Implants Too Close: Can I Use Orthodontics To Create Space?

OMG, Are you serious?! There are many many problems with your question. First of all, your surgical placement was not "fine" as you state. If it was, you would not be asking for advice about implants placed too close together. Second, by asking if you can use orthodontics to "move" the implants, you demonstrate your complete lack of understanding on the healing and physiology of dental implants. You should plan on kissing your interdental papilla good-bye, because if you placed implants so close together that you are worried about them, you have violated another surgical principle regarding dental implants.

ALL I can say is SHOCK AND AWE. I can't believe the novice level of people doing advance surgical procedures. There is an old saying that you are held to the same standard of a specialist. I really cant wait to see the posts attacking me for being to hard, and all the other bleeding hearts defending this gentleman for asking a question. But before you do attack me, please think of the above patient as your family member......What is dentistry becoming....is it all about the money. When did we forget about referral and consultation? The above question demonstrates there needs to be a credentialling process, if one doesnt understand the basics, your going to hurt the patient.

Dr. A, Go back to dental school! With your apparent level of knowledge you should not be doing implants. You give the rest of us a bad name and are a Lawyer's dream-cum-true! Stick to your ortho...

Dr A, please open a text book like Misch, read it, study it, understand it. Ask question befoire doing the procedure. Don't place any implant or do anything on a human beeing without knowing everything about the procedure and how to treat the complication. Your post make us (GP) look really bad.

Dr A., I agree with the my colleagues' comments. Please understand the basic biological and surgical principles prior to implant surgery. To answer your questions: 1. You need about 3 mm between your implants to preserve the inter-implant bone and hence the papilla. Read the Tarnow studies from NYU. 2. You need a PDL to be able to move teeth. Implants do not have a PDL therefore you cannot move them orthodontically.

this question demonstrates the problem with companies like nobel promoting GP's in doing implants. many of the novice "weekend surgeons" will attempt procedures out of their league.

I'm sure this person is just joking and trying to stir some emotions!!!!!

Doctor please spend some money and time. Garg,Misch etc. have great didactic courses. Too sad that your understanding of the basic principals of implant dentistry are so lacking.

I would notname it"orthodontics", but if you feel that the problem needs a resolution you may create a small osteotomy and move the integrated implants away from each other. The procedure is called "osseo-distraction" and it probably doesnt work so well without the osteotomy, but it works with it. You have to move the implants as long as the woven bone is not rigid/mineralized.

See? Ihde actually offered something useful! I would ask Dr. A several more questions before I jumped down his throat. But I'm not an OMFS. They are known for that. Seriously, though. If you have primary stablity 35-65 ncm, you can only hope to remove one (or both), you'll not move them with wires after they integrate. If you have biological width, you can keep the implants and MAYBE compensate with custom abutments. And finally, GPs aren't the only doctors who screw up. I just saw a huge screw-up by a "big-name" OMFS near here. BOTH of his implants need to be trephined out. I'll lend him my Misch after I finish it... Good luck, Dr. A, sounds like you may need it.

As you have already read you have made a mistake and you question shows a basic lack of knowledge, HOWEVER I had to treat this very problem myself when a surgeon placed two ITI implants too close. Due to their tulip design it is possible to accidentally end up with the implants closer than you thought they would be. It is possible to carefully and with copious irrigation to trim the interproximal area of the tulip that is supraosseous. The impression copings may also have to be trimmed. It is a compromise at best.

Yes, this doctor made a very junior mistake, and clearly doesn't understand the most basic things about implantology. But another issue not looked at here is the aforementioned "tulip" or polished flare of the older Straumann design. Please, if you must use straumann, at least switch to the "new" bone level design implant.

You cannot use ortho to move the implants. Try prepping the abutments while attached to the implants or a segmented osteotomy and fixate with bone screws. Good luck. In the future use a well designed guide. Do not feel bad, it's part of the learning process.

Read Misch Prostho and Surgery, They cover these issues. I know some of the other Docs are hard on you, but you have to start somewhere. We all start as beginners. Also, read Charles Weiss text on dental implants and Norm Crainin's as well. I am sure some of the other docs have never ever made a mistake!

