Loose Cement Retained Crown on Implant: How to proceed?

Without crown through drilling, nobody can determine exactly the cause of loosening. Do not hesitate to do it, but explain this necessity to the patient. It’s a PFM crown with free of metal pink shoulder porcelain. I think the abutment is coupled to the crown firmly and the screw is the problem.

Implant appears to be well integrated. Access from ligual. Hopefully previous dds placed cavit over a cotton pellet. Fish around and you should be able to re-torque abutment down again once you remove the 2 layers. Reclose with cotton pellet and composite. Explain to patient crown may or may not need to be redone in future. Inform before you perform!

Jim said it all but maybe PTFE tape (Plumbers tape ) is better than cotton wool. BUT here this case is a mess surely the best would be to attempt to make something better. Peter

Try taking several PAs with the crown in different positions. You might be able to see movement in the abutment-fixture connection.

I recommend removing the crown with a forcep in gentle rocking motion until the crown comes loose. Then torque the abutment and then re-cement the crown back. If the porcelain chips during this process, it should be ok, because esthetic does not seem to be high on this patients agenda by looking at the horrible crown.

Only choice without damaging the implant or breaking the crown is to try to gain access thru the lingual to tighten the screw. Most times the weakest link is the screw and thank goodness its not the implant. Hopefully there is something covering the access hole and you should be able to find it - not easily but you need to take your time. Tell patient that you don't want to damage the implant and this is the only way. Banging it off you could have a problem. Dont touch the facial of the crown as it was suggested. I agree that you need to tell the patient what you are doing first. Good Luck.

x-ray and a-p lateral photo shows good alignment of abut/crown, should be able to drill on angle and find opening. all screw-retained cases are re-entered eventually! just a question of how long the patient lives.......point is, dont feel bad.

I think if you try to pull crow to down and you take periapical photo while the crow is pullingso you con sure asif the crown is only or abutment is loose.

Not all custom abutements are fabricated with lingual access. Without knowing how the anatomy is for access to re torque the abutement, you must tell the patient that minimally replacing the crown is necessary. The dilemma is that you will need a provisional and you will have to have on hand a temporary abutement the day you start this adventure. You could use the current abutement and build a temp onto that and then have a new custom abutement and crown made. Always best for relations to inform in advance.

This appears to be a Straumann implant or clone. My advice? Disassemble everything and start over. Even if you follow all the good advice already posted, you won't know the full extent of the problem until the crown is removed. I've done several in my career and have never been disappointed by seeing what it was I was dealing with. It could be a fractured screw. It could be a loose abutment. It could be a knockoff abutment with poor tolerances. Do the patient a big favor by gently drilling off the crown with light pressure and diamonds. Less chatter by far. You'll chew up a few diamonds, but the trauma to the implant is mitigated. Then design a proper abutment and new crown. From your good photograph it appears you can improve the gingival fit anyway. I'd want to know my problem was fixed, not probably fixed.

Looks like screw loosening. Push crown apical to see it fix or not. Vibrate the crown with an ultrasonic scaler prostho tip.Then use a GC crown plier or similar. Remove cement from crown and abutment. Torque the screw or replace it.Place plumbers tape on the abutment hole. Re cement the crown after sandblasting. Don't you forget...high fees!!! Worst case scenario....screw fracture (have a backup!).

The implant should be a Straumann tissue level, not sure If is standard or standard plus, probably the first choice, and there is a chance that the implant was installed with its neck supra gengivally, the problems than began.... Trying to hide the metal collar, they - dentist and thecnician - tryied to use non original components, check that in x-ray the screw does not reach the all his patch... With comes later is history. Try to reach the screw lingually, knowing that you WILL make a new crown. Make a previous impression and buy provisory components to use in the same session you drill the crown. Contact Straumann dealer from your area

It look like two many position of abutment when no crown down to open the margin of the restoration. If you want to verify do what for so it doen and then it can be so to access for implant crown. This not only help for access to open crown but to allow for better only position to go with. I hope this helps. God bless you my friend.

