Should I Redo this Case?

This 3.25mm diameter implant was placed yesterday in #9 site [maxillary left central incisor; 21]. Patient has no symptoms, but the radiographs do not look good. What do you think I should do at this point?

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43 Comments on Should I Redo this Case?

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CRS
2/22/2013
The radiographs look funny because you are almost in the floor of the nose. I can't see how much labial plate is present it is cut off on the photos. Do you have a clinical photo? The patient will have a very long abutment and will probably need pink porcelain. The upper teeth have bone loss so you will be duplicating that. I would probably have used a shorter and wider implant and planned for a diastema since there is a lot of width between the centrals. This implant should heal just fine but I 'm not sure how esthetic it will be. This is a tough case due to the vertical and probable horizontal bone loss. The patient may be heading for a full denture with locator retention. Another option is removing the front teeth grafting the sockets and building up the ridge with prgf and a resorbable or titanium mesh so that an implant supported bridge can be placed and the teeth will match. If you are wise have the implant crown be screw retained so that you can switch it out later. Very tough case when the cejs don't line up. I would try to get the four incisors lined up and treat the canines for the perio. Good luck.
david chan
2/22/2013
The labial segment is missing from the first view. Apart from the problems mentioned by CRS, the implant had been placed too palatally and drifted from the mid-line apically. It will be difficult to restore the implant satisfactory later. I would redo the placement and use an implant without coronal flare/ countersink if the horizontal bone width is not great. There is no advantage in using this type of bone level implant in the anterior region. Good luck.
Pynadath George
2/23/2013
Apart from it being just under the nasal lining and too palatal in its placement, what other issues are there? You could've used a wider implant but you don't have to. The patient has generalised bone loss. So your replicating this with your implant. Your implant will also have. Long crown like the adjacent natural teeth. So I can't see why pink porcelain is needed. Aesthetically unless the patient has a high smile line it's not a issue as it will match with the other teeth. Just likely there will be black triangles due to the perio. I would say NOT to remove the other teeth unless thE perio is unstable. And if that was the case you should stabilise it and not even thought of an implant.
Peter Fairbairn
2/23/2013
I think as said too palatally placed , hence a difficult bite relationship ( Pseudo Class 3 ) but with these images difficult to assess. As to extracting further , I feel we should be generally extracting less teeth using adjacent implants with bone regeneration to improve stability. Every mobile tooth is not another future implant even if the Porsche does need a service, our patients best interest is our priority . Peter
CRS
2/23/2013
Here is what I what to explain, when you are watching generalized bone loss over time the bone level is flat and very difficult to graft. If I have the topography of the extraction sites I can rebuild what is being lost. My typical experience with my patients is "my dentist has been watching this for years" often by the time I see the patients there is not lot to be done. Holding off on needed treatment is not what I feel in the best interest in the patient and it is sad to see his these patients could have been helped at an earlier phase. Unfortunately many dentists like to kep the patients "in house" and watch the disease process progress. I get pushback like oh my patient can't afford it or it won't work or it won't be successful. It is sad to get the patients when they are referred at a late stage and it Is not good care. Hiding cases and needed work I feel is not what is best for the patient, bottle necking these cases is not to the patients best health. Fortunately patients do seek other sources to get the referral and care they need. Don't get me wrong I advise a lot of patients to keep their teeth per individual cases but often it is after they are retired and don't have discretionary income, " if I only knew sooner, my dentist was watching it " typically there is no "flight plan" or these patients and there is no future thinking . Cases are not being presented let's just watch I. Just my viewpoint when I see what is possible. Thanks for reading!
Pynadath george
2/23/2013
Yes I agree and I'm sure others would too. Leaving Perio too late compromises further implant placement due to lack of bone. But the above case doesn't illustrate that. If its stabile Perio then there is no need to take the teeth out and replace with implants as the Perio is stabile. If it isn't stabile boneloss then implants shouldn't even be considered!
CRS
2/23/2013
What you just stated contradicts itself. If this stable then the bone can be regenerated if it is not then implants should not be considered. So keeping teeth with 50% bone loss as illustrated by the new implant and assuming this s stable then it is a good time to consider implants. How much bone loss do you want to allow? That's my point which your response just illustrated. Thanks for reading!
Pynadath George
2/23/2013
Sorry. I don't understand where I've contradicted myself. On another note the teeth do not have 50% bone loss. And if they did we wouldn't be assessing it from the bone around the implant (as you said).