I would recommend contacting your Straumann rep to get their opinions on what to do. Was it the rep that got you involved in these surgical procedures? They are to be commended.

please consult with a prosthodontist if he or she can manage the prostho procedure with existing situation you are happy if not another solution is: 1-explantation the second implant. 2-socket preservation procedure, 3- reimplant after 6 -9 month

It never hurts to ask!You can try block sectioning of the implant and bone and creating space. Just kidding .

Just how much bone due to have between the implants? Are the implants parallel or do they converge at the occlusal table?

I would evaluate which implant is in the best position to restore 19 or 20. I would remove the implant that is not in the best position. This could be done by unscrewing the implant, if the implant has not fully integrated, or by using a trephine. Graft the remaining socket, let the area heal, place the implant in the proper position.

I agree that you (or anyone else thinking about becoming involved in implant dentistry) need to understand basics of implant dentistry better. In my mind there is an extensive, simpler, easier, more cost effective training program and more GP oriented training program offered by WhiteCap Institute.

Taking out one implant is surely one option. However what is really "too near"? It looks like the old dogmatic ideas are not valid any more: see Novaes et al (Int.J.Oral. Maxillofax Impl. Vol 21, No.1 2006, pages 45ff) and Papalexiou et al (J Periodontol Vol 77 No. 4, 2006, pages 614 ff) and Novaes et al (J. Periodontol, Vol 77, No.11, 2006 pages 1839 ff) To Mike Stanley: Ihde allways offers a solution; see www.implant.com

I agree ,16 years ago I placed 2 implants a little too close to each other and cantilevered a pontic off them ! Took a x-ray 3 months ago less than 1mm of bone loss on one and no bone loss on the other and the inter implant bone (about 1mm) no loss. So things may not be dire.

LOL..ha thats a funny thought....try it ...i cant stop laughing

Most likely a joke, but an osseointegrated implant has no PDL. You cannot orthodontically move something with no PDL. Hope it's a joke.

No one can advise you unless they know the diameters of the implants, width of alveolar bone, and mesial-distal distance between the adjacent two teeth. There are a number of treatment alternatives, but which is best depends on knowing more about the situation. Please update your case info and advice will follow.

Remember, implants do not have a PDL, thus no movement.

First an observation: I see cruel and demeaning responses where questions are asked to obtain help. Frankly, I suspect the questioner is not a doctor at all, a patient or an attorney perhaps, or a concerned spouse... This forum is open to the public. In this case it is far from reflecting the best I see in my colleagues. Two questions asked: 1) How close is too close? Well in the molar and premolar region of the mandible I've double abutted with

Well in the molar and premolar region of the mandible I've double abutted with less than 2mm in between; esthetics is not the driving force here it is cleansibility. I heard an implant inventor talking about replacing every root with an implant---that would be two per molar and the space in between would be very much on the narrow size!! Definitions exist, however they are medical-legal rather than physiologic. 2) Ortho to move implants? No PDL no 'agent' to stimulate osteoclasis. Ortho is impossible. In fact Orthodontists are using implants as anchors for moving multiple natural teeth, and to support traction in lieu of headgear. R Neff

Dr Neff, The point is maybe we need to be cruel and demeaning to wake up some of the dentists out there that are more concerned about making a buck then doing whats best for the patient. The above doctor had no business placing two implants on patients if he doesnt understand the basics of surgical implant dentist. Maybe our profession needs a few more lawsuites for us to realize that hey we are working on people and not animals. I am not willing to except substandard care for any patient in this world. We have an obligation as dentists to protect our profession and protect our patients. Thats what peer review and evidence based dentist is about. In medicine most doctors are affliated with hospitals which credential them to do advanced procedures. If a doctors screws up a patient within the hospital they are subjected to a M&M review. Which if you think we are being harsh you should see those reviews, however it allows medicine to elevate thier profession by learning and preventing mistakes by policing themselves. Unfortunately, in dentistry we dont have a credentially process so any bozo with a dental degree can do what ever they want in the office. There was a time that they taught you in dental school to refer. Now the referral is disappearing because people want to make as much money as possible. We have dentists graduating dental school with minimal skills barely able to do a crown or a simple root canal, yet we allow them to start doing sinus lifts, block grafts and implants. Anyone else have a problem with that???????????? Now im not one of these guys that say general dentist cant do there own surgery. There are plenty of great general dentist doing quality surgery, but these same dentist went to quality implant programs like NYU, loma linda and so on. You cant learn this stuff in a weekend, and you have to walk before you run. If we dont police and protect our profession, the government will step in and do it for us. And lets be honest Dr. Neff, the above question isnt the first time we seen questions on this site that show that dentists are over there heads in implant dentistry. Dr. Neff lets be more concerned about our profession and our patients and less concerned about this dentists feelings, because if he is a dentist which I believed him/her to be, I hope he learned from this thread and refers his implant cases or goes and enrolls in a residency program.

