Misplaced Implant: When can I remove and place a shorter implant?

Hi, Here's my question that I ask myself when a procedure doesn't go as planned. Am I better off if I just keep continuing with the procedure even when I know it's not going to be standard of care or not going to work out? Pretty much every time (100%) the answer is NO. I should stop, think about some other options, inform the patient and then move forward with a new treatment. My intention is not to scold you, but to give you a question to ask yourself whenever you are in such as predicament as above. Now, I would have backed out the implant at that time. Placed some bone graft and close, and then placed the implant where I see much more bone. Did you take an x-ray after your pilot drill? That could have shown you that the implant is way off. Now, even if you back this out, you will have lost patient's trust that you did not inform him/her at the moment of complication. Good luck with this case. Let's hear what other more seasoned doctors have to say.

What are you doing with this implant? Is it a partially edentulous patient? A fully edentulous patient? Remove the implant and replace with an angled implant as described by Malo et al. to avoid the sinus. Then either use an angled abutment if fully edentulous or a custom angled abutment for the partially edentulous.

You can take it out now and seal the osteotomy site with a collage plug now. No need to waste any graft material. Once the fixture is removed just place another more anterior. As far as perforating the sinus it obviously was not your intent but this happens often when maxillary molars are removed and it heals with very little attention given. I do applaud you for admitting your error and not just blaming it on that "other dentist".

Depending on what you plan to do prosthetically with this case, you can place another implant mesial to the one in question at a slight angle and miss the sinus. Don't wait for an infection or other complication to happen, remove the implant and use a collagen plug to the level of the sinus floor. Cover with antibiotics. In the future, follow the correct protocol and take several periapical films as you prepare the osteotomy to determine the position and length of the implant. Good luck!

If there is no longer an infection......regardless of the position where it is placed, you are not going to use it...…. if you try to remove it, there is a possibility that in unscrewing it, you will send it deep into the sinus....and it will float around like a ghost ship..... and that every time you will take an xray, it will be in a different position... and will haunt you for the rest of your life !!!!.so leave it alone and forget it. Wait a few months, and then place a new implant into the correct position.

In removing you should be very easy with the cover screw removal. Do not put apical pressure on the fixture when removing the screw or removing the implant. For insurance you can place a transfer abutment on the implant and turn it out with a hemostat. An implant perforating the sinus floor is not necessarily a failure ( bicortical stabilization) but certainly not the standard of care. Use your pilot drills a little more wisely and don't get in a hurry. Good luck

Coming up with a “real time” plan for checking and regaining proper implant position will go far in avoiding this type of final result. We all have to understand that when flaps are tied back and blood is flowing, our adrenaline levels soar and special judgement distorts. We must design a series of position checks at steps along the prep/insertion process. For one, a short 4-6 mm deep 2mm pilot drill with an x-ray of a dummy 2mm post would immediately guide you to a corrective angle/position. After that, a dummy implant (expansion plug, or the like, attached to a handle or “T” post of subsequent prep sizes could be inserted and measured or x-rayed. The last thing I do BEFORE even opening the implant packaging is to insert an identical, full-sized (or slightly smaller size in sinus lifts) into the site and check depth, angle, position, graft areas, etc.. Just the process of double checking prior to full prep/full insertion, lowers your stress level and readies you for the then boring step of final implant insertion.

You have been given excellent advice on how to correct the situation and how to prevent it in future. However let me add an even easier method of prevention (especially for inexperienced dentists). Use a CADCAM designed surgical guide and appropriate surgical kit. Using this (with the correct protocol – irrigation, slow speed, correct drills etc) is not quite idiot proof but it is pretty close. When I use them I usually get within 0.25 mm of where I planned to place the implant. Once you gain experience with implant placement using a guide, you may want to try without one - but considering the ease and speed of placement, I recommend using one virtually every time. All the hard work is done prior to the operation and you can relax knowing that placement will be essentially exactly where you want it.

hi, “we learn most from our failures...” , I think Hippocrates said that . (kidding) Just follows the great advice above , but be sure to suture in the collagen plug and seal with periacryl adhesive . (prp/prf membrane even better but you may not be doing this method.) Or -call a specialist in your area that you work with and explain the shortcomings. Than complete the case together . If me I would go to that specialist office and assist in the procedures and pay him/her for their time and instructions. The patient would love it, you would gain a solid referral relationship and a great instruction. Thank you

Good advice except I wouldn't immediately place another implant, Unless there is enough bone to avoid the sinus. The membrane will tear further if you must re-enter the sinus. I would wait 3 months before retreating if that is the case.

Can you just explain to us what you were intending to place on these implants? I assume the distal implant is in correct bucco-palatal alignment. If you were intending to place a 3 unit bridge can't you just convert your plan to a 4 unit bridge? It is not uncommon to see an implant protruding into the antral cavity and they don't usually cause any harm. May not be the counsel of perfection, and this wouldn't be a case you would want to use in a slide presentation, but the fact is that this implant should osseointegrate successfully and function just as well as a shorter implant.

First of all thank you guys for all your comments and advices. In this case I had a totally edentoulus upper jaw and I placed 4 implants with the intention to connect this implants together with a Dolder bar and a removable denture on top of its.

Hi Anon all good advice and if you take note you will learn from it. My cents worth - if the offending implant has no symptoms then let it sleep - could have more complications if you try to remove it, and place another more medially where there is enough bone. Remember as John says you have to drill 4-6 mm deep and then check angle and depth with an xray and dummy post - you will never place it in the wrong position if you always do that. As to what you're going to tell your patient - that's a tricky one - it depends a lot on your relationship with this patient. Good Luck

Many years ago , I had a similar situation....when I went to uncover a recently placed dental implant after letting it become osseointegrated after four months, after opening the gingival tissues and exposing the dormant implant, when tightening a healing collar on it.....I pushed the implant into the sinus.....BOTTOM LINE IS THAT IT IS HARMLESS, UNLIKE AN INFECTED ROOT WHERE YOU HAVE TO DO A CALWELL LUKE PROCEDURE TO GET IT OUT.... I place a new implant into the same site after the hole was regenerated, and then a crown, and it worked well...…… then 25 years later, the patient called me and said, that he had an urge to sneeze, and when he did..... he found this strange piece of metal in his mouth and he mailed it to me......it was the implant and the healing collar in his mouth..... unfortunately, this patient now elderly and frail because of pancreatic cancer, was not well enough to come to my office to take a new xray of his sinus......so I cannot show an xray with the floating implant no longer there to this forum.....

Why not repair it? Do a lateral walk approach to the sinus, elevate the membrane (note how thickened it is), place graft material, place collagen over the opening, and close. Problem solved.