This looks like a straumann implant and many times a solid abutment is used which does not have a screw, instead the solid abutment is torqued in and the screw and abutment are one piece. Therefore, drilling an access hole won't help. If the crown is loose, it'll fall out in your hand. If the implant is loose, there will be pain with rotational movements. If the abutment is loose (most likely), try and tap crown off. I recommend the pneumatic crown remover by DentCorp to try and tap it off. It's reasonaly priced and a great product. You can tell if it's the abutment that is loose because the crown will be able to rotate slightly as the abutment rotates inside the implant. If there is no rotational movement then possibly an angled abutment was used which indexes an internal hex and the abutment screw is loose. You might as well cut the crown off if it won't tap off since you'd only be guessing where the screw head is.

With this high neckline presentation, access may well be on the buccal due to implant angulation. Try to remove the crown as it is likely to be on with TempBond. Agree with others on preparing patient and yourself for the worst scenario, time and expense wise let alone temporisation. Good luck.

Not likely to be a cement failure, if the cement fails the crown comes off, unless it was cemented with a resin based cement and has some internal retention between the crown and abutment partialy holding it in place. Crown movement would be minimal. If the prosthetics was done correctly, it is a loose screw on a non rotational abutment and the crown and if pressed in to the gingiva, should not have any rotational movement. Then drilling on the lingual will probably provide access to the screw and permit removing the crown/abutment unit. Keep the crown stabilized while cutting on it to avoid damaging the implant. If it is a one piece rotational abutment, with the screw machined on the abutment, It was used incorectly for a single unit restoration and will not stay tight very long, since it lacks lobes on its base to provide the abutment anti rotational retention, The crown will present a tendency to rotational movements and if you make interproximal slices on the crown to clear interproximal contacts, you will be able to rotate the abutment crown unit out in one piece. Do not re use this screw, since it has suffered permanet deformation, once it has been torqued down and specially after being stressed by a lose abument under oclusal forces. A thread retification tool might also be in order to rectify the treads on the implant. If it is a Strauman, they are made from Commercially Pure Titanium and are very easy to damage and then the implant will have to be removed and start all over again. Any type of crown puller, depending on the forces applied will permanently damage the treads on the implant or the delicate machined surface on the implant margin, making it almost impossible to restore.

This crown may have no problem with how it looks. If the lip covers the gingival area it may look fine. I am sure that the submitting doctor knows this, so why all the comments about how bad the crown looks? The doc is asking how he might salvage the situation , he is not asking for an evaluation on how it looks. Perhaps some vibration could cause the screw to back out a little more or maybe a thin instrument could be worked between the crown margin and the abutment finish line and the crown removed. With an anterior restoration access to the abutment screw will almost always be through the facial of the crown. The safest way to approach this problem is to inform the patient that the crown will most likely be destroyed to avoid irrepairable to the implant and the implant abutment. So also inform that the abutment might have to be replaced as well. With the patient agreeing to the risk of crown and abutment needing replacement only then may one may procede with an attempt to salvage the existing restoration for replacement. Do not try this unless the patient accepts this risk or you will own it.

First off, this is one UGLY crown and a total esthetic Failure. If I received this POS for a tooth that looks like someone stuck a candycorn on #8, I'd ask to have it removed and just give me a bridge from #7-9. That said, if you're trying to access this from the lingual to find the screw hole, you will not be able to find it, b/c it's on the FACIAL! The radiograph shows the platform of implant #8 to be at the same level as the apical margin of the crown on #9. But the clinical photo shows the pink porcelain on #8 going all the way down at least 8mm (in relation to the crown margin on #9) to the gingival margin of #8. This may give the illusion that the implant was placed very deep apically, but it was not. The surgeon angled the implant too facially so the patient lost all the facial bone along with the gingiva covering the smooth collar of this particular implant. This winner of a crown was made with a facial flange like a modified ridge-lap pontic to cover the 'silver' neck of the implant. You can obviously tell the huge space b/t the porcelain and the gingival margin while the radiograph shows top of the implant platform to be at same level as the margin of crown on #9. So, even if you can get the crown off (try Facial approach), you will always of an Esthetic Failure, b/c you will have to try to cover up the shiny silver of the implant neck. My advice: Take out Implant #8 and redo the implant surgery/crown or do a bridge #7-9. You can also try a CT Graft to cover up the metal of the implant and then fabricate a crown, BUT the exposed neck is so huge and facially inclined that I wouldn't bet my money on it.

