Disappearing dental implant: recommendations?

It's probably under the flap not that deep in the maxilla

Agree.,,unlikely in bone. Get a CT.

Take a CBCT. If you don’t have one, you should be asking yourself “why did I try to place implants without one. “

Agree with Javadi, its probably deep in soft tissue under the buccal flap. Also appears to be perio problems on adjacent tooth

I assume you had not raised a flap, flapless placement?! It seems you can’t do anything yourself. Refer to ENT specialist or max-fac surgeon to make the patient to sniff it out! Don’t worry too much the implant has been possibly pushed in to the nasal cavity between the palatine process and lining of the floor of the nose.

Come on, dear colleague! straight away go with him to the maxillofacial dept at the nearest hospital and let an experienced oral surgeon remove the implant ASAP!

Agreed....when things go off the rails as it always will, forget yourself and do whats best for patient.

I dont think we need to be derogatory to our colleague who is asking for help. Everyone has had something go not quite to plan at some stage and if you havent you havent been doing it long enough. I think in this situation, if you are not confident to sort it there are a number of steps to take: 1. CBCT if you are confident to re-enter and recover OR 2. Referral to OMFS if you are not confident to recover 3. Reflect as to what went wrong and why 4. Get educated to broaden your skills and prevent this from happening again, we can never know it all and never stop learning. Even the greats Like Tarnow etc never stop attending CE and learning. Good luck and best wishes

I would contact my closest oral surgeon friend and tell him what has happened,ASAP. HE can diffuse a possible problem with the patient.Keep in very close contact with the patient, show your concern for them in every way possible .Honesty is very important. Bad things can happen to all of us. Take something positive out of this negative and stop doing implants unit you have the clear vision of a cone beam unit! You will sleep better.

Panorex, then depending on what you find, cbct or CT scan Maxilla. Could be on the palate, sinus maybe floor of nose. Get an Oral Surgeon to help you be smart be safe. Good Luck.

why would you expose the patient multiple times when you can get a small field of view CBCT?

CBCT to locate where the Implant is ASAP then it should be removed: by you, OMS, or ENT depending on Implant location and your comfort zone! DO NOT DELAY THE PROCESS! Good Luck

Hi, I am sure you are dealing with your best amd patient's well-being in this situation and since the comments are somewhat repeatitive, I won't repeat. (Btw, I do agree with most the.comments.) I apologize if I am out of context, but I would like to ask you what the implant brand this would be. What I am trying to get is that we as a clinician have a tremendous knowledge and sincere responsibility towards the patients well-being but sometimes, as a human, we are inclined to be influenced by people around you including a sales rep. Please do not get me wrong but sadly, there are 50+ shades of sales rep personality in our implant industry. Once this resolves in a well-carried out plan, please kindly let me know what system this was behind you( unless you just bought it via On-line). Best wishes for you and the patient. Thank you for your post as it takes lots of courage to do so. Thanks JWC

Dear colleagues, What most likely happened is as follows: Without a CBCT the dentist misdirected his placement. Instead of dragging into the maxillary arch at the proper angle, he directed into the vestibule.! Take a CBCT and verify its location, Leah flap remove the implant. Augment the bone as necessary, wait appropriate amount time and place anew implant .

Agreed with Dr Jae and Dr Dean, continuous learning is best way to increase confidence in required field

Things like this can happen to anyone of us with or without CBCT. In these situations I think we need to support one another instead of mentioning if you would have done this or that ..... our colleague is stressed out already and definitely did not want this. We need to help him in any way we can. First thing you need to do Doc is to explain the situation to the Pt let him understand that this is one of the complications of implantation in the maxilla with a poor bone. Let him know that it can be treated and is not a life threatening situation. Give it a couple of days for the implant to Seattle. If they are loose in the sinus it is hard to find them. Take a CBCT to find the exact position of it I don’t know if you have ever opened sinus or not and how experienced you are if you think it is not your job to remove it refer to OMS. Don’t worry and be positive everything will get back in line. All the best.

