Malpositioned and misangled implants: thoughts on restoration?
The doctor sent this impression of two dental implants that need to be restored. Many seemed to think there is no possible way to restore this case, due to the malposition and misangulation of the implants. The patient had bone graft surgeries done previously. One seems to be placed way more buccally. The dental implants are osseointegrated, no mobility. We were thinking of possibly restoring it with a hybrid. Anyone have any ideas on how this could be restored? Any feedback would be much appreciated.
Buccaly placed implant
36 Comments on Malpositioned and misangled implants: thoughts on restoration?
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CRS
11/1/2013
Perhaps the services of a maxillofacial prostodontist, as you would restore a surgical defect. The implants appear to be in the vestibule angled across the ridge. An xray would be helpful.
paolo rossetti milano
11/1/2013
I have never seen something like this. The implant in the central incisor site is in the middle of the muscle . The platforms of the implants are above the level of the tissue, suggesting that the graft has resorbed leaving a good amount of rough surface of the implants exposed.
The prognosys of these implants is probably not good.
Kevin Caruana
11/2/2013
Take the implants out and place new ones in using a surgical stent for guidance
Richard Hughes, DDS, FAAI
11/2/2013
Four options!
Take it out and start over.
Put the central incisor implant to sleep and bridge from the lateral incisor implant to the natural central incisor.
Vital segmented osteotomy to reposition the misaligned implant.
Use an implant and tissue born removable prosthesis.
CRS
11/2/2013
How about removing and restoring with a blade in the thin ridge?
Richard Hughes, DDs, FAAI
11/3/2013
CRS,
First remove the malpositioned root forms. Then graft and give it tincture of time.
Depending on the available bone, blades or root forms are appropriate. We do not know if the ridge is thin or sufficient in width and height.
This is a clinical FUBAR
I would like to see radiographs (PAs and pano)
As Palo stated I have never seen anything like this.
CRS
11/3/2013
One should not drink and drive, nor place implants.
Sb oms
11/2/2013
Non restorable
Obviously you can bolt anything in here,
You could even make a substructure and make it look somewhat normal-
But it's such a disservice to the patient.
Is it possible that your impression copings weren't down correctly?
The central implant looks like it would come out the nose.
I've had better outcomes in maxillectomy patients.
Michael Gross
11/5/2013
Don't even try to restore.
Implants have to be removed and grafted and then has to be started with planning, preferrably with 3D planning and guided surgery, of course performed by another surgeon. Might be besides drugs there could have been a very nice looking dental assistant which was distracting the surgeon :-)
A nightmare this case....
Ali
11/5/2013
Technically, It can be restored with a custom abutment and cross pins but making it maintainable will be a challenge.
Redo/ realign implants is a far better solution
Dr G
11/5/2013
There's more to this story. The canine is supra erupted, there is a severely decayed premolar visible in the cast. Give us more background. Maybe extract 11,12 then cantilever x-10-11-12?? A panorex of FMS would be helpful.
Dr G
11/5/2013
Sorry I meant exo 5,6 and cantilever 5-6-7-x.
John T
11/5/2013
I agree with everyone else. These implants are simply not fit for purpose. Even though they are integrated you should be able to remove them with a Neo Biotech implant removal kit without the need for trephining. The defects will heal rapidly without any need to bone graft. Then you can start from scratch and place new fixtures as indicated by a placement guide, etc. In the UK one can hire the removal kit from the distributor and no doubt you can do the same where you are based.
Cliff Leachman
11/5/2013
Holy moly! Whenever I'm feeling inadequate I will remember
this case and think it's just not that bad! Thanx for posting.
The implants almost look like they are laying down to sleep.
Rotten premolars, drifting canine, maybe they should have been
dealt with first, but still a "Rocky Horror Dental Show"!
kurt wirth, dds
11/5/2013
What exactly does the patient want? Is the patient looking for removable or fixed? Is the patient willing to go for more surgery?
Just checking. kw
Gerald Rudick
11/5/2013
Everything in life is timing........why was this case not posted a couple of days before?
There is no doubt that the way those implants were placed, they could have been restored and been price winners for Halloween.
