What do you recommend?

[Brett Hansen CDT]

One of my doctors placed a Nobel Replace implant in #8 for a patient. He has done 2 bone grafts without being able to cover the entire implant with gingiva. He doesn't want to have to put her through another procedure. What options can I present to him other than bringing the porcelain of the crown up to cover the implant? Here is a picture:

 

[actittle]

Just screw it in a little deeper

 

[Brett Hansen CDT]

While I like the response, I don't think that will help in this case.

 

[Clear Precision Dental]

I agree. The collar of the implant fixture is not placed "deep" enough. This will be a nightmare to restore and will never look good or be a healthy situation. To make matters worse, IT IS RIGHT UP FRONT. Either way, if this implant is already osseointegrated then it needs to be removed and replaced or if it is still fresh, the threads are contaminated and there is no way to graft this type of defect, so it needs to be removed and another implant surgically placed correctly.

 

[JohnWilson]

Brett your screwed,

Actually, you and I both know the fixture is not going to be removed until it fails. Fixture lapping to fill the defect is what can be done with a nice custom abutment. It will not be hygienic, it will promote more bone loss, it is a bandaid.

I did one like this for a lady that just got married with pink porc and it worked out great, at least for the wedding photos


Get a disclaimer, get the DR to write up exactly what you are fabricating so that its his idea not yours. Check to make sure your product liability insurance is in good standing

OR

You could just refuse the case and say that you don't want to make a bad situation worse.

Either way your screwed , however you may sleep better at night doing one or the other

 

[TheLabGuy]

Yep, as others have said, you're screwed. Even if you do make the abutment with pink gingiva you will still have to create a ridge lap (food trap) to hide the platform of the implant. I'm truly hoping this patient has a really, really, really, low lip line so it doesn't show the implant. As other have stated, document, document, document...these type of cases are cya one's. Along with what John stated, I'd suggest that a implant template placement guide be used on all future implant placements. I've done many of these cases but if you don't inform the dds that he/she has to do better than this, you'll keep doing them from them.

 

[CoolHandLuke]

i'd refuse the case. either that or send the doc an incendiary piece of registered mail.

strike 1: he placed the implant.

strike 2: he did it twice.

strike 3: its wrong twice.

 

[k2 Ceramic Studio]

You can get around this, the surgeon needs to look at the job/implant as if it were a one piece implant, ie you need to fabricate the abutment to ensure a good path of insertion down to the gingival margin and once the surgeon has placed the abutment get him to create a shoulder about 2 mm below tissue level (yes on the implant) because all bone resorption will reduce the crestal bone ridge by two mm. once he has prepped his "one piece implant" then get him to take a good imp and you make a nice new Zr for him and then ask for a case of very dear single malt for getting him out of the sh1t.

 

[sidesh0wb0b]

One of my doctors placed a Nobel Replace implant in #8 for a patient. He has done 2 bone grafts without being able to cover the entire implant with gingiva. He doesn't want to have to put her through another procedure. What options can I present to him other than bringing the porcelain of the crown up to cover the implant? Here is a picture:

a few things come to mind here..... being that the bone grafts arent taking as they should the Dr has a few options. first, back out the fixture, pack more bone, let it heal for 6months or more and try again. (potentially needing sinus lift as well). hopefully the placement is a bit further lingual but thats going to depend upon other matters entirely.

if that doesnt work...... option two is a bit more tricky and may or may not succeed as well as option one..... if the Dr is willing, he may want to place the smallest height healing cap he can get, do a tissue graft OVER the entire site and let it heal for a few weeks at least.....in the mean time you fabricate a zirconia abutment and add the proper shade to the marginal areas ON the abutment. fabricate your crown as well, and lap down over the facial some (its going to be bulky). at the time of seating the Dr should cut open the healed tissue from the LINGUAL and flop it over facially, then seat the abutment and the crown and suture the tissue back interproximally to form some papillas and hopefully the tissue wont recede nearly as much as what you have now.

