HOW DID THAT GET THERE?!? The Dilemma of Misplaced Dental Implants

Most of us are aware of the current advancements in dental implant therapy. They have led to great improvements in the final prosthesis for the implant patient. However, one common problem persists. Too often there are compromised results from poorly positioned implants. The knee-jerk reaction is to blame the placing surgeon. Within this article, we will put the surgeon and the entire implant team on trial, examine the evidence, and render a verdict.  Our findings may surprise you!

Advancements in a Snapshot

Over the past few decades, numerous advancements in implant dentistry have been made. CAD/CAM technology for pre-treatment analysis and stent design has lessened the probability for misplacing fixtures. Also, placement of dental implants has become easier while new component design has made prosthetic fabrication simpler. The art of implant dentistry is striving to keep pace with the demands of cosmetic dentistry. Milled zirconia abutments, all-ceramic crowns and restorations are providing the next steps in esthetic-implant dentistry. Implant fixture design for maximum bone utilization and maturation continues to extend longevity to prosthetics.

Presently, Something is Not Working

Many fixtures continue to be placed in the wrong spot. Rarely are misplaced implants removed or replaced. Restoring doctors often blame surgeons for the errors. Surgeons often rationalize their mistakes. Implant dental technicians blame both and attempt to restore these cases while everyone, patient included, settles for some degree of compromise.

The best source for gathering evidence relating to misplaced implants would have to be the dental implant department of a dental laboratory. Typically, a general dentist will restore a few implant patients per year. More ambitious doctors will restore a few patients per month. Equally, surgeons will place implants in a few patients per week. An implant laboratory department, however, will continuously fabricate stents and prosthetics on numerous implant brands within the scope of their daily routine. Thus, the evidence presents. More often than not, treatment protocols are violated or bypassed. Poor angulations and missed site positions are common.  Furthermore, restoring dentists often rely too heavily on dental technicians for their component and prosthodontic solutions and, in too many cases, for very basic information. For a restoring dentist to be requesting basic impressioning information from an implant sales rep or technician as the healing collar is removed is a true sign of the need for a competence review of training standards and qualifications. Would one ask how to take an impressioning of a simple crown and bridge preparation?

The Defendants and their Alibis

The general dentistís office:
"We explained everything to the patient - from a timeline to a payment schedule. The patient was informed. Therefore, the surgeon must have screwed up."

The implant dental technician:
"We made the surgical guide and I'm sure it was never used. It's not our fault."

The surgeon: 
"My job is to locate adequate bone quantity and quality and surgically place the fixture to achieve osteo-integration. I work closely with my team to insure minimal problems, however, when they happen I almost always can explain why."

The patient:
"I really thought that for this kind of money my teeth would be perfect. I was even shown a pre-treatment wax-up of what my teeth would look like."

The State of Implant Dentistry vs the Failing Implant Team 

An esthetic and hygienic failure due to poor planning and improper placement of fixtures. Often this scenario may be corrected by a simple review of the success criteria.¹

A confused, restoring dentist relying on everyone except oneself.

Too often the general dentist views implant dentistry as another treatment profit center. Realistically, many present treatment modalities are easily adapted to ones practice. For example, an anterior PFM converts to an all-ceramic restoration rather easily. Orthodontically, wires and clasps transform into an invis-o-line prosthesis. The analogies are obvious, yet when it comes to implant therapy the rules change dramatically. The onus is not as simple as one may imagine.  Extensive study is, at minimum, a requirement.

A frustrated implant technician.

Frustration rears its ugly head when one is involved in a decision making process that one is not experienced in making. Usually this manifests itself in redirecting responsibility or blame to others. In as much as the Certified Dental Technician is not a caregiver, much of the prosthetic objective is expected to be achieved through his or her experience and craftsmanship. Too often the technician doesnít know what he doesnít know and neither does the restoring doctor.

A rationalizing surgeon.

Even with the most precise planning, properly designed tomographic/surgical guides, and an astute treatment team, variables abound. In fairness to the surgeon, once reflected, the patientís hard tissues may appear as the ultimate deception. Where once there was a tooth or landmark, now there is a desert. Where bone is soft, in a heartbeat it has become hard and the drill is skewing off into an unknown valley. Technicians often incorrectly design surgical guides. Without specific direction from the restoring doctor/surgeon, errors are bound to happen. Whether misdirecting placement or fabricating a guide that is unusable, it is not the responsibility of the dental technician to direct surgery. Even a competent restoring dentist rarely attends the surgeries of their patients.

A manufacturing rep surmising, "the next time it will be better."

Most manufacturers provide technical assistance via a technical hotline or the field sales rep.  Unfortunately, too often the manufacturer has spent too little time on training and too much time on targeting sales objectives. Field reps historically understand surgical protocols far greater than prosthetic components and the specific troubleshooting that is required, to allow a complex case to be restored uneventfully. The trained and experienced sales/tech rep is a rare, valued and often (unfortunately) discounted member of the implant team.

