Case Report
Correction of Malpositioned Implants through Periodontal
Surgery and Prosthetic Rehabilitation Using Angled Abutment

Érica Dorigatti de Avila,1 Rafael Scaf de Molon,2

Luiz Antônio Borelli de Barros-Filho,2 Marcelo Ferrarezi de Andrade,3

Francisco de Assis Mollo Jr.,1 and Luiz Antônio Borelli de Barros4

1 Department of Dental Materials and Prosthodontics, School of Dentistry at Araraquara, Universidade Estadual Paulista, UNESP,
Rua Humaitá 1680, 14801-903 Araraquara, SP, Brazil

2 Department of Diagnosis and Surgery, School of Dentistry at Araraquara, Universidade Estadual Paulista, UNESP,
Rua Humaitá 1680, 14801-903 Araraquara, SP, Brazil

3 Department of Restorative Dentistry, School of Dentistry at Araraquara, Universidade Estadual Paulista, UNESP,
Rua Humaitá 1680, 14801-903 Araraquara, SP, Brazil

4Department of Social Dentistry, School of Dentistry at Araraquara, Universidade Estadual Paulista, UNESP,
Rua Humaitá 1680, 14801-903 Araraquara, SP, Brazil

Correspondence should be addressed to Érica Dorigatti de Avila; erica.fobusp@yahoo.com.br

Received 17 March 2014; Accepted 22 April 2014; Published 14 May 2014

Academic Editor: Gianmario Schierano

Copyright © 2014 Érica Dorigatti de Avila et al.This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

When dental implants are malpositioned in relation to the adjacent teeth and alveolar bone or in an excessive buccal or lingual
position, the final prosthesis rehabilitation impairs the peri-implant health of the gingival tissues and the aesthetics of the patient.
Thus, the purpose of this case was to report and discuss a multidisciplinary protocol for the treatment of a compromised maxillary
tooth in a patient with an abscess in his right central incisor due to an excessive buccal implant position. The patient presented
with an implant-supported provisional restoration on his right maxillary central incisor and a traumatic injury in his left central
incisor. The treatment protocol consisted in (i) abutment substitution to compensate the incorrect angulation of the implant, (ii)
clinical crown lengthening, (iii) atraumatic extraction of the left central incisor, and (iv) immediate implant placement. Finally,
(v) a custom abutment was fabricated to obtain a harmonious gingival contour around the prosthetic crown. In conclusion, when
implants are incorrectly positioned in relation to the adjacent teeth, associated with soft-tissue defects, the challenge to create a
harmonious mucogingival contours may be achieved with an interdisciplinary approach and with the placement of an appropriate
custom abutment.

1. Introduction

One of the main challenges in esthetic dentistry is the
preservation and reproduction of the natural mucogingival
architecture surrounding the malpositioned implants in the
anterior maxilla, especially when the patient presents a high
lip line [1]. There are several factors that can influence the
healing around dental implants: (i) systemic conditions such
as diabetes mellitus [2]; (ii) soft and hard tissue contours;
(iii) implant position [3]; (iv) the manufacturer abutment
designs; and (v) the design of the definitive prosthesis [4].

However, poor adaptation of the prosthesis can overload the
implant system, and microgaps can be formed between the
implant and abutment, which results in bacterial accumula-
tion [5]. In some cases, the inflammation of the soft tissue is
observed without bone level changes, a condition called peri-
implant mucositis. However, when bone loss occurs due to
the presence of bacteria in the microgap between the implant
and abutment, the development of peri-implantitis will occur
[6].

Preferably, implants should be installed parallel to each
other and to adjacent teeth and be aligned vertically with

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Case Reports in Dentistry
Volume 2014, Article ID 702630, 9 pages
http://dx.doi.org/10.1155/2014/702630

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2 Case Reports in Dentistry

axial forces. However, when implants are incorrectly angled
or improperly positioned and soft-tissue defects exist, con-
ventional abutments cannot be used; therefore the use of
custom angled abutments is required [6]. Furthermore, some
factors influence the abutment choice, especially related to
metal band height and aesthetic appearance, as follows: (i)
probing depth; (ii) amount of the gingival tissue; and (iii)
implant platform [7, 8].