Richard Hughes, DDS, FAAI
2/23/2013
I am still curious about how an implant drifts or migrates. Is this a fact or babbling BS? Endosseous implants, blades included, are placed with primary stability. Implants have very little movement in bone, which is similar to the secondary movement of teeth. The implant was placed to far to labial, not palatial. This case is a restorative/ esthetic challenge with just one implant. The perio condition has to be addressed, if not, it looks like the patient is heading for a bar overdenture or denture!
CRS
2/23/2013
The case was placed to deep near the floor of the nose because there isI not adequate bone, no site preparation period. There is palatal perforation in the higher ct views. You can 't see the labial plate. And yes "drifting" is BS. Dr. I totally agree with you!
TOBooth
2/24/2013
Nope it's palatial look at images again , ie the camber of the anterior mandible.
tonyvu
2/23/2013
How about removing the implant, filling the space with bone graft material, then place a tissue level mini implant later on.
CRS
2/24/2013
Look closely at the film! I 'm sorry you don't seem to comprehend but that is the way I see it. I personally like to intervene and rebuild what was lost to benefit a patient for the future. That is my point. But if you prefer to do nothing that is your choice. Thank you for reading.
TOBooth
2/25/2013
hey, look where the bone lossis and follow the palate posteriorly - that is not a nose!!! I'M 100% SURE ITS THE BONY DEFECT IS PALATAL. WHAT DOES EVERYONE ELSE THINK!
Pynadath George
2/24/2013
Slightly condescending to say I'd rather do nothing. If you think stabilising and maintaining periodontally involved teeth is doing nothing, well then we do have a difference in opinions. Going back to the X-ray. It reveals bone margins 1-2 mm below the cementoenamel margin. That's hardly my definition of 50% boneloss. I wouldn't even consider proposing extractions without further info. You don't know loss of attachment, pocket depths, bleeding scores etc to provide the opinion of extractions. To me it's jumping the gun. If you'd rather practice by extracting teeth which can be potentially stabilised (we need more clinical info, not just xray) and replace them with poor imitations of nature (implants), then that's your choice. But I'd disagree with extracting them at this point.
Pynadath George
2/24/2013
However looking at that X-ray it's quite poor quality. As I said before more clinical info is needed before suggesting that the teeth are of a hopeless prognosis. For example would you really look at extracting if those bone levels have been like that for 10 years with no deterioration? Or if the patient is in his 80's? Or cost/financial issues? Or limited opening for length of time? Etc etc
CRS
2/24/2013
Correct if these is a ten year result I agree. My point is if I have more to work with this could end up a fixed case( individual bridges) vs a bar or locator case in the future. The issue is the soft tissue which needs a good bone base. If the patent wants a final prosthesis which is individual crowns or bridges now is the time to jump. And true, I admit I am trying to predict the future! I just observe what this poor poster had to work with, a long narrow implant in the floor of the nose with palatal perforation it would be very interesting to see a cone beam! Actually I could maintain this with a LANAP procedure. Thank you for the discussion and challenging me! Best wishes.
Peter Fairbairn
2/24/2013
Occlusal balance is the issue that is always ignored ( inconvenient ) as all the "evidence" suggests occlusal imbalance has no effect on bone loss . But using some Implants to stabalize the occlusal situation does appear to have long term benefits. Taking out teeth merely because they may be lost in the future is a bit bit like committing suicide now as we will all die one day. Peter
CRS
2/24/2013
It is a judgement call that I am comfortable with, always weighing all the options. Believe me often I talk patients into keeping teeth from my perspective I often hear from refered patients "I wish I had done this sooner" But who knows perhaps they did not follow thru on their dds recommendations. I just like to have a flight plan or algorithm for the case. Then when I see the patient again I refer back to it, I don't have the luxury of seeing the case every 3-6 months. However like the " frog in the slowly heating hot water" it is sometimes shocking to see the long term progression of the "watched bone loss". I guess it is a matter of perspective and balance. I also rely heavily on team treatment, benefitting from the patients own dds who knows them best, there is no substitute for that.
CRS
2/24/2013
Also the occlusal balance is extremely important for long term maintenance of the bone! I agree wholeheartedly. We all die someday, and if our days are numbered why spend them with poor teeth! Thanks for reading hope I did not offend!
TOBooth
2/25/2013
Also!!! you were wrong the implant is too palatal look at the camber of the lower jaw!!! In my opinion you would maintain the perio before extracting the remaining teeth. I.e maintain once you have performed your initial therapy and monitor. I suspect if you were to do this the teeth would last longer than any implant therapy. Its far more ethical, and hey if he / she doesnt do her bit they just dont get more implants in the future.