It appears that most of you have missed one important detail, if you look at the incisial edge of #8 it is 3/4 mm longer than # 9, which to me it will indicate that the abt. is not torqued in that being said stop knocking the esthetics of tissue porc. and look at the color of the gingiva apicaly it does not look healthy as the rest of gingiva around #"s7 and 9. due to food trap and irritation by the patient trying to keep it clean. Dr T,explain to the pt. that this crowns future is to be used as a temp. restore wit a new custom abt. Etkan, . Atlantis will do fine as for porc. gingiva have your dent. tech. use as close to the match of tissue porc overlayed with very transluscent enamel mixed with a b1 vita shade in a ratio t70% b1 30% for the pink bony effect. Good luck

From the position that the crown restoration starts (high and labial), and the length of the implant on the radiograph, it is fair to assume that the screw hole will not be accessible from the lingual. Attempting to remove the crown by tugging, pulling or twisting increases the risk of damage to the threads of the implant, so the prudent thing to do is advise the patient that the crown needs to be sacrificed in order to avoid damaging the implant. If my gess is correct you can drill a hole from the labial at the level where the pink porcelain starts and you will be able to access the screw head and dissassemble the restoration. You may find that the abutment is adequate, but use a new screw. thread locking compound may help since it is a long crown with off-axis forces applied to it. Good luck!

You may consider cutting off the crown and removing the abutment. You may also consider a custom abutment and crown. There is a distinct facial shadow which may not be an aesthetic smile line issue. Usually when these are lose, it's the abutment. A lose crown will dislodge without much effort. This can happen to any of us. Just give it time and it will. Dr Mark Miller you are correct. We do not know how this case presented prior to implant placement. The younger docs will find out that the world of implant dentistry is far from perfect. There are many imperfect situations.

The implant is failng and you cannot rely on PA radiograph because PA does not provide any information on facial/lingual aspect of the implant/tooth. This implant does not have any facial bone therefore I recommend plan to remove implant. Do not waste your time to look for an access hole on facial or lingual; just raise the flap to see a hopeless prognosis for this implant. A blusish gingiva should tell you that facial bone is missing even if looks OK on PA radiograph.

This is by far one of the worst crowns I've seen. Pink is used for dentures, not fixed crowns. The links at the base of the abutment lead me to believe this is a Biomet 3i abutment 4.0. The gold screw was probably to torqued properly becuase of the fear of stripping the gold screw ( I have seen this many times). John Kong has a very good point. Esthetically this is a total failure. Drill into the crown through the long access and determine the screw access from there. 3i will warranty any crown and abutment that has failed. I would charge my chair time no matter what.

If the crown itself was loose it will easily come out. In fact it would have fallen out by now. The most likely scenario is a loose screw, and if it has been loose for any amount of time, there is a high probability that either the abutment and/ or the internal locking in the implant has been damaged by the constant movement. The only real way of checking is to remove the abutment and crown and try in a new abutment to check for any rotational movement. I disagree with those that advocate cotton wool or the like on top of the screw. There are only a few certainties in life, and one of them is "a screw will always come loose, given an opportunity". By not locking in the screw down to the screw itself, there is a strong possibility that the screw will come loose, particularly if there is any bruxing or the implant experiences significant loads. My technique is to cover the screw hole only with a semi soft material such as cavit, then fill the access hole down to the top of the screw with Ketac Molar. I find this material is not that difficult to remove but provides a degree of certainty that the screw won't unwind and it is still possible to access the screw to remove it. Also in this case, if there is significant in and out movement, removing interproximal porcelain can often allow the abutment to unwind by turning what's left of the crown and the abutment. Also it is possible to regenerate the crown after it is removed by replacing the porcelain.

Thank you Mark.

Thank you for all your suggestions. After discussion with the patient. We decided to remove the crown and implant, then GBR 3 months after healing and Implant placement 4 months later.

