Bone Loss on Proximal Aspect of Adjacent Natural Teeth: Options?

you probably did not get 1º closure of the site. The first mistake was not placing a large tissue level healing abutment. Ankylos do a number of shapes and sizes. You can also place a standard abutment and make a screw reained temp in these cases. For immediates you need to either place a free tissue punch graft, slightly oversized from the palate, or occlude the socket as much as possible with a flared abutment. The second mistake was placing a membrane, which will have become infected, thus the underling graft will have too. this leads to large immunological response, leading to resorbtion of the membrane, graft and any bone nearby. Thats the why, the what to do is more difficult. you will have to let it heal fully and then decide. Upon uncovering, use a large palatal roll flap and bulk up the soft tissue as much as possible. You aint going to re grow bone around the teeth. These situations need to be assessed on a soft tissue and lip line basis. If the implant is placed too buccal on a lady with a high lip line, you may have a restorative nightmare on your hands. If you have an unconcerned old fella with a bushy mousache then you may be fine. What im getting at is that it depends upon the patient as to how you proceed. Good luck, its a tricky on this...

ps loving the margins on the crowns!

ps i'm a sarky idiot!!! lets see all you post op rads of crowns mr perfect- i think you may have been bullied at school, or be incredibly short!!!

Right. sorry DR M, was out of order - didnt mean to cause offence. Never sugessted that you did those crowns, and I know that it's hard to manage patients with old work which looks like that. TO Booth, Got me on both counts I'm afraid, definately no need to get personal though.

no worries just making a point dentistry isa hard subject to get perfect every time god knows i try. Right comments basically correct but i ahevto say i'm not mad keen on immediates lots of papers out there suggesting questionable short and longterm results keep it simple just do delayed placements and generally you'll sleep better at night.

Couldn't agree more, glad you pulled me up, Was a stressful day! Been photographing my cases for over a decade and I think I have mabey a hand full that I am truly happy with! Cockups are too numerous to mention. There are only a few specific instances where immediates are great, but as you say the delayed option is much more predictable long term. For this to work , all the ducks have to be in a row, when it does its spectacular, when it doesn't its equally so. Back to the case in question. It may be an idea to get a post op CBCT at 3 months just to see where the bone is in 3d prior to planning any restoration phase. If you are lacking buccal bone, it may be an idea to open up, clean the surface and re graft the area. Get very good 1º closure and leave it to bubble away for a few more months. The reasoning for this is that defects are much better delt with preprostheticly, indeed when we do see patients with buccal dehischenses I tend to take abutments off and allow the tussue to heal up as far as possible prior to grafting. A good amount of buccal bone can turn a really bad potental result into a perfectly acceptable one. Hope this helps, mike

hi all, It's very hard to measure bone loss with intra oral pa only- my initial suspeccion is that, looking only to the x rays there is an angulation issue-did you measure the bone loss with a perio probe?is there any swelling/inflammation present? Regards

Unfortunately, I believe that the bone loss is secondary to poor implant placement. The implant platform should be no more than 5 mm below the contact points of the adjacent teeth, otherwise you will get bone loss and "black triangles". The implant looks too deeply placed in the extraction socket. Also, the implant should be a minimum of 1.5 to 2 mm from the adjacent roots. Unclear if this maxim was violated. This is based on Tarnow's work. Keep an eye on things. You may have to try and prosthetically correct deficiencies, or remove implant, try and graft to regain bone height, then replace the implant.

Assuming intact facial and lingual plates, the bone loss should stabilize at the shoulder of the implant (where it is right now). I agree with the implant being placed too deep. At this point I suggest careful soft tissue management, with long term provisional abutment and crown and periodic soft tissue emergence addition/substraction until you get an acceptable esthetic result.

I agree with oms in that the implant was placed too close to the adjacent tooth. That was precisely where the natural tooth was. An effort could have been made using a lateral cutting bur like a Linderman bur, to prep the osteotomy toward the distal aspect of the socket. Placing the implant deep guaranteed bone loss. We can all learn from our failures. Taking an immediate post op x ray and seeing this proximity problem, one is best off removing the implant, grafting the socket and retreating the site after healing. It can be difficult to get perfect placement with immediate placement.I do many immediate implants but never promise the patient that I can. Now after the fact there are 2 options. If esthetics is not a problem I suggest placement to an angled abutment and a provisional crown. If this is or becomes unacceptable then remove the implant. Do this at the expence of the metal with a bur, don't use a trephine.