The implant is not in the sinus. It apparently went out the labial plate and is in the muco-labial fold. A good way to confirm this is to use Clarks x-ray rule. Use the pneumonic acronym SLOB take 2 x-rays of the object one straight on and one moving the x-ray beam toward the midline. The rule says that if you move the x-ray beam toward the midline and the object moves in the same direction on the x-ray the object must be on the lingual if it moves in the opposite direction of the x-ray beam the object must be on the buckle. S stands for same L stands for lingual O stands for opposite and B stands for buccal. You should be able to palpate the object high in the muco-labial fold. This incident should easily be resolved with no detriment to your patient or yourself. Please let your colleagues know the the outcome of this matter. You may find Clark’s rule will supersede the need to use a CBCT. Once you confirm that the object is on the labial you can lay a flap palpate the object down and remove it.

How the sales rep can be implicated in this one I do not know!

Dr. M. Daneshgar very well said, our colleague really need above words. Dr Barrow Marks good suggestion of SLOB. I think this forum is good platform learning from others Doctors experiences. Please do update us about conclusion.

I agree with Barrow Marks completely! A pano plus disto- and/or mesio-angulated pa's (a basic technique taught even in dental school) is the first imperative logical step here, and probably the only one that will be necessary! The implant is NOT in the sinus and it is NOT in the nasal fossa! That is self-evident from this x-ray! That implant migrated (slipped actually) caudally AND distally -- note that it is above the 1st bicuspid, just distal to the canine apex. It is almost IMPOSSIBLE for the implant to have "slipped" into the sinus from a UR 2 position! Our colleague clearly described how the implant just vanished from his view -- that is a "suck-in" effect. In order for that implant to end up in the sinus or the nasal fossa it would have had to have been actively PUSHED in -- even more so, the sinus (or nasal fossa) floor would have had to have been actively perforated with at least some force. Or that is not what our colleague described. Come on you guys (the ones who claim it might be in the sinus), WHAT in the world are you thinking?!? Even according to this x-ray that implant is in the mucco-buccal fold, having been accidentally mis-directed. It should be quite easy to locate with x-rays and palpation, and easily removable with a flap. Are you all trying to give this guy a heart attack? If it can't be felt on intra-oral palpation in the muccobuccal fold, then it's probably a little higher and it will certainly be felt on extra-oral palpation high on the upper lip, in the distal of the canine fossa. The implant should be easily removable with a flap, the only caveat being that if on palpation it is found that it is placed too caudally (too high) in the canine fossa then an OMS should do this. I doubt you have the experience to actually elevate a flap THAT high, and you shouldn't risk it. Raise the flap ONLY if you are confident enough that you can access the implant without turning the operative field into a mess! Otherwise refer to OMS! Besides all the foregoing, the most difficult part of this will be explaining to the patient without looking foolish, or incompetent. It's all a matter of careful wording in the end, but the idea is to make it sound like the bone quality was so poor it couldn't support the implant and that additional bone augmentation (with the appropriate healing time) will be required after removing the implant and before proceeding further. Good luck and take away an important lesson here: treatment plan more carefully, and execute more deliberately, slower, with more patience, until you build up your proficiency. This could have been avoided!

I wonder how many of these doctors commenting here has no complications since they all imply that this wouldn't happen to them....? If something happens like this, it is always easy to explain what to do else, but most complications or disasters in life happen because of small unnoticed errors that build up to the problem ( look to aviation) and are rarer the cause of a single event. CBCT is a wonderful tool but also with this, you can be some degrees off as a result of the software...

I agree with Dr. Helm. Will also that once you locate the implant via XRay or palpation, lay a flap as if you were doing an apico. A smilunar flap next to the incisal tip of the implant, removed and may only need to place one suture. Please do it as soon as possible before friends and other doctors start pacing unnecessary thoughts into the patients mind.

refer to an OMFS immediately.

