Osteotomy Site Not Parallel to Adjacent Implant: Suggestions?

Last Updated: May 16, 2012

I placed these implants. Â I used paralleling pins to guide my pilot hole and osteotomy, but the result is as you see below. Â I am not sure what I did wrong. Â Obviously I did not produce an osteotomy site parallel to the adjacent implant. Â Should I untorque and reverse this implant out of the osteotomy site and try to redirect the direction of the osteotomy and re-insert the implant? Â Can I go ahead with the prosthesis? Should I reverse the implant out and do a bone graft and re-enter later with a new implant? Any suggestions? Thank you.

(click to enlarge)

![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/05/impl-e1337160704877.jpg)

30 Comments on Osteotomy Site Not Parallel to Adjacent Implant: Suggestions?

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Seth Rosen

05/16/2012

honestly, I would remove the implant and graft. Then let it heal. There is no way to prosthetically restore this as is.

rsdds

05/18/2012

i've restored this cases before without a problem. in fact to me this a very easy case to restore

Seth Rosen

05/23/2012

short term, you can restore anything. Long term there isn't enough bone between the implants. When restored you will see cupping and severe bone loss. There was an article just written about splinting implants that are off axis to one another or do not have enough bone between. It seems as if this scenario multiplies the bone loss.

Dr. M.

05/16/2012

Do you think I can put asleep the central one and make a bridge between first and last implant? And about bone, you think I will have resorption? thx!

Allen ong

05/23/2012

I think the surgical stent is not very important in this case. May be the problem is extent of mouth's opening and your experience. 1. Reverse the last implant ,and re- implant 3 months later. 2. Reverse 2nd implant out, make a bridge. If remaining the middle implant and make a bridge above, cleaning and esthetics is a problem.

JIM

05/16/2012

Take an implant level impression and make custom abutments. Splint the antrior two implants together and make the posterior implant as a sperate unit.

Paolo Rossetti - Milano

05/16/2012

The problem is not the lack of parallelism (think about the all-on-four concept), but the fact that the implants are too close to eachother. No doubt that you can restore them somehow, but the long term success of the rehabilitation would be negatively affected by the lack of inter-implant space. In my opinion the removal of the implant in the middle is a good idea.

Dr Chan

05/16/2012

Paolo is right. Removal of middle implant is a good solution. If you put the middle one to sleep, you will still get bone loss as the implants are too close together. From the position of the sinus, these implants are in the anterior esthetic zone. Any bone loss would compromise the esthetics of the final restoration.

A.Tarek

05/16/2012

You can leave the Middle Implant sleeping, because you can't restore as it is very close to other implants u do a bridge between 1st and last implant... you can use angled abutments or custom abutments to correct your angle.. The middle implant will preserve bone height under bridge so leave it as it is ;) Don't remove implant cause it will be disappointing to your patient.

Paolo Rossetti - Milano

05/17/2012

Dear Tarek, due to the closeness of the two implants, it is likely that the middle implant develops bone remodelling around its platform, although this implant is left uncovered (sleeping). The area of bone remodelling will eventually merge with the one around the second implant, causing vertical bone loss (and soft tissue loss) between the two screws. That's why I would remove the implant in the middle. Disappointing the patient is not an issue if this leads to a better rehabilitation.

Baker vinci

05/23/2012

Don't remove the implant because it will upset the patient? Don't you think a reasonable explanation and 10-15 minutes of corrective surgery, would satisfy your patient in the long run. If an immediate post op pa film is not standard procedure, it should be. This is exactly why being able to treat the complication, is every bit as important as placing the implants. Bv

Gregori M. Kurtzman, DDS,

05/24/2012

Agree one should take a radiograph of a pin in the pilot hole to verify trajectory and anatomy and then when finished another documenting the placement. Its very easy to redirect the osteotomy when its only a pilot hole.

Dr. Alex Zavyalov

05/17/2012

Implants integrated well. I would proceed further. To distribute mastication forces equally and lessen bone loading around single implant, I would combine crowns (if the abutment position allows to do it).

Adam

05/17/2012

Assuming implants were placed recently, remove the middle one carefully and graft. Allow remaining implants to integrate and restore If integrated, there is no way to assess the BL dimension of bone between the two distal implants via the xray. MD potentially too close to avoid compression necrosis of bone in function. If you have 2 mm interproximally between two distal implants, bury middle implant; alternatively, reduce height of middle implant and graft the area. Restore using remaining implants.