To MainOralSugeryman: I like your comments. I do implants myself and understand the biolgical principles of implants and I am a GP. In more servere cases I refer to an Oral Surgeon. And as you stated the best man to understand how to place implants?? I refer I patient of mine ( a retired oral surgeon) and even made a mal where to place the two implants. Whit this mal I saw a had to do a bone block transplant to get it right in the area of the nerve in the lower yaw. That's why I refered my case! you think this is right like you stated because he is a oral surgeon. I end up with a case where the mal wasn't used becaue it was made bij a GP and they are stupid!! The implants where place to close to each other ( 1,5 mm apart) and angled towards each other in a way I couldn't put on the impressioncopings the same time!! And this Oral surgeon does many implants! So how did I end up like this if I read your comments about your oral surgeon group and how much greater the are then GP's in placing the implants!! The funny thing is that the oral surgeon did it to another oral surgeon with your opinion about GP's doing implants and wants to be refered to an oral surgeon because GP's are stupid people and don't know anything about hard tissue surgery!! ( what about cavities in teeth: maybe we should let do the oral surgeons also this procedure because it is hard tissue surgery as well!!!)

Mainoralsurgeryman- I have been in organizesd denistsry for over 50 years and must say your remarks are some of the most pompous statements I have seen. Not only do you extol what a magnificient specialists you are but you are but are equally knowledgeable in the level of training our young professisonasls now receive. Shame, Shame on you. How sad that a specialist would sink to such derogatory accusations in a public form. Why don't you post your professional name and practice location for your referring GPs to know your true feelings. FYI- I graduated from NYU as well and am sadden to have to count you as a fellow alumni. Hoplfully we have only a professionals that do not have the compassion to mentor fellow professionals. I suppodrt Dr Neff's comments.

Ivan, you obviously need to reread my comments again. I said that there are plenty of good general dentists out there doing fine surgery. But the ones that know what they are doing and follow good surgical techniques went to implant programs like NYU, LOMA Linda and so on....Not a weekend coarse. Believe me I feel specialist have plenty of there own issues and are far from perferct. The point is we need to educate and enhance our profession and we cant be willing to except what is miinimally acceptable treatment. Being you are an educator for over 50 years, I believe you would agree the level that dental students come out today with clinical skills is far less then in your day. Especially now when there is such a focus on medicine and not on clinical dentistry. Yet these same graduates jump right into advance procedures when they still dont know how to cut a crown. Why are we as a profession willing to except substandard care on patients? Most people in this blog recognized the issues we are facing with the above question in the thread. And Shame on you Ivan that you let your anger not allow you to see the forest through the trees. Shame on you for not thinking about patients first. Remember, my statements is just an opinion. But hopefully it may make professionals stop, think and reflect on how they can better treat patients. Maybe it is through referral or maybe its going back to residency program such as NYU or loma linda implant program. Or maybe its just walking before you run. Dutchy Where did I ever say specialist are the best for implant placement?????? This isnt about specialist vs GP. This is about getting the training needed to provide high quality dentistry on our patients and elevating our profession to a high level and not think about the almighty dollar over whats best for a patient. Hope that didnt come off to pompous. But Im trying to shock us back into reality before someone else does it for us.

