Crown design over implant positions

PDC

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I'm sure everyone gets those cases with less than desirable implant placement but I am trying to find what the acceptable protocol is for some of these situations. The case below was lingually placed and was slightly above tissue level. When I try to do these with the margin flush with the implant on the facial, it seems patients always have food pack problems. So I started bulking them out almost like they are a pontic. I don't like doing it this way but it seems I am caught between a rock and a hard place.
When I have supra gingival margins as a result of the doc not doing bone level placement, they want them bulked out ...kind of like an apple on a stick. Banghead
Does anybody have any specific guidelines for these situations? I really don't like doing these things like this.

Buccal view of crown at gingiva.png

Buccal view with opposing.png
Crown only.png

Occlusal view.png
 
sidesh0wb0b

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can always pack some gingiva porc down there after sintering and close that up some. but once the bone/tissue receeds again (and most likely will) you will be back to a food trap. best to keep it cleansable to begin with in my mind.
 
CreativeTech

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Implant placement is the surgeons responsibility, & not your problem. All you (or I) can do is make the best of a bad situation. It's important to be sure the patient can get floss or a waterpic in there. That's my view based on having dealt with a lot of these, & never redoing one of them.
 
CoolHandLuke

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this is a doomed case unless the pt can get to a surgeon.
 
rkm rdt

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You have the advantage of cad here.

These are the same pics that you need to send to the surgeon and restoring dentist.

I would stop there until you get the acknowledgement from the drs that they own the this problem.
Let them decide on the design from this point forward.

There is no magic solution other than to do it right from the beginning.
 
CatamountRob

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You have the advantage of cad here.

These are the same pics that you need to send to the surgeon and restoring dentist.

I would stop there until you get the acknowledgement from the drs that they own the this problem.
Let them decide on the design from this point forward.

There is no magic solution other than to do it right from the beginning.

.....and the Dr. says:
"I see what you mean, but that's where the implant had to be placed because that's where the bone is. Do the best you can with it."
 
rkm rdt

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.....and the Dr. says:
"I see what you mean, but that's where the implant had to be placed because that's where the bone is. Do the best you can with it."

... and then you say " This is a denture lab, we don't do implants here.!"
 
CoolHandLuke

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... and then you say " This is a denture lab, we don't do implants here.!"
or

'you really picked the wrong implant platform to do this case then. you could have done it better with a deeper set 4mm based implant so that we could acheive emergence.'

click
 
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Ive been arguing this exact point to a couple Drs for years, but the standard answer is 'theyre a surgeon, theyre doing the best for the situation'. At our most popular perio-shop they now have a guy that's getting it right and theyre seeing my point, that better was possible. We have a moral obligation to the patients, not to the dollars. This is no different than installing a knee backwards. Someone needs to make it right, and its not the prosthetic shop.
 
rkm rdt

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or

'you really picked the wrong implant platform to do this case then. you could have done it better with a deeper set 4mm based implant so that we could acheive emergence.'

click


...and the dr says " no dice son you gotta work late!"

 
sidesh0wb0b

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or

'you really picked the wrong implant platform to do this case then. you could have done it better with a deeper set 4mm based implant so that we could acheive emergence.'

click
or, they should have used a better healing cap to help with tissue placement and emergence profile
 
PDC

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or, they should have used a better healing cap to help with tissue placement and emergence profile

When the implant is not below the tissue the healing cap won't have any effect...there is no way to get an emergence profile. I've got another case just like this I'm working on now. What a terrible situation. I have talked to one of the docs about the difficulties involved with design and food packing and he has agreed to start doing bone level.
Unfortunately, I receive a lot of cases from the GP's with the implant already in place. They are merely passing the problems on down the line from the oral surgeon.
 
CatamountRob

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When the implant is not below the tissue the healing cap won't have any effect...there is no way to get an emergence profile. I've got another case just like this I'm working on now. What a terrible situation. I have talked to one of the docs about the difficulties involved with design and food packing and he has agreed to start doing bone level.
Unfortunately, I receive a lot of cases from the GP's with the implant already in place. They are merely passing the problems on down the line from the oral surgeon.
Tissue level implants suck for replacing molars.
 
rkm rdt

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1NJPi2z.jpg
 
sidesh0wb0b

sidesh0wb0b

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When the implant is not below the tissue the healing cap won't have any effect...there is no way to get an emergence profile. I've got another case just like this I'm working on now. What a terrible situation. I have talked to one of the docs about the difficulties involved with design and food packing and he has agreed to start doing bone level.
Unfortunately, I receive a lot of cases from the GP's with the implant already in place. They are merely passing the problems on down the line from the oral surgeon.
you are correct, I was just repeating some solutions to the excuses I hear endlessly over the years

get in touch with your local surgeons. we are making surgical guides for some now and its helped a bunch. its a learning curve for us, the surgeon, and the gp, but the end results are far superior.
 
PDC

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you are correct, I was just repeating some solutions to the excuses I hear endlessly over the years

get in touch with your local surgeons. we are making surgical guides for some now and its helped a bunch. its a learning curve for us, the surgeon, and the gp, but the end results are far superior.

Surgical guides could eliminate so many problems. Compared to a tissue level implant, a bone level offers much improved esthetics but only if it is placed in the proper position. You are right though, someone has to educate these guys on the many problems a poorly positioned implant causes. Wasted money!
 
doug

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For years I have said that EVERY implant deserves a guide. If I told a doc that I put the contact in what I thought was the best place and to deal with it, I'd be out of work fast. The real problem is the the surgeons, the perio guys and the GP's are all friends and no one wants to criticize their friends.
 

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