Nothing frustrates me more than having an implant show up in my office that's in the wrong place. Here is a case that showed up on my doorstep the other day that I had to bat clean up on. As you can see the implant in the #20 site is angled to the lingual too much to allow for the crown to be in proper alignment.
Normally I would restore an implant with a zirconium abutment. But with the ridge lap that was not an option. So I needed to send it to the lab for a metal abutment capable of handling the unsupported load. I sent the case to the Winter Lab for their opinion on the best abutment choices.
In discussing the case with Veronica McPeak at the lab, we came up with two solutions, well three if you include removing the newly placed implant and reposition it to a more ideal position. The first wax up would keep everything centered over the implant.
Note the arch wire on the lower anterior teeth. This patient went through ortho. I don't think she would like to have her new tooth be crooked. So we looked at option two: A ridge lap abutment with the crown then positioned in a more ideal location from an esthetic standpoint.
I discussed the options with the patient and made sure she new that with the ridge lap version the forces would not be loading directly over the implant and that if we saw bone loss we would then remove the implant and place a new one after site development. She wanted to proceed with the ridge lap abutment design.
So how do we avoid this? There were two big mistakes the surgeon made in this case. They did not do a diagnostic wax up to determine where the crown needed to be and then they didn't transfer this wax up to the mouth for a CBCT to determine if there was adequate bone to place the implant in the proper place. To transfer you do a suck down and then at the proposed tooth, place acrylic mixed with a radiopaque material. This allows you to visualize where the proposed restoration will be in relation to the bone. The real kicker is this surgeon has a CBCT; however, in his narrative he stated there was no need to take one. Obviously there was.
In this case with a little GBR the implant could have been placed for optimum restoration. The option was never given to the patient which led to a much more expensive restorative process for her. Not to mention the possibility of the need for implant removal and replacement in the future.
A little planning goes a long way when it comes to implant placement and restoration.
Darin O'Bryan, DDS [ www.onemorereasontosmile.com ]