Dr.miller, there is no way you can make this tooth look esthetic or remotely natural. Also most women show 1-2mm of the gingiva when smiling. If she had a low smile line or it wasnt an issue, I think Dr. Teoh would have left it alone (but your point regarding smileline is a valid one). Temporary abut and crown is a waste of time and resource for this case b/c it's so obvious to me that it cannot be made esthetic when so much of the silver collar is exposed. Left alone, the pt remains an esthetic cripple. You take out the implant, and replace the implant in better position or do a bridge. If this is not in your comfort zone, send to a prostho for 2nd opinion instead of tinkering with it b/c you cant visualize the end product.

Dear Dr. Kong, I'm sure that between the two of us, we can solve this patient's problem. Let me point out some things to you. Go back to the Chief Complaint. It is not esthetics. It is a loose crown on an implant. This is the purpose of these posts...to help Dr. T solve this issue. You seem to be hung up on esthetics when you have no valid reason yet if this is indeed an issue...and even if it were, this is not the reason Dr. T posted the case. Your entire last post continues to make suppositions that don't exist. "Most women show 1-2mm of gingiva when smiling." This is not most women. This is ONE woman with a loose crown. 'Silver collar exposed'. I guess I don't have the photo that shows that. All I have is a frontal view and sagittal view and I'm failing to see a silver collar. 'Esthetic cripple'. This is a very judgmental type of comment. Read my previous posts. You are Monday morning quarterbacking the esthetics when it has not yet been addressed as a problem. Early Branemark cases from the 60's and 70's were high water hybrids and patients were most of the time just happy to have teeth. How do you know this isn't the case here? I don't think you do. And please tell others on this blog how a temporary abutment and crown to work out esthetics is a 'waste of time'. I'd be willing to bet the vast majority would not consider it a 'waste of time'. Let's see what gets posted. As for a bridge-not a bad call if indeed esthetics is an issue. One caveat. From what I can barely see from the x-ray, #9 has an endo and post. Although an ovate pontic on #8 might help, now you are crowning a virgin #7, and asking a compromised #9 to support a 3-unit bridge. Again...risk/benefit. And as far as esthetics on a 3-unit bridge, the ovate pontic might be quite long apically if the implant were to be removed. And then, God forbid, 'pink porcelain' might have to be used. If you like, I will be glad to post photos of the many successful 'pink porcelain' cases I have completed in my 40 years of dentistry. Best wishes as always, Dr. Kong. We're having beautiful weather out here in Southern California. I hope New York is treating you well, too.

The reason of removing the implant is that there is no way I can be sure the loosening of abutment will not happen again. Because of the excessive buccal inclination; unfavourable force on the abutment may be the cause of loosening. Removing implant; rebuilding foundation and placement of new implant in ideal location is the only way I can make sure abutment loosing will not happen again, in addition, I can improve the aesthetic. (Although the patient accepted the present situation, she was not entirely happy).

Dr.T, thanks for the clarification. Dr.Miller, though we may differ in opinion, I appreciate your thought process and insightful comments; you sound like an excellent old-school dentist.

Usually abutments come lose for the following: an external hex implant is more inclined due to poor design, an internal hex due to poor seating of the abutment. If you do this long enough, you will incorrectly seat an abutment. Some implant manufacturers use to (maybe still do) employ gold screws. I have never understood this poor logic. To the younger docs, you will learn that pink porcelain is your friend! There are times when hard and soft tissue grafting does not work, the patients do not want to do it. Also consider maxillary implants are usually placed in a position of having off axis loading, which cannot be corrected.

Dr Miller: again you brought out many good points. The reference to a 3 unit FPD from 7 to 9 is a good take home lesson. This presents from time to time in clinical practice. A neophyte might make this mistake of bridging from a lateral to a central (w, or w/o endo tx). If one has to do so, at least apprise the patient of the potential for failure. Sometimes something that looks so simple, can be so difficult.

In lieu of removing the implant, one can perform a vital segmented osteotomy and move the implant into the desired position. Tatum Surgical teaches this technique.

Dr chan: I understand your thoughts. However, the OMS has to understand the concept. You are correct, it is not for the average GP. There are not many that understand Tatum's concepts. Tatum is an American GP!

