Poor implant placement: How should I manage this case?

Don't be embarassed but you should learn from your "mistake" however. Simply explain to the patient you are not happy with the placement of the implant, apologize, and tell them you want to move it the new one to the appropriate spot. It will be fine. It will head-off problems as well as explaining treatment in the future. Deal with your issues when they occur. No different than having a file separation during an endo procedure. Your patient will appreciate your honesty!

First of all, it was a supervisor's fault. If he had controlled your initial drilling-position, you would not have made this mistake. You were focused on surgical procedure too much while you forgot about the prosthetic component. It's not a difficult case to correct.

i have done this too, all the beginners do this. U should tell the patient, the patient will not be upset. Remove the implant graft the site, You can avoid doing this in future by simply following this, say for example you are going to place a 10 mm implant . Drill with ur pilot drill till 3mm and take an x ray. Analyse ur angulation, distance between the adjacent teeth and ur drill , keep in mind that this is the 2mm pilot drill and the final diameter of ur implant is going to be more than ur pilot drilL. Once everything is fine move on to next 3mm i.e. Upto 6 mm now. Check all the above things again. If u have to do any corrections at this stage use a side cutting drill to do so. , and then take x ray image. Then proceed to ur final depth of 10 mm. By doing this you will never go wrong. You should also start using a stent. a stent can help u where to begin ur osteotomy site. stent can be made easily take acrylic teeth and make a stent fixing them on the edentulous area and stabilizing them over the adjacent teeth, cover only the incisal/occlusal third and in clear acrylic. Use it once u raise the flap and mark a central hole thorugh the acrylic tooth and point on the crest of bone. This will tell u the most appropriate prosthetically driven implant position. And also avoid placing the implant too close to adjacent tooth. Believe me this is your last case you have done in this way. All the coming cases/are going to be better. We all learn. I am glad u posted this case here. Good luck and sleep tight

The advice you were given at the time by your supervisor was appropriate.I assume you did not take it and left the implant as is? Do as you were asked and remove the implant. Come back another day and follow appropriate protocol that you have undoubtedly now learned.

Further... to answer your question you have been given good advice above for the semantics for the patient by JIM. Do not try to restore this ! Any attempt to restore is fraught with so many issues that it will come back to haunt you...by comparison both you and the patient will be much happier with this out and replaced properly in the long run. Your "supervisor" is correct to ask you to remove it ...but do not replace immediately...your osteotomy site right now will mess things up.

You need to review some of the basic principles in the placement of implants, and there are a lot of sources available. Here are some points to consider: In the first molar area you would like a wide diameter implant if the bone width will allow it. Use your periodontal probe as a ruler. If bone height is adequate you measure the width of the bone. You want 1.5 mm of bone minimum on each side of the implant, so for a 5 mm wide you need an 8 mm ridge at the top part of the osteotomy. You also want 2 mm distance from the implant to the adjacent tooth, this means that you need to measure with your probe 2 + 2.5 (radius of the implant) and start the pilot hole drill 4.5 to 5 mm from the root of the adjacent tooth. Drill to 8 mm with the pilot drill, place a direction indicator secured with a piece of floss and take an x-ray. If it does not follow the right direction adjust the osteotomy with the pilot drill and take another x-ray. Do not go to full osteotomy length until your direction is correct and you have verified that you have the bone height you need. If you do that you will find that you can avoid all the mesiodistally misaligned implants. Buccolingually is another story. What to do now: If you measure and you can place an implant in the right location with good stability, back this one out, graft the first osteotomy and do it, if not, remove this one and graft, and come back in a few months and place it in the correct position. Good luck!

Hi i just want to say thanks The patient came in and i told her about the misangulatuon and we need to do again next tuesday(which will be 7 days post-op) obviously, patinet was dissappointed but she accepted it. I have made surical template and i think i know what i have to do to correct this. However, about the bone grafting of the defect site where the implant is in now, My periodontist suggested to repostion and leave the site without the graft but apposed the site well like ( stage2 surgery) i have not done any grafting and i think if i don't do the graft properly may be better ti leave the site? Would you guys comment on this what if i don't graft the site what would the problem?

