Soft tissue inflamed: Should I replace the crowns?

This patient recently walked into my office. There are no implant related concerns. However, the soft tissue appears quite inflamed around implants replacing 1.4 and 1.5. Radiographs reveal ill-fitting crowns (splinted), possible mild bone loss associated with 1.5. Implants are approximately 3 years old and they seem to be osseointegrated.
I’m thinking replacing the crowns would be the way to go. What do you think? Would you do anything else? Also, does anyone have any idea what kind of implants they are?
Thank you.

periapical image
periapical image
part of panoramic radiograph
part of panoramic radiograph

13 thoughts on “Soft tissue inflamed: Should I replace the crowns?

  1. Tony says:

    Ankylos implants. Remove crowns, make temp crowns, after tissue healing take new impression.Probably also wrong abutment selection.

  2. mwjohnson dds, ms says:

    two things:
    1) abutments too wide, probably impinged on the alveolus and soft tissue causing inflammation so need to place narrower abutments. Should have at least 1mm between the alveolus and abutment for soft tissue cuff without mashing soft tissue causing alveolar remodelling due to pressure.
    2) crowns don’t fit! Need to get the finish line no more than 1mm subgingival to make sure of marginal fit and to get cement off.

    Unfortunately, looks like a total remake to me.

  3. CRS says:

    Can I ask a really dumb question, why are the implants buried so deep and why so short? They are also splinted which I would think be hard to keep clean. Expecting that wide platform to be under the crestal bone does not make sense to me. I would have placed longer implants at the crest of the bone not below it, when I did this early in my career I would see the die back. The bone is not going to grow into those smooth collars. Am I missing something?

  4. haraldo says:

    ankylos implants protocol is 1mm subcrestal placement. Just needs new abutments and crowns, excellent OH and will likely be fine.

  5. Kaz says:

    I would agree that he needs custom abutments with less flare so soft tissue can stay healthy and about 0.5mm below the free ging on the buccal and even with the ging on the interprox and lingual.

  6. mpedds says:

    The implants are too deep, no need for this on posterior teeth. Although a platform switch such as this may help to preserve crestal height and tissue health, how about physiologic contours? The interface between the abutment and crown should be seemless and follow a natural emergence profile. These are no different than gross marginal discrepancies on a crown made for a natural tooth. No wonder the tissue is inflamed.

  7. mwjohnson dds, ms says:

    Actually, Heraldo is correct. The surgical protocol for Ankylos is to place them subcrestally, at least 1mm and usually more. The implant is etched to the platform and even onto the platform so bone retention is amazing. Because the implant is placed subcrestally and we don’t see crestal bone loss like other systems, the abutment must be more “tulip” shaped to not impinge on the alveolus after it exits the implant. Using Ankylos takes a little getting used to; a different surgical protocol, but the bone retention is second to none. Check out the radiograph. Even with too wide abutments and a lousy crown fit there’s no apparent bone loss.

    • CRS says:

      So these could be fixed with the more tulip shaped abutment to allow the soft tissue health. I do see the bone margins I am just unfamiliar with this system and since I don’t restore I want to understand the emergence profile and esthetics. Thanks

      • mwjohnson dds, ms says:

        The ankylos system has a classic platform shift and morse taper abutment connection. A true morse taper was in the original Straumann bone level implant as well as the original Astra.. No internal hex for orientation, just screw the abutment into the implant. A morse taper is an engineering joint where two mated surfaces at a 6 degree taper or less form a “cold weld” when torqued together. The Ankylos system is the same connection. This internal type of connection has minimal micromovement and virtually no microgap that leads to no bacterial percolation in and out of the microgap. This lack of micromovement and percolation keeps any inflammation away from the bone. With platform switching, if there is a zone of inflammation, it’s onto the platform of the implant and does not extend laterally out to the crestal bone. It is generally acknowledged that the body needs .8mm (rounded to 1mm for me, a less precise type) of connective tissue between the inflammatory zone and the alveolus. The bone will either remodel from the microgap to form this cuff (bone loss) or the abutment can be more tulip shaped, more concave coming out of the implant not convex, to give space for soft tissue. A good article on the inflammatory zone and connective tissue cuff is by Ericsson I, et al. Clin Oral Impl Res 1996;7:20-26. I lecture a lot on implant engineering and am a big fan of the internal morse taper and platform switching to retain crestal bone. You probably have seen that nearly all implant companies are now selling some form of platform switching/shifting and an internal conical connection mimicking the morse taper

        • CRS says:

          Excellent thank you for setting this humble oral surgeon straight with some valuable information that makes a lot of sense and ties up many principles I happen to stumble upon. Well said. Perhaps with my Zimmer, BioHorizons and Straumann crestal level placements I am avoiding the dieback problem. It is hard for me because I only see the patients return when there is a problem with the restorations and platforms. So I don’t have a clear picture of what the ideal restoration and I am focusing on that since I can regenerate the bone and soft tissue at surgery, that’s the easy part. If I can set the restoring doctor and patient up for success that’s a “bingo!” Thanks Doc!

          • mwjohnson dds, ms says:

            I couldn’t agree more. Keeping bone is easier than replacing bone. The newer implant designs, i.e. roughened to the collar, morse (internal conical) connection, platform shifted and microthreads at the coronal aspect all work towards reducing damaging abutment micromovement and dissipate forces to the crestal bone that can lead to bone loss. It certainly helps us restorative guys maintain good soft tissue contours and profiles around our restorations when bone remodelling is minimal… and it makes our surgeons look good too!

  8. Konstantinos Kordatzis says:

    Ankylos implants, my favorite ones! Definitely ,the etiology lies to the wrong abutment selection . The abutments in this case have to have their shoulders not so close to bone. This has to be done before the remodeling process causes further resorption . Enjoy!

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