Some studies suggest that angled abutments result in
increased stress on supporting implants, adjacent bone, and
the prosthesis [9]. On the other hand, other studies [10]
show that it is possible to correct the implant positioning
using angled abutments. The authors stated that angled
abutment did not adversely affect the retention of prostheses
or implants and did not interfere in the survival of the reha-
bilitation. Tian et al. [11] evaluated whether angled abutments
could decrease stress and promote better stress distribution
on surrounding bone of single-unit dental implants. The
authors concluded that angled abutments might result in
decreased stress on adjacent bone of single-unit dental
implants when implants are not placed in the ideal axial
position. At the same time, from a biomechanical point of
view, angled abutments may be a suitable restorative option
when implants are not placed in the ideal axial position.

Thus, given the need to correct small angles and cus-
tomize the connection between the implant and prosthesis,
the aim of this paper was to report a case of an esthetic
and functional anterior maxillary rehabilitation using peri-
odontal surgery and custom abutments to correct the implant
positioning. Moreover, the clinical implications of the use of
angled abutments were discussed.

2. Case Report

A 57-year-old Caucasian man presented to the Department
of Periodontology, School of Dentistry at Araraquara, Sao
Paulo, Brazil, with an implant-supported provisional restora-
tion on the maxillary right central incisor. The patient had
no significant medical history and denied use of alcohol. He
had sustained a traumatic injury involving his left maxillary
central incisor, which had been treated endodontically and
restored with a core and a crown.Themain patient complaint
was the uneven gingival level with consequent increasing of
crown length in the right maxillary central incisor (Figures
1(a) and 1(b)).

Clinical examination showed an abscess in the right max-
illary central incisor mainly caused by the cement retention
(Figures 1(c) and 1(d)) and due to an excessive buccal implant
positioning (Figures 2(a) to 2(d)). In this case, the short
abutment resulted in an inappropriate marginal adaptation,
favoring the accumulation of a cement line between the
crown and abutment interfaces. The first treatment proposed
was a local curettage allowing the abscess drainage. The
standard abutment implant in the region of right maxillary
central incisor was removed and replaced by an EsthetiCone
abutment angled at 25 degrees with a 4mm brace in height
(Conexão Sistema de Implantes, Sao Paulo, SP, Brazil) (Fig-
ures 3(a) and 3(b)).

The periapical radiography revealed endodontic treat-
ment in his left maxillary central and lateral incisors, root
resorption of left maxillary central incisor, periapical lesion
in his left lateral incisor, and the presence of a dental
implant in his right maxillary central incisor with a prefab-
ricated titanium abutment (Conexão Sistema de Protese, Sao
Paulo, SP, Brazil) maintaining a fixed provisional restoration
(Figure 3(c)). Also, the preoperative radiography evaluation
of the left central incisor revealed a wide dentin loss in
consequence of the prosthetic rehabilitation, associated with
root resorption, hindering the aesthetic and functional reha-
bilitation of the patient. Due to uneven gingival level of the
maxillary anterior teeth (Figure 4(a)), the proposed treat-
ment for the patient was (i) removal of the provisional crown
(Figure 4(b)); (ii) endodontic retreatment of left maxillary
lateral incisor; (iii) prosthetic rehabilitation of the right
maxillary central incisor and for the leftmaxillary central and
lateral incisors (Figures 4(c) and 4(d)). Endodontic retreat-
ment of left maxillary lateral incisor was performed using
prefabricated glass fiber. Then, clinical crown lengthening
was performed aiming to improve the aesthetics through the
leveling of the gingival margins (Figures 5(a) to 5(c)).

Prior to the prosthetic rehabilitation, a longitudinal root
fracture in the left central incisor was observed; thus, an
atraumatic extraction of this tooth was performed under
local anesthesia (Figure 5(d)) followed by curettage and root
planing (Figures 6(a) and 6(b)). A 4.3mm internal hexagon
implant (Correct Master, Conexão Sistema de Protese, Sao
Paulo, SP, Brazil) was immediately placed in the fresh extrac-
tion socket, with proper 3-dimensional orientation (Figures
6(c) and 6(d)) [12].

The implant was placed 3mm below the bone crest and
in a more palatine position, allowing a minimal distance of
2mm from the buccal cortical bone (Figure 7(a)). Primary
stability was achieved by the selection of implants with 15mm
length, which extended 5mm from the apex of the extracted
tooth. The final insertion torque was 45N⋅cm.