TOBooth
2/27/2013
i might add i teach anatomy to undergraduates!!! (medical and dental students), besides when do you retrocline an implant tyhat much !!!! bone loss is at the platform palatally. I'm quite shocked at someones lack of knowledge when placing implants-scary! no sorry when practicising dentistry.
Peter Fairbairn
2/25/2013
Dr Booth agreed as I said in first post that it appears too palatal. Anyway there is way too insufficient information too truely assess this case and what we have is poor as well. CRS, boy it was cold in Michigan Peter
CRS
2/27/2013
You know, I took a closer look at the ct scan, I bet this was an immediate placement after an extraction, I see space at the crestal edge and the implant was placed narrow and deep to the palatal which explains the odd look on the panorex. This was not a case for an immediate because of the bone loss, site prep 101. I don't think Maxillas drift as previous poster stated and there are teeth on either side of the implant site so there had to be some buccal plate interproximally. I actually like the roundhouse c&b ideas and treatment planning posts! And Peter NOBODY goes to Michigan in February, God bless you! Next time Florida! Safe travel! CRS
CRS
2/25/2013
Dear TOBooth, I am afraid that the implant is in the floor of the nose, adjacent to the naso-palatal canal on the first film you can see the perforation of the cortical plate on the other ct films and perforated the palatal cortical plate. I have done enough LeForte osteotomies to recognize this. You may want to take a closer look, the structure above is the turbinate. The nasal mucosa may be elevated, I can't tell on this film. But the floor of the nose is superior to the anterior teeth in most humans. I'm not sure how one would follow palatal bone loss perhaps swelling or a perforation in the mucosa. This implant will probably osteointegrate but it will be difficult to restore.That is the beauty and the curse if implants they can osteointegrate in the wrong place and need to be placed judiciously. I would love to see a photo .
TOBooth
2/27/2013
last time i checked we had genial tubercules lingually check it out and do some anatomy courses! very basic if you read other posts people think correctly its palatal bone loss!!!! geeze being a maxfax it scares me that apparently your doing le fort (not forte)-i dont think you are. If you were you wouldnt make such basic incorrect assumptions.
CRS
2/27/2013
Since we are correcting spelling it is genial tubercles. I think the implant was done as an immediate with it placed too deep floor of the nose, too palatal with perforation. Not sure what the genial tubercles have to do with my comment about the maxilla, perhaps you are trying to point out something you can identify. It is still the floor of the nose and the turbinate just above the implant, not an assumption. I find that when posters become defensive it could be that you are taking this personally which was not my intent. I try to be respectful. And polite. The bone loss of the palate was a perforation since this was a recent post operative film. Practical operative experience always backs up a didactic anatomy course of which I have had several, I wish you great success in your teaching endeavors and thank you for reading, peace!
Richard Hughes, DDS, FAAI
2/25/2013
Ok I see the plate, the angulation is poor. It should be removed and placed with a proper trajectory that would bring the platform into a more restorable position, ie. more labial. Occlusion is very important for long term success. Considering the periodontal condition and crown root ratios. This patient needs global treatment, not one implant for the maxillary left central incisor.
CRS
2/25/2013
Well Said!
DrT
2/26/2013
Am I missing something?? What was the thought process in placing a single implant to replace tooth #9 in a mouth full of periodontal and occlusal pathology??
grw
2/26/2013
I agree 110%.
John Manuel, DDS
2/26/2013
Just a corroboration of the benefits of a few implants in a periodontal case under specialist care: In cases where a challenged tooth was overloaded and replaced by an implant or three or four, I've seen remarkable stability come about in the remaining teeth. Perhap the extra support, or more likely the provision of a stable "stop", seems to allow the remaining teeth to tighten up. John
MWjohnson DDS, MS
2/26/2013
The only reason to place a 3.25mm implant into a central incisor position is because there's alack of bone. When the maxilla resorbs, it moves medially. This is why the ridge is very narrow and palatal and it is why the implant appears to be palatally positioned. I would wonder whether a radioopaque guide was made to evaluate the osseous topography BEFORE implant placement. My guess is that the implant was placed without much prior planning and without a surgical guide. Yes, remove the implant, graft the bone labially to create a broader ridge and move the ridge crest facially to properly position the new implant. then, make a radioopaque surgical guide to evaluate the success of the graft before replacing the implant. Also, use a surgical guide to properly place the implant and usea larger diameter implant, never a mini implant as discussed previously.
Grw
2/26/2013
Whatever happened to perio/prosth.? Could this whole case been approached with perio surgery and a roundhouse? It's hard to diagnose the perio condition with what information we have but it sure looks like that's a treatment of choice. Not everything has to be implants and let's not throw out traditional perio treatment. BTW I am not a periodontist.
