Unsure about lab work with Nobel Replace Conical Internal: thoughts?

Qualifying question, why is the implant buried so deep, if it were at bone level the long abutment which seems to be trapping food would not be needed? Is the system designed that way?

-Yes, it is seated Ok. -The implant is deep -The crown should be corrected, add porcelain to avoid food collection in the contact area. -It would be useful some clinical pictures to value the distance between porcelain and gingiva and shoulder of the abutment.

look at the flare of the impression coping you used. This is what the abutment should have looked like in the trans-gingival portion. This would have given you a better emergence profile to fill the enormous inter proximal spaces. Nobel active is a good system. However, this implant is 4.3mm, platform shifted to 3.9 mm. Your trying to replace a molar that is probably 15mm mesio-distallly. The numbers just don't work for me, and this is what you get when you put these implants into molar spaces. Also no need to place them sub-crestally in this part of the mouth. I agree, the crown should be made differently, with more porcelain to fill the space. I do not use these implants for molars, only for a bail out if I can't stabilize anything else. Consider something with a wider platform. There is no reason to platform shift in this area. You need strength and hygiene in the posterior, and you have neither with this implant. I am a big Nobel Active user. It has changed my practice for the better. I do not use them in molars, for just this reason.

I have few thoughts about this case: 1.there is nothing wrong about subcrestal placement . On contrary, it will prevent the crestal bone loss during function, since the top of the implant surrounded by thicker bone. 2. Emergence profile is the issue here, that's why there is a food trap problem. It happens when you place RD implants into molar sites and loose control during lab phase and let a tech to decide what is the best for the case 3.Going back to the treatment planning, I would place a 7mm diameter implant ,regardless how thick the bone was B-L. This called biomimetic implantology because you want to mimic the size of the root surface of this first molar with WD implant vs "regular" one. It is challenging so I had to develop a special, reliable surgical technique for that. And of course PRF helps a lot. Everyone is invited to see the sample cases at my website If you follow my biomimetic protocol, you'll never have a "food trapping" problem

The issue of food entrapment lies with the gingival embrasures. This can be an issue, regardless of the system used! You may consider disking the adjacent proximal contacts, to allow for broader contacts. This said, the patient will still have food entrapment. That's why we have dental floss! As far as more porcelain, the porcelain needs metal support. If there is too much porcelain, it is prone to fracture.

Still don't get why the implant is buried so deep, I think that the bone will die back in a few years, the abutment interface is subcrestal in a non esthetic area and how can one tell if it's Nobel active when only the top of the implant is on the film. I place these at the crest in the posterior to avoid these issues. Probably a good case for a Straumann transmucosal implant. Looks to me like the principles for an anterior esthetic implant were utilized in the posterior oops!

I did not place the implant. Sometimes, the surgeon placing it has suggested a platform switch but that was not requested here. Would the platform switch be because of the system used, the impression coping chosen or just the lab deciding again?

I will definitely be speaking to the surgeon about it in the coming days. Going back to the lab work - from the impression, the lab would know that it is deep from the soft tissue model but wouldn't know where it was in relation to the crestal bone? Could it be that the food is collecting because the thickness of gingiva is causing it to give way as opposed to the excessive contour. If I have the lab construct a more gradually tapered connector section, will the food collection remain because of 'floppy gingiva' that is too easily displaced? Any experience or observations of these phenomenon?

Robert P, Sometimes we can only do so much. You gave the patient a functional and probably esthetic prosthesis! Therefore, JOB DONE. I tell my patients that they still have to brush and floss and that maintenance is greater for implants and that their level of responsibility has greatly increased. Yes, do what can be done about the proximal contacts and embrasures. It still amazes me how some patients do not want to take any responsibility for their problems. You have to inform them that you are offering the best that dental science and technology has to offer, but it's not perfect. They had the best and that's what God gave them and that everything else is second best! Don't beat yourself up!

Nothing was done wrong. It's a rather typical moment, but most patients consider it to be OK, and do not have many complaints if you foresee this situation and explain it to them before treatment. Food accumulation was less if you asked a dental technician to create medial and distal occlusion rests from the restoration on the adjacent teeth.

The placement of the implant looks fine. The patient needs the basic reduction in the width of the occlusal table, contact of the opposing lingual cusp in the central fossa with freedom in centric, reduced cusp inclines and broader inter proximal contacts. Do not have contact on the marginal ridges. Again they still have to brush and floss. Hell, patients complain about food entrapment with fixed bridges, removable partial dentures etc. We can only do so much!