I agree, the implant is placed way too deep. Good suggestions above, a difficult case at this point. I would also agree that the crown margins on adjacent teeth, especially # 9, #10, are indeed very poor, to the extreme. Dr Ainsworth should not be reticent about mentioning this. This is not about being perfect, this is about being clinically acceptable, which these certainly are not acceptable. Don't shoot the messenger, for his perception was accurate. If this is happening in the front of the mouth, what is going on in the posterior? Iatrogenic periodontitis is nothing to scoff at. Anyone doing implants should be well versed in periodontics as well since peri-implantitis and periodontitis are related with similar bacteria. These cases should be carefully evaluated for the benefit of the patient and this requires a global perspective, not simply a concentration on the implant area by itself. We have no idea who did these crowns so no barbs are being tossed at anyone in particular. Facts are simply being expressed. TObooth was out of line here with the defensive comment, not Dr Ainsworth. Placement of crowns like these are not accidents that happen to not be perfect, rather they are crowns placed by someone that should find another profession. This level of dentistry is inexcusable. As for the question regarding the implant, the above comments by others is sufficient given our limited materials for evaluation.

Dr. M: - From what is described and depicted above in this case, I would tend to agree with OMS. The implant does appear to have been placed too deeply with regard to interproximal crestal bone considerations alone. Since facial and interproximal bone are usually at different heights, a compromise is generally in order to satisfy the esthetic component. As a result of doing that, degradation interproximally (to some degree) is often seen. I believe that some of the techniques mentioned above (i.e. flared abutments or healing caps) may help to preserve more bone. Also, this bone recession problem tends to be worse, in my hands, if I can't maintain or regenerate a thicker buccal plate (1.5-2mm) over the implant laterally. Just some thoughts from the cheap seats - Good Luck! - Dr. No

Dear Dr. M, I think the implant is placed very deep, of course is a bone level implant but remember that your point of reference is the mesial and distal bone, not the bucal, so if you have a dehisence on the bucal wall you should graft and not place the implant at that level. Remember the bone is osseointegrated just in the rough surface, so you are having bone loss at the level of the abutment that is highly polished. So you should use a probe to diagnose if you are having a periodontal pocket in the tooth, maybe not. Maybe you are just having a large epithelium joint. If that happens, do nothing, everything is going to be all right. If you are having a pocket or even loosing papilae appearing black triangle, the only solution would be to replace the implant in a not too deep position, because if you try to regenerate, your are going to loose the graft again. Good luck.

Dear All, Please read about biological width , and micro movement . It was noticed that the interface,and the implant abutment connection were subgingivally and sub bony level by more than the acceptable level(1-2mm). The last X ray revealed that the bone is remodeld based on the crestal bone level to sub implant platforme level(2.3 to 2.7 mm ) ( Biological width and Micro movement). What to do?, Evaluate the smile line if the margins show, It will be a problem you have to work on it , Tissue graft may solve it but You end up having deep pockets It will couse perio problems and bad smell. If no smile problem , restore it as it is, put the tooth out of Occlusion and notify the patient for the problem and other options (Removal of the implant , bone graft the area, then put other implant after success grafting (4-6 Months). Good luck from DR.Ali DDS,MS New York

I think there are enough angles in the first 3 films to show plenty of space between the fixture and the adjacent teeth. I would question the device for the temporary, it appears there is a sleeve that is going over the abutment that is not seated. It appears hung up on the distal bone crest with a fairly large gap. That will trap perio pathogens and cause bone loss. That is the consquence of placing the fixture too deep.

First of all attempting to asses quantitatively the amount of bone loss this early in the integration phase is impractical with pa films, and it's just as hard with a cbct scanner until you become proficient in making the appropriate adjustments , when reading the scan. Secondly , I completely disagree with suggesting you need primary closure upon grafting and gtr. . Even though I'm not a big believer in immediate loading , even with the provisional out of contact, a lot of guys in the south do load these immediately, and there is some decent data to support this practice. There are plenty of big recon. Cases that do Require primary closure , but this is not one of them.My biggest concern with obtaining primary closure , is that in order to advance your soft tissue flaps you are in essence destroying the blood supply. Some operators create long "burger" type flaps,thus obliterating the vestibule and others create vertical releasing incisions ,which by all accounts " murders" one of the most basic principles of surgery. William Bell and R. V. Walker proved that the greatest supply of blood comes from the palatal mucosa, even if the descending palentine vessels are sacrificed. Yeh , maybe your implants maybe a little deep, but with a creative effort , you can provide this patient with an acceptable restoration. Even as an omfs , I might push to get better margins on the adjacent teeth , and mandate routine oh visits . I have seen a whole lot worse than this!! Bvinci