A CeraOne abutment (Conexão Sistema de Protese,
Sao Paulo, SP, Brazil) was installed immediately after the
implant installation (Figure 7(b)). Thereafter, a new provi-
sional crown involving right and left central incisors and
left lateral incisor was prepared to peri-implant mucosa
conditioning during the healing process (Figure 7(c)). After,
periapical radiography was taken to verify the proper implant
position in relation to the adjacent teeth and the correct
adaptation of the prosthetic component (Figure 7(d)). In an
attempt to personalize the abutment preparation and increase
the contact between the implant and the components and
considering the low cost of the component, UCLA abutments
overcast in cobalt-chromium (Conexão Sistema de Protese,
Sao Paulo, SP, Brazil) were selected.

After four months, the EsthetiCone and CeraOne abut-
ments were removed in order to make a cast. From this
cast, the custom UCLA abutments overcast with cobalt-
chromium were prepared. One commonly used method to
mitigate the poor appearance of peri-implant tissue caused
by cobalt-chromiummetal is to alter the metallic color using
the application of porcelain on the component. Therefore,
Ivoclar press ceramic was applied to obtain better aesthetic



Case Reports in Dentistry 3

(a) (b)

(c) (d)

Figure 1: A 57-year-old female presented with an implant-supported provisional restoration on the maxillary right central incisor. (a, b)
Image showed the uneven level of the gingiva of the maxillary anterior teeth. (c) Clinical examination showing abscess in the right maxillary
central incisor region. (d) Cement retention of the implant-supported prosthesis.

(a) (b)

(c) (d)

Figure 2: Clinical examination showing buccally implant position.



4 Case Reports in Dentistry

(a) (b) (c)

Figure 3: (a) Right maxillary central incisor abutment removed. (b) Angled abutment to correct the implant malpositioning; (c) periapical
radiograph revealed endodontic treatment of the left maxillary central incisor and the left maxillary lateral incisor and the root resorption of
left maxillary lateral incisor.

(a) (b)

(c) (d)

Figure 4: (a) Uneven gingival level of the maxillary right central incisor. (b) After removal of the provisional crown. (c, d) New provisional
resin crown to favor the gingival aesthetics.

results on the pillars (Figures 8(a) to 8(d)). The copings
were fabricated with IPS e.max Press (Conexão Sistema
de Protese, Sao Paulo, SP, Brazil) and were injected with
translucent ceramic with a lithium disilicate base (Figures
9(a) to 9(d)) in the maxillary central and lateral incisors
and left canine. The injection of hot glass-ceramic gener-
ates the desired final dimensions of restoration and, after
being painted with ceramic pigments, was covered with a
glaze of powdered glass and subject to final firing. After 12
months, the rehabilitation shows excellent aesthetic results
(Figures 10(a) and 10(b)). The three-year follow-up results

demonstrate an improved clinical situation, allowing an opti-
mal aesthetic outcome without probing depths or gingival
recession (Figures 11(a) to 11(c)). Figures 12(a) and 12(b)
showed the initial and final clinical situation, respectively.

3. Discussion

Usually, the use of parallel abutments to elaborate an implant-
supported prosthesis instead of abutments is preferred. How-
ever, there are caseswhere it is not possible to place an implant



Case Reports in Dentistry 5

(a) (b)

(c) (d)

Figure 5: (a, b, c) Clinical crown lengthening of the anterior teeth to correct the uneven gingival level. (d) Atraumatic extraction of the left
central incisor.

(a) (b)

(c) (d)

Figure 6: (a, b) After tooth extraction, root planing and curettage of the alveolus and bone removal for crown lengthening, with the aid of a
chisel, were performed. (c, d) A 4.3mm internal hexagon implant was placed 3mm below the alveolar bone crest in the direction of palatal
cortical bone.



6 Case Reports in Dentistry

(a) (b)

(c) (d)

Figure 7: (a) Occlusal view of the implant placed. (b, c) Immediate postoperative views with provisional resin crown in the central and lateral
incisor teeth. (d) Periapical radiography after implant installation.

(a) (b)

(c) (d)

Figure 8: (a, b) 4 months after the implant placement in the left central incisor. (c, d) Application of ceramic Ivoclar press on the abutments
to improve the aesthetic results.



Case Reports in Dentistry 7

(a) (b)

(c) (d)

Figure 9: IPS and max press copings used to restore the maxillary central and left incisors and left canine.

(a) (b)

Figure 10: Buccal view of the implant crown and its excellent aesthetic results at a 12-month follow-up.