Back out the first one. Put the second one in carefully as per Carlos's post. You can deviate into the first osteotomy site easily so check and check again. Use a sharp pilot drill with the guide so you don't deviate from the correct path. Generally speaking, mesio-distally, the implant should parallel to the long axis of the second premolar. b-l, try to get it parallel to the buccal plate. There is no problem if you don't graft the first site. Tension free soft tissue closure is more important. Go slow and good luck.

Multiple checks with x-rays, pilot drill, and direction indicators is the only way to be perfect. Don't forget to also have the patient close into occlusion to evaluate the position of the maxillary teeth. You can always correct in the pilot drill stage. Never let time influence your decision making. No harm in waiting for solid bone to place the implant. Graft and wait.

Take it out and do it again...Everyone has made this type of mistake. My suggestion for the future is to make a simple guide to help you put the 2mm twist drill in the right spot. This is another thing you can do: Let's say you need to place a 10mm implant. Start with a 2mm drill and go to 5mm depth, and use your guiding pin to make sure you are in the right spot with an xray. If it is continue. If it isn't then correct your positioning and retake an xray...and continue for each width. There is no rush to place an implant. take your time. Your patients will appreciate it.

As has been mentioned, presurgical planning can reduce or eliminate many placement errors. Make measurements on models and a diagnostic wax up or stent from your lab depending on your case complexity. Cone Beam CT's are invaluable aids for placement. I have placed a few thousand before I had a CBCT and a few more thousand since. Still some surprises, but no where near the surgical decision making intra-op that there was before. If this happened to me today, once I saw the post-op film, if there was sufficient bone posteriorly and inferiorly to place an implant with good initial stability(. 35 N/Cm2)I'd do that. I like a Nobel Active to accomplish that goal, graft the anterior defect, and do a 2 stage if the anterior margin of the implant is close to or engages the existing defect from the removed implant. Most clinicians are recommending at least a 5mm restorative table for a molar with at least a 10mm length. Hopefully you at least had a pre-surg panorex to asses the position of the IAN.

Hi W The above advice is sound and I know how you feel. We have all made mistakes while learning to place implants, I have heard it being said that you only start to know what you are doing after about the first 100 placements. I will say that you should not be placing implants if you do not know how to so some basic grafting techniques. This is an essential skill that you will need to use time and time again- don't be afraid it's really not that big a deal. I would suggest taking some courses- Misch, Garg, Tatum there are many choices. Not only will these skills improve your results but will make you a more rounded implantologist. Guided surgery with ct stent is also a possible way to go if you want to avoid grafting. My personal feeling is that it's best to learn hands on and develop a feel. Good luck and enjoy your journey.

Mistakes happen, looks like you're getting good advise here. As everyone has said, tell the patient the truth "You do not like the position of the implant and it needs to be changed in order to give the patient the best outcome" you really don't have to go into any more detail than that. This has happened to everyone who has placed a lot of implants, no need to be embarrassed about it. I did not read every post all the way through, but I trust you will put in a NEW implant and not just replace this one. You'd probably be okay using this one over - but don't.

Remove the implant. You will have a defect with all walls present. Buy "Foundation" made by J Morita, place the plug & close OR plugs from Ace surgicals. Redo implant correctly afer 4-6 mths according to experts advice on this blog. This will be your first and simple case for bone grafting to start with :-) GOOD LUCK!

I would remove the fixture asap when its easy and no integration has occurred. fill the osteoomy site with osseous graft material. and place a new fixture distal to the current spot. Did you use a surgical stent for the original implant placement?