Dr. Lieblich: - You may be right, but I was thinking that the device mounted on the implant was an insertion fixture. I was also assuming that the two films in the center were immediate post-op and that the insertion device was then removed, replaced with a closure screw and finally covered with a membrane. The last film would then be the implant much later with just a closure screw in place and the bone loss, no temporary. Maybe some clarification From Dr. M is in order? - Dr. No

OMS is exactly right, no doubt about it. Was this a Zimmer or Implant Direct? You will get dieback usually to the 1st thread in general so since it is buried too deep it is just acting like a normal bone response to what you did. Good luck!

Loss of tooth equals loss of blood supply leads to bone loss. Did you do a surgical extraction by any chance. Because if you did, that is what might have caused the bone loss. In order to try and maintain as much bone as possible, you need to keep as much blood supply around the area as possible. That means no flaps during extractions.

This, again, looks like a lack of planning. First, there is the depth. You have got to understand that bone loss is going to happen when the implant is placed this deep. The fact that this surprised you makes it clear you have very little training. I know you want to place an implant, but you have got to plan it out. Second, you let the extraction socket guide your placement. These are things that have to be considered before treatment. It looks like you decided to place the implant the same day the patient presented with the missing post/crown. Not that this couldn't work, but it's pretty obvious you don't have much experience. It's not worth the risk. Yes, immediate implants can work, but you will have more complications and more failed implants, especially early on. You and your patients will sleep better if you perform, "one miracle at a time". At this point, the bone loss has taken place, you will not get that back. Assuming you have enough buccal plate and gingiva around the implant, the bone is probably stable now. So if esthetics is not an issue, restore it and learn from the experience.

I agree with Dr Dan, maintainging to blood supply is paramount hence no flap. This is an ankylos implant. The device is the implant carrier. I see in film 3 plenty of space betwen the implant and adjacent teeth, we also cant tell if the implant was placed in the correct place from a BL point of view. Yes its a bit deep but for this particular type of implant, not out of the ball park. I use these implants in this application all the time and (from the 2d xray) can't see a massive amount wrong with the actual surgical placement, and maintain that the bone loss came from the immediate post op management of the case. With this type of placement the bone could have been maintained with no or a small amount of grafting, placement of the final reatorative abutment and a temp with a contoured base to fill the residual socket. (or a highly flared healing abutment) 1 implant 1 abutmant 1 time, tarnow salama etc. My hypothesis is still dieback from an infected graft.

Hey Guys take a look at the apex of the central incisor. That lesion on the apex is a time bomb waiting to take the implat with it. Retreat or a apico.

I agree with ttmillerjr completely.It is pretty obvious you did not make an effort in inserting the implant slightly palatal,to have sufficient buccal bone width. I was wandering how much NT was applied while inserting the implant.Excessive pressure will affect the proximal bone walls. In the last workshop i attend with Dr.Dennis Tarnow, he advocated two main issues that need to be taken into consideration whilst implanting in the frontal maxilla. 1. observe the biological width and not exceed 2.5 mm below or over the bone margins.2 The moment you have primal stability of the implant, allow the blood clot to heal naturally without using membranes. Treat it as a normal extraction wound.

From the first periapical film,what remains of the lateral root was very fragile, and no mention is made how this root was extracted...surely the force of the extraction had to have caused trauma to the adjacent teeth if it was taken out in the conventional ways. Dentatus will soon be coming out with a new system of extracting teeth in this condition ( which I have developed), and this will cause no harm to the adjacent natural teeth. Comments were made that the implant was placed too deep.....but once the sterilized abutment is placed, will it not have the same effect as a one piece implant?

Now mike, we are reading all of your entries, in that you have good insight, but you have contradicted yourself from first to last entry. You suggested that not obtaining primary closure was the cause for the unsatisfactory result and in your last entry you suggested not raising a flap. In my opinion raising conservative flaps accommodates all scenarios, for very obvious reasons. One misconception that I would like to clear up is the definition of surgical extraction. A flap does not have to be raised in order for an extraction to be surgical, unless we are letting" the man in the suit"( reference " low spark") define our speciality. I remove bone and section teeth routinely , without raising flaps, how, with a very small round bur. My quote, that bodes well with the guys that don't remove a lot of difficult teeth, is to" keep the surgery within the tooth". This prevents nerve damage , unnecessary bone destruction and damage to adjacent teeth. One other thing that I disagree with from another observer , is success rates with implants placed upon extraction. In the correct candidate rates in my small facility are the same as implants placed In virgin bone, and I never attempt to get primary closure. Just some personal thoughts . Good day. B Vinci