I think that if you feel you are skilled enough to place implants, you should be able to correct problems/ failures

I think this problem is a result of an osteotomy possibly prepped too vertically. Very easy to do. Labial surfaces of anterior teeth can be very misleading. Hardly possible to perforate lingually. I think this is where a cone beam of pilot drill is invaluable and can prevent many problems.

@Raul Mena and Barrow Marks: congratulations to you both for the most TRULY clinically-sensible comments here! Reading some of the above comments one does have to question the level of actual OVERALL clinical experience of some of these posters, or if they simply live in an “implant bubble” of their own making. It’s as if some of them are wearing blinders. It's as if they don't know the value of a simple periapical any more, and the absolute need for diplomatic patient management in a situation like this. Most of all it's as if some have forgotten all about finesse and clinical skills. The problem at hand in this case pertains less to implants per se, and much more to overall clinical experience, expertise, acumen, sound judgement and, knowledge of anatomy. Perhaps, above all, it pertains to LOGIC – a logic that is, or should be, deeply rooted in all of the aforementioned skills. And it is troubling to see that you’re the ONLY ONES HERE to actually think SENSIBLY on your feet and to realize that the implant is at the bottom of the canine fossa -- not in the sinus and not in the nasal fossa! It is even more troubling to see our colleagues practically jumping down this poor guy’s throat, as if they had never erred in their careers. And even more troubling to see everyone throw out the window all of those things relating to sound clinical judgement and fine clinical skills and immediately jumping to a CBCT, as if it was some magic bullet. IT IS NOT! Still more troubling to note that not one of them has considered that this situation can easily degenerate into a malpractice lawsuit. Imagine the reaction of a patient who has to pay for an additional CBCT because of what he perceives as his Dr’s mistake. Can't these commenters see how the totality of events here can very easily devolve into a malpractice law-suit? The only place where we differ, Raul, is in the surgical approach. Whereas normally I also prefer the semilunar incision for apicoectomies, in this particular case -- and considering his probable lack of experience -- I would advise him to raise a full trapezoidal flap from the free gingival margin to the muccobuccal fold, so that he can gain adequate access and vision. One of the most important adages of oral surgery is "you can't do well what you can't see well". Since that implant is at the bottom of the canine fossa, one wrong move can easily push it up further into the canine fossa, complicating things GREATLY because now he'll be getting into the area of the infra-orbital nerve branches. That is why it is absolutely key that he does this with the utmost care, finesse, and deliberation. Kudos again Raul and Marks!

@Ties, agreed: CBCT is great of course, but it’s not the end-all-be-all in every situation, and this is not a situation where it’s the most useful. Sometimes a couple of simple periapicals in talented hands, as described above by Marks and myself, coupled with clinical skills, can be much more efficient and cost-effective and, solve a problem faster, with much less fuss, and no additional cost to the patient -- and that's particularly important in this case from a patient-management standpoint. I fully agree that, as in aviation, this is the sort of mistake that is the result of prior, smaller mistakes that just built upon each other. BUT, as opposed to aviation – where, in a dire situation a pilot has only seconds to react and correct the situation, sometimes not even getting that chance simply due to a lack of altitude – we DO have the luxury of that “altitude”, i.e. the luxury of time. We have the time to think, reflect, and consider the most appropriate course of action. And I DO say this as a licensed pilot! Our – probably young and inexperienced – Dr here should have double checked his osteotomy AND insertion path, ad should have constantly checked his insertion angle and corrected accordingly the MILLISECOND that he felt something amiss. And he MUST have FELT that the implant is not meeting the necessary resistance upon insertion, and he must' have seen that the path was wrong, and that he should have angled the implant more palatally. It is therefore imperative to measure twice and cut once, as the old adage goes. Also, rule number one in patient management is to never panic and, never let the patient see it even if you do. Mistakes can happen, but your patient should be prevented at all costs from perceiving it as incompetence. This is the sort of event that, from a patient-management standpoint needs to be handled with kid-gloves, with the utmost diplomacy AND sensibility. It is the kind of mistake that can easily damage one’s reputation – and yes, it was a mistake born out of inexperience and probably a rush, and a failure to be cool and calculated and CAREFUL. But while our colleague deserves the criticism, he also deserves our support and guidance, so that he can take sensible steps going forward, and learn from this mistake not just in a purely clinical sense but, in a patient-management sense as well.