(a) (b) (c)

Figure 11: (a, b)Three years follow-up; the result showed esthetic excellence of the definitive prosthesis; (c) periapical radiograph.Three-year
follow-up showing the accurate fit between the abutments and implants and between the crowns and abutments.



8 Case Reports in Dentistry

(a) (b)

Figure 12: (a) Initial and (b) final clinical situations.

in an ideal tridimensional position without additional surgi-
cal procedures [13–16].Thus, the aimof this casewas to report
an esthetic and functional anterior maxillary rehabilitation
using custom abutments to correct the implant position-
ing. According to Cavallaro and Greenstein [10], to restore
peri-implant soft-tissue health, surrounding malpositioned
implants, correct prosthetic component designs should be
chosen, since the wrong choice of abutments could result
in aesthetics and peri-implant commitment. Abutments can
affect the implant stress and strain distribution, changing the
forces transmission to the adjacent bone [10, 11].

Successful anterior esthetic of a single-crown restoration
is achieved when the crown color matches the neighboring
teeth, the peri-implant tissue contours simulate the gingiva
around the crown, and the peri-implant tissue matches the
patient natural color. In this particular case, we chose the
UCLAabutment.This component has been indicated in some
cases, including (i) implants positioned in the same gingival
level; (ii) angled implants; (iii) presence of small interocclusal
space; (iv) or if the final prosthesis cost is a preponderant
factor [17]. Using UCLA custom abutments and overcasting
to fabricate a duplicate titanium abutment simplifies the
clinicians ability to replace a metallic abutment [17].

In this particular case, the patient presented with a deep
peri-implant area and an angled implant, which contributed
to the esthetics commitment. In relation to the implant
position, the scientific literature is contradictory about the
problems caused by angled abutments. In 2008, Kao et al.
[18] observed that angled abutment up to 25 degrees can
increase the stress in the peri-implant bone by 18%. This
result is in agreement with Lin et al. [9], who found higher
implant and cortical bone strain for a 20-degree angled
abutment compared to straight abutments. On the other
hand, Saab et al. [19] measured and compared the bone
tensiondistribution around an implant in the anteriormaxilla
using 2 different abutments, parallel and angulated, by means
of finite element analysis. The results showed that most of
the tension produced on the cancellous and cortical bone was
within the range that has been reported to increase bonemass
and mineralization.

Another treatment option is the use of CAD/CAM
technology. CAD/CAM allows the creation of duplicate abut-
ments, whereby two precisely shaped abutments of similar
or dissimilar materials can be fabricated from the same

computer file. A crown that is fabricated for one of these
abutments will fit the other, despite any material differences.
However, this treatment alternative is still restrictive in
developing countries due to the high cost to the patient
[20]. Another option that offers better precision between
the abutment-implant and abutment-crown is the use of
UCLA overcasting. In this case, a customized abutment was
modifiedwith the application of porcelain over the coping; an
injection of IPS max press prolonged the aesthetic life of the
restoration and the soft tissues surrounding the implant.

Passive adaptation between the abutment and the implant
and between the crown and the abutment prevents the onset
of the inflammatory process that causes peri-implantitis.
Interventions prior to the complete healing process in
response to patient demands may result in unpredictable
soft-tissue manifestations. This outcome may include an
inadequate zone of attached gingiva, as well as the com-
pression of the soft tissue surrounding the abutment from
an overlying provisional prosthesis [4]. Achieving a better
aesthetic outcome in the maxillary anterior area is necessary
to obtain harmony between color and position of the crowns
in relation to the adjacent teeth and the contour of the peri-
implant tissue around the crown. Custom UCLA abutments
overcast with cobalt-chromium allow for easy restoration of
the gingival tissues, which offers precise adaptation, associ-
ated with an accessible cost. At the same time, the aesthetics
of the metal collar can be corrected with the application of
ceramic to the metal copings with IPS e.max Press and the
injection of translucent, lithium disilicate-based ceramics.

In conclusion, when implants are incorrectly positioned
in relation to the adjacent teeth, associated with soft-tissue
defects, the challenge to create a harmonious mucogingival
contours may be achieved with an interdisciplinary approach
and with the placement of an appropriate custom abutment.

Conflict of Interests

The authors declare that there is no conflict of interests
regarding the publication of this paper.

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Case Reports in Dentistry 9

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