Dr rudick, I'm sure your extraction device is an excellent invention , but nothing, absolutely nothing, replaces good fundamental surgical technique. I've been asked to use some of these prototypes and find it hard to believe that anyone is going to re-invent the wheel. Conversely, however , this Is the exact way we get better. Good luck with your device and hope you make some cash. Bvinci

Baker, you got me, just re read the post and it does read like that. I meant over the membrane. I think if you do decide to use a resorbable membrane, the you should close over it. I don't use membranes at all any more but if I did I'd want it buried. I don't "close" my immediate placements, I do use big diameter tissue level abutments (or temp crowns) to occlude the socket as much as poss though. I routinely leave easygraft to granulate over without 1º closure. Definitely agree with you re extractions, sacrifice the hard stuff that's going in the bin anyhoo.

Everybody Is going after you. Tell them you have feelings to. I enjoy the information, and am finding the site quite helpful. Bon soir. Bv

Dr Stu Lieblich's post carries more weight than many others. My experience in these platform shifted implants is very limited. So it isn't as if I write as an established expert. Rather I write as a ordinary but logical audience member. A guy who knows little but can reason it out, often. Aren't these platform shifted implants expected to be placed sub crestally in the first place? And so are immediately placed implants expected to be placed subcrestally? We cannot fault him for following that. Apparently the bone loss seems to have more to do with factors other than deep placement. Firstly the trauma of surgery when teeth are elevated where interdental bone is used as a fulcrum (often unavoidable). The tooth had a post and was hollowed out. It can be imagined that it was a difficult extraction. The interdental bone though looked great on day one gradually withered away because it didn't tolerate the onslaught. Some times implant placement protcols are overlooked. (I don't know what protocol was recommended for this implant) like slow speed reaming, countersinking or crestal widening. This can create pressures in the crestal zone if the implant has even the slightest amount of taper apically or flare coronally. Also look closely, the temporary abutment collar is compressing on the interdental bone. If that kind of temporary abutment and temporary crown was placed why should any one expect conservation of interdental bone? Like what Dr Stu suggested the immediate temporization could be causing the violation of the Biologic width due to pinching of the margins, probably due over extension or looseness. Immediate temporarization is a necessary evil. Often unavoidable in anterior teeth. Tongue pressure can be considerable in Solitary upper anterior implants. That can lead to micromovements and insufficient osseointegration, I am not so sure that caused the crestal bone loss but yes it may have contributed to an infinetisamaly small extent. We have no information regarding whether a flap was taken during extraction or implant placement. We all know that trauma to flap can contribute to crestal bone loss. We know noting about about suturing etc. Nothing about the kind of occlusion that the patient had below the implant. We know nothing about whether the drill bits were blunt or not or for the matter about cooling. Next we have no information about smoking habit, diabetes, calcium metabolism, nutritional status, patient age. For that matter we know nothing of oral hygeine maintainance, the artificial crowns have poor margins. It doesn't matter who made the crowns, the posting doctor or his predecessor, they are plaque traps. For a patient with poor immunity and a difficult extraction the plaque can only worsen the crest bone loss. There could be a myriad of possibilities. I would put deep placement at the lowest level in the list of probablities. We don't know enough. More details should have been given by posters along with clinical pictures. So it is jumping to conclusions too early without a complete background check. But this healthy discussion has given many bits of new information and that is very useful. I know that all contributers here are most experienced implantologists. My opinion here is just that, an opinion. But in this case I see things differently. So I beg to differ. Thank you for contributing. It was enlightening and professionaly nourishing. Dr Sanjay Jamdade

Dr. Jamdade: - Very well thought out and presented comments which are certainly of significance. While we often want more information, even having it will not likely determine an exact cause for any given problem or failure - hopefully, just some good ideas or clues! Even if the information is there, some will not read, opt to consider or even use it. - I would question part of your comments regarding the temporary abutment collar. The original question states that the implant was covered with a resorbable membrane, not temporized. Unless I am mistaken, I believe that the two center PAX film's are immediate post-op with the "insertion device" still in place which was then removed and a closure screw placed. Please see the 9/6/11 pm postings previous to yours. - In any event, if it were a temporary abutment I would be concerned that it would cause more than an "infinitesimally small" amount of bone loss as you suggest. My biggest concern would be the sharp steps in the "perceived" abutment which would be a significant food trap, above, at and below bone level, with no good way of cleaning. I would be the first to admit that I am not always right, but I'm not always wrong either. - Please consider the above and continue to post - you seem to have a lot to offer! Regards, - Dr. No

Dr. David Nelson, there is something that I have learned after 40 years of practice and i`t say`s: Discomfort that does not molest, do not molest it. A lot of patients I have seen live with a negative response to endodontic treatments and they never get a time bomb response.