Yaron Miller hit the nail on the head, if you can't graft you should not place implants. It's like being able to extract a tooth, but not be able to suture the tissue closed. Thanx for posting we all make mistakes(I do) and learn from others mistakes. Take more training, it will give you confidence and help prevent future missteps. Good Luck

It is always disheartening for this to happen. As the other Dr's have suggested, a surgical stent with a drill guide would have prevented this from happening; also the stent would have acted as a diagnostic "wax up" showing the final outcome of he case. We must remember is that implant dentistry is driven by it's prothetic outcome.

Sorry but, from what I understand, Foundation is not an appropiate material next to an implant. It is for bone preservation done at the same time the tooth is extracted. Thoughts?

This has happened to lots of us....including me, It's a very common mistake for the new implantologist to make. Placing an implant without a surgical stent is ok if you have done hundreds and have seen it all but it's not for the new starter. The advice given re check radiographs will prevent this happening again :) You sound quite unsure about quite a few important points in this case. Grafting, positioning, material selection etc. Maybe a little more support during the surgery would be appropriate. Your mentor should take the time to assist at the surgery so they can provide instant advice and support. There are no poor students, only poor teachers!

Someone here suggested that all molars implant fixtures be five mm etc.. Can someone explain to me the logic of why a wider implant is any better than 3.5 or 4.5 mm implant? It would seem to me that more bone surrounding a fixture is better than less bone. Its also safer and allows more flexibility of placement. An implant is not held in by ligaments and reason would indicate that as long as it can resist forces applied ..even non axial forces..it should do its job quite well

when you say "handle a load better"..what does that mean? does that mean the narrower implants cant handle the load? or that they fail? ..Does it mean that the imlant body will fracture? I havent seen any of these things As far as the size of the restoration..we know that platform switches show that the fixture and the restoration dont have to be identical.

doesnt make much sense to me that to lessen the bony support by a larger fixture makes the bone more able to handle the load. I routinely use 3.5 and 4.5 ankylos implants in molar regions and we never see the fractures you are referring to. I believe the evidence will show that there is no advantage to larger fixtures and that most of the time the diameter of the implant in the molar region will never be analogous to a tooth root

BIC is dependant on surface of the implant that contacts bone as we increase the diameter of the implant there is more surface area on the implant to contact the bone thus the more BIC the better the load is handled. Fracture depends on the implant design all implants show cases of fracture either in the implant or the abutment connector, some designs are more prevalent to this others less. Please provide lit references to support your statement "I believe the evidence will show that there is no advantage to larger fixtures"

W, I have to call some BS on this. If you were under the direct supervision of the periodontist why did you not remove the implant and replace at the time of surgery (i.e. why is the patient coming back for you to do this a week later?). It sounds as though the periodontist was not right there when it was placed but maybe you are in a class where you bring in your case and then present it. I am not sure but I can not imagine someone experienced in implants such as a periodontist who is educating allowing you to leave the implant as is after he "just told you" to remove it. Sounds like there was not direct supervision to me but I may be wrong. Everyone has mistakes like this at times but I would really like to know the circumstances of the placement (i.e. if the periodontist was right there when placed and what was said when you did not do as he recommended with the patient in the chair).

Hi, Dont worry coz its a beginners learning curve,try repositioning or grating the site but keep in mind the reverse torquing is while removing the implant is associated with a lot issues like neck fracture of the implants if u have inserted with a very high insertion torque and most importantly to avoid such misalingned implants please try using the universal implant guide by INNOVATIVE IMPLANT TECHNOLOGIES which is simple guide which can be used for most implant systems and with great results or atlesst check out their website ,since we have moved away from using custom built stents coz they hav alot of issues like they are not sterilizable , hope this works well and all the best

Why would you choose a periodontist as your mentor for placing dental implants? Wouldn't an OMS make more sense? ......That was your first mistake

Drvinayak ,MDS,PERIO Correct me if am wrong ,last heard that implants placed by peroodontists had the highest survival rates maybe coz we know and understand bone more intimately than any other speciality but key to this endless debate on who is the best lies in handling the soft tissues for which a periodontist is better trained than any other specialist

