Patient considers abutment a failure: suggestions?

It is unfortunate that you were not able to place the implant deeper like you wanted. Deeper placement would have avoided that problem allowing a better emergence profile. Many times a succesfuly integrated implant in the esthetic zone turns into a prosthetic failure cosmetically when it is not placed properly. If the exposed metal is on the abutment, the fix is simple, redo the crown to cover the exposed area. If the prosthetic platform of the implant is exposed, it is necessary to include this area in the impression, and the design of the bicon implant's platform creates an undercut area that does not allow you to properly cover it extending the margins of the crown without creating a plaque trap. Prosthetically you may be able to hide it from the patient, but it will create a problem in the long term. It would have been better if you had included a radiograph and/or picture of the case. Good luck!

You need to put this back on the patient. If the patient had not had a "panic attack" you would have been able to place the implant properly. A maxillary implant can be reverse torqued with approximately 120ncm of force. So explain to the patient he (or she) can live with the minor cosmetic defect or you can bring in a dental anesthesiologist (at the patient's expense), remove, redrill and retorque the implant, and start the prosthesis over after appropriate healing.

What was the reason of the "panic attack"? If an implant surgery is performed, the patient has to be instructed before and has to be compliant. At least you started with the surgery, and you are talking about a very short implant., and this in a second premolar site. The creation of an osteotomy in correct depth would not have lasted one second longer. So what was the reason that the patient got in panic? Was there pain or discomfort, or happened something which produced that the patient lost confidence? After refusal of deepening the osteotomy the patient allowed you to place the implant, why this and not deepening slightly more? I see a big lack of patient guidance with this surgery, and you should have refused to place the implant without correct osteotomy. A Bicon implant has to be placed subcrestal (bone level), and never at gingival level. Definitely threads will be exposed. I am sorry for my clear words, but I agree that this implant surgery was a failure. You would have been better off to suture without placing the implant, or explaining good enough and convincing the patient to let perform the surgery adecuately. Best regards Michael

Your patient's complaint seems a bit unrealistic. A bit of metal showing on the palatal aspect of #13 is not a normal esthetic concern. Take pictures of her smiling and even open-mouth laughing. It is highly doubtful anyone will see this without a mouth mirror.

Some of the above responders are not familiar with the Bicon abutments and their attachment mechanism - an ectreme Morse taper with no screw. The lack of x-rays and photos make suggestions diddicult, but you hav many options with Bicon not commonly available. First of all, a small palatal metal exposure on an upper second bicuspid is common on PFM crowns and rarely an esthetic problem. These abutments are easily removed to allow a number of solutions: You can groove the exposed metal and bond composite to the surface as long as its an axial surface, not contacting deep structures. This can be done in the office. If the standard abutment cannot be prepared to extend a new crown's margin over the metal, then you can order a "blank, " laboratory abutment and turn the angle to the palatial side before prepping it. This will move the polished, spherical undersurface to contact the sub gingival tissues and allow a deeper crown preparation. Most labs can easily prepare these, but it's difficult for the Doctor to trim that much titanium away while hand holding the abutment. I used to trim all my lab abutments myself, but now have our local lab machine them for a very small fee and they are perfectly done. The Bicon in-house lab could likely prep this, but you'd get a composite crown which may or may not be what you are after. I use Zirc crowns on areas o moderate esthetics and E-Max on the standard shouldered abutment where ther is room, and PFG crons where situation requires a thin marginal area. Call your local lab and the Bicon lab to visit about options. John

I would like to suggest that an soft tissue graft could be an option as it provides a few mm thickness over the exposed threads. And this would be your best shot as other techniques may result in more complication due to infections. A sub epithelial connective tissue is the best choice. This treatment option was an suggestion from a pioneer in implant and GTR. WISH YOU BEST OF LUCK.