Having just this minute used the Neo-Biotech Implant removal device to remove a fractured Straumann , which was amazing , I now can say removal is an easier alternative for the best long term result. It was simply stunning. Peter

I just read these comments and there are some very insightful and experienced, common sense implant doctors commenting. I would suggest to those that completely denigrate the use of tissue colored porcelain to read articles and case presentations by Salama and Garber. Truly, this is an option that can and should be given to patients along with other options. While I agree that this crowns looks un-esthetic, it is a poor judgement to immediately condemn this and all "pink" porcelain as bad, in this particular case, without much more information, which Dr. T has been now providing. I read the posts above by Dr. Kong and now that I have read more of his posts, I see that he is highly educated but apparently young and limited in his years of experience. I would bet that over the next 20 years or so he will become much wiser. Having been through postgraduate training myself many years ago I know what it is like to think you know it all. Just like playing an instrument, it takes many years to blend knowledge with wisdom and for some it does not come easy. The worst trap for a clinician to fall into is a mind of absolutes. Implant dentistry requires creativity. Absolutes limit creativity. Personally I have been doing this work since 1982, beginning with Dr. Robert James at Loma Linda. Richard Hughes, who comes at these discussions with a large degree of experience, and others on this site like him, fully understand what I am saying. Unfortunately, those that take their training as a license to pontificate from a platform of absolutes are doomed to limits in concepts for that very reason. To be specific, Dr. Kong, you really should step back from a close view of cases and develop a much more global perspective of each case. Far too often the mistakes in reconstruction come from thinking too close. In your defense I would also comment that this crown, from most any view is not very esthetic. However, even though the patient is not very happy, of course, I could not find a reference to lip line. Anyone that stands in front of their mirror and pulls their lip up would not "be very happy" with this restoration. My point of my post here is simply to urge Dr. Kong and whomever else to step back and take time to develop wisdom and refrain from absolutes. Never say Never and Never say Always. And, Dr. Kong, you are probably a very nice fellow, very highly educated within the concepts of whoever educated you, but be careful for many periodontists can be focused and miss the over-all. Thus the concepts of Periodontal Prosthesis. Arnie Weisgold, among other very wise folks (my mentor Mort Amsterdam, for example) state that the end point in interdisciplinary cases, such as the one we were discussing yesterday, is only deliberately found by those that have the skills to treat the entire case. Again, thus the concepts and training in Periodontal Prosthesis. Dr. Kong, I would respectfully submit that you learn to step back and discover wisdom like Dr. Hughes and others on this forum. And hey, I do apologize for having so much fun at your expense yesterday. I will refrain from going there with you in the future. And please keep posting on this site for many of your comments have foundation in accuracy.

Musicman, makes an absolutely prophetic suggestion, in that there are NO absolutes in medecine/surgery/dentistry. This is why we say, " we are practicing" dentistry . Be ware of the emphatic response and yes, when I finished my 14 years of education, I knew nothing, relatively, but was not scared of anything. Repairing the injured nerve, opening the joint that would have been better served by physical therapy, opening fractures that would certainly heal on their own, to just about everything. I am much more conservative now and learn more and more each day. I call old teachers and colleques all the time, when I am not sure and will not hesitate to tell a patient, I don't know. Bv

Almost 60 responses and not one of us mentions the frenum! At least I don't think we have. If the implant is integrated, have some one do a laser frenectomy ( patient compliance upon healing is critical by the way). This, in my opinion, is going to give you a significantly greater, emmergance profile. Forest : trees ??? Bv

Great comment about the frenum BV , all too focussed on that not so nice crown. As for learning , one of my 8 year old twins said to me the other day he wants to quit school , when I asked why , he said he knows everything , had a laugh as the great aspect of learning and getting older is the more you learn the more you realise you do not know. My Mentor began placing in 1964 and always says he is only learning. Peter

When looking at the sagital photo of the offending crowned tooth, I do not see titanium metal under the crown...it looks like tooth structure that is decalcified..... When looking at the radiograph of the implant and crown, the crown seems much shorter than that portrayed in the photo....I think this is a mismatch of information !!! When presented with a loose crown on an implant, and not knowing the history or having the model on which this crown was built....it is very difficult to guess where the access hole for the abutment is....it may very well be an angulated post, and the access to the screw would be through the facial surface of the crown.....best to slit it and take it off ....without hammering or pulling that may strip the internal threads of the implant or damage the implant. Gerald Rudick dds Montreal, Canada