Journal of Indian Society of Periodontology
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   Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 24  |  Issue : 1  |  Page : 83-86  

Management of a malposed dental implant in the esthetic zone


1 Department of Prosthodontics, MES Dental College, Perinthalmanna, Kerala, India
2 Department of Periodontics, MES Dental College, Perinthalmanna, Kerala, India

Date of Submission08-Dec-2018
Date of Decision11-Mar-2019
Date of Acceptance01-Apr-2019
Date of Web Publication24-Jul-2019

Correspondence Address:
Dr Priyatha Purushotham
Department of Prosthodontics, MES Dental College, Perinthalmanna - 679 338, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_733_18

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   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 Sep 26];24:83-6. Available from: http://www.jisponline.com/text.asp?2020/24/1/83/263387




   Introduction Top


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.[1] 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.[2]

When a dental implant is poorly positioned, it can be managed by prosthetic compensation or surgical correction.[3] 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.[4]

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.[5]

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 Top


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 5: Implant relocated to the desired position

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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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Figure 10: Final prosthesis

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   Discussion Top


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.[6],[7] 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.[8]

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.[9]

The indications for segmental osteotomy to reposition a malposed dental implant include well-osseointegrated implant with sufficient surrounding bone [10] 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.[11]

Uncompromised vascular supply is an important factor for the success of the repositioned bone.[4] 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.[12] 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.[9] 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.[13] The piezoelectric inserts generate minimal heat and minimize mechanical stress on the surrounding bone, thus preventing injury to the adjacent tissues.[14]

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,[11] orthodontic brackets,[10] and fixed prosthesis attached to neighboring teeth with resin and wire [4] or with a mandibular block graft.[3] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Vere J, Bhakta S, Patel R. Prosthodontic complications associated with implant retained crowns and bridgework: A review of the literature. Br Dent J 2012;212:267-72.  Back to cited text no. 1
    
2.
Porter JA, von Fraunhofer JA. Success or failure of dental implants? A literature review with treatment considerations. Gen Dent 2005;53:423-32.  Back to cited text no. 2
    
3.
Olate S, Weber B, Marín A. Segmental osteotomy for mobilization of dental implant. J Periodontal Implant Sci 2013;43:243-7.  Back to cited text no. 3
    
4.
Kassolis JD, Baer ML, Reynolds MA. The segmental osteotomy in the management of malposed implants: A case report and literature review. J Periodontol 2003;74:529-36.  Back to cited text no. 4
    
5.
Warden PJ, Scuba JR. Surgical repositioning of a malposed, unserviceable implant: Case report. J Oral Maxillofac Surg 2000;58:433-5.  Back to cited text no. 5
    
6.
Asvanund C, Morgano SM. Restoration of unfavorably positioned implants for a partially endentulous patient by using an overdenture retained with a milled bar and attachments: A clinical report. J Prosthet Dent 2004;91:6-10.  Back to cited text no. 6
    
7.
Duff RE, Razzoog ME. Management of a partially edentulous patient with malpositioned implants, using all-ceramic abutments and all-ceramic restorations: A clinical report. J Prosthet Dent 2006;96:309-12.  Back to cited text no. 7
    
8.
Stacchi C, Chen ST, Raghoebar GM, Rosen D, Poggio CE, Ronda M, et al. Malpositioned osseointegrated implants relocated with segmental osteotomies: A retrospective analysis of a multicenter case series with a 1- to 15-year follow-up. Clin Implant Dent Relat Res 2013;15:836-46.  Back to cited text no. 8
    
9.
Akkas I, Toptas O, Akpinar YZ, Ozan F. Segmental alveolar osteotomy by palatal approach to correct excessive angulated dental implants in anterior and posterior maxilla. J Clin Diagn Res 2015;9:ZD03-5.  Back to cited text no. 9
    
10.
Gholami M. Mobilization of malpositioned dental implant using segmental osteotomy: A case report. J Stomatol Oral Maxillofac Surg 2018;119:52-5.  Back to cited text no. 10
    
11.
Netto HD, Olate S, Mazzonetto R. Surgical repositioning of osseointegrated malposed dental implant with segmental osteotomy. J Craniofac Surg 2012;23:1540-2.  Back to cited text no. 11
    
12.
Kaya A. Segmental osteotomy to reposition a malposed dental implant in the anterior maxilla: A clinical report. Oral Health Dent Manag 2017;16:1-4.  Back to cited text no. 12
    
13.
Stacchi C, Bonino M, Di Lenarda R. Surgical relocation of a malpositioned, unserviceable implant protruding into the maxillary sinus cavity. A clinical report. J Oral Implantol 2012;38:417-23.  Back to cited text no. 13
    
14.
Seshan H, Konuganti K, Zope S. Piezosurgery in periodontology and oral implantology. J Indian Soc Periodontol 2009;13:155-6.  Back to cited text no. 14
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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