Dr. Nelson, that would not surprise me if there was a new lesion at the apices of the central, but how do we know that this isn't a shadow from the nasal fossa or a resolving lesion. I do think I see a slightly widened pdl,but you are making a gloomy suggestion based on very little evidence . Bv

We've all seen seemingly good endo tx on xrays but somehow failing and then some looks terribly done but the patient tells you ' I haven't had any problem with it for last 20 years..'. I do see a bit of lesion/scar at the apex of #8 but would look into when the rct was done, if any symptoms... etc first before I do apico. With my experience, when you do immediate placement, even with grafting, there will be small amount of crestal bone loss. I advise generally sinking an implant a bit deeper for that reason in a immedaite case.

Dr. M, I disagree with some of the information you have received. Questions: Did you sound the facial plate of bone, remove all soft tissue associated with the periapical lesion, get adequate fixation (torque), was there more than 5mm of tissue cuff coronal to the buccal bone crest, did the implant platform encroach on the distal interceptal bone, did you flap, has the implant migrated (the x-ray with the abutment attached indicates resonable position)??? These are some of the questions that come to mind when you show your case and ask why. Dennis Tarnow and Stephen Chu put on a full day program at the American Academy of Cosmetic Dentistry Annual Meeting in Boston and it was the best and most current information on Single Tooth Implants in the Esthetic Zone. Their information is evidence based. If you want to be successful with anterior implants(immediate or not), call the AACD and order the DVD of their program. It may cost you $400-500 but will be the cheapest education ever. Information they present will give you the knowledge to diagnose and treatment plan this and any other anterior case. As a point of information; We have all had issues like this. Can you post photos? You may need to remove the implant and graft the site to re-develop the ridge. However, particulate graft will not restore the interceptal bone. A fixed bridge may achieve the most estetic result. Regards, John

Congratulations Dr M, your case has elicited a string of 34 replies! Is this a record?

Thanks for all the responses, I've been out of town so just getting back to the forum. I beleive some clarification is due on my part for better case representation. - 1st, I'd like to clear up any questions to my involvement w/ the crowns on #8 & 9. I wasn't there, don't know who was, &/or the circumstances but they were done many moons ago by a dentist who is no longer practicing. Though bulky as the margins are, the condition of the patients bone level underneath the margins of these crowns after 20+ years (patient is 65yo female, avg. health, non-smoker, insulin regulated diabetes) does give a bit of incite to her above avg. oral hygiene. I know her diabetes can be a contributing factor to slower healing but probably not the "major malfunction" here. - As for the procedure, the extraction was done as minimally invasive as possible, ligaments severed, tooth luxated until slightly mobile & then removed w/ deep grip forceps - No Flap, No excessive pressure, No unnecessary trauma to site ~ nice and gentle. Osteotomy site moved slightly palatal w/ lindermann, twist & tri-spade drills(~ 3mm palatal tissue released gingerly w/ periosteal elevator prior). Drill speed/torque set @ standard mfg. recommended specs (Dentsply), used sterile saline dual internal & external irrigation, hand torque wrench to final depth (w/in recommended depth range in relation to buccal wall & crestal ridge of adjacent bone when following manuf. recomm. protocol) – for those unfamiliar w/ the Ankylos system, it’s platform switching & recommended for subcrestal placement , stability & depth reached w/o exceeding 50nt… basically, “By The Book” as far as site preparation & implant insertion. removed placement fixture, placed cover screw, wettened(sp?) graft part., covered site to ridge height, placed resorbable coll. membrane over graft to secure, sutured released tissue w/ PGA over membrane acheiving 1* closure, covered sutured tissue w/ polyacryl for added stability. Pt. for what ever reason (no pain=no need) didn't return for 1wk post-op. I do err myself in the lack of stressing the importance of a follow-up/ post-op visit but it is was in the patients post-op instruction booklet, Right?? Kidding aside, I have since revised my priorities on this. The 6 week image is the most recent, Placed temp abutment & crown slightly out of occlusion. This was done b/t the time I submitted the case to the forum & when it was posted. Tissue completely healed over implant, ~3mm thickness when uncovered. Though the patient oblivious to the obvious esthetic issues (having low smile line), there is no way i'd be able to sleep at night if I just placed the final restoration & sent her on her way. Having a good relationship w/ this patient & her family, I do plan on resolving the issue w/o additional cost to the patient so I don’t mind forking out the extra cost for the materials . Any thoughts for success w/ osseous remodeling via additional grafting? Don’t waste your time on it, concentrate on the soft tissue? Your SOL, send her a nice gift basket & hope she never smiles in a mirror? Thanks ~ Dr.M

