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Apexa posted an update
The case I am sharing has been quite challenging for me restoratively. Patient was referred out for implant placement #31. It is a Nobel implant WP. First time I restored it, within a week of insert abutment fractured. Fortunately, retrieving the abutment screw was not that difficult. When I inserted the first time I did know something is off (other than angle of implant) but could not figure out what it was and all I did is schedule a post op in 2 weeks. Perhaphs, I wanted to delay dealing with the problem. I dint have to wait too long within a week patient returned. On discussing with the lab realized they used BioHorizon parts with Nobel implant. I re-impressed and send it back to lab. Second time correct parts were used. However, the crown decemented twice within a week of second insert (while flossing and second time doing nothing as per patient). The only good thing is that abutment did not fracture this time. I can think of three solutions but cant settle with either one.
1/ Taking the tooth out of occlusion. However, that defeats the point of repalcing the tooth.
2/ Discuss with lab if its possible to cast abutment and crown together with/without porcelain facing and/ or making it screw retianed even if the screw access comes out at weird angle. I dont know if that is even practically possible.
3/ Refer to prosthodontist. However, at this point I feel I am so invested I want to try and figure it out myself. I also feel patient may get lost in the system of referrals and wont have a solution that would be more favorable for the patient. I may be wrong. I feel bad that ultimately patient is at the recieving end of all this.
So here I am in my quest to figure out what can I do for the patient so they can have a crown as soon and as reasonably as possible.
Thank you.
Erick and Ivan8 Comments-
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This one is a bit tough. I say that because it looks like it was a little difficult on the surgical aspect with minimal bone height. It always seems to work out this way–in the cases where you wish to have no problems, you often encounter them.
It’s okay though. Let’s try to get to the bottom of this.
First: I understand you cemented the crown and it keeps popping off, right? What did you cement with?
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I used premier implant cement
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While your suggestions make sense, let’s take a look at the options from most simple to least simple:
Turn it into a screw-retained crown.
You can just send it back to the lab to have them convert that crown and abutment into a screw retained crown. They would cement the two and make an access hole through the crown. No problem there. It can be tricky to seat the crown when you choose this route–because you are beholden to the contacts of the adjacent teeth. But this option is very simple and might be an immediate solution for you.
I think it would still be advisable to remove the occlusion from this crown. The implant is very short and has some bone loss and is placed at a bit of an angle. These things make the occlusal load potentially damaging to the bone as well as messing with the cement/screws.
Remake the abutment and crown.
Moving on to a slightly more complex option. You might consider having the lab make a new abutment and crown. The abutment that you show appears not to have much support for the crown. It is such a small abutment and such a large crown. As the implant was placed at an angle, the occlusal forces on this type of small abutment – large crown interface can commonly cause what you are describing. If you go this route, you can ask them to make a larger custom abutment that extends further mesial and distal.
UCLA abutment.
What you currently have is a crown and an abutment. They are separate. When your lab cements them (as discussed in the previous option) it becomes a screw retained crown. However, there is another option in which the abutment and the crown are the same piece. It is all a single piece. And the lab can do a porcelain facing for it. This is usually reserved for cases in which there is limited restorative space. It could work for your case–although it might not be absolutely necessary.
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Thank for taking your time to explain this. If the lab makes abutment wide mesial and distal with already some exposed threads of implant won’t that create room for more plaque accumulation and can long term cause increased bone loss and higher chances of periimplantitis ?
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I don’t mean for the abutment to just shoot out abruptly in a mesial and distal direction. I just mean that the abutment should be designed so that it has a wider base on it. Given that it is a posterior area, it is not a huge cosmetic issue–so it can be at a higher level
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