I am a specialist and on two occasions I have placed implants too close together. (I've placed thousands over 20 year span). There is a solution if one can fit impression copings a single abutment incorporating both implants can be made basically splinting the implants together. Both cases have been successful over a number of years. Frankly I have more often surprised when I thought implant placement went perfectly than with the two above cases.

Bruce the implants being placed to close togethor isnt the big issue with case question from above. Sure everyone makes mistakes as nobody is perfect. To me the main issue here is asking if he/she can move the implants orthodontically. That shows me that clearly this dentist doesnt have the basic knowledge to be doing implants or implant related procedures. And if he/she doesnt have the basic knowledge or skills what other mistakes are being done in his/her office. We all go to similar conferences and we all see similiar implant complication lectures. How many lectures do we need to see where there are implants floating in the sinus or nerves impinged upon before we say enough is enough.

I think MainOralSurgeryMan needs to start a new discussion on this topic since it has drawn such interest and more that a little bile. It seems he has struck a nerve about training & qualification. I wonder if he sweated, just a little, the first time he placed an implant? Did he consider his training until that time to be 'adequate' at that moment, or did he go re-read some literature? IMHO, some Oral Surgeons, Periodontists & "Implant Specialists" forget to consider what is needed to restore the implants and leave the restoring doctor with poor options. Maybe only Prosthedontists should place and restore implants? Me, I'm starting to read Misch, so that I am more help to my doctor (a GP with hundreds of implant training hours, around a thousand implants placed and, only 2 failures). I'll let you know what I learn.

Dr. Ihde, you've been very busy! My limited German reading ability still can't hide your work. Good slogan: Ihde always offers a solution.

I didn't want to bring up the specialist against the GP. My point is that we all can come in to troubles and it is better to learn from mistakes from other people and make yourself a better surgeon. I believe you as mainoralsurgeryman does surgery at a routine base, but allthough you get the good education you sometimes get in troubles when starting with implantlogy and sometimes you can say it is stupid but I believe if you are a good surgeon it is not all about doing nothing wrong and learning the tricks but also to learn how to handle complications, etc. In most courses this point is less pronounce and that's why we see so many questions at this board. But what woud you do when you get in this kind of trouble?

This is all the result of the Implant Industry claiming and marketing implants with " as easy as 1, 2, 3". That is the result of the great work of companies like Nobel, straumann etc, that have done nothing but to "train" GPs with weekend certification courses. It is time to do something about, to spread the word of examples like this one, total lack of responsability. Even worst, to read some solutions posted, claiming that actually implants could be move by distraction procedures. amazing

Dr A. - Obviously I can only hope you are smart enough to read through all this ego mania. This frequently happens when some of our colleagues feel threatened. They forget that this form was setup to allow such questions to be asked. As Dr Mckelvy stated, more than likely this is a salvageable situation and I am sure you will learn from this as we all have done with our own mistakes. Ten years ago I too placed two implants too close together in a non-cosmetic area. I simply placed the first abutment on and then prepped it to allow placement of the second and then prepped both together for draw. The two splinted crowns are doing fine as of 6 months ago. Obviously, there is no papillae between them and the patient cannot get between them. This is not the way I intended the case to be but there it is. That being said my patient couldn’t be happier. The placement discrepancy was documented and explained to the patient originally. I am sure your situation will do fine also.

Perform a fixture level impresson and see what you have. Let your lab determine what they can do. We all start out as beginners, so do not let the comments by some of the other Docs upset you. I bet none of these perfect people ever made a mistake. Plus, this is not life and death!

I have seen poorly placed implants by specialist and implants very well placed by specialist. So do not take this so hard. You will learn from this.

After placement, take a PA and evaluate the placement. If it's not what you want, remove the implant and place in the proper position. Also you can use the guide pins to evaluate the position after using the pilot drill. If not correct you can use a Lindeman bur to correct, then proceed. You may have to grout the implant with a densely packed HA (RESORBABLE).