Sounds like the patient is dictating the treatment. If the panic attack caused a compromised placement I would have stopped and not place the implant. Sedation is a good option for this patient population. However if everything was okay at uncovering I'm suspicious that the tissue was traumatized at the impression, retained cement or impression material or a patient habit. Why did the dentist place the crown if the patient was not happy? There are many great suggestions above, perhaps a palatal island or finger flap would help. A picture would really help since the palate is a non-esthetic area. Very good suggestions on patient management also. I'd proceed slowly observe how the tissue responds is the patient traumatizing the tissue?

There is an easier way to avoid this in the future. This is what I always do without exception. After I have tried in the implant crown and abutment and everything is to my liking, I show it to the patient. I talk to them about oral hygiene, incremental loading and any other issue that pertains to their case. Then I ask them how it looks and feels. If they say it is o.k., they I have have them sign a form showing that we have discussed all the issues mentioned above, that they approve the appearance and feel. If they do not approve, it does not get placed and corrections are made. So far, everyone has signed because they want their tooth. Once the form is signed if they wish to have another tooth, it is on their dime.

Understanding what this patient wants is a main problem. Is it mainly how the restoration feels or is it how it looks when standing on his/her head while looking in a mirror? Once it is determined that the patients desires are realistic only then try to correct the problem or you will never fix it.. Remove the abutment with the crown attached. Do an implant level impression. Prepare the lab model with soft gingival material. The abutment can then be evaluated for "correction" by placing it on the lab model. If the existing restoration can not be altered to satisfy the patient send the case to the Bicon lab for a consult. Be careful to speak one on one, do not just send a note. There may or may not be a fix for this patient. No one can do what is impossible. Has the patient paid in full, perhaps this person is looking for a refund or to avoid paying the balance? Be very careful to understand this person's perceivced, even if unrealistic, needs and convey this to the lab.

One last thought, since the implant was uncovered by the dds you have no idea what was done at the uncovering, too much tissue removed, probing of attachment with stripping, impression material left in sulcus, you don't even know if the implant is well integrated if you don't get to check it at exposure. Even a too large healing head can disturb the gingival attachment. You did not get to finish the case and release the patient from your care, I.e. healing abutment placement. I really like the comments posted above especially the waiver. It is unfair for you to take the blame when it seems to be a restorative issue. There are just too many unknowns. Once the patient walks out the door you can't be expected to be responsible for the restoration. Excellent advice. I

I do not blame the dentist....he tried his best. The patient obviously thinks they are a Hollywood Star with a perfect camera ready smile in every dimension.... TAKE THE PATIENT TO THE CANCER WARD OF A HOSPITAL...LET HIM/HER SEE WHAT REAL LIFE IS ABOUT.......MAYBE THEY WILL FORGET THEIR 1MM OF METAL SHOWING WHEN THEY ARE UPSIDE DOWN.......... There are some ungratetful selfish people in thhis world...unfortunately this dentist had the misfortune of treating one of them.

Are a We talking the same thing This is about abutment nets that connect to the implant Custom abutment nets that connect to the abutment are not fully custom and abutments that connect to the implant can be

wow! if its metal on the lingual palatal of the restoration. As long as it fits i would not replace it. Show us a rad and a pic. Seriously does she not have any metal-ceramic crowns? amalgam? ear rings? bracelet? I would give her her money back for the restoration along with all her notes and radiographs and advise you cannot reach her expectations, i doubt anyone will! Sleep well!!!!

let's hear it for gerry rudick....you're gonna give this (lady) her money back 'cuz her dds couldn't grind a mm. of titanium off the platform to bury the margin?really? REALLY? tell her to get lost....there's bigger worries out there.

I would remind the patient of the panic attack and that they prevented you from obtaining ideal results. In addition another doctor was involved in treatment and that you do not know how they exposed the implant. I would also mention that its their biology you are working with. All in all, I would not worry about it. Dr Dowd hit the nail on the head.

Dr CRS also has made valid points on this patient management issue.