@The ORIGINAL POSTER: Since I went as far as to teach you step by step how you could have retrieved that implant and saved this little accident on the spot, I will now go all the way and will teach you what no one here will take the time to teach you: the quintessential “trick” maneuver, that would have completely prevented this fiasco. Had you used this maneuver, you would not have misdirected the osteotomy and you would have – most likely – successfully inserted the implant. (Because I am almost certain that the chain of errors started with a poorly directed osteotomy.) The first thing to consider, as Dr Steve accurately said above, "Labial surfaces of anterior teeth can be very misleading." That is true. To counteract that, you need to not only look carefully at your pre-op CBCT, and at the angle of approach and picture it in your mind but ALSO, AS YOU DO the osteotomy look at the proximal of the existing centrals and visualize their proximal AXIAL BISECTING line (where the nerve canal would be), and you’ll be much closer to the real angle of approach. But that is not enough. Here is THE KEY: I assume (or I certainly hope) that you know that when doing an elevator extraction of an anterior tooth (or root) you should be grasping the maxilla’s alveolar process between your fingers, right over the root which you are extracting, as you work the elevator around that root. As you know, this finger placement is meant to prevent the elevator from slipping into the sulcus and causing an accidental lesion. Use the same finger grasping technique when doing your osteotomy AND when you’re inserting your implant! I.E.: assuming that you are right-handed, to do it the right way, using your left hand put your thumb on the palatal and your index finger on the buccal of the maxilla, right over the point where you will place your implant, and KEEP the maxilla between your fingers throughout the whole osteotomy, and then throughout implant insertion until you’re sure that the implant is properly angled bucco-lingually and mostly seated and you only have to give it the last couple of turns. (Of course you can take your left hand off between osteotomy and implant insertion, or just about any time you need both hands, BUT reposition it as I described when you’re back to working on the implant site.) What this does is it adds an additional dimensional AND directional sense, or feel, in your mind, and your right hand will almost automatically act accordingly. Your visual sense combined with this dimensional/directional sense provided by your left hand will automatically alert you if your angulation is off in any direction, if you look carefully, of course. Use this technique both on the anterior maxilla and the anterior mandible, the only difference between the two being that in the mandible you place your thumb on the buccal of the mandibular bone and your index finger on the lingual. That’s it. That’s all there is to it. I am VERY experienced, and I still use this invaluable finger positioning when inserting mini-implants on very small and atrophied anterior mandibles, where there is NO room for error, and where even a couple of degrees of wrong angulation can compromise the whole case. It always steers me right. (Mini-implants are most often much harder to insert accurately than regular implants, specially when dealing with very atrophied mandibles. I don’t advise you to try them until you have a firm grasp of regular implants.) Hope this will be helpful to you.

Refer please, -Don't try and raise a flap as suggested... watch out for that "nose bone" -You shouldn't need this forum to figure out how to locate the implant -Just seeing the a slight amount of the platform on the xray tells me the implant is too large for a lateral, especially with "considerable bone loss, especially on the buccal" I feel that just reading the initial post describing the incident tells enough, sorry for the tough love, but you are practicing beyond your abilities at this time. Doesn't mean you can cant get there, but this should be a wake up call. For those saying to be nice and help.... helping is informing that this was completely avoidable. Accidents happen, and we all have outcomes we wish didn't happen, but this is different Sorry, Just too many red flags. Sugar coating this is not helpful to anybody. Slow down, Just keep training and you'll get there.

Hi . I wanted to thank you all for all support. I did Take a ct scan . Implant was in buccal soft tissue . I did measure the exact place and cut the gum and removed the implant. patient was inform n every stage . he was happy with result.