The patient needs to get a good pair of running shoes and run as far away from the dentist(?) who placed them......... get rid of them and start over with a skilled dental surgeon.
Vipul G Shukla
11/5/2013
Something is seriously wrong here. You have to be seriously incompetent to place implants this way. I think either the dentist is having fun with you or the impression copings moved during the impression procedure and the dentist did not realize it.
On the lab side, I see the soft tissue mask is not properly poured prior to the die stone.
Clinically, I see the impression was made with a stiff polyether or putty type VPS without any light body to capture margins in detail. The material obviously did not flow around the copings hence those lumpy pink areas in the vestibule.
Worse thing I noticed is that the dentist probably did not even wear gloves when taking this bad impression! Notice the fingerprints?
As Dr. Rudick says, Run fast. Run hard. Don't look back..
B. Saib, DDS
11/5/2013
Very difficult indeed. The only possibility to restore this case would be to have very thin material in the buccal space. Although a hybrid may seem like the only option, it will require a multi-unit connection which will add to the buccal extension, then a titanium frame and then resin. All of which will add to the buccal extension. The only thing I can think of without actually removing the implants would be to fabricate a milled all zirconia restoration with pink porcelain. The milling process would have to involve milling the abutment as part of the entire structure (if this can be done) which means the implants would need to be parallel.
Start with is:
1. Take a better impression where the two implants are splinted with resin in the mouth and using an open tray technique.
2. Mount the case on an articulator (semi adjustable)
3. Wax up of ideal incisal edge locations.
4. Fabricate a provisional using resin. (most labs doing zirconia restorations can also mill resin)
5. If things look good and the patient accepts it then fabricate the final zirconia.
You will not make any money off of this case due to the complexity of it but you will learn a lot.
Good luck!
B
Tom Wierzbicki
11/5/2013
If those implants are truly in those positions, this is malpractice! They are not restorable! Remove them, graft the defects and the ridge to allow for proper placement. Once all is healed place new ones in the proper positions and angulations!
MPEDDS
11/5/2013
This dentist should not be placing implants. At least one of the implants is in the vestibular mucosa and has a poor prognosis for maintenence. There are grossly carious teeth in the arch. How about eliminating disease so as to have optimal health before placing implants? This DDS needs to refund the patient his money and refer them to someone competent. He/she should slso be responsible for any complications for this botched case.
K. F. Chow BDS., FDSRCS
11/6/2013
Ideally, the implants can be removed by reconnecting the drivers and reversing them out.This is quite possible since the fixtures can be clearly seen with their receiving openings stark wide open. A reversing torque of about 100 ncm usually does the trick. Trephining a little around the fixtures and then elevating them out with a couplands is the last resort. The implants should be removed and replaced in the right spots because where they are is unrestorable and maintaining them will obstruct proper reimplantation of the site or any other prosthetic solution you can think of. Whiz them I say.
Zvi Fudim
11/7/2013
This is a really marginal case but there are many cases that don't look so spectacular and still they are disasters from the prosthetic point of view. The problem is that there is no affordable surgical guide on the market. You can buy great implants for less the 100$ and even get the abutment for free, does it make sense to add 500$ for a surgical guide. The answer is no. How about fabricating a surgical guide for 15$ super accurate? That's more logic. Check out the SGLA. It is a 3 dimensional guide made out of CBCT, no compromises on precision. I have an SGLA more then a year it works like nothing else. We have completed cases one on four and one implant cases, flap or flapless, always works.
CRS
11/9/2013
I think it is an interesting tutorial. Eventually I think a wax up is needed for adjacent implants due to crown morphology I like to use the same stent for the ct guide and surgery which is a waxed up barium guide. My lab charges $150. But at surgery I only use them at the beginning and end initial drill guide and final with implant to check how close I am. I've rarely had a perfect stent due to bone morphology even in orthognathic surgery there is a slop factor. Close is good in horseshoes and intra oral splints. However I will take a little more time to investigate your technique. I have such a variety of stents sent with me to work with, like a box of chocolates. I agree that there is a large market on surgical stents that are overpriced. I used to make my own stents the old fashioned way on an articulator so I trusted what I had. Nice product you invented thanks. I don't honestly feel in this case a stent would have helped this guy is an idiot who doesn't get anatomy.
