Too late for healing caps for implants?

All the lower implants have multi-Units placed! The will be no problem with them... The upper, leave them as they are, while osteointegration occurs. Betwen wekk 1 and 3, the bonding strenght to the bone is at its lower level, so they should not be disturbed.

Years ago, when I started with implant dentistry, It happened to me twice with bone level implants. No adverse reaction occurred. When the time came to uncover the implants, I could observe some soft tissue ingrowth in the hollow of the fixture.

I'm sorry but I see a large radio-opaque mass in the right sinus which appears to be slightly distal to the implants. Don't get the tilted implants on the bottom. What is the restorative plan? I think the lack of healing heads are the least of your concerns.I don't get the implant placement was there a plan?

Nope I don't see a lift looks symmetrical from the other sinus, don't see a graft.

Why were the mandibular implants tilted? There is sufficient vertical bone in the arch for correct vertical placement. What is the radioopaque mass in the right maxillary sinus? Try to place the cover screws ASAP. This case has several questionable issues!

first of all the concept of all on four has been ruined totally , in all on 4 concept of dr malo the posterior implants are tilted and the anterior implants are straight ,if you wanted to place 6 implants then you had enough vertical bone to place all the six implants in parallel position in the region of first molars , first premolars and canines and provide the patient with a FPD i feel you have to reposition the tilted implants as early as possible to prevent any problem arising at the time of prosthetic restoration, what kind of bone substitute you have used for the sinus lift?

When I was a lad my old Mum would every now and then make a cake with all the bits and pieces lying around in the kitchen cupboard. We used to call it "Run Round the Larder Cake". Somehow it came to mind when I saw this x-ray. I suspect the surgeon was having a stock clearance and - Voila! - a "Run Round the Surgery" case. PS. Sometimes the cake worked and sometimes it didn't.

what is the treat. plan here .in the mandible you have enough space and hight to insert 8 parallel implants and construct a FPD on them . i can see cover screws in the upper implants though it should be your least worry here.

Jane if I were you, I would be cautious restoring this case. When it goes south it will be ugly and the last person touching it will get burned. An implant case is only good as its treatment plan and placement of the implants. I still don't get the tipping and the asymmetric placements and I don't think you understand what's going on, if you accept this case beware. If you are the restoring dds it is customary for you to determine where and how the implants are placed according to the prosthetic plan, it is restorative driven surgery not the other way around. Good luck.

I use a modified Ante's Law for large fixed cases. I divide the number of teeth to be replaced by two and add one to this number. This gives me the number of implants to use. This is not an absolute but a starting point. I hope this helps someone!

I hope your malpractice liability insurance is up to date

I hope this is the last case you sent to this fellow. I get a bead of sweat down my back just looking at it. Thanx for posting, great for learning!

looks like the patient got hit with an implant shotgun! First, remove all the mandibular implants. The concept of all on four or all on six is to fabricate a hybrid restoration with a metal platform and denture teeth processed to the frame. This restoration requires at least 15mm between the mandibular ridge and the opposing dentition. Even with ceramometal you need 8-10mm of interarch space. There isn't enough interarch space for any restoration. Remove the implants. DO NOT GRAFT THE SOCKETS. That is a fallacy. Only graft when you want to keep the ridge height. In this case, remove 10-15mm of alveolus to create room for your restorative material then replace the implants according to a restorative game plan. Either 4-5 and a hybrid or 6-8 and a fixed bridge. My rule of thumb: if you're new to the implant game you need three players, surgeon, restoring dentist and lab. Two out of the three need to know what they're doing to help the novice stay out of trouble. This goes for novice surgeons and lab techs too. They should work with an experienced prosthodontist. In this case, it looks like none of the three new what they were doing which is a shame since the patient loses.

I agree that the whole surgery hasnt been entirely thought out and is definitely not prosthetically driven. It seems that it has been planned as a modified All-On-4 (with 6 implants) this is very rarely indicated unless there is very little bone or thin ridges. At lease 2 of the multi-unit abutments are incorrectly seated and the top looks exactly like what John T said - clearance sale. It will most likely work with a great lab and good prosthetic work but be sure to radiograph & photograph & document everything in explicit detail. Great learning tool

It looks like the surgeon attempted an All-on-4 set up in the mandible and decided to place 2 more for luck behind them! All-n-6 is fine but not in this configuration. Not well planned at all. As Peter said, a mess!

Healing abutments are the least of your problems. Check you multiuints are seated - LR tilted looks like its not down. You may have vertical issues and space for a framework - did the surgeon reduce the mandidular ridge to get you space or just put in implants. The surgeons given you a headache with the upper left third molar site implant - why did you want an there in the first place?? Lower left terminal implants will be a hygiene issue when framework and teeth go on. Antes law is an aniquated conecpt with no real place in implant dentistry. I thnik reviewing your basic treatment planning and case work ups would be help for you and finding a surgeon who would mentor you.

Tuss, Can you refer us to scientific literature that clearly states that Ante's Law is outdated in implant dentistry and from something other than Malo or Nobel!

Has anyone yet worked out what the radiopaque "thing" in the right antrum is? Sorry for the facetious comment earlier but in fact it should be possible to build up some bridgework on the lower implants, given a bit of ingenuity by the technician - who deserves a Christmas bonus if he succeeds. My only concern is with the two left fixtures. Their platforms are almost touching and there's definitely going to be a hygiene maintenance issue here. Might be wise to remove one of them. Incidentally the original posting asked what to do about missing cover screws/healing caps. Obviously although the surgeon had lots of spare implants at the back of his drawer he had under-ordered the covers. However, I suspect he's not the first one to forget to put on a cover screw. In fact I know he isn't because I've done it! Usually doesn't cause any harm. If the fixture is buried the gingiva will heal very nicely anyway. If it's exposed it will tend to collect food in the screw hole but you can irrigate it out and place a cover screw at the next appointment. Musn't forget that appointment with the Alzheimers clinic.

I don't want to comment on implant and their placement, because I just want to ignore the radiograph. The question is, what if there's nothing covering the internal hex of Implant.... The worst you, will face at times when Bone covers the entire Implant and at times the cover screws. Imagine the bone is grown, think about removing it now. Even if it's 21 day's clear it up flush with lot of saline and think to consider putting the cover screws in place. They come free, don't worry you can store it after you replace it with abutment.... Just kidding All the best

Hi everybody, Unfortunately this case demonstrates why not everyone should be allowed to place implants. The patient ultimately suffers and the practice of implant dentistry is smeared. Too many things to criticize in only a 2 dimensional image, let alone a series of transaxials with a radio-opaque prosthetic plan in place. Advice: If you placed these implants, cease and desist immediately without further comprehensive and tested training thorugh a reputable program. Then refund in full the patients money and refer to a colleague that is willing to take this case on and make it right. You will be eating a bit of crow, but that is a small price to pay compared to the alternatives. If you are thinking about restoring, read the posts and learn from those of us that do this full time. Proceed very cautiously and get lots of opinions with those in your referral area with expertise in full mouth implant rehabs. Thanks for the post as it demonstrates the unfortunate ugly side to implant dentistry run amuck.

at least the lowers can be fixed by replacing the implants. Im more concerned with that radioopaque mess in the right antrum

What was the restorative plan here? Why tilt the mandibular implants and then place implants behind them. The idea of tilted implants is to increase the AP spread. Also, has anyone addressed this patients overall periodontal condition? I'm perplexed