How to restore this palatally placed implant?

Implant placed 1.5 years ago overseas. Patient not able to travel overseas to get it restored. Much too palatally placed. The buccal gingival tissue level is much higher (occlusally) than the palatal aspect. It seems a Straumann implant from the xray. What is the best way to restore this implant without compromising the esthetics and arch form too much? Is the cross pin the way to go to sort out this kind of issue? I am planning to contour the buccal ginginval tissue by temporary abutment/crown, but how to make the final crown less bulky on the palatal side?

Dr.Mahijeet Singh Puri comments:


Dr indraniil comments:

Wait for covid to pass and let him travel overseas

Deanna Anderson comments:

What is the occlusion like in this area? Angled abutment, Very small crown and no contact in excursions???🤷🏻‍♀️

Dr.Mahijeet Singh Puri comments:

Two options 1.Restore in this position 2.Take it out and place a new one more buccally 1.How to restore Use angled abutment 17/25/30 as the case may be let the screw go towards palatal side and abutment towards buccal side. First make a temporary crown Let the patient use it and then if the patient is happy and no bulge on the palatal side,you will have idea about the final crown position. This you should try if the implant length and sinus proximity is OK If you think that there are many unfavorable factors ,it is better to sacrifice and place a new one at a better position. OR Use the same one at a better position.

Lalaali comments:

Great and thanks. I was just wondering how you are going to fabricate the temporary crown in this situation? Are you going to use a temporary cylinder?

Richard Hughes comments:

Two options. Restore as is or remove, graft and start over in an idealized position.

Dale Gerke-Prosthodontist comments:

If integrated then you can leave the implant. It is not ideal but should be functional. Transverse screwing is not the way to go. It would add too much bulk to the palatal aspect of the crown and would be difficult to screw in. Using a re-directional abutment is relatively easy and you can leave the palatal surface of the crown as thin metal (it will be quite strong enough). The screw exit point may end up on the palatal surface rather than occlusal but that will not matter – it will be functional. In regards to the buccal gingival height you have several possible options which I cannot be definite about without checking clinically. • If there is enough attached gingiva you could laser and reduce the height and recontour • Or you could raise a flap and slide towards the sulcus • Or you could shape the emergence profile of the crown in the buccal direction and place some relief cuts in the gingiva (m-d direction) and push the gingiva buccally when placing the crown. There would be a good chance the gingiva will reshape lower and have more width than as shown. If you are going to restore it is important to shape the crown so it does not trap food and can be cleaned. Dr Dale Gerke – BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS(Pros)

Lalaali comments:

Thank you for your detailed reply. Do you prefer the screw-retained crown than cement-retained in this situation? Do you use the temporary crown during the buccal ginigiva re-shaping stage?

Nondas comments:

A custom made abutment on a Ti hexed base can correct the palatal inclination and to give different transmucosal heights buccaly and palataly + cemented crown. Before imprint make a cemented temporary crown on a abutment with inclination of 15° or 30° with transmucosal height 2-3 mm subgingivally at the buccal side. Try to remove the excess cement completely! By adding composite buccaly every 1 week you can push the gingiva gradually and create a better emergence profile. This will move the free gingiva apically as well. At final imprint, copy the shape of the transmucosal part of the temporary abutment/crown to the imprint transfer.

Lalaali comments:

Do you make a custom abutment first and then cement the temporary crown on the custom abutment?