if neither can be done, good luck. best you can do is make a Ti custom abutment, have the Dr torque it in, and then prep down onto the fixture and reimpress. this will allow you to capture down where its exposed and fabricate the crown.

hope this helps some

 

[BobCDT]

Two possible options.
1. Make a titanium custom abutment and have the doc put it in and prep the abutment and the implant to create a feather edge margin either at crest of slightly sub-g. Take an impression and make a crown using a ston die.
2. Put the implant to sleep and make a 3unit bridge. The crown on 9 looks like crap and you could put pink porcelain on the Pontic for what would likely be the most esthetic result possible on this one.
I really feel for this patient spent big bucks and got screwed!!!
Bob

 

[sidesh0wb0b]

Two possible options.
1. Make a titanium custom abutment and have the doc put it in and prep the abutment and the implant to create a feather edge margin either at crest of slightly sub-g. Take an impression and make a crown using a ston die.
2. Put the implant to sleep and make a 3unit bridge. The crown on 9 looks like crap and you could put pink porcelain on the Pontic for what would likely be the most esthetic result possible on this one.
I really feel for this patient spent big bucks and got screwed!!!
Bob

copy cat on number 1 LOL

good thought, just leaving the fixture would preserve bone if the Dr and pt are willing to spend all the extra cash to do a bridge of sorts. looks like sales time for the Dr, with the amount of recession seen, he should sell 6 through 11, or 5 through 12 and recreate a much more esthetically pleasing smile line.

 

[disturbed]

removable gingival mask. hwell: :: Creative Solutions ::

 

[lcmlabforum]

removable gingival mask. hwell: :: Creative Solutions ::

I totally agree - just received one from Kim and it was a WONDERFUL piece of work.
Pat said "I can smile again" and so gleeful it was like a little girl at Christmas.
If you make a non-cleanseable prosthesis and cause infection of the peri-implant mucosa,
or cause bone loss, guess who get's the blame? With the mask, at least it is removable
and you can clean it still, which would be critical to good gingival outcomes.
This might be one that the patient can go after the lab for making something that can
be blamed, rightly or wrongly, for a negative outcome. Even if, and I wonder if the
DDS would, spell out exactly he expects you to do, how much of a overlap, etc.
As someone said in the movies, "Proceed with extreme prejudice" or caution, whatever
floats the boat . . .
LCM

 

[Marcusthegladiator CDT]

Lose the implant and build a Maryland or 3 unit bridge. But then there's some explaining to the patient about wasting her time and money and pain during the implant process. So, build a custom zirc abutment and over extend the margin on the custom abut andatch the tissue shade.

 

[JohnWilson]

Another shout-out for KIM her masks are great!

As for a mask for this particular case the adjacent teeth are not perio involved and most likely a mask will not work great on this case since there are no spaces.

I have enough nasty tough frustrating cases in the lab now, I am glad I do not have this one too

Good luck!

 

[rkm rdt]

Is a tissue graft possible?

 

[user name]

You can get around this, the surgeon needs to look at the job/implant as if it were a one piece implant, ie you need to fabricate the abutment to ensure a good path of insertion down to the gingival margin and once the surgeon has placed the abutment get him to create a shoulder about 2 mm below tissue level (yes on the implant) because all bone resorption will reduce the crestal bone ridge by two mm. once he has prepped his "one piece implant" then get him to take a good imp and you make a nice new Zr for him and then ask for a case of very dear single malt for getting him out of the sh1t.

Excellent thinking.

 

[2thm8kr]

Is a tissue graft possible?

Sure, but it's not going to stay without bone and blood supply.

 

[Brett Hansen CDT]

Wow, I was out of the lab yesterday so I haven't seen all these responses until today. You guys are awesome. I will be presenting my doc with some options and let him choose his own adventure.

The doc isn't happy with the situation. He has tried grafting a couple of times, but this is the best he can get. I think I like the prepping of the implant solution the best.

Thanks again for all of the responses. This site is invaluable.

 

[EJADA]

Let me guess. Another surgeon that claims guides are for Winnie's.