Amir mirzadeh

05/17/2012

I think if u want to have long term success And due to the position of implants and patient Remove last implant Correct the path of insertion Use bone graft with 0.5 or 1 mm particle and put it in the wrong path Use a bigger size of implant with the same platform( ITI for example) And wait 6 months for last implant But do you prothesis for first one and second one

Dr M.

05/18/2012

Thx to everyone to your comments and suggestion. I omitted the detail that the patient is 79 y.o. so I don't want to stress him too much with another surgery. I think I will restore first and last implant leaving asleep the central one. Obviously other comments and help are welcome!

H.Barghash

05/18/2012

Dear Dr.M I do agree with your decision leaving the middle implant as sleeping one but I just add one thing that follow up and oral hygiene is very critical in such case especially with the expectation of pocket formation if bone resorbed around the loaded implant . another important point is gradual loading concept which means clear instructions for the patient after loading to follow gradual increase in diet constancy ,some goes to start with acrylic crown first which I think you don't needed in your case. good Luck

rsdds

05/18/2012

i don't see a problem with this case i've done cases like this without a problem.

Carlos Boudet DDS

05/18/2012

If your question is can you restore this, the answer is yes. One way to restore is to back out the middle implant or leave it uncovered and do a bridge. Is that the best that you can do for your patient? No. You could also remove the most distal implant, graft and place it further distally using a surgical guide. You should know that when the implants are so close together you will loose bone between them. The problem may not be evident soon after the implants are restored, but it will be evident later and affect the long term survival of the case.

Richard Hughes, DDS, FAAI

05/19/2012

One can use all three implants. Just modify the Impresson abutments and take a fixture level Impresson. Let the lab do it's magic. Hygiene may be an issue. If that does not work, puttee middle one to sleep and make a three unit FPD.

David Nelson DDS

05/23/2012

I totally agree. The transfer coping on the distal implant will need to be modified and the case is a chalange, but is very workable.

Dr. Alex Zavyalov

05/20/2012

Leaving any implant "asleepâ€œ may be considered by a patient as unnecessary charge added to the cost of the treatment.

Jace Hansen

05/20/2012

Remove the center implant. The patient will develop a defect between the posterior implants if you leave them. You need 3 mm space between implants to avoid overlapping bone loss.

Gregori M. Kurtzman, DDS,

05/22/2012

As the middle implant is almost touching the posterior implant at the crest restoration will be harder and oral hyg maintenance will lead to bone loss over time. Would recommend remove the middle fixture and graft come back in 6-8 weeks to place another fixture. This case is also a good example who surgical stents are needed, one can without one hit some denser bone with the drill and change the direction of the osteotomy as its made.

Gregori M. Kurtzman, DDS,

05/22/2012

Another option is remove the middle implant graft the site and at the same visit place another implant the proper distance distal to the last fixture present now and do a longer span bridge there is sufficient height it seems to place a fixture in that distal position

DrT

05/22/2012

For all of the above posters who say to keep all 3 implants and try to restore them, I would pose the following question: Would you want this done in YOUR mouth?? Ultimately, the question is not COULD this be done, but rather SHOULD it be done???

Baker vinci

05/23/2012

Take it out while you can and just replace it, as if you were placing an implant in a molar extraction site. A small graft and membrane. This preverbial "hole", will get deeper and deeper if you don't . Bv

Deks

06/03/2012

This might be a very simple question - It seems that the x ray was taken from a more mesial aspect, which will make the space between the two distal implants look smaller. Take a x ray from slightly more distal and re -evaluate - especially since you did use a stent right in the beginning. Also perhaps take a cone -beam and check again. Good luck.

CRS

06/05/2012

In the posterior Maxilla there is sometimes not enough intra-arch clearance to keep the drill parallel. If you have an assistant at the patients feet looking in the mouth, she can help line up the implants,as you will have a tendency to pull the drill toward you. After the implants are placed at surgery, take an xray and remove implant at that time or within 6week prior to osteointegration.The middle should come out and be replaced or do a three unit bridge.

uli.friess

08/23/2012

If the patient is already 79 years old,the implants will survive him.I`d just leave it as it is and try the next time better

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