Hi Dr M, its as I thought, you got the surgery correct. Just next time place a little graft to close the gap and use a regular 3mm healing abutment (the one with the big flare) to almost occlude the socket and then let it heal. You will see that the bone stays put and grows over the healing abutment. When you change it sterilize the abutment and place it straight away, torque it down and never touch it again. (Prep like a crown if necessary) the bone will stay. If you can, place the final abutment at the time of surgery and you wont face this problem. All the best, Mike

Let's access the whole picture here. The right central has an odd shaped tapered root and not has significant bone loss so we need to determine long term prognosis on this tooth which IMHO is not good. Lets also look at the left central which has a very poor crown and will need to be recrowned. I can see a glimpse of the lateral crown and that looks poor marginally too. yes the implant was initially placed too deep and now with some bone loss is has compromised the cuspid which has 50% bone loss on the mesial. Osseous grafting wont help the cuspid due to the implant position so I think its time to evaluate all of it and see what the best treatment is.

Dear Dr No OMS thank you for your compliments! It's one such case where all of us could be right all at the same time! Yes Dr M says he grafted but exposed the implant at 6 weeks to place a temporary abutment. So the fixture we see in the second and third picture is a temporary abutment. Especially notice that there is bone forming on top of the implant platform(second film as well as third film), which is very typical of Ankylos implant. So the implant had integrated properly even in 6 weeks! The problem probably started after the temporary abutment was placed. I guess the neck of the abutment selected for temporization should have been longer. The present length of the abutment seems to have crushed the tissues on the mesial side. Look real closely at the pictures. So there you have it. ID Diabetic patient, lady with average health, plaque traps in adjacent teeth, 6 week exposure, short abutment neck compressing tissues below. I have used Ankylos so I know some peculiarities of the sytem. Nice thread going on. Wish Dr M could append some pictures, may be an immediate post op X ray picture which is missing.

The attachment is a mount used to drive in the implant with an implant motor. I f I am not mistaken this implant used to be fully manual torqued only. Now the issue would be only one, whether the mount was used as a temporary abutment. The periapical radiolucency seen in the first picture is gone in the second and there is bone on the shoulder of the implant.

To clarify, the 2nd & 3rd image were taken on day of surgery @ final position w/ fixture mount still attached (different angles which would explain the pseudo-misalignment toward the distal in image 3 & again at hygiene recall visit 6 wks later -image 4) Image 2 is the best diagnostic image as far as the placement alignment & relativity to adjacent teeth. *Assume 2 & 3 are the immediate post-op pics - no addtl. images taken after removal of fixture mount, placement of cover screw, graft, cover,& closure since implant was in desired position & stable. *No temp, temp abutment, healing collar/cap, etc.. placed prior to the 6 wk image. After looking back at the patients records, it was not till 4 weeks after her recall visit (4th image taken) or 10 weeks after placement that the tissue was opened to access the implant & place temp. At this point, I have received many mixed incites to what could have gone wrong, some very helpful & some maybe less than encouraging, but all responses appreciated. Scattered in the mix were a few suggestions on direction to ammend the issue. I guess maybe I should concentrate my request on those suggestions. For those whom already have, thank you ** If this were your patient & the last image represented the bone level at 10 weeks, aside from removing the implant, what would you do? *(if your answer is "this would never happen to an implant I placed".. just assume you inherited the patient)

Several years I learned from one of lecturer that immediate implant is excellent outcome.Now he told me he never do any immediate implant anymore.Biologic width,gently extraction,rule of 3 mm,2 mm.of buccal bone left,not too deep not too shallow placement,do site preperation before implantation.It' means clean every thing before placement.CBCT every cases. Regards, pisitroj

I agree with dr. Pisitroj . The envelope continues to get pushed, and when the threshold of acceptable is broached, it will bite you on the ass. What is the big hurry? I'm going to allow my implants to integrate, pretty much every time. Bv