Now here my question to all... Can u still use this implant to place in new position after removing from the earlier site.... Just a question ..

guides, my friend. at least for pilot 2mm drill. we do waxups and simple pilot guides on duplicate models with the tooth 1/2 reduced to see the centerline of placement in .080" vacuum forms. we then place pilot hole in the guide and use it after we miniflap and check the site for smoothness. the guide then gives us proper centerline for the 2mm pilot, which we can confirm by x ray, especially when learning, i did a lot of digital check pas when i was starting on my own after training. you then simply follow the drill sequence within the pilot hole to depth and things work well. anyone can make such a guide and you dont need to spend $800 to get a keyed guide on a simple division A case. good luck!

What about leaving that implant too and have a molar with two implants? It looks that it have a lot of space there. Could that implant cause the loosing of second premolar?

GP, OMSS,Perio doesn't matter, its the skill set they bring to the table. Some excellent Implant training out there by GP's, Pacific Implant Academy comes to mind and excellent specialists training in grafting and implant placement.

Hi, Dear Rule of “P” Proper Pretreatment Planning Prevents Prosthetic Problems and 2 role during surgery u should absorve yourself and u always see your hand where to work and you imagine the result,so i think everything is ok.(everyone must know what to want before starting). about patient u can explain him with smilling on your face which will earn trusting and u can replace implant and patient will be happy to do that again.

sushant rohilla just made a great question and yes, it is possible to reuse this implant on a new site and in fact it is the easiest way to solve this case. first remove the implant quickly. second: drill 5mm distal to the margen and place the same fixture 5mm distally and graft the site with bone (I recommend you to use hydroxilapatite bone substitute like Bio oss or Puross and a membrane collagen crosslinked (cytoplast works great)) If you wait more than 2- 3 weeks then you will not be able to use this implant and you will have to use a new one.

As I said on June 19, NO NOT REUSE this implant. You could, and it might work, but if it doesn't, and nothing is 100% except death, you'll never know if it was just bad luck, or something to do with re-using the implant (like being contaminated by PDL cells from the premolar). And then you'd have to explain THIS to the patient. No fun to have some 'splaining do to again. Besides, most (every?) company will give you complete credit when you return the used implant, so there is no cost to you. BTW Drvinayak's comment on 6/20 of "last heard that implants placed by peroodontists (sic) had the highest survival rates " made me laugh out loud. I believe those with the most training and experience, probably those who are ABOI certified, probably - but not assuredly - have the best success rates.

I couldn't help but notice you had the Sirona Galaxis software in the background, I would certainly recommend guided surgery to make sure of placement 2nd time around. Especially as a novice. It simplifies things so much for you. Goodluck

HELLO don't worry place a second implant between the impalant(smaller in diameter) and the second molar and wait for 4mounths do not charge the pacient again!! if the all goes ok with your first implant please use it also in your prosthetically plan no one lasts for ever!

It is better late than never...:) Remove the implant; let the site heal 4-6 wks with or with out a graft. Good pre-op work up 1, on a study model- use a putty impression- do it like a custom made special tray- cut this mesio-distally by half. You should be able to see cross section of the gap of missing molar. Now you can transfer the position of the implant/tooth - just by using a pencil- on both putty and on model. check this against -surgical stent/Radiographs. 2. you can use this putty template- even to start your pilot drill, which could avoid future complications. Hope this of little value All the best

surface area of implant touching bone is important of course ..but you if take that principle to its absurd conclusion ..you will get a fractured jaw. and if you take your concept to the minimal than all mini implants should fail. and they dont so clearly there is prima facie evidence that you idea is wrong. I think the correct paradigm should emerge that the smallest diameter implant that will have adequate surface area and preserve the most osseous thickness should be used. I believe that to be in the sweet spot of 3.5 to 4.5 . I dont have any research to quote but what I do and common sense.