Central incisor placed too buccally: recommendations?

If the esthetic demands of the patient are not too high, you could go to a screw-retained crown with the screw access to the facial. Otherwise, it is have the lab do the best they can or remove and replace.

Almost invariably maxillary incisor implants are labially inclined because the anterior maxillary bone is labially inclined. In most cases it is possible to do an “Angle Change” in the abutment, This requires placing the implant platform relatively deep so that there is enough “Running Room” to achieve the desired emergence profile and sufficient bulk to incline the preparation portion to the desired form. This is best done with a custom Zirconia core luted to a Ti Base component The abutment is screw retained and the final crown which goes over the abutment is cemented. When planned out properly and executed well this can produce a fine result.

Very well explained pearl of wisdom by Peter Hunt. One commonly done procedure that often compromises the gingival line in these cases is the use of a prefabricated healing abutment at the time of uncovering. The straight healing abutment will often create the gingival line at a higher level than desired. I prefer to start creating the emergence profile at uncovering with a temporary custom abutment and restoration. The use of an angled custom healing abutment will allow a more ideal gingival line in the final restoration.

Both Drs. Hunt and Boudet offer good advice....when working in this area in future, pay extra attention to the anticipated emergence profile.....

Fortunately the platform is deep enough that the coronal of the implant will be covered by the soft tissue. I would have a zirconia custom abutment with metal insert made (under contour the facial so that the soft tissue stays positioned coronally. Then have a ceramic crown and lute over the abutment after its placed. Due to the angulation issue that is the only way to get an esthetically acceptable result. Doing a screw retained crown will leave the screw access in the visible facial and no matter how good you are that spot will be obvious when they smile.

Also I have a concern as it appears there is not much bone on the facial and am willing to bet that of flapped you will see some threads. You may want to consider flapping and placing graft over that area to make sure there is sufficient bone on the facial to preserve the implant long term

I’m with Paul on this!

Consider using an angled screw channel abutment screw from Dynamic or Nobel which can allow for a screw retained crown with the channel being on the lingual. This can help if the placement is too buccal, or if the access is through the incisal edge as per a cementable case. Your Lab tech can measure the angulation of the implant to see if this suggestion is applicable in this situation, and I think corrections up to 30 degrees are possible.

There is not enough information to provide a certain answer. If the implant has only recently been placed it could be removed by unscrewing it. The buccal angulation is not ideal but as has been described there are a variety of ways to get around this. However it always requires a less than ideal treatment. Therefore if the implant is not yet integrated then it is likely that removing it would be prudent – best for you and the patient. However what worries me most of all is that one radiograph views seems to indicate that the implant is touching the adjacent tooth and there is little or no interproximal bone. As I said, more information is required (a better radiograph) but if this is the case then I think there would be no option but to remove the implant. If removed - and after grafting and healing; a surgical guide (after CADCAM analysis and design) would be a good way to avoid this problem reoccurring.

An angled abutment which is either stock or custom made may offer a solution depending on the severity of the buccal inclination. The use of trial abutments may be of use clinically to determine whether a stock abutment will provide sufficient angle correction to bring the proposed crown within the ideal prosthetic envelope or whether a custom abutment will provide increased angle correction. A cemented crown could then be fitted. Another solution may be a biaxial screw which could provide for a screw -retained crown . This depends on the amount of correction that could be provided by the screw in order to have a palatal screw opening

Absolutely Remove it Now. Refer this to someone experienced in grafting and placing implants in an esthetic area. Then watch what they do and learn. This restoration will not go well, forget about your ego and do the right thing. I’ve removed plenty of implants I’ve placed poorly, that’s why we take a post op film. The patient’s arch is fine use a wax up and guide next time. Most of these comments are not great solutions and just want to make you feel better. ,

Sometimes in the anterior maxilla it is hard to avoid buccaneers placement for anatomical reasons already mentioned. What I often find is soft tissue deficiency which can easily be augmented at time of placement or any time prior to restoration. A very simple and relatively painless technique is to harvest CT from the tuberosity and place it between the buccal flap and bone. Great advice on custom healing abutment rather that standard straight. I have used Contour Healers (order through Blue Sky Bio) and Anatotemp. Both are anatomically contoured for the specific area an easily modified chairside.

If your implant is placed more buccaly than chances of bone loss on buccal side is higher and also gum level may goes higher on healing..can post more cbct images to see the bone plate on buccal side

Sorry about poor CT image. Buccal bone was intact at the time of placement.

Sorry but I would probably just remove this implant, re-angle so that it is placed on the palatal and so that there is a definite space on the facial. If you are impinging on the facial then the bone will definitely resorb and overtime this will become an esthetic and functional problem. You will probably need to place a shorter length and diameter implant to do the proper position. If you can obtain immediate stability, then place an immediate implant that will maintain the emergence profile and minimize bone loss. The use of a shell to support the socket(made by Vulcan company)will greatly help you.

You do see it is. placed too far palatally with the implant angled to emerge from the labial. It needs to be emerging from the cingulum. With an immediate there is only preparation of the apical third. You can see the original position of the extracted tooth where it was grafted. The occlusal forces will not be along the axis of the implant and the abutment. Just take it out it will be a problem in the future.

Your challenge would be to insure that no excess cement would flow into subgingival area to cause peri-implant mucositis, which in turn could lead to peri-implantitis, after you cement your crown on a custom abutment that would have screw opening on the facial. This placement of the implant may also lead to slightly less esthetic result such as slight gingival recession (1-2mm) on the facial due to emergence of your angulated abutment/crown. I have restored these cases multiple times because that was the way you would get implant case from specialist before CBCT time especially in the lateral position. The placement is considered more buccal than it should be. So try next time with the surgical guide and procedure would go very easy. Since there is plenty of bone around the implant there is really no need to remove the implant. I highly disagree with people that think it should be removed, because you often see this angulation of the implants in placements of areas #7, 10 where we find less presence of bone, unless of course, your patients want to pay for unnecessary lateral ridge augmentation procedure to ensure that implant’s access screw is on the lingual. Also, you should not be worried about implant or screw fracture, and screw loosening because you are still within most manufacture limits of 35 degrees of angulation. Good luck.

Based on the CBCT, I am under the impression that the implant has sufficient bone separating it from the adjacent teeth to allow an osteotomy around it without jeopardizing their vitality. Therefore, I would suggest separating the implant with some of the surrounding bone, and once the segment is mobile it can be relocated where needed for an ideal restoration. Following, using a a 1.5 or 2.0 mm bone plate, the loose segment can be stabilized and if indicated a temporary restoration should fabricated simultaneously. (There are several papers describing the exact technique - and I would be happy to forward a reference if needed. ) I find this procedure very useful and quick solution for misplaced implants, avoiding the need to remove an integrated implant in order to replace it with a new one, and allowing and ideal final restoration.