At the SMS Neoss Conference in Australia, Professor Neil Meredith of the University of Queensland moderated a panel of restorative dentists. One question posed to me by Professor Meredith was a case that looked like this:
So clearly the implant has been placed too far palatally. REALLY far palatally.
A final restoration would have a custom abutment that reached all the way buccally to where the incisor needs to be. A messy bit of business that would look something like this:
Professor Meredith’s question: what do we do next? Should we restore this?
Here’s my approach:
(1) We have a conversation with the dentist who placed the implant.
What the heck happened? Never judge someone else’s work until you hear the whole story. Granted, this kind of severe palatal displacement is a bit strange. If this was a case I sent to a periodontist or oral surgeon who I normally do cases with, I would expect a phone call from them before, during, or immediately after they treated this case with an explanation.
Possible explanations include:
(a) There is a severe defect in the buccal bone and the patient absolutely refused grafting.
(b) The dentist had a really, really bad day (hey, we’ve all been there).
(2) Is it restorable?
This may fail for esthetic reasons. What is the smile line? If it is restorable, will a ridge lap restoration look bad?
This may fail for functional reasons. What is the patient’s overbite? The incisal edge of the lower incisor may come too close to the platform of the implant. We’ll be saved by a shallow or edge-to-edge bite on this case. But even if the bite will permit clearance of the abutment, will the buccal cantilever fracture on a regular basis?
This may fail for hygienic reasons. The final restoration will have some interesting nooks and crannies. Will the patient be able to maintain this or will there be chronic inflammation?
This may fail for psychological reasons. The patient may never get over the weird feel of the final restoration. They might be uncomfortable by the odd shape that would be required to get the job done.
(3) The patient wears a provisional implant for a few months.
Once we have the full story from the dentist who placed the implant and we’ve determined that there is at least a chance of the case being restorable, we should put the patient into an implant provisional for at least two months. In an extreme case like this, I’d probably have a dental lab make this temporary.
I want to check the criteria that I described in the first section. Is it esthetically acceptable? Are speech and mastication unaffected? Can the peri-implant tissue be maintained hygienically? Was the patient able to adapt to the unusual contours?
If the provisional restoration doesn’t pass our tests, then the implant cannot be restored. Now our options are to remove the implant or bury it under the tissue. This patient will get a new implant or an alternative restorative option, depending on the circumstances.