Does this implant placement look right?

[Peddeh]

Hi there,

First post here, so go easy on me.

Back in June of this year, I had 4 implants placed to replace my missing teeth (due to neglect - I had not visited the dentist in over a decade but I needed to change). The treatment included included bone grafting in 2 areas and a sinus lift. To cut a long story short, I visited the dentist on 6th of December to expose the implants, 'test' them and taking impressions for the eventual crowns.

Thankfully all the implants have bonded really well to the bone, and the dentist seemed very elated with the outcome, gaining 60% of my bone in the sinus area (I saw the big difference on x-rays).

It wasn't until I got home and looked at the LR6 implant, now exposed, that the positioning seems a little off to me. Maybe I'm just being paranoid, because surely the dentist would have brought it up, right?

Am I right to worry that the positioning of this implant seems far too close to LR7 (image attached).

Thanks,

 

[MattKW]

Too close for my liking. It's going to mean that the replacement crown is going to get a lot of tipping forces.

 

[Peddeh]

I've dug out the report my dentist sent me before undergoing the treatment and have noticed that the placement doesn't even match this original plan (image attached).

I think I might have to have an awkward conversation with my dentist...

Is there any logic to why this might have been placed the way it was?

 

[MattKW]

Yep, a discussion is required; I'm guessing he did this without a template guide and so the drill has followed the soft socket bone where the other tooth was extracted. Get a new Xray of where it is now. You might be able to get another implant in the remaining space, but this may not be the person to do it. The angulations of another implant and resultant crowns are certainly going to conflict with what you already have there. Probably time to see a prosthdontist.

 

[Peddeh]

Contacted my dentist by telephone and he has stated that the implant is where it needs to be. He's told me not to worry about it and that it will be fine.

Not sure what to do next.

 

[MattKW]

Go in for an appointment. Be polite and keep calm; maybe take a friend or partner with you. Ask for an Xray of the current situation and upload a copy. Ask him to explain how the different placement from the original will affect the final crown. If not happy, ask for referral to a prosthodontist.

 

[Peddeh]

Hi Matt,

Thanks for your reply. A one to one appointment has been made with the dentist so we can discuss my concerns. I feel really awful about doing this to him, I just hope he won't be offended, as I feel like I'm criticising his work.

In the meantime, I've booked an appoint with an implantologist a bit out of town, who is very reputable, who has agreed to see me for a review/second opinion.

I did not think to ask if the dentist could send me an xray but I will request this tomorrow morning and upload it here if I'm able to get them to send it electronically, otherwise I will wait until my one to one appointment.

 

[MattKW]

We all make mistakes, and if he's genuinely concerned he will take your concerns on board and help you out. He will have insurance which should cover any extra treatment. And I don't think there is a specialty as an implantologist, but rather a general dentist, periodontist, oral surgeon, or prosthodontist who have experience in implants.

 

[DocT]

Well, I would not be so certain and monosemantic In regards to this matter. As far as I could see, on provided CBCT / 3D image with a virtual implant placement prior actual surgery from June, posterior or back tooth LR7 already appeared inclined, tilted, leaning forward. In 5-6 month, depends on how fast it was moving, tooth easily might show even more advanced inclination combined with tooth bodily movement in the absence of restriction from missing tooth LR6. In this case you have two options : 1 - limited orthodontic treatment to upright LR7 or 2 - implant level impression with customized gum contouring around implant platform to creat more desirable and physiological crowns contour and contact with adjacent teeth.

 

[MattKW]

In 6 months, with no opposing occlusion, the LR7 won't have moved. And the dentist can't move the implant so any pontic will be unfavourably cantilevered.

 

[DocT]

Dentist doesn't need to move implant - tooth on the distal of implant was tilted from the very beginning and can be upright orthodontically in a reasonably short time; approximately 3 month period .Half a year is sufficient time for tooth to move and inclined even further.

It is really hard to tell where implant was positioned in respect to remaining dentition when image is taken 6 months later - implant can't move, but teeth connected to bone via ligaments, definitely can and will. That is why people go for provisional for healing period.

 

[MattKW]

What will be achieved by up righting the 2nd molar? I will assume that there is also an opposing upper 2nd molar that possibly locks it in. Nor will uprighting improve the poor positioning of the implant, and any crown placed on that implant will have a large cantilever effect.

