If you get an attachment you are done, if you need a future bone graft you are set up with good connective tissue. You may want to ask the original periodontist to do the graft , they do these all the time quite well! On a personal note, I would be very supportive of my employee but I would not work on her just advise I would not get in the middle. The size and placement is appropriate and the crown looks good. It can be tricky with an employee. Good luck hope the graft goes well! Good assistants are hard to find and she will be thrilled that you care!

I agree onlay block graft would be a good solution. Make sure u make good perforations into the body of implant so that the titanium of implant is communicating well with the onlay graft as titanium is known to be osseoconductive and osseophilic and the perforations will promote angiogenesis which is so badly needed bring oxygen to the onlay graft. This is a technique I learned from my local omf who was kind enough to let me watch the surgery which he performed on a dehisced implant #10 just like this.....with missing entire facial wall and placed facially violating the envelope of facial plate just like this one. Sam Jain DMD Center for Implant Dentistry "We image, we plan, we place, we restore, and we advise"

I would keep it simple here and if you can involve the or a periodontist . Whilst the bone may be thin ( scans notoriously do not shown bone on the buccal aspect of Implants well , a Synchotron Scan would be great to show ,but cost would be prohibative ) the best approach would be a CT graft "drawn through " to thicken the gingiva without raising a flap ( please do not do that as it may worsen the case ). The other big issue is the abutment and here use of ceramic ( Straumann casres ) would be a great improvement . Then just and nice new all ceramic crown and hopefully a very happy assistant. Peter

I like the all ceramic crown option with a decent attachment and routine monitoring I think your done.

Probably, a pink composite material like "Amaris-Gingiva" (VOCO) might correct the situation. If not, the crown should be rebuilt.

Hi CRS , the US school I teach at uses Zimmer and they have some great results using the Trabecular Implant . As to Ti and its capacity to encourage bone formation the book to get is Titanium in Medcine by Donald Brunette in which a friend has written a chapter . This is why the Implant is the best graft material and is best placed at the time of grafting not later ( after site repair ) . Regards Peter

A few things to start with. Unfortunately the sagittal view of the implant is difficult to read. Firstly because of the size (not your problem, the website does not allow a larger view) and secondly due to inherent artifacts around implants in CBCT images. These are 'volume averaging' and 'beam hardening' both of which make it more difficult to have an understanding of the volume of bone surrounding an implant such as this. One cannot definitively say that there is no bone on the buccal aspect, but I would make a bet that indeed there is not any buccal plate (at least on the majority of the body of the implant). Now we come to the choice of implant, and obviously we cannot change that at this time. In a thin biotype (IMHO in any anterior implant situation) I would not use an abutment with such a significant flare to it...one small change in the gingival architecture and, well, you know the end result, it is what we now see. Great you say....what do we do now? I agree with Peter, my first choice of treatment would be a thick connective tissue (CT) CT graft harvested from the palate. try to position this without raising a flap on the buccal. Perhaps a better option would be to remove the crown and abutment, place a cover screw back onto the implant and complete a Rotated Pedicle CT flap, this maintains it blood supply and has a great chance of survival. Stage this with a redo of the uncovering (Stage 2) and a new abutment (perhaps Zirc) and a new crown. This i think is the best band-aid solution at this time. Another would be to removed the crown, re-graft the buccal area and redo the implant. As for the comments from Sam, I have never heard of perforating an already place Ti implants causing angiogenesis, may I have a reference for my own elucidation. Thanks.

