Implant fixture seems to be too close to adjacent tooth: Should I remove this fixture?

Yes I would explant and place a more vertical implant

It might be better long term if you can remove that implant and place it in the proper angulation and position.

would be nice to see a CT scan... How long has the implant been in?

That's a great question. How has it been since implant placement? I agree that an implant more vertical and taking care of occlusal forces will be more predictable in long term. But, patient has no symptoms at all, maybe if you remove that implant this symptoms may appear. Nowadays we have prosthetic solutions for surgical complications. I my humble opinion I would wait at see; If premolar starts giving symptoms I would treat it (Root canal), in the meanwhile I would do the implant crowns. If premolar doesn't go well, a would perform the extraction and reevaluate the implant in the second premolar. Atraumatic explantation and implant in first premolar site? Leave it and implant in first premolar? One thing I would do Is inform the patient. best regards!

I would wait and see what happens...if the tooth (first premolar)doesn`t show signs of pathology, make the implant crown...if.it is in fact affected,then perhaps an endodontic treatment is required... I don`t agree with the extraction of the premolar(the pacient came to put something inside,not get ride of a good tooth) if symptoms arrise...endodontic.treatment under microscope is most effective.If the tooth causes problems after the loading of the implant..same-root canal. Inform the pacient and best of luck

I think the best answer to this question is What would you want done if this were YOUR mouth?? DrT

I agree with Don Rothenberg. As a general rule far too many CBCTs are being performed without any justification, but in my opinion this is one of the few cases where it would be worthwhile. If you have penetrated the first premolar root it would be wise to remove the implant, but if not I would be inclined to accept the status quo. Incidentally, if you do place a more upright implant there will be a significant risk of damaging the mental nerve.

Do NOT remove. This is a pano 2D therefore there may appear to be an overlap on the sagittal view, but when you look at it coronally on a CT there most likely is space between the two. If you penetrated the adjacent root, there will be pain. Observe then Restore.

Great Point John T! You're really close to the mental foramen so be careful. If the implant is touching the root the implant will not integrate so I'd say a CBCT is not a bad idea to both rule out root proximity and then if you're removing the implant then you could use the CBCT to make a surgical stent to place it more exactally.

You don't have to guess, re-open and measure the distance. There are significant risks here; vitality of the adjacent tooth and potential bone loss between the implant and natural tooth. If there is a problem with the bone you most likely will see it after you restore, then you'll have a real mess. Take it out and do it correctly.

observe the premolar for any tenderness or any other symptom also get the cbct done and if no symptom wait as this is 2D images

I don't think it could be touching the premolar root and there would be symptoms. Is this going to be a three unit bridge or two individual crowns? The mesial distal spacing looks odd and the first implant looks tilted and would be difficult to restore. If it is not integrated I would remove it and placed it parallel. Did you use a surgical guide to align the implants? Free ended multiple implants are tricky. I give you permission to remove it and align it, in the long run it will be a better restoration, no big deal to replace since it is not integrated.

well safest minimal distance b/w implant fixture n any vital structure is 2mm. Iam sure this case was planned without CBCT and drilling done without surgical(planning) stent,, BUT now after this mishap to plan next course of action, its prudent to go for CBCT..do not wait for the symptoms. if on cbct there is enough bone b/w the two as i said 2mm minimum, then you can plan prosthetic corrections.(its better to err on safe side) good luck))

HI Crs , I agree no symptoms , maybe take x-rays at different angles . BUT my main reason for removing and placing correctly is when they see other Dentists it is always going to attract comment and any future issues with the adjacent tooth will be your liability , here in the UK the medico-legal aspect of this job has exploded leaving even the US way behind . Again the use of a pilot would have prevented this happening , always assume you do not know . Fear of the MF possibly led to angling more this way but the pre-op Pan should have alerted you to the shape of the canine root . As to 2 mm to adjacent tooth , the EDI European consensus which I sat on was 1 mm with provisos , so in the right situation you can get closer. BUT the other IMplant is less than 2 mm from the IAN and that in the UK would be indefensible medico-legally. Anyway my advice . remove and redo Regard Peter

I would take two periapical films at slightly diferent angulations - the same way when when looking at an impacted canine or multirooted teeth for endo (parallax view) and that will give you a better ides of where the tip of the implant is and much lower radiation dose.

