|Year : 2020 | Volume
| Issue : 1 | Page : 83-86
Management of a malposed dental implant in the esthetic zone
Patathil Abdul Razak1, Prasad Aravind1, Priyatha Purushotham1, Remya Ravi1, Ravi Kunnaiah2, Shanoj Ramacham Parambath1
1 Department of Prosthodontics, MES Dental College, Perinthalmanna, Kerala, India
2 Department of Periodontics, MES Dental College, Perinthalmanna, Kerala, India
|Date of Submission||08-Dec-2018|
|Date of Decision||11-Mar-2019|
|Date of Acceptance||01-Apr-2019|
|Date of Web Publication||24-Jul-2019|
Dr Priyatha Purushotham
Department of Prosthodontics, MES Dental College, Perinthalmanna - 679 338, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
With the increased research in the field of dental implantology, there has been an extensive rise in the application of dental implants in various clinical situations. Complications arise with the frequent increase in the placement of dental implants; one of the common difficulties faced is placement of a malposed dental implant. Rehabilitation of prosthetically unfavorable implant is a serious challenge to a restorative dentist, a laboratory technician, and the patient. This is of great concern especially when it is in the maxillary smile zone. Prosthetic modifications, surgical corrections, or combination of both may be required in such situations. This case report describes a severely malposed dental implant in the maxillary left lateral incisor region in which an esthetically satisfactory result may not be feasible with prosthetic corrections alone. Hence, a surgical approach termed partial segmental osteotomy was initiated to reestablish the osseointegrated implant segment to a more favorable position before prosthetic phase.
Keywords: Bone–implant block, corticotomy, green stick fracture, malposed implant, segmental osteotomy
|How to cite this article:|
Razak PA, Aravind P, Purushotham P, Ravi R, Kunnaiah R, Parambath SR. Management of a malposed dental implant in the esthetic zone. J Indian Soc Periodontol 2020;24:83-6
|How to cite this URL:|
Razak PA, Aravind P, Purushotham P, Ravi R, Kunnaiah R, Parambath SR. Management of a malposed dental implant in the esthetic zone. J Indian Soc Periodontol [serial online] 2020 [cited 2020 Jan 21];24:83-6. Available from: http://www.jisponline.com/text.asp?2020/24/1/83/263387
| Introduction|| |
Dental implants have been a popular treatment of choice for the prosthodontic rehabilitation for almost four decades. The constant increase in the use of implants has also led to the increase in complications associated with it. One such situation is improper positioning of the implant, especially in the esthetic region. Implant malpositioning may be due to inadequate diagnosis and planning, inexperience of hands, freehand implant bed preparation without the use of surgical templates, or the “bone-driven” placement of implants.
When a dental implant is poorly positioned, it can be managed by prosthetic compensation or surgical correction. Prosthetic compensations include the use of angulated abutments, custom-made abutments, or modification of the characteristics of the crown in both size and form. In the anterior region, such corrections may not fulfill the esthetic requirements. When prosthetic corrections are insufficient, little options are available. In such situations, usually, the malpositioned implant is either abandoned under the soft tissue or surgically removed. Surgical removal of implants can result in hard and soft tissue defects, which would require further sophisticated corrections.
Segmental osteotomy is an alternative surgical procedure to bring a nonrestorable dental implant to a favorable position so that one can restore it comfortably. This procedure has been used widely in the correction of skeletal, dental malocclusions that could not be corrected by conventional methods.
This article presents a case report in which a severely malpositioned dental implant in the maxillary anterior region was corrected using segmental osteotomy.
| Case Report|| |
A 21-year-old female patient reported with a dental implant in the maxillary left lateral incisor region that was placed 5 months back. Intraoral examination revealed partial edentulism in relation to the left maxillary lateral incisor and a labiopalatally positioned implant between the left central incisor and canine with permucosal extension [Figure 1]. The width and length of the edentulous region were 5 and 6 mm, respectively. There were no signs of inflammation in the peri-implant mucosa. The radiographic examination revealed no signs of peri-implantitis or alterations in the osseointegration, but there was little space between the implant and the lamina dura of adjacent teeth [Figure 2]. On detailed case history, the patient informed that the space for the lateral incisor was created and retained by orthodontic treatment.
|Figure 1: Malposed dental implant in the maxillary left lateral incisor region|
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|Figure 2: Radiographic examination revealed an osseointegrated dental implant between the maxillary left central incisor and canine|
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Various treatment options were ruled out including restoration with a 25° angulated abutment [Figure 3]. It was decided to surgically reposition the implant to a restorable position, and risk factors such as trauma to adjacent teeth, bone necrosis, and chances of treatment failure were explained to the patient and consent was obtained.