 

[DocT]

1 - https://www.osseonews.com/mandibular-left-second-molar-tipping-how-should-i-manage-this/

... 16 weeks after surgical installation, I performed the Stage 2 uncovery surgery and found that #18 [mandibular left second molar; 37] had tipped mesially into the space for #19 reducing the mesial-distal space available for the implant crown.
A fixed retainer should be placed as a preventive measure (immediately after 1st stage surgery )
But now :
Orthodontic uprighting of mesially tipped 2nd molar...
2 - https://benthamopen.com/ABSTRACT/TODENTJ-11-466
Tipped lower molar over edentulous space is very common in orthodontics practice when adults seek treatment.
3 - https://www.intechopen.com/online-f...ual-spaces-of-missing-molars-decision-factors
...In case of permanent molar absence, making decision becomes even more delicate. The practitioner must use his/her critical sense and clinical common sense to make the right choice ...
4 - https://read.qxmd.com/keyword/23736
Orthodontic treatment to upright an inclined molar adjacent to an edentulous space is often necessary before implant placement.
4 - https://www.ncbi.nlm.nih.gov/pubmed/31784019
The severely inclined second molars were uprighted in 5 months, and the enhanced implant sites were ready for implant placement without complications.
I would be extremely careful with any conclusions based on intra oral photo taken unprofessionally, under unknown angle and probably with cellphone. Without radiographic image we can't really estimate what the exact implant position in regards to the root of posterior molar. Uprighting tilted tooth on the distal of implant would allow to create parallel path of insertion / positioning of planned prosthetic restoration - implant supported or implant abutment supported crown. In single unit restoration you can't really create cantilever restoration due to limited space; besides, implant supported anterior cantilevered restorations are still widely accepted, unlike posterior cantilevered design. The only real concern in this situation is proper development of emergence profile, that still can be designed by customized tissue management, like custom healing abutment followed by implant level custom impression coping. Of course it would be more important decision in case of implant positioning distally, rather that molar tilting mesially. About overerupted opposing dentition, I'm not an orthodontist and honestly do not know technical details, however I work in close proximity to the orthodontist. Between our two practices we have a lot of cases with misplaced and worn dentition required interdisciplinary approach

 

[MattKW]

Perhaps this particular complication and extra work could've been avoided if the 3rd molar had been extracted before the implant surgery.

 

[DocT]

It was not the matter of discussion, and yes, I would extract third molar and provide patient with provisional for healing period,( never go without space reservation) and if any ortho is needed it would be done prior implant placement ( personally I do not allow braces removal till implant supported provisional is in place). But we do not know what happen, not enough of data. Of course implant appears to be positioned posterior and asymmetrical; but for conclusion we need at least two images : x-rays or two CBCTs taken - first - when implant was placed and - second - after second stage surgery. Besides, patient might develop insufficient amount of bone at the site of the mesial root of extracted first molar and dentist positioned body of implant in the most stable well developed area for the most predictable result. As we all know, ridge width is a critical criteria. Besides that, as more I look at 3D image, as more I think that we are talking about third molar and implant positioned in second molar edentulous site - space b/w second bicuspid and existing / remaining molar is way too big for single tooth missing. In this case, first molar was lost long time ago, most likely without any ridge preservation treatment and might show significant horizontal resorption resulting in insufficient ridge width for proper implant diameter for posterior restoration.

 

[MattKW]

Perhaps you misunderstand, but I was referring to the case you showed in previous answer. Not talking about the OP.

1. Even without the most recent Xray of the OPs implant, don't you think that the dentist has allowed his implant drill to accidentally follow the softer tissue into the space created by the extraction?
2. His planning radiographs show where he intended it to go, but I think he didn't use a surgical guide and has made a simple error.
3. Trying to put a crown on the implant where it is currently placed and angled will make for a very poor crown.

 

[Peddeh]

Apologies for not responding, work and the Christmas festivities has had me tied down.

I've since had my one to one with my dentist and unfortunately (or fortunately? I'm not sure what way to take it), my dentist still doesn't see a problem with the placement.

He filled the previous 'hole' (sorry if this isn't the dental technical word for it) with bone graft material that was left after the tooth extraction during the initial placement surgery, which makes me wonder why we didn't just wait for that to heal and then place the implant in the position where the tooth was but he re-assuringly told me that the placement of the implant is in the best place based on the quality of my bone.

He's told me if I'm still not happy after the crown placement, we can re-assess. I'm inclined to believe I should trust his judgement but I don't know, I'm conflicted. I guess all I can do is wait .

I'm looking for a second opinion, specifically with a prosthondist (as you suggested, Matt), I just need to find one locally first.

The dentist told me they would send me digital copies of my latest 3D scans / xrays but I'm still waiting for them. I will chase them up after the new year (the surgery is closed until then, except for emergencies) and post them on here for your opinions.

Thanks,

 

[MattKW]

OK, post up Xrays when available.