Dear collegue, I second the motion of Dr. R.Hughes. Take the impression at implant level and discuss the case with your lab tech. We all learn from our mistakes. ElieVictor

Dr. A. It is good that you realize you are not perfect, unlike so many of our collegues, it only proves that you are human... to err is a human trait. It is unfortunate that OsseoNews does not provide us the ability to post radiographs and photos; because this would add other dimentsions to the questions, that the contibutors would have a better understanding of the situation. Although you feel that the implants are placed too close together, so that the pair are unrestorable in an acceptable manner.... however, if one of these implants were put into a 'SLEEPER" catagory, by putting back the cover screw, and allowing the soft tissue to close over it...as long as it is well below the tissue surface; then perhaps you and your lab could design an acceptable looking and functional implant crown and cantilever to make it esthetically and functionally acceptable supported by one solid implant. Your question about orthodontics on implants is nothing to be ashamed of... as there are procedures in orthopedics to reshape long bones with external forces..... perhaps this question of yours may entice some people to do research on this matter. For future cases, try to preplan with study models, and make surgical guides to have a better control.Good luck Gerald Rudick dds Montreal

With some basic dentistry, these things are so easy to avoid. Do you take check films while placing implants? i take at least 3 x-rays per fixture, one after my pilot drill, one after the implant is seated to its final position, and one to send out to my referral after a healing abutment is on. Your problem would have been so easy to avoid if you just took a simple periapical film. think about endo, do you take a check film to evaulate your length?? these types of mistakes are so avoidable with just some basic dentistry - i think that's why everyone is so aggravated here. when you post something like this you should expect to be slammed.

I´m sure it can not be serious, it´s not true or go back to read the basic priciples of implant dentistry.

You might be able to using distraction osteogenesis and ortho. I just read an article in the august issue of PPAD. "Distraction Osteogenesis and orthodontic therapy in the treatment of malpositioned osseointegrated implants: a case report." Gotta, DDS, Sarnachiaro, DDS, Tarnow, DDS.

Perhaps if the implants are not deemed as safely restorable then maybe you could take out the worst one, graft the site and 3 months later, place a new one of a smaller diameter?? And by the way, I'm sure I'm not the only one whose blood boils around guys like Mainoralsurgeryman. If he had his way every GP would just be relegated to doing simple fillings and prophys. Thats usually typical of an Oral Surgeon and a lot of other specialists too, especially if you're doing something along their line, which they think they should have the exclusive RIGHTS to do! ie Turf infringement$. I myself have a Certificate in Prosthodontics (Board eligible but not certified) and have completed Misch's Pros and Surgery programs, Pikos and Salma's Ultimate grafting courses etc., and am a Fellow of the ICOI. I however practice as a GP finding out that referrals in Pros are rare in my area unless he case is in litigation. I do not help any party going after any dentist..!!! So there's nothing wrong in learning something new and innovative!! Lets face it the days of making a living from decay related services are comming to an end!! Just get the training, Misch in Detroit and Med College of Georgia I thought were good programs.

I can't believe I am actually reading this. This is the problem with going on a 2 day course, placing dummy implants on plastic mandibles and getting stuck in (literaly)! No you can't move implants. Treatment planning is as important as the surgery. I would suggest getting mentoring from a highly experienced surgeon and possibly joining an organisation like the ITI who has strict guidelines and procedures. This may shine some light on your situation and help you get out of a pickle. Best of luck.

Yeah. We all make mistakes. Whats new? The issue is not that we have made a mistake but that we resolve it and learn as much as we can from it. In this case, it is an opportunity for the said colleague to be so stirred up that he will set out to educate himself in this most revolutionary of disciplines.... dental implantology. There are no stupid questions....only stupid people don't ask questions. Smart people ask and learn in spite of all the brickbats from thrown at them. Having said that, I would suggest that if the implants are not too close, use the narrowest possible abutment on the fixture. Thus, you will be practicing very advanced implantology called "platform switching" which will result in minimal or no bone loss. Incidentally, this discovery occurred due to a mistake which was that the dentist did not have the "correct" sized abutment and tried to get away with a smaller one. He got away with it! Three years later, he took an Xray to see what his mistake did. With great trepidation he looked at it.......and to his pleasant surprise found that compared to his other correct abutments, this particular small abutment showed no resulting bone resorption. Platform switching was discovered! So there. Cheers.