|Figure 3: A 25° angled abutment could not compensate for the poor implant angulation|
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Under local anesthesia, a full-thickness labial mucoperiosteal flap was elevated, leaving the palatal mucosa undisturbed. Longitudinal osteotomies parallel to the long axis of the malposed implant were performed at a distance of 1 mm on the mesial and distal sides [Figure 4]a. Labial cortical plate was weakened as much as possible from a labial approach with 0.5 mm piezoelectric inserts with extreme caution to not injure the adjacent teeth. The two longitudinal corticotomies were connected with an apical osteotomy involving both labial and palatal cortical bone which further weakened the bone–implant segment. Then, a green-stick compression fracture of the bone–implant block was created by applying progressive controlled pressure in the palatal direction using Kocher's forceps [Figure 4]b while the index finger and thumb of the assistant were used to support the segment from both labial and palatal direction. Once the fragment was approximated in the planned position [Figure 5], the gaps created by the osteotomy and relocation were filled with graft material (osseograft) [Figure 6], and barrier membrane was placed (healiguide) [Figure 7]. The barrier membrane was stabilized by tucking in the membrane apically below the flap adequate to cover the osteotomy site with bone graft. The flap was replaced to its original position, and tight sutures were placed [Figure 8]. Amoxicillin 500 mg every 8 h and a combination of mefenamic acid and paracetamol every 8 h were prescribed for 5 days. The postoperative healing was uneventful.
|Figure 4: (a) Longitudinal corticotomies were performed on the mesial and distal side of the fixture at a distance of 1 mm along its long axis. An apical osteotomy was performed connecting the longitudinal corticotomies; (b) Kocher's forceps was used to relocate the implant using progressive controlled pressure|
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|Figure 6: Voids secondary to osteotomy and repositioning of the segment were filled with bone graft|
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|Figure 7: Barrier membrane was placed. The stabilization of the membrane was achieved by tucking it apically below the flap to cover the osteotomy site|
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|Figure 8: The flap was approximated to its original position and sutures were placed|
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Periodic follow-up was done up to 16 weeks before prosthetic rehabilitation was initiated. On clinical and radiographic examination, it was observed that the hard and soft tissues healed well [Figure 9]. There were no signs of bone defects or infections. The prosthetic rehabilitation was completed using a 15° angled abutment on which an all-ceramic crown was fabricated [Figure 10] and a 1-year follow-up was done.
|Figure 9: (a) Immediate postoperative radiograph; (b) 4 months postoperative radiograph|
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| Discussion|| |
Treatment options for malposed dental implants depend on degree of malposition. Moderate malpositioning can be overcome with hybrid prosthesis, angulated abutments, customized abutments, overdentures or by modifying size and form of crown placed over the fixture., In this case, the use of angulated or customized abutments alone could not compensate for the poor implant angulation and therefore was unable to create an emergence profile to improve the esthetic outcome of the restoration.
In severely malposed situations, the dental implant is either “put to sleep” or surgically removed with a trephine and replaced with a new implant. Such surgical procedures may lead to irreparable hard and soft tissue loss especially in the esthetic zone.
Segmental osteotomy is an alternative procedure to implant removal for the management of severely malposed nonrestorable dental implant. This procedure has been widely used in dentofacial orthopedics not only to reposition impacted ankylosed maxillary canines but also to close single and multiple tooth diastema.
The indications for segmental osteotomy to reposition a malposed dental implant include well-osseointegrated implant with sufficient surrounding bone  and the ability to achieve stabilization of the mobilized segment. This procedure is contraindicated if the segment has to be mobilized > 8 mm to correct the malposition and when adequate stability cannot be achieved.
Uncompromised vascular supply is an important factor for the success of the repositioned bone. In this case, a full-thickness labial flap was elevated, and the palatal portion was left undisturbed to maintain vascular supply to prevent necrosis. Palatal periosteum and vessels are the most important source of vascular nourishment of premaxilla. A green-stick fracture was created instead of complete mobilization of the bone–implant block to preserve the blood supply and thereby fasten the healing. The bone–implant segment was gently pushed to a favorable position so that the implant crest module will engage an angulated abutment without compromising the emergence profile of the tooth to be replaced.
The greatest risk faced during the osteotomy and mobilization of the segment was the narrow space present between the adjacent teeth. The mesial and distal osteotomy was done at distance of 1 mm from the fixture on either side. A minimum gap between the relocated segment and the adjacent bone is also crucial for adequate and faster bone healing; this was achieved by using piezoelectric inserts. The piezoelectric inserts generate minimal heat and minimize mechanical stress on the surrounding bone, thus preventing injury to the adjacent tissues.
Another problem associated with repositioning the implant is the stability of the mobilized segment. The mobilized segment can be stabilized using plates and screws of various types, orthodontic brackets, and fixed prosthesis attached to neighboring teeth with resin and wire  or with a mandibular block graft. In the case discussed, adequate stability of the segment was achieved without any fixation as the segment was not fully separated and due to the close approximation of the relocated segment and the parent bone.
| Conclusion|| |
Segmental osteotomy is a predictable and effective procedure for correction of malposed dental implants if parameters permit. The prosthetic complications associated with malposed dental implant and the surgical trauma for the removal and replacement of dental implant can be avoided.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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