I've uploaded a very similar case, if not being the same, here asking for experience. I did implants for lower right 2nd premolar &1st molar with tilted one in premolar area avoiding the mental foramen. The implant touched the natural tooth, there was complaining by the patient, symptoms like tenderness & thermal sensitivity & continuous discomfort. But I've confirmed the contact between implant & root by a CBCT. More of them told me here to remove the implant but the patient despite suffering preferred to leave it! One month later I elevate (descrew) the implant & really got far from the root for about 2mm. After that I face complications like abscess & swelling, yet thermal sensitivity disappeared, in addition to patients complain. Now everything is OK since last visit except little radio-opacity surrounding the root of 1st premolar which make me prefer endo treatment of the tooth. After all these complications for both of us I prefer if I did remove the implant form beginning & replace it next.

Peter, I'm sorry to hear that limitation is out of hand in the UK. Every doctor will have a bad outcome from time to time. It does not mean that they are bad doctors. Sometimes there are bad situations, patients that are noncompliant or flat out oblivious, or refuse to take the onus for their condition. So they litigate against doctors for an outcome that was initially compromised. So maintain good records. One does not want any warts on their defense.

Agree with Peter as UK is just becoming a legal nightmare. Even the GDC is taking out adverts asking patients to litigate/ inform etc and they are the governing body for dentists! Just a joke

I'm a UK based OMFS surgeon, now retired, and do some medicolegal work, mostly for the Claimant - someone has to do it! As such I've seen implants put in some pretty strange places, much worse than this. In my experience this tendency to angle an implant mesially when it is immediately distal to a standing tooth is not uncommon. It's all to do with the drill handpiece coming in over the top of the standing tooth. The handpiece is held at about 45 degrees to the occlusal plane so inevitably the drill hole tends to be angled mesially. I suspect this is something most of us have done during our learning phase: I certainly have. With experience one learns to take particular care to align the drill head with the adjacent root. In this case the awkwardness is compounded by the adverse root curvature of the first premolar (although this is largely an x-ray artefact) and the proximity of the mental foramen. I doubt whether you've penetrated the premolar root but an axial CT will tell you for sure. If so the implant should come out and be realigned. If not, and the patient is symptom free, I think it would be safe to leave it but this is a matter of clinical judgement and discussion with the patient. So far as all this talk of litigation is concerned I wouldn't be too worried. In both UK and US law the claimant has to show both Breach of Duty and Causation i.e. that not only did you do something you shouldn't have done but also there was an adverse consequence. Well, there hasn't has there.

HI John , hope you are well and we see you sometime at the LDF , these are just the stats that are published . I lectured at Implant world last Saturday on exactly this area about caution , using technology to help us make Implant dentistry safer . After me was the head of the main Dental liability insurer in the UK and whilst there we have taken the lead in medico-legal claims , Implant Dentistry is only 7 th in the list of areas , endo being number 1. Regards Peter

Peter, I'm not surprised endo is the commonest source of litigation but this is probably because more root fillings are done than implants. Endodontists squirt calcium hydroxide all over the ID nerve whereas implantologists skewer it with their drills. Oral surgeons, of course, just slice straight through it. It's a great life!

I've had cases like this with a good outcome , I personally would not remove this implant. what I would do is take a cone beam to know the exact location of the implant. We all have the best intentions but let me tell you something I have come across many implant errors from very famous colleagues in my area. We all have better days but in my opinion angulation is not a problem when it comes to implant placement...

In the future, take a simple PA xray immediately postoperative. The poor inclination of the implant fixture would have been immediately apparent and could have been corrected at that time. Even better, take an intra operative PA at the final drill stage to evaluate angulation and length, prior to actually placing the fixture.

first of all thanks for posting such a case, i would like to ask you whether you have taken a RVG after the first or second drill ? then it would have been very easy for you to judge the placement and act accordingly . after two weeks down the line leave it like that and wait whether symptoms are there

Dr. Azima: the answer to your question is very simply, Would you be happy if this were in YOUR mouth????

Dear dr First do the periapical xray it will tel u the exect position ,if there is no symptom keep it as such

remove it and place another in long rub best choice

Dear Dr Azima, My humble experience would suggest that take a CBCT and find out the proximity of the implant with 4.4,any damage to the PDL urges you to remove the implant and pray for natural healing to take place and NOT an external resorption. Even if the implant did not penetrate the PDL,still I would suggest to remove the implant and if CBCT says there is enough bone width and height then consider another implant placement probably a wider, shorter one with correct angulation, Since if you want to wait and load it anyway you will end up with offset occlusal forces (due to distal tilt) which eventually lead to bone loss around the implant, so the prognosis is poor if you don't explant that.

This case was posted 11 months ago Would be great for the original poster to give an update on what happened.