Dr. Bill Woods
2/26/2013
What about a ridge split prior to an implant and a wider shorter one? Pics would be great. What are the goals of the patient ? Just one implant? What about the other teeth? The diastema? Every time I don't plan something out in advance everyone loses. If you are not sure about things, then take it out, tell the patient you aren't sure it is in the best place, then have all the options out on the table and the re- proceed. Just a thought. Bill
Tuss
2/27/2013
Ideally the natrual dentition should have been stabilised prior to even considering any advanced therapies (implants) Lindhe approach to roundhouse bridges is still valid but sadly the art has been lost as so many people have varying opinions in occlusion. Knowing that the diameter of #9 at the CEJ has a certain value then ideally follow a top-down approach and hard-soft tisue graft the site to get a properly sized implant with the correct emergence profile in place. Not treating the whole mouth and just looking at a space to fill with an implant is the issue here - didn't plan so planned to fail. What is the smile-line like?
Richard Hughes, DDS, FAAI
2/27/2013
Dr Woods and Grw and Booth, brought up some good points. This case needs a classic work up. Study models, Face bow, Dx wax up etc. the patient needs a Forrest before the trees diagnosis and treatment. Perio tax and a max round house are in order, not a single implant for #9. No one has considered what the patient wants or can afford. Dr Booth, I also wonder!
John Manuel, DDS
2/27/2013
Acknowledging the scant records on line, it looks to me like this is a Division 3 Anterior, i.e., both upper and lower anterior teeth were flared labially in their natural state. This makes the Maxilla appear to have moved back when the teeth are no longer there. Sometimes the flaring is an adaptation to a small Maxilla. In any case, an Orthodontic or Orthopedic growth study could help a doctor decide upon the desired implant angulation. The palatal plane is a good guide, a good hint, in considering a Maxillary implant angle likely to result in the upper teeth sitting in proper relation to the lower. These Div. 3 Anterior cases tend to rapidly resorb attempts to build up that Labial bone. Of course a guide stent, or partial denture with radiopaque teeth is good. And, as mentioned, the solving and discussion of diastema, etc., will result in a better final result and a happier patient. Even a roundhouse bridge option would benefit from a good pretreatment wax-up. John
CRS
2/27/2013
This is at best speculative without a ceph. The buccal plate is not fully visible on the ct scan and the anterior nasal spine is not visible to help locate point A. I bet if the poster showed the whole buccal plate it would be obvious how far palatal the implant is and we would not be having this discussion. I agree that there is flaring of the anterior with posterior bite collapse with a tendency for auto rotation but given the large width of the anterior maxilla, mesial/distal (diastema) I doubt think is an example of a deficient premaxilla. Interesting point however. Thanks for readin!
John Manuel, DDS
2/27/2013
I need to add that it is fairly common to have a normal size Maxilla that is set back in relation to the Anterior Cranial Base. They can be normally positioned in back and short in front. Under development of the PreMaxilla is common. We commonly see 6-8mm shortage in the Anterior Maxilla and double that is not rare. John
John Manuel, DDS
2/27/2013
CRS, I agree, but the implant also appears to be more perpendicular to the Maxilla than were the natural teeth. I am asking those making quick guesses to consider the Palatal Cortical Plate, and the flared anterior teeth, over speculation of implant and bone "drifting". A person planning reconstruction could benefit from a Cephalometric analysis, perhaps from an orthodontist, to evaluate how the patient got to this state, and how Division 3 anterior arrangements tend to burn up the Labial Plate. Better to know this before major surgeries, than to find out later. I appreciate and follow your expert advice here. John
david chan
2/28/2013
John I may have been misunderstood.. I used the term 'drifting' to describe the deviation of implant from the intended path during placement. This usually occurs due to different bone density (hardness), poor guide and big jump between the sizes of drills. Interesting read.
John Manuel,DDS
2/28/2013
David, I apologize for my lack of clarity. I am familiar with drifting in the reamers, but usually not instigated by a thin labial plate to the point of forcing the prep into the thicker palatal plate. As already mentioned, the emergence is too palatal, the implant is too deep, and I'm thinking the implant angle is too vertical. I mainly wanted to stimulate consideration of the benefit of stepping back from the minute details to gain an overview of the major skeletal discrepancies and the problems they bring to the table prior to any surgery. As mentioned, this case needed a thorough, comprehensive, preliminary evaluation and construction of the desired final result before beginning therapy. John

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