Prosthetic management of malpositioned implant using custom cast abutment
Identifieur interne : 000177 ( Pmc/Corpus ); précédent : 000176; suivant : 000178Prosthetic management of malpositioned implant using custom cast abutment
Auteurs : Aishwarya Chatterjee ; Mallikarjuna Ragher ; Sanket Patil ; Debopriya Chatterjee ; Savita Dandekeri ; Vishnu PrabhuSource :
- Journal of Pharmacy & Bioallied Sciences [ 0976-4879 ] ; 2015.
Abstract
Two cases are reported with malpositioned implants. Both the implants were placed 6–7 months back. They had osseointegrated well with the surrounding bone. However, they presented severe facial inclination. Case I was restored with custom cast abutment with an auto polymerizing acrylic gingival veneer. Case II was restored with custom cast UCLA type plastic implant abutment. Ceramic was directly fired on the custom cast abutments. The dual treatment strategy resulted in functional and esthetic restorations despite facial malposition of the implants.
Url:
DOI: 10.4103/0975-7406.163528
PubMed: 26538957
PubMed Central: 4606699
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Prosthetic management of malpositioned implant using custom cast abutment</title><author><name sortKey="Chatterjee, Aishwarya" sort="Chatterjee, Aishwarya" uniqKey="Chatterjee A" first="Aishwarya" last="Chatterjee">Aishwarya Chatterjee</name><affiliation><nlm:aff id="aff1">Department of Dentistry, SMS Medical College and Hospital, Jaipur, Rajasthan, India</nlm:aff></affiliation></author><author><name sortKey="Ragher, Mallikarjuna" sort="Ragher, Mallikarjuna" uniqKey="Ragher M" first="Mallikarjuna" last="Ragher">Mallikarjuna Ragher</name><affiliation><nlm:aff id="aff2">Department of Prosthodontics, Yenepoya Dental College, Mangalore, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Patil, Sanket" sort="Patil, Sanket" uniqKey="Patil S" first="Sanket" last="Patil">Sanket Patil</name><affiliation><nlm:aff id="aff3">Department of Prosthodontics, Yogita Dental College and Hospital, Ratnagiri, Maharashtra, India</nlm:aff></affiliation></author><author><name sortKey="Chatterjee, Debopriya" sort="Chatterjee, Debopriya" uniqKey="Chatterjee D" first="Debopriya" last="Chatterjee">Debopriya Chatterjee</name><affiliation><nlm:aff id="aff4">Department of Periodontics, RUHS College of Dental Sciences, Jaipur, Rajasthan, India</nlm:aff></affiliation></author><author><name sortKey="Dandekeri, Savita" sort="Dandekeri, Savita" uniqKey="Dandekeri S" first="Savita" last="Dandekeri">Savita Dandekeri</name><affiliation><nlm:aff id="aff2">Department of Prosthodontics, Yenepoya Dental College, Mangalore, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Prabhu, Vishnu" sort="Prabhu, Vishