When Dental Implants Go Wrong: A Case Study in the Importance of Comprehensive Treatment Planning

A detailed analysis of a complex implant case and what patients need to know before proceeding with treatment

The Case That Started It All

A few months ago, a general dentist—a great colleague of ours—referred a patient with a concerning situation. He had placed three dental implants in the lower anterior region just 3-6 months prior, and the patient was already showing signs of trouble: visible implant threads and openings in the gum tissue called "fenestrations."

His question was simple: "Can we do gum grafting to fix this?"

Our answer would reveal a much more complicated story—one that highlights why comprehensive treatment planning is absolutely critical before placing dental implants.

What We Found: The Red Flags

When the patient, a woman in her 60s, came to our office, we immediately ran a CBCT scan (3D imaging). What we discovered confirmed our concerns:

1. Severe Bone Loss

The 3D imaging revealed virtually no facial bone covering the implants. The implant threads were completely exposed—you could see them right through the tissue. This meant there was no bone support on the outer surface of the implants, which is critical for long-term success.

2. A Severe Class 2 Bite Relationship

This patient had what we call a "severe Class 2" bite, which means significant overbite. The upper jaw sits far forward relative to the lower jaw, which is positioned more toward the back of the mouth. This creates a challenging horizontal gap that needs to be bridged with any dental restoration.

3. Implant Positioning Issues

The implants were placed where the bone existed, not necessarily where the teeth needed to be. This is a critical distinction. When bone resorbs (shrinks away) after tooth loss, it typically resorbs from the outer edge inward. But we can't just place implants far back where the remaining bone is—we need to place them where the teeth will actually be positioned.

Additionally, the implants used were quite wide (4.7mm), which further compromised the thin bone in this area.

4. Inadequate Restorative Space

Looking at the photos, we could see spacing on both sides, suggesting the patient couldn't fully close their bite without the teeth getting too close together. This indicated a lack of proper restorative space for the planned bridge.

Why This Case Was Destined for Problems

The Class 2 Dilemma

Treating a Class 2 bite relationship with implants is inherently challenging. Here's why:

When you have a Class 2 bite, there's a significant horizontal gap between the upper and lower teeth. To bridge this gap with a restoration, you typically need to open the bite vertically. But here's the catch: the more you open a Class 2 bite, the worse the horizontal discrepancy becomes.

Think about it mechanically: the lower jaw is the one that moves. When it's already set back and you open it further, it moves even farther away from the upper teeth. This means you need even longer, more flared-out teeth to bridge that gap—which looks unnatural and creates unfavorable forces on the implants.

The Force Problem

Dental implants are designed to handle forces along their long axis—straight up and down. But in this case, with the severe Class 2 relationship and the horizontal gap, the forces would be coming at an angle. This creates a significant horizontal component to the biting force, which is exactly what you don't want with implants. It's like constantly pushing on a fence post from the side rather than pressing straight down on it.

The Implant Positioning Mistake

Looking at the cross-sectional views, we could see the implants were positioned too far toward the outer (facial) aspect of the jaw. Ideally, implants should be:

Smaller in diameter (3.7mm would have been better than 4.7mm in this thin bone)
Placed deeper into the bone
Angled appropriately to align with the final tooth position and create better force distribution

Instead, these implants were too wide, too shallow, and positioned where almost half of the implant body was outside the available bone. When there's no bone, the gum tissue can't stay healthy either—hence the fenestrations.

Could Gum Grafting Have Saved This Case?

In our experience, free gingival grafts (not connective tissue grafts or cadaver tissue) can produce excellent results for exposed implant threads—but only under the right circumstances.

If this patient had come to us years after the implants were placed and functioning well, we would absolutely explore options to save them. But this case was different. The problems were showing up just months after placement, before the permanent bridge was even fabricated.

As Dr. Syed eloquently put it: "This is like trying to build a new home when the foundation is already cracking."

With the combination of:

Severe bone loss
Unfavorable Class 2 relationship
Poor implant positioning
Early signs of failure

Attempting to gum graft would be putting a band-aid on a much deeper problem. It would be expensive, unpredictable, and likely wouldn't address the fundamental biomechanical issues dooming this case.

What Should Have Been Done Differently?

Comprehensive Workup First

Before placing any implants, this case needed:

Bite analysis: Understanding and planning for the Class 2 relationship
Restorative planning: Determining exactly where teeth need to be positioned
Bone assessment: Evaluating what bone grafting would be needed
Implant planning: Designing implant size, depth, and angulation based on the final tooth position

Guided Bone Regeneration (GBR)

This case needed significant bone grafting before or during implant placement. The procedure is called Guided Bone Regeneration, and it would involve:

Building up the thin facial bone where it's deficient
Using smaller diameter implants (3.7mm instead of 4.7mm)
Placing implants deeper and at better angles
Potentially keeping the patient without teeth in that area during healing (which can take months)

Yes, this means the patient would need to wear a temporary removable appliance and wait longer. But as we say, "It's like stepping on wet concrete"—you can't put pressure on bone that's trying to regenerate.

Consider Alternative Treatment Plans

Given the severity of the Class 2 relationship, the multiple missing teeth, and the compromised remaining teeth, we discussed whether an All-on-4 approach might have been more appropriate from the start.

Why? Because:

You're going to need to bridge everything together anyway with this bite relationship
You can't do individual crowns with implants positioned this way
The existing teeth already have multiple crowns and questionable prognosis
Opening the bite with just three implants creates problems elsewhere in the mouth

An All-on-4 allows you to:

Address the entire arch comprehensively
Better manage the Class 2 bite relationship
Create more predictable aesthetics and function
Avoid the compromised remaining teeth becoming future problems

The Hard Truth: Starting Over

After our consultation, we recommended removing the implants and starting fresh with proper planning. We know this patient had already invested $15,000 in the process, and this recommendation wasn't easy to deliver.

But the alternative—proceeding with an expensive bridge on a failing foundation—would likely lead to even more money lost and more heartache down the road.

What This Means for Patients

If you're considering dental implants, especially if you have:

An overbite (Class 2 relationship)
Multiple missing teeth
Previous bone loss
A history of failed dental work

Here are the key questions to ask your dentist:

Before Treatment:

"What does my 3D scan show about my bone quality and quantity?"
"How will my bite relationship affect the implant treatment?"
"Where exactly will the implants be positioned, and why?"
"Will I need bone grafting, and if so, what's the timeline?"
"What are the alternatives to this treatment plan?"
"What's the long-term prognosis, and what could go wrong?"

Red Flags to Watch For:

Rushing into implant placement without comprehensive planning
Not addressing bite problems before placing implants
Placing immediate temporary teeth when significant bone grafting is needed
Implants that feel loose or show gum recession shortly after placement
Being told "we'll just graft the gums later" when bone loss is present

The Bottom Line

This case illustrates something we see too often: well-intentioned treatment that wasn't properly planned for the patient's specific anatomy and bite relationship. The referring dentist is a good clinician, but this case needed specialist-level planning from the start.

Dental implants can last a lifetime—but only when they're placed in adequate bone, positioned correctly, and integrated into a comprehensive treatment plan that addresses bite, aesthetics, and function.

Sometimes the longer, more expensive, more comprehensive approach at the beginning is actually the more conservative and cost-effective path in the long run.

If you're facing a complex dental situation, don't be afraid to seek multiple opinions, ask tough questions, and insist on seeing the 3D imaging and comprehensive treatment plan before proceeding. Your smile—and your investment—deserve nothing less.

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