Misplaced Implant: best options?

A new patient recently came in for prosthesis on 2 implants, placed 2 months back in another city by. He has no complaints, but when I took a radiograph (see below), I was surprised at the placement. Not sure what the intention was here. But, now there seem to be 2 options: 1. Reposition /Replace implant or 2. Go ahead with making the prosthesis if it has good prognosis. What would you advise in a case like this?



24 thoughts on: Misplaced Implant: best options?

  1. Carlos Boudet, DDS DICOI says:

    First and foremost, discuss your findings with the patient in a professional manner (non-derrogatory towards the surgeon) and inform him or her of all the options and risks involved.
    With all the tools and components at our disposal today, you should be able to restore the implants. You also have the option to put implants to sleep and place more implants. If you provide the patient with adequate informed consent, you should be ok.
    Good luck!

    • Carlos Boudet, DDS DICOI says:

      My personal opinion would be to let the patient know these implants are prone to fail (especially the distal one, a bone level implant placed several millimeters above the bone) and recommend replacing them. If there is a radioluscent area around the tooth, that implant is also likely to fail.

  2. Timothy C Carter says:

    It looks like the anterior fixture is deep enough to allow for adequate angle correction via a custom abutment. Clearly with all of the options available today this is an easy fix. Just proceed on with the restoration and let the patient know of the minor compromise. Please don’t resort to subjecting this patient to unnecessary procedures and expense.

  3. roadking says:

    I may be wrong but endo treated tooth looks to be failing. that along with the incredibly poor placement of the fixture (doubt a surgeon did it) would make me want to remove and replace. At 2 months it may still screw back out. Be respectful and have your discussion with patient about the possibilities of treatment. You will own the restoration regardless of which implants they are on. I would be uneasy restoring what is there. If you restore the case as it is maybe the patient will move again and your golden! Poor attempt at humor! Good luck with this case.

    • LSDDDS says:

      The two worst implant placements I have ever seen were done by OMFS’s
      One insisted on HIS OMFS to place it not my refrrral.
      Same happened with another pt Orthognathic casegone wrong.
      If they had just listened

      • roadking says:

        Probably the exception and not the rule. That picture looks to me like someone out to make a buck regardless of what happens to the patient. Anyone regardless of skill can place an implant under the gingival tissue maybe even in bone and collect a fee afterward. I would suggest that patient contact the “dentist” that placed the work and suggest they return the fee or face dealing with a hungry attorney!

  4. Greg Kammeyer, DDS, MS, DABOI says:

    I agree with the comments about informing the patient. These implants fail because of the soft tissue from the PDL. At the mesial apex of the tooth, I see what appears to be a radiolucency. I would not want to see a patient invest in a 3 unit FPD with such a shaky foundation.

    I would remove the implant and graft. Then after some healing time get an endo consult..
    When you replace the anterior implant you can address the crestal bone loss on the posterior implant with GBR.

  5. Dr. Moe says:

    I would NOT restore these implants, someone who does wants to lose their license. You need to gently, as best you can, inform the patient that both implants are inadequate. If you place a prosthesis on these implants as is, well you just bought the case for negligence. The “doc” who placed is the one who should be dealt with for negligence. I would stay away. Let’s say you place the crowns/bridge on and patient goes into function and now the tooth starts hurting, who is at fault? You are doc, you placed the prosthesis, it was not hurting before you did this. Always a good rule, making easy money, by slapping in a prosthesis, should never be the motivation. Only saving grace can be that maybe the implant is lingual and tooth is buccal or vise versa and not actually encroaching on each other, but I doubt it. Take x-rays from different angles.

    Those are my $0.02

  6. Dr. Gerald Rudick says:

    Avery strange situation indeed….. ask the patient to get a cbct scan so that the situation can be properly analysed…….where is the bicuspid implant in relation to the endodontially treated bicuspid? Is it very buccal to it, so that it is not interferring with it or disturbing it. Did the endo heal properly…… If the patient has no pain whatsoever, and is comfortable, and the CBCT shows that there is no interference to the natural tooth………it is very simple to install a temporary fixed prosthesis connecting the two implants together, and watching the situation for a while to see hoe it works out…if a problem develops, it wil indicate where the problem is coming from, and then we have a course to treat,.

  7. DrG says:

    I can’t imagine being the surgeon who placed this implant is sleeping well at night knowing the patient is out in the world showing off his/her malpractice.
    It’s a mess, don’t get involved. You’re a better dentist than that and you know it.
    Send the patient back to his/her surgeon and ask that doctor to make the call on what to do. If that is not an option then I’d take out the implants (both places poorly) and the canine. Graft the area, (I’m sure it needs a full ridge augmentation) wait 4 months. After a CBCT and proper pre placement planning use a stent, place three implants and immediately temporize.