There is a food trap as others outlined. i think the emergence profile should have been a wider flare and this can be corrected by the lab by adding porcelain to this area of the crown. This can be an issue as the tissue can collapse when you take any healing abutment out and take an impression as the impression head doesnt support the tissue in the wider position. See this article on it

Please explain something to me - I apologize in advance if my terminology is lacking in any way here...I don't see how a wider implant would have produced a better emergence profile when there is a long straight connector between the root form implant and the supragingival crown. It seems to me that even with a narrow implant buried deep, there is lots of space to have a more tapering connector - unless this produces some other sort of hygiene problem....Thanks for all your input so far.

I call these types of restorations "lollypop" crowns, which do not replicate natural anatomy and emergence profiles. The patient is probably retaining food debris because of a lack of papillas to fill the gingival embrasure. Any one with gingival recession (including me) knows how annoying it is to have to reach for a toothpick every time you eat something. This can be solved with an abutment and crown that is flared properly and contoured to fill the embrasure. Most labs place a soft tissue material around the implant when they poor the impression. Instruct your lab tech as to how you want it. There are various ways to do this. The final restoration may be tight and may blanch the tissue when seating, sometimes even requiring anesthetic to seat it. Alternatively you can remove the restoration, and place a custom healing abutment for a period of time to develop a better emergence profile. This case looks like a simple fix, you just need to start over. Hopefully the lab will give you a break on the fee.

The lollipop kind of surprised me - I don't recall seeing them before - the labs used did use soft tissue models but I never specified the emergence before for posteriors. After reading the article posted earlier on anteriors (techniques used that I have used), I think that what is happening is three things: 1. lollipop through loose gingiva to a deeply placed implant results in more need to clean 2. the healing abutment was a broad tapered one so the tissue likely collapsed after the lollipop was inserted leaving a gap 3. I need to make the distal contact broader I will await your feedback before deciding how to proceed but my treatment in the future will be better for this forum - Thank You!

These photos relate to the case title above... Here is a separate case I put in yesterday - another inherited patient midtreatment - same surgeon, same system, different lab. Should this one be any more successful? (Existing caries and overhangs inherited and will fix!) Impression Coping: Crown Fit

The second case looks much more ideal. I'm not sure why your surgeon is using the Nobel active implant in the molar region. This implant has a very aggressive thread design that is there to offer good initial stability in cases where you want immediate loading with a provisional i.e. an anterior case. There are lots of good implants available for molars and this would not be my first choice. Talk to your surgeon about implant selection.

The dichotomy of implant platform diameter vs M-D dimension creates the problem sometimes solved by a custom abutment which can provide much better cleansable contours . There is a need here for starting with a wider platform implant when possible. So there are options.

I think the implant is well placed, and the situation is easily correctable. We have not been told whether this is a screw retained crown or is it cementable..... I would remove the crown......place a stock abutment and make a chairside temporary crown, and observe the gingival form....that being done, anaesthetize the patients; "shave off some gingival tissue" around the abutment with a blade or a laser, add acrylic resin to the gingival portion, and extend it to 1.5 mm above the implant body, polish the crown and cement back in with temporary cement.( making sure all temporary cement is removed) Check in a few days as the gingival architectural will now be more closely adapted to the area....and see if the patient is satisfied....if so modify the crown, or take a new impression and have a custom abutment made. Dr. Gerald Rudick Montreal, Canada

No matter what kind of implant you use, if the food collection exist, I suggest you to make a temporary crown for couple of weeks and then adjust the trans-gingival profile to close the gap. And we still need more information from clinic photos. The abutment profile is concave or not will effect on food collection. Anyway, bone level implant are basic same in restoration, but different implant-abutment connection will effect on abutment seating and stability, not effect on food stock.

Is there a reason why no one has mentioned an Atlantis abutment, or am I missing something?

I only scanned through the comments but did not see anyone mention that the impression coping does not appear to be fully seated. If that is the case then the implant analog would be set too occlussally in the model. The crown when fabricated on the implant analog and model would fit ideally, but when you screw it down to the actual implant that was placed more apically the crown would be out of occlusion and that would result in food impaction due to inaccurate contacts