Implant Fixture Orientation: Diagnosis?

a panoramic x-ray is relatively useless for this region of the jaw. to really answer this question, a scan is required. a peri-apical film may give you a bit more info, but agaain, the scan is the only way to answer your question.

please get a occlusal xray of this area , and tracing a priapical x ray with the occlusal view then you can conclud that your fixture is in incisive foramen or not?

Why not request a CT Cone Bean? What is the complaint of this patient? How long that performed the surgery? Osseintegrado?

I believe a cone beam ct would give you a definitive answer to your question, however simply taking a pair of pa's and using parallax would yield you a great deal of information for a fraction of the cost and patient dose. I believe The dpt is a terrible view of the anterior maxilla due to all the distortion and shadowing. Hope this is of a little help :) I'm a big fan of the pa, and by taking a couple check pa's at placement you can usually avoid too much miss-angulation.

A panoramic X ray is not the best image to evaluate an anterior implant, because the anterior segment (pre-maxilla) is overlapped by the images of the cervical vertebrae and some distortion also occurs. Please take a periapical x ray, or CAT scan (better yet), and clinical picture of this case and post them. The more information, the better. Also: 1. How long ago did you perform this surgery? 2. Was there any intra or post operative complaint from the patient (pain, excessive swelling, palatal or vestibular hematoma formation, numbness)? 3. While drilling the osteotomy site, was there an increase in hardness of the bone, followed by a vacant feeling or drop sensation of the drill, and an increase in bleeding or profuse bleeding? 4. Have you clinically inspected (palpation) the nasal cavity floor to confirm any changes? It seems indeed, that the implant's position is misangled and too profound. If the patient reports no clinical signs of pathology or discomfort, and some time has elapsed, you can leave the implant to integrate. Definitely you will have to dedicate extra time during the restoration phase to correct the angle of the abutment. Also consider the added risk of abutment or implant overload and fracture, and the possibility of inappropiate esthetics if the patient has a high smile lip line (emergence profile, soft tissue drape). I would inform the patient about the situation and the risks involved, and have him decide if he wants the implant removed and replaced. I think if I was the patient, I would want the implant repositioned. Of course, I am only saying this with the little information provided. Please add more information, maybe it isn't as bad as it looks in the panoramic x ray.

Dear Dr. G., You have presented a valid concern...However, given the depth and angulation of the implant, you are confronted with a more pressing situation. High lip line or not, using tooth #8 to coordinate your position, can you confidently conclude that you can RESTORE FUNCTION for that particular implant? From my perspective, it must be at least 3-4 mm below the CEJ of neighboring teeth. Of course, you are in a better position to confirm this. Please take some pas to ascertain this calculation... Just as critical, how do you intend to maintain esthetics from that position? Please bear in mind that the basic principles must be adhered to in order to succeed. The need to act is now, before it fully integrates ( I hope). It simplifies matters to work on a cementing medium (bone) that has not fully set yet when you have to make necessary adjustments. Wouldn't you agree, Doctor? Why prolong the agony of an impending failure? The need to be decisive is at hand...

I think it is your responsibility to your patient to complete this treatment to the most optimally possible result. Let me ask you if this was YOUR mouth, what would you want done? If this were my mouth, I would not feel comfortable with an implant either in my incisive foramen or protruding into the floor of my mouth. I don't think think that in cases such as this, when, in my opinion, the final result is due to "operator error", we should either ask or expect the patient to settle on something that we know we would without question not accept in our own mouth. Yes, we all make mistakes. The issue now is not to perpetuate one.

Though here is a forum concerning bone and implant, why don't you consider a bridge to finish the case at the beginning? Implant is not a myth or a miracle. You cannot make a difficult scenario without adequate assessment and then ask for opinion. Let's back to the topic. Once the implant has engaged into the incisive canal without non-replaceable bonegraft (such as Bio-oss), the fibrous tissue would wrap the fixture and result in no osteo-integration. You need not to hesitate to remove the implant. Just wait for 3 months. If the implant has failed to integrate, please amend your treatment and consider a bridge. Tragedy is obsessing to do an implant.

Moreover, I wonder if there is an angled abutment of 35 degree (or more) available for you.