  8. Dr Dale Gerke, BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    All the comments so far are reasonable.
    However before any definitive treatment can be proposed, you need more radiographic information.
    Get a cone beam taken and see what is going on with the positioning of the anterior implant in relation to the endo treated tooth and bone loss of posterior implant. Also assess the success of endo treatment.
    Until you have these answers you cannot properly make a call of what best to do. Once you have answers then you can pick any of the appropriate recommendations from the above comments.
    However it is very likely this case may develop into a negligence claim. So it is important you get proper and adequate documentation and analysis so firstly you can help provide the patient with required information in the event of legal questions being asked. However would also prudent for you to have adequate information to defend whatever treatment you end up doing because there may be a “cross over” claim against you.
    The patient is the one who needs help here. But you need to do things correctly to help the patient and also protect yourself. It is therefore important that you fully explain the situation to the patient but only after 3D analysis – so you can be precise and also show “pictures” which should be easy for the patient to understand.

  9. Mark says:

    It is always uncomfortable to be in a position to throw a collegue under the bus. I hate being in that position , but the patient deserves to know. Did you speak with the dentist who placed these? I might consider sending this patient to my local Oral Surgeon for the CBCT and another opinion on positioning ( which is obviously horrible) . Perhaps then the heat is off you and the new surgeon can let this unfortunate patient know things are amiss , instead of you. It’s punting, I know, but I would consider it.

  10. Dok says:

    Show the patient the problem without handing out blame. Remove the endo tooth gingerly and curette/clean the extraction site to the implant threads, again gingerly. Bone graft and wait to see how it heals. If all looks well after healing with the existing implants plan on a third implant in the position of the extracted tooth then simply bridge the space with a four/five unit, three implant retained bridge. The patient keeps the implants, looses a failing endo tooth and is happy as a clam.

  11. Dr. KAL says:

    I thank you all for the great advice.

    I am
    1. Contacting the dentist who did this.
    2. Explaining all possibilities to patient.
    3. Also i am calling an endodontist, prosthodontist for inter disciplinary approach.
    Shall post however this is managed.

  12. Dr. Bill Woods says:

    You are doing the right thing. We have all had decisions to make in borderline situations. In my view this is not and will eventually turn out bad to proceed. Telling a patient you are not able to prosthetically restore this to make it work out well is a mark of integrity. The patient will know it. You will be relieved and you can give options he or she will be much more receptive to. JM2C.

  13. Timothy C Carter says:

    I agree with all of the comments as the implants are not well placed. It is not, however, malpractice to restore malpositioned integrated implants. What I really find interesting is the idea to refer this case out and essentially punt it to another “trained” clinician. Anybody who posts on this site and talks about their own implant experience should be “trained” well enough to handle such cases. I also find it interesting that poorly performed cases are always done at “another office” by “another dentist”. Let’s hope that we are all equally as critical of our own work.

  14. Albert says:

    Food for thought. Before doing anything, have any of you read:
    Mithridade Davarpanah/Serge Szmuckler-Moncler Clin. Oral. Impl. Res 20, 2009 (851-856)
    OR by the same authors, in Intl. Journal of Perio and Restorative Volume 29, Number 4, 2009?
    Both articles deal with putting implants right through ankylosed teeth – successfully. While this tooth is not ankylosed, and there was no CT scan to show the true Buccal Lingual extent of the overlap, before you throw anyone under the bus, please be considerate enough to read these articles as it was clearly thinking outside the box in 2009 and is now an accepted treatment mode. I just heard Dr Maurice Salama speak in October 2018 and he gave a talk on submerged root therapy (SRT) which means a tooth is decoronated (vital) and left behind to hold the bone from shrinking. Years ago that may have been considered negligence, but here it is being validated. If we take away the spirit of creative thinking, then Dr. Branemark would never have done or finished any implant research, even when he was almost booed off the stage in 1962 when he first presented the ‘heretical’ concept of Osseointegration.

  15. DrG says:

    Albert,

    I’ve read the studies. It was Brito my attention after a patient was referred to me with a massive infection from a failing implant that was perforating an adjacent incisor. Two extractions, a titanium mesh graft with prp, and 8 months later the defect isn’t “so bad”. This is negligence plain and simple. The dentist either didn’t take a post placement radiograph or worse didn’t care.

    Don’t group this poor attempt at dentistry with the likes of Salamma.

  16. Timothy C Carter says:

    But these bad cases always seem to come from “another dentist”…… It doesn’t matter it always seems to be that other guy. It is possible that in this case the patient is asymptomatic and everyone it making a mountain out of an ant hill

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