Kastytis Zymantas
5/11/2016
Take a look on youtube for BlueSkyBio and you will find you can get a surgical guide made for less than 50 dollars. This technology is growing super fast with lots of new developments because the company is listening to the users and advancing the technology quickly to the users requests.
John T
11/7/2013
Er ... Excuse my ignorance. Wot's an SGLA? According to Google it's the St George's Lighthouse Association of Florida.
John T
11/11/2013
Surely someone can enlighten me. What's an SGLA?
K. F. Chow BDS., FDSRCS
11/11/2013
Surgical Guide Laser Aligner. Never used it myself but here is the link: http://www.stomatotech.com/surgical-guide.html
Like all surgical guides, I assume you have to spend time fixing it to the mouth firmly. Then you must meticulously drill along the drill holes without any deviation whatsoever. It will work provided the stent was accurately and intelligently done, and you have spent time to fix it accurately and firmly. And that may be the reason many implant dentists prefer eyeballing and drilling freehand instead.
Zvi Fudim
11/12/2013
Yes, the SGLA is a SURGICAL GUIDE LASER ALIGNER. It is a desktop tool, equipped with two digital lasers, a parallel arm and a small software. You just measure two CBCT angles fill up the two fields in the software press calculate and you are almost done. The point is that you don't have to fix it in most of the cases, because the material is like a firm thermoplastic material with some degree of elasticity. The base-plate passes the undercut of the teeth by clicking into it's place. That's why it is very stable and your both hands are free. By the way it is good for edentelous cases too. The tube is adjustable to the bone level. The tube is also a stopper at the same time. After all the "hell" that we had with the Rapid Prototyping Manufacturing guides it is hard to believe that there is something really practical and you can use it on case by case basis. With the SGLA it doesn't cost more than 15 bucks to fabricate a guide, as far as you have the tool in your office or lab. You make 15 guides you get your investment back. I want to point out a very important thing: The main purpose of the surgical guide is not about placing the implant straight in a raw, it is about to plan correctly the treatment. Most of the time when you make your implant eyeballing and drilling freehand you also not putting an accent on the planning. Another mistake that we do; is that we think that the surgical guide is mostly meant for the surgeon. No, it is firstly important for the restorative dentist. An experienced surgeon or periodontist can stick an implant anywhere, will it deliver a prosthetic result? I'm not sure. Who will pay the price? The restorative dentist.
Dr. Sampson
11/12/2013
We should always be careful with our words. I would never use the term malpractice as one does not know the whole story behind this outcome. Malpractice is an extremely perjorative word and a legal word and really has no place in discussing a medical/dental situation like this. A bad outcome does not necessarily mean malpractice. Choose your words carefully.
CRS
11/12/2013
This outcome seems to me to be iatrogenic and an instance of negligence and incompetence. Whether it is malpractice is up to a jury to decide.
Dr SenGupta
11/21/2013
I cannot imagine a clinical situation that could in anyway justify this .Compounded only by poor quality impressions.
Dr SenGupta
11/20/2013
What a terrible case.
I certainly would not be working with this surgeon.
Remove the useless implants and start over.
"Implant dentistry is a prosthetic discipline with a surgical component"
Dr SenGupta
11/21/2013
A second look at the quality of impression and material and tray.. used to the right of the image confirms this is either a joke... or complete amateurs who have no place doing this kind of work.
PW
12/3/2013
I agree with Dr SenGupta, look at tooth #2 in the impression, there is no way it would have produced the model shown. Someone is having some fun at everyone's expense.
Bruce
8/9/2016
I'd start with a thorough vision acuity and depth of field assessment of the person who placed these gems.
Howard Abrahams
2/28/2017
You may want to consider a metal substructure that gets screwed in and then cement crowns on the metal substructure. Think of it like a full arch implant case where you individually cement 12 or 14 crowns on the titanium substructure. Good luck !