But most of all...

A patient who has committed a year or more of their life, in some instances, endured physical pain/discomfort, paid thousands of dollars and is now dazed, confused, and very, very angry!

The Prosecution

The results speak for themselves. Misplaced implants are causing restorative difficulties and un-restorable fixtures are being routinely buried. Poor occlusal design is leading to bone loss and limiting case longevity. All of this compounded by frequent esthetic disappointments.

Many authors over the past few decades have written about the importance of the dental implant team. Until the generalist commits to the cost of time and money to become trained then the team will be lead by field reps, surgeons, or dental technicians and this, as we see today, is not satisfactory.  

Little knowledge of treatment planning strategy or protocol rationale.

Understanding that the treatment plan strategies are only the outline that, coupled with experience, can create firm treatment protocols. The restoring doctor will need to work with many specialists and surgeons. Additionally, it takes time to learn how to restore with different types of implants.

Relying heavily on others rather than taking the leadership role is not what leaders do. However, to rely on a surgeon to select the proper fixture or the laboratory to order components does not relinquish or abandon leadership.  On the contrary, it is a part of leading the team.

Leadership is understanding how a treatment plan successfully evolves into proper placement, acceptable timelines and a truly achieved success criteria for a specific patient.

The Defense

Beyond finger pointing, many general practitioners rely on their laboratory to lead the way. They seem to be intimidated by the surgeon and the nuts and bolts. This lack of initiative is understandable due to the multi-disciplinary nature of the event. Inexperienced general practitioners often expect their surgeon to lead. However, when surgical or prosthetic problems occur they are more apt to contact the implant technician for an explanation as to why and how.

Judge and Jury

One must ask, where does moderate incompetence within one's learning curve end and malpractice begin? By no means is everyone at fault and it is not this author's intent to be judge and jury. However, it is time to face the facts, begin at the basics, and then sequentially move forward from there with any implant approach that lends to greater successful predictability than we are experiencing today. 

The Guilty

In as much as all participants in the implant team have played a role in a compromised case it is the restoring dentist that is to be cited. Although, there is a reprieve in the sentence and a solution for the team.

The Sentence, With Recommendations

The restoring dentist's responsibility to direct the case as the team leader simply because prosthetic objectives will always dictate surgery. That is to say if a prosthetic objective cannot be satisfactorily met then dental implant therapy should be reevaluated and other treatment modalities considered.

Do not be intimidated by the surgeon that refused to use proper protocols or denies responsibility for their work. Simply locate another surgeon.

Do not be reliant on the implant technician. They are the prosthetic mechanic that you have hired. They are not licensed to direct surgery by drilling holes in stents nor should they be relied upon to instruct any clinical procedures or to design a treatment plan.

Learn to say no. Today, implant dentistry has become a required modality in dentistry. If the team has not taken the time to learn the proper procedures it is not a team and the general dentist will need to refer the patient to an experienced colleague.

Ideally, the general dentist should place implant fixtures on the smaller, less complicated cases, using their specialists on the multi-discipline cases, much like the endodontic, orthodontic and periodontal patients in a general practice are treated. Laboratory technicians should fabricate the tomography and surgical guides, however, the general practitioner should be directing fixture placement by working one on one with their surgeon.

Do not be afraid. Implantology education takes time, effort and money. But the rewards are well worth it for those who make the commitment.

The Solution

Albeit true that implant dentistry is a multi-discipline responsibility, the onus must fall on the restoring dentist. Taking full responsibility requires the understanding of surgical and restorative capability. Until the restoring doctor takes control of their implant education and ultimately their patient's case, history will continue to repeat itself. Surgeons and technician are the hired specialists of the restoring doctor. Should they fail to achieve the desired outcome, their work should be redone after an examination of where protocol failed. A restoring doctor that relies too heavily on team specialists renders no one in charge.

Establishing Success Criteria

Once the patient has elected to restore with dental implants, the restoring dentist discusses and records the desires and goals of the patient. The restoring dentist categorizes and documents the five essential concerns of the patient and himself. The implant team will clearly see all of the goals, including to what degree of importance those objectives are required to meet.

Each subject illustrates the degree of importance the patient and restoring dentist have placed within each category. Higher percentages represent greater importance of the category to both the patient and the dentist. Establishing the success formula at the treatment planning phase averts many potential misunderstandings. This agreement between the dentist and patient becomes a reference for the implant team to refer to throughout pre-treatment, surgical, prosthetic and home care phases.   

The first phase of the dentist - patient relationship begins with acquiring data for evaluation. Any patient desires that appear to be unrealistic usually surface at this time, allowing the dentist and other team members the advance opportunity to address and educate the patient. 

Footnotes ^{1 and 2} reference excerpts from the following article:  Following a Rigid Plan and Treatment Protocol Will Maximize Dental Implant Success - Part I, by Robert Ingrassio, CDT, printed in the Journal of Dental Technology in June, 1997.