Some dentists like Mainoralsurgeryman are Godlike they never make a mistake. i.e. to say they forget the mistake they made as soon as they made it and pretend every one else didn't find out they have made a mistake! And the shroud of secrecy with a pseudonym! Telling others that they are wrong convieniently forgetting that writing under pseudonyms may be good for novelists but not University qualified doctors. Pseudonyms don't give credibility. Why don't we turn back into our own professional histories and pan through our own patient case papers and X-rays of patients and just glance at the things we wouldn't have done had we known better. Are those root fills ideal? Was that curettage perfect. Was that inlay/crown margin perfect. Was that suture tight/loose enough? Was that X-ray processed and preserved well. Was that Amalgam triturated properly? We all know we weren't giving our best at that point in time. Acknowledging that we don't know something in it self is great. I know of some people who wouldn't even acknowledge that they are lost in a strange town. The quality of acknowledging ignorance separates the saints from the swindlers and the honest from the pompous. And here you won't even acknowledge your name and expect him to acknowledge his ignorance of implantology? " And why beholdest thou the mote that is in thy brother's eye, but considerest not the beam that is in thine own eye?" says the holy book. Let Mainoralsurgeryman come out of his closet himself, let him search his soul before he finds fault in others. I have been around in this profession for 20 years and I will tell you with a confidence filled with conviction that pointing fingers doesn't get you anywhere. Your point may have merit but people will as easily point your faults in return. You may discuss your heart away in private, but when in a public forum you end up making a fool of your self this way. Mainoralsurgeryman has as yet to mature and learn the ways of the world. "'Tis better to light a candle than curse the darkness." Hope you see some sense some day. Dr Sanjay Jamdade P.S. If the posting doctor didn't care for his patient he would not have posted his worries here to begin with.

"Judge not that ye be judged"

Again another maid up scenario to get everyone hyped up, and raise mainoralsurgerymans blood pressure. If this is a real case you either have to trephine out one of the implants. The minimal distance necessary is 2-3mm if the implants crest modules are touching then you have a real problem. If not use custom abutments to create more space above the implants and restore the case. If it is in the posterior mand, and the implants are not touching dont worry about the papilla it will regenerate. We do not have all the details to make these judgement calls, but it creates good discussion. We specialists cannot stop this train so, we just have to be prepared to fix things, which is 1/3 of my practice. So if you have patients that you have had to tell that implants are impossible because of severe atrophy of the maxilla or mandible, call me and I will get the bone there and you can place the implants if you want.

One may considering a vital segemented osteotomy, inorder to possably move the implants in a more ideal location. This technique is being promoted by Tatum.

Assuming that it is really close.... Again, like the previous doctors said..." it is hard to tell without the X rays".... these are my experiences with ITI the " big Lotus Head": 1. I love ITI, but especially for S type, the head is 4.8mm while the body may be 3.3mm resulting in a larger flare than imagined, without taking into consideration 2 S head will eat up all your planned space. May be it is really your fault like all the other dentists said,may be it is not. 2. ITI in my opionion has the most superior surface treatment; the SLA. Sometimes you may get away with things that other system won't allow you to. A lot of times what we heard about "standardized spacing" may or may not applied to you case. 3. Thank you for putting up this post, assuming this is not a crank joke. the close approximation of implants will not allow you to use the impression transfer components, so they are right, do a fixture level impression. 4. Yes, after reading the above posts; you are not going to have inter-implant papilla. but i am not sure the real importance of inter-implant papilla is for non-esthetic zone...do design your prosthetics to avoid overloading, food impaction and make your pt's mastication ability better. And they will thank you. 5. Yes, implants can be moved "orthodontically", but it is quite complicated. you can use peizoelectric surgery to make cuts and " surgically reposition" them. but you need room for that. 6. Dont be discouraged, if you really are as bad as they say you are, don't do implants anymore. But if you and only you think they are too close and in fact they are really not. Publish this case in 5 or 10 years and let us know how it turn out. Tell us what pt in the long future thinks about your prothetics and implants. P.S. I don't have any financial interest in ITI. Actually it is ITI that have financial interest in our clinic lol.