Implant placed too far distally from #20: Solutions?

I would definitely place a 3.3 implant mesial to the existing one and make it 2 single unit crowns

Extract #20. Place implant at #20 and splint new crowns on #19-#20

Remove implant and start again with proper treatment planing and guided surgery

I think you might be making this too complicated. I agree it is not ideally placed and is too distal. Placing another fixture is going to create more spacing problems. The original restoration could have been improperly placed, not properly torqued or aftermarket components used, you don’t know since you Didn’t place it. I would start with making a new abutment/crown using custom milled and original manufacturer parts. I know others are going to recommend extraction of 20 since it has endo, post etc but it is not a problem yet so keep it simple.

I think the best option long term is to remove 20 and place an implant to support a small splinted bridge (whether 2 units or 3 small bicuspids). Why even consider a restoration that still has that huge mesial cantilever, poor mechanics and hygiene/food trap nightmare!

As stated by others, you could remove 20 and place implant(patient may not want this), add another implant if buccal lingual bone exist anterior to the existing implant( starting to have a lot of titanium/bone ratio). Other options: 1) place a rest seat in crown of 20 for some mesial support of the crown 2) remove crown on 20 and place new one with a stress breaker for new implant crown. 3) remove implant and replace(not easy process and patient may not be happy about this? Personally for cost to patient and ease of procedure, I’d go stress breaker and new crown on 20 then remake crown abutment on 19. But I’d surely present all the options to the patient.

Crown loosening was probably fortuitous, as fracturing of the coronal portion of the implant may occur as the mesial wall fatigues, once bone is lost. One approach is to restore with an open contact on the mesial so that the anterior cantilever is eliminated. Considering open contact occurs naturally in about 50% of these locations, you might as well plan for it and make a normal dimension crown to reduce load on the implant. Certainly a vertical wall on the mesial of a new crown at least 3 mm from the natural tooth will be more cleanable than the sloped contour required to achieve contact. Alternatively, consider extracting the molar posterior to the implant and placing another implant, splinting the two and design as 2 bis and 1 molar. Splinting will eliminate the rotational force on the single implant.

Place another implant as a curtesy and make 2 premolar crowns; to avoid shear forces.

I don't see a big problem, this is not huge cantilever. Don't complicate your life and leave it that way - a lot of implants were placed in mesial or distal alveolar sockets and they are functional for years.

Evaluate closely the adjacent teeth. The molar #18 is hopeless and placing an implant in it's place would allow you to splint the two molar crowns, making the cantilevered mesial part of the crown on the mesial implant a non-issue. The restoration on #20 at the distal margin may or may not have a radioluscent lesion. is hard to tell on the x-rays. Good luck!

this happens me all the time i got tired of it so i quit doing immediate molar implants . Damned if you place it in the mesial socket, too close to the bicuspid...damned if you put it in the distal , as in this case. give him a free one to fill this gap

There appears to be microgapping between the abutment and fixture interface. Check the correct abutment used, fitting etc.

As a clinician with 34 years of excellent care behind me, it is so disheartening to see so many comments here that clearly show a lack of forward thinking as well as a total lack of conservative thinking that is in the best interest of the patient! Have you all forgotten that everything we do should be in the best interest of the patient, and not for the sake of expediency? Too many have either forgotten -- or have not even learned -- that a natural tooth remains the best implant! Therefore, do NOT extract the #20! Your most efficient and conservative solution, by far, is to place another implant between the #20 and the existing implant, and restore both either as single unit crowns or as splinted crowns mimicking a molar. For the sake of hygiene I prefer the single unit crowns. Extracting the #20 as some have suggested is pure mutilation because it is a perfectly viable and functional tooth. (You may have to re-do the post and crown on it, but that's simple.) Also, do remember that extracting the #20 can also be parlayed into a malpractice lawsuit if things go south on you. Patients can be unpredictable when they become dissatisfied and, most patients with a half a brain would not allow you to extract the #20. Additionally, there are long term benefits to having another implant there, for when you'll have to place an implant to replace the #18 when it fails -- it will fail sooner rather than later. Extracting the #20 and fabricating a 3 unit bridge sets you -- and the patient -- up for more trouble, and limits your options when the time comes to implant in the #18 site. Hope you make the right choice. Good luck!

A simple option I have used with my patients, ask them three questions: Why are you here, what are your concerns and what would you like me to do? Quite often, a technical issue for us clinicians are not a concern to the patient. As long as the patient is informed of what may be an issue in the future, let the patient decide. Junaid Ahmed

Thanks for posting the case and radiographs... 1. first radiograph shows failed 2nd premolar- with screw type post and crown- appears fractured root at the junction of post meets root canal filler. (or do we need a CBCT to prove it..?) 2. two other radiographs shows over-sized cante-levered crown. 3. Usual culprit for restorative-prosthetic failure is poorly balanced occlusion. [Our patients managed to wreck- beautifully designed natural dentition and there is less hope for our work] 4. In the past, I did change in some cases from cemented to screw retained crowns/bridges- due to change in occlusal schemes options : 1. I understand- you are trying help another Office, but anything less than adequate - will fall on our face. 2. send back to original restorative dentist 3. Adventurous? - It is solvable- only by accepting the risks and analysing the situation. Of course nothing lasts forever. 4. IS the second premolar going to last or survive couple of years..? 5. Does - new bridge or independent crowns going to withstand the existing occlusal scheme..? if the answer is NO, then we definitely need new prosthesis with better support and occlusal scheme. I would remove 2nd premolar - additional implant(s) as required and will splint the implants with natural tooth. [Of course with proper informed consent] yours curiously.... Dr Mahendra Bagur BDS MDS FDSRCS Ed Oral and Maxillofacail Surgeon

There is a saying that "the last person who touches the tooth, owns it." Your patient obviously has a very high dental IQ and will understand the need to remove it and replace it with a better positioned one. Why in the the world would you want anything less for your patient, especially when you are not the dentist of record to have originally placed it? They will need to bite the bullet on this one unfortunately , in order to obtain long term success in the future

Since this is compromised situation, options are not ideal. One option is as suggested to place another implant a 3.0 to 3.5 range can be placed in after work up on a CT. Then splint both crowns as a Molar with 2 implants as mesial and distal roots. Splinting is much better long term vs two single crowns. Best option. Second option, not my favorite at all, would be make splinted crowns on #20-21 with distal cantilever to fill some of the space, then make #19 crown smaller mesio-distally. This is just to avoid extraction so the patient is not shocked!. If However, the patient is ok with ext #20, then an implant at 20 and then a bridge from 19-20 is another option.