Anterior Implant Complications. Tx Approach

3 consecutive Implants with obvious Esthetic Compromise on young patient in mid 20's. Wants a solution. What do you feel can be done?
Thanks Dr. S

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What are your views on removing the implants ?

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These photos dose not show the lip line, but pink porcelain could be the fastest solution in this case.

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Babak. We are limited to 4 photos but the lipline was high.
Pink Porcelain would be a problem. Look at the position of the implants on the lateral view?? they may be too far angled and positioned to the labial??
Any surgical solutions??
Dr. Salama

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Segmental osteotomy and repositioning of the segment along with the implant in the right prosthetic position.

Dr.Tarun Kumar

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bone graft to cover the labial defect followed by coronally displaced flap?

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TO know is one thing , to do is another~

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I thing this is a very complex case. If there is suitable buccal plate and perimplant soft tissue, I think a selective repositioning by crowns and braces, doing a complete osteotomy of the block containing the three implants and apply the concepts of corticotomies (Wilcko) to reposition completely each implant in place (distraction osteogenesis). If no suitable tissue I would remove the implants, allowing the soft tissue close and then rebuild the area with a bone graft, and then place the implants in the correct position.
Thanks for this forum. AFR

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since there is a huge horizontal defect with a high lip line ,i think we need a huge chunk of graft may be from illiac crest and have to fix in the region followed by healing period followed by implant placement ,followed by waiting period of osseointegration , followed by prosthetic phase with all ceramic crowns with pink ceramic in the gingival one third.

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since there is a huge horizontal defect with a high lip line ,i think we need a huge chunk of graft may be from illiac crest and have to fix in the region followed by healing period followed by implant placement ,followed by waiting period of osseointegration , followed by prosthetic phase with all ceramic crowns with pink ceramic in the gingival one third.

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Mid 20's + complex case. Disconnect the crowns + cover screws, wait and allow the soft tissue to cover the implants, then explant + Bone graft + CTGraft+ healing, then place implants in right position. As Huang says: "easy to know...". Thanks!

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Andres and all my friends; Great discussions and very creative treatment plans and options. No wrong answers here. Andres suggestion is one I had not thought of before and that is why these forums are so GREAT>
thanks and let's keep posting to learn from each other.
Dr. S

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I would go here for segmental osteotomy and reposition the segment in the ideal position. This would be to my opinion the most elegant and time saving option.

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Si el defecto vestibular es amplio como se puede uno imaginar por lo que se ve en la fotografia una alternativa seria injerto de hueso autologo . Podria ser hueso molido con membrana reabsorbible.Con respecto a la papila ,se podria hacer una especie de guia quirurgica para relleno con las hoquedades en los sitios donde estan ubicados los implantes . Lo mas importante a la hora de formar papila es no comprimir los tejidos,ya que eso puede traer reabsorcion a futuro .La idea es formar la papila junto con el relleno . disculpen si lo escribi en español ,mi ingles es muy basico .

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Remove the implants , give time for soft tissue to heal , graft the site with bone vertically block sandwich tech , after healing , place the implants in the right position . Soft tissue management , allow healing time around the temp crowns then place the final crowns. This problem started as the bone level was high at the implant insertion time ,

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I think that any solution will involve reverse torque to remove the implants. After that, many solutions can be made, like imediate placement of new implants in proper position, combined with hard and soft tissue graft. I think that allograft+prp+collagen membrane and prf would be great. This is only one of the many approches that can be made.

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Lo que yo haría
a- Eliminar restauraciones y poner tapas de implantes y provisorio removible.
b- A la semana ya se cubrio nuevamente de tejido blano
c-Hago un colgajo mucoso arrastrando palatino hacia vestibular, pongo cicatrizadores de 2mm que queden sumergidos debajo del colgajo.
d-A el mes ya se produjo la expanción del tejido
e-Levanto nuevamente el colgajo saco cicatrizadores t relleno todo con injerto conectivo de palatino o alloderm.
f-Una vez conseguido el nivel gingival correcto y habiendo anulado los implantes realizo una protesis fija de !3 a 23.
Conclusión:
Anulo los implantes, regenero nivel gingival, soluciono sin implantología.

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TX1) if you want to keep the implants:forced eruption tooth #12 , segmental osteotomy and/or D.O for the 3 implants.connective soft tissue graft.probably 3 unit bridge supported by 2 implants(submerge the middle implant), greater chance to create the papillas.
TX2)fabrication of a new 3-unit bridge,The missing tissues (hart and soft) can be reconstucted/replaced by ping composite( i.e anaxdent).
it all depends on the skills of the treating team and the PATIENT'S DEMANDS.thanks

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Orthodontics treatment. Is an anterior open bitte, and osteotomy distraction of the tree implants together.

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Very challenging case! Nice to see so many interesting treatment plans!
I think communication with the patient is very important in such a case. "How far" is the patient willing to go?! Each suggestion has very different risks, benefits, time-plan and costs.

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Please see my treatment option for this case.
Double CTG from Palate, placement of 3mm high Healing abutments for space maintenance under coronally positioned flap. Restorative options now expose only 2 implants for 3 unit bridge or Conventional bridge with 3 pontics leaving all 3 implants asleep.
thanks for all the comments.
Dr. Salama

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dear Dr. salama as you mentioned as a second option would be a conventional bridge.do you mean that u r planning to prepare 2 teeth on each site.how old is the pt?is he/she willing to have this tx option?

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Theo;
That would be up to the patient but I would suggest Option #1 using 2 implants and pontic in between.
thanks
Dr. Salama

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i totally agree 2 implants and a pontic inbetween.maybe also some composite filling on #12 to close the"open bite"

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Hola
Estimado Maurice quieiera saber si ese es el caso final.
Segun la foto es el caso a los 6 meses.
La pregunta es
¿que sucede al año?
¿La rehabilitación se hizo sobre los tres implantes?
Desde ya gracias por la respuesta

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Excellent forum Dr. Salama! I agree with Dr. Fernandez , Distraction is a great choice, but we need the sufficient amount of bone in height and width to transport a segment that can provide the dimensions for optimal implant placement. Other two options can be: to use rhBMP with a mesh or a DFDBA Filler impregnated with Gem21 and a membrane. Is a fact that for long term results is advisable to increase the hard tissue before thinking in any soft tissue grafts.

Dr. Azofeifa

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