Lateral incisor implant not deep enough: thoughts?
This patient had failed root canal with large periodical pathology. The tooth was extracted and thoroughly curetted then allowed 6 months to heal. The patient also has chronic periodontal disease which had been treated and controlled, he has generalized moderate bone loss throughout his dentition, but had shown stability over the past few years. After 6 months, implant was placed with excellent primary stability, a screw retained temporary was placed for 5 months with great esthetic. There was no increase in clinical recession, tissue remained healthy throughout healing period. The implant was placed 2.5 mm apical to the desired final soft tissue margin, but due to pre-existing bone loss, this resulted in the implant being placed 1-2 mm supra-crestal.
The images shown are the pre- treatment ; 6 months later when the implant and temp was placed and then 5 months later when the final impression coping was placed. At the time of placement the implant head was 1.5 mm supracrestal, but 2.5 mm below the soft tissue margin and at the time of the final impression was 2 mm below the gingival margin.
In restropect the implant probably should have been placed deeper, but due to existing horizontal bone loss present, I didn’t want the crown -abutment to be so long and the implant head is already 5 mm below the CEJ on the adjacent lateral incisor. Please let me know any thoughts you may have on this case. Thank you.
13 Comments on Lateral incisor implant not deep enough: thoughts?
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Periodoc
10/19/2017
What is the tissue biotype? If thin, you could have recession with exposed metal showing resulting in an unpleasant aesthetic result.
With bone grafting proven to be successful, there is no reason why you couldn't put it in its correct position and augment with bone.
My concern is the rarefying osteitis that I see, a remnant of the infection of the extracted lateral incisor. Could result in retrograde peri implantitis.
Kk
10/19/2017
Yes this is a valid concern however the lesion was followed for 6 months after extraction and currettage and continued to improve and continued to improve after implant placement , a pre op cone beam showed good cortical bone and an area of improving radiolucency ... how much longer would you wait ?
CRS
10/20/2017
Absolutely agree you said it kinder than I did.
Chris Woid
10/19/2017
Two thoughts. The fixture should be placed relative to one, not soft tissue. If your fixture has a polished collar, as a tissue level implant would, then that should rest above the crest. In the anterior, most would place a bone level regardless of the tissue thickness for esthetics.
If you use a custom abutment in a case where the tissue is so deep, you can make the "CEJ " or margin anywhere you like. Thanks
Bill M
10/19/2017
That dark halo may also be a fenestration in the buccal plate from long standing endo problems. If you flapped this case then you would have seen this either at the graft or at implant placement. If you did a punch or limited crestal incision for implant placement then you may be out the buccal concavity and you still have a deficient buccal plate. Your 3D image post op would show you. If the 3D placement has not been verified with conebeam then that would be my next step. If you have placed this significantly to the lingual then grafting both hard and soft tissue may keep things stable. If not then you might consider re-positioning it vertically and horizontally
Kk
10/19/2017
Thanks a pre op Cone beam showed no fenestration and the buccal and palatal cortical plates intact ... there was an area radiolucent from the old endo lesion in this cone beam taken 5 months after exo and currettage but this was followed and the radiolucent area continues to improve as you can see in the photos
Vipul Shukla
10/19/2017
What is done is done.
I agree with both posters above, there may be a fenestration on buccal wall where the old endo bugs lived happily for many years. Or just scar tissue.
You may use a custom-milled zirconia abutment with titanium base. Very good aesthetics. Called Ti-base or Variobase depending on which system you are using. These come in various angles and can be prepped in the lab further depending on the case as well. If you keep the zirconia crown facial margin two mm below gingival crest, and patient finds salvation in dental floss and good oral hygiene, the margin stays hidden. Everyone is happy.
Unless you wish to remove everything and redo it.
By the way, is the patient complaining about something or are you simply over-analyzing?
Kk
10/19/2017
Thanks. The patient has not complained and is happy with the result so far, just being critical and looking for comments to improve for next time
Zachary Papadakis
10/19/2017
A few thoughts. Placement supra-crestal (should be polished collar) in premaxilla should be avoided. Placement should be 3 to 4 mm apical to anticipated buccal margin (usually judged by adjacent teeth), this allows for sufficient running room. One piece scre retained all zirc abutment/crown if placement allows. If not, cementable crown over zirc abutment with slightly subgingival margins. So here is the potential controversy. I believe if you have sufficient hard and soft tissue preoperatively that satisfies the patient cosmetically, these cases should be immediately placed and immediately temporized for the least amount of post operative change. Remember the implant supports the bone, but the restoration (temp or perm) supports the tissue. If you let the tissue (hard or soft) go away, its hard to get it back.
FES DMD
10/19/2017
The error here was not placing the implant 2mm below the CEJ of the adjacent cuspid. Had this rule been followed, you would have placed the implant at the alveolar crest and all would have been good. Additionally, I would have grafted the extraction site after thorough curettage(which you did correctly).
Girish Bharadwaj
10/19/2017
Ok . Interesting case .
Please clarify if this is Biohorizons Laser Lok?
Back to basics . Since this is a reflection I would like to add few comments .
1. If your bone volume was reasonable then I think immediate implant post extraction would have addressed the issue. Of course this is demanding surgically but it can mitigate the effects of 2-3 surgeries causing additional soft tissue problems .
2. As few have mentioned thorough apical curettage with a sizeable envelope flap would address the access and soft tissue problem .
If this was combined with CT graft then bulking up soft tissue could add to stability of case in the longer term .
Any plans to CT this patient ? This would help .
CRS
10/20/2017
A lot of good periapical bone deeper past the pathology could have been used, hopefully over time there will not be recession follow closely. I would have Nd-Yag disinfected at extraction and I like to graft at implant placement to maintain the space so bone can regenerate over the implant. This implant may be trouble in the future in always a tricky esthetic site good luck. Don’t see the rationale for the Supra crestsl placement doctor.
Dr. Amayev
10/23/2017
All these comments about contraindication of placing implants supra gingiva should be avoided its not correct. This will depend on each individual case. I don't see any problems placing 1-2 mm supra gingival if you have to. Of course ideal will be to place at the bone crest but if you placed implant 1-2 mm supra gingival because you have to its OK. As long as you have enough gum tissue you should be Fine. You will not get bone loss because your implant is supra gingival. Remember the better attached gingiva you have less bone loss you will get.
The only thing I see on the x-rays is PAP on the implant. I don't know this is because of thin bone and resorbed, old PAP, or scar from PAP remains. You should know better. If it is PAP then if you have CT then CT scan and check what is going on.