I lectured for Straumann for 10 years and all the posts have missed the obvious. This is a Straumann tissue level implant, not a bone level implant. The tissue level was designed for posterior placement and was used in the anterior. It never should have been used in the anterior. This is partly the reason Straumann came out with a bone level implant patterned after many good companies that were producing bone level implants at the time. You all are looking at this from a perio perspective and no one has mentioned the restorative aspect of this case. The first thing I would do is inform the patient of your intention to improve the situation. Then...prepare the facial aspect of the implant. Go 1-2 mm into the sulcus with the preparation. It looks like this would be a total of about 3 mm from the existing crown margin. Leave the abutment alone. Then have fabricated a lithium disilicate or zirconia crown. Zirconia will mask the metal better and a good lab can shade the zirconia correctly. Then see what happens. A tissue graft would be a later alternative if the masking is not fully achieved, but in my opinion, tissue grafting alone will not correct the problem. This is fundamentally a restorative caused issue and needs to have a restorative component in the fix. Grafts are not without consequence. Just get rid of this crown, prep the implant like it were a tooth, retract the tissue, take an impression, and make a new crown. Use a temporary for a while to judge if further prepping will be required and whether or not you can achieve the results you want from restorative alone. Wrong implant, wrong location, wrong placement (too far facially).

change the crown .....by covering the defect ... it would be practical ..... and not a big deal take care

I'd like to see a frontal photo of her entire anterior dentition, at repose and full smile before recommending anything.

Thank you Dr. Miller for the voice of reason. Dear surgeons; please take note of his comments. This is a surgical oops by using a tissue level implant. 1) The flare of this implant is too wide to create a decent emergence profile for a lateral incisor so even though the implant is a 3.3mm body it has a 4.8mm wide platform and this "too wide" implant acted like a labioverted tooth which pushed the labial tissue apically and thinned it out. 2) the tissue level implant should only be used posteriorly, use the bone level anteriorly so we restoring guys can control the finish line. 3) Look closely at the radiograph and you can see the "finish line" of the implant coronal to the adjacent CEJ. There is no way to create an esthetic restoration when the crown margin is this coronal. The flange of the tissue level implant is the crown margin and needs to be more apical so we can create a gradual emergence profile, and only posteriorly where the alveolus is flatter and not scalloped like an anterior tooth. It is vitally important to select the correct implant for the job and not force a one size fits all scenario. I am a prosthodontist who too often has to fix these issues that could have been avoided with proper prior planning.

Dr. Miller's post is right and very conservative.I like that approach.

Thank you to Dr. Johnson and Mr. Usher. With all the technology we have today, we still get responses from our surgeons that "Oh well, the drill wandered to the facial." Of course it did. The palatal bone is quite dense and the facial bone in the anterior is quite fragile. It is your JOB, surgeons, to place it correctly EVERY TME. I have more than my share of good surgeons in my area use that excuse. Another issue-inventory. Surgeons will tell us, "Well that's what I had in stock." Not a good answer. If you don't have what you need, then reschedule the patient and order what you do need. You don't have the right length of 4.0 mm or 4.5 mm implants and all you have is a 5.0 mm? Then order what you need and reschedule. Is the almighty dollar that important? Would the patient care is they knew? I'm doing a bathroom remodel right now. The framer screws up? No problem. The drywall guy will fix it. The drywall guy screws up? No problem. The painter will fix it. The painter screws up? No problem. The finish carpenter will fix it. Well guess what? The surgeon has the responsibility of placing the correct diameter implant at the correct length, the correct distance from the labial plate, and the correct depth in bone-both apically and at the restorative table. No excuses. If a lab sends me a crown 1.0 mm shy of the margin, I send it back for a remake. A little more difficult to send an implant placement back for a remake. Surgeons-is what you're doing EXACTLY what you would want done in your own mouth? If not, fix it. Unfortunately, this discussion will go on as long as there is dentistry. And as a former chair of a local peer review committee, no one will be held accountable…and the patient loses. As P.K. Thomas once said, “Trifles make perfection, and perfection is no trifle.”

Dr. Rand, entering into this with shyness is understandable. Very few of us have done this before or been faced with the possibility. There is a dentist in the Denver area as I recall that has published a paper documenting hundreds of these cases where the implants were prepped. At first I wondered what was wrong in Denver, but that is neither here nor there. The fact is, dentists are doing it successfully when called for. Use your best dental skills and training and prep it. You are simply prepping titanium instead of enamel, dentin, and cementum. The good news? The implant won't be sensitive or need a root canal ! ! !

The area may be corrected with a shaded zirconia abutment. It looks like it is the neck of the titanium abutment that is showing. A shaded zirconia abutment with a zirconia or all porcelain crown may work out.