Implant Fixture moved buccally and gingival margin higher: how to manage?

I'm not sure how an implant can move buccally during osteointegration but it appears to be outside the dental arch when lining it up with the other central and lateral. Could the buccal plate have been lost either during the extraction or implant procedure ? Was the extraction/implant placement done flapless? Was the extraction site grafted/ Any special site preparation or a surgical stent used at implant placement? Cone beam could be helpful don't know where the buccal plate is. Seemes like on the third xray the implant is very long and placed deep which leads me to believe that there was bone loss present at placement?

If you had primary stability the implant most certainly did not move while integrating. For now you can only: 1 - deal with the buccal bone resorption and gingival recession, probably do a big gingival graft to enlarge and get more keratinized tissue, change healing plug to a thinner one (1mm less) --> not a good option; probably not good results; long term fail. 2 - REDO Next time here's what you should do if the buccal ridge is intact: Place the implant furhter palatally. Very simple. Either use a countersink bur to enlarge the osteotomy to the palatal side or use the pilot bur (if it is a good one) and perforate the palatal wall of the alveolus (+/- in the middle way between the crest and the ex-apex) and start to turn the bur to the correct osteotomy position so that you have AT LEAST 3,5mm from the bur to the residual buccal ridge (if using a 4mm implant; leaving at least 1/1,5 mm of space between the implant and the buccal ridge depending on the residual ridge width), place implant and graft with autogenous (you have it available during osteotomy) or TCP or whatever your experience tells you. If you did not have buccal wall integrity then graft and wait

I can't really see clearly in the pics but also appears to me that the labial frenum is messing around with your surgery.

Here is how I handle the esthetic area. Remove the tooth atraumatically but raise a flap to evaluate the buccal plate. If there is a fenestration or dehiscence you will need a membrane, Teflon is a good choice. Graft the socket with an allograft get primary closure or allow the Teflon to assist in this. Let it heal 12-14 weeks, keep the Teflon in 6 weeks if possible. When you go in to place the implant it can be placed in the arch with it lined up with the cingulum of the adjacent teeth so that the restoration can be screw retained. It is very important to remember that based on the original film there was significant bone loss which needs to be put back. The implant will not make up for the lost bone. I also tell the patient I may place a connective tissue graft with the implant, the fremun in this case was a problem sinc the implant was placed high. The palatally placed implant/immediate technique with a Lindeman bur works well when you have a thick buccal plate and a thick biotype. Now if this patient is male and has a low lipline

The implant integrated rather well. I would leave it and use pink porcelain to correct gum level and future black triangles.

As Leal stated, if the implant was fixated, it will not migrate. This problem was caused due to the placement of the implant. Paying attention to apical sink depth and bucolic-lingual running room are of paramount importance in the esthetic zone. The solutions are varied. Alex mentioned pink porcelain. This is very acceptable. One can also perform a "VITAL SEGMENTED OSTEOTOMY" ( taught by Tatum Surgical), graft the ridge with dense HA and alloderm to raise ridge height.

My thoughts here are it was mainly that huge healing cap ,remove it let it heal, then bring attached gingiva from the palatal side after healing ( 4 weeks or so ). Then use a customised healing cap with a better profile and you may rescue this situation. There is already half a cow in there judging from the x-ray but the patient would be happier with a less agressive protocol. Hi CRS if you want to remove impants the Neobiotech system has made it very easy and pain free for the patient . But I do agree about referal to a perio with skill to manipulate a solution as soft tissue surgery can be challenging. Peter

CRS great comments about site development and smile line.

You have done a givgivoplasty in an effort to correct the esthetic contours and I assume the frenectomy was done in an effort to correct frenum pull and inflammation of the gingiva. However I think you have bigger problems than esthetics. You have significant swelling and inflammation on the buccal surface interproximal to the central and lateral. In addition you have a significant exfoliation of graft partials occurring around the healing abutment. Because there is no purulence associated with the graft particles this is not infection. The inflammation and exfoliation of graft particles is most likely due to an immune response to the graft material. Don't be surprised if you have a fistula developing in the area of swelling and inflammation with graft particles exfoliating from the fistula with a serous exudate. If this develops antibiotics are of no value and the inflammation will resolve when all of the graft particles are exfoliated. It appears that the pre op radiograph presents with significant bone loss to the floor of the nose and in the grafted radiograph there appears to be a radioopaque foreign body. Is the patient complaining about any nasal drainage? Once the inflammation is resolved because the gingival margin is directly related to the position of the tooth in the arch (or implant) I would remove the healing abutment and allow the crest of the gingiva to heal. Once healed make a lingual incision in the crest of the attached gingiva and push it buccal to regain proper gingival contours and place a custom abutment with a properly contoured temporary. Greg Steiner Steiner Laboratories

Ah, the dreaded buccal migration phenomenon. At least you have thick biotype and it looks like a fairly low lip line. Good luck.

I would like to jump in on the "dreaded buccal migration phenomeneon " conversation. A few years ago Hom Won LAY ( forgive me if I spelled it wrong ) made mention in an article to what he called " buccal shift " when placing immediate, or delayed immediate. Jest of the brief discussion was the facial plate has a higher precentage viv a vis volume of bundle bone than elsewhere in the alveolar housing. That this area and subsequent large concentration of sharpey's fibers reponded to the regional acceleratory phenomenon with a greater remodeling.....and as such if your apical/palatal anchorge was not tight enough you would experience buccal drift as healing occurred. I believe this has happened to me on a few ocassions. that said, upon trying to discuss this with a presenter at a seminar, I was roundedly put in my place that no such thing occurrs and that my surgical technique ( specifically not obtaining primary stability upon insertion was to blame ).....

These are all good comments and could work to improve on the existing problem. If after trying these suggestions the implant is still to far to the facial and the metal is showing modification to the abutment and the implant itself could help. This is done like a crown prep on a tooth. Use carbide burs not diamonds and create a crown margin on the implant slightly subgingival. The abutment should be preped first outside of the mouth. This may make it easier to maintain the graft by reducing the bulge on the facial. The gingival shade porcelain may still be needed. Cutting the implant can be done. I have done this and it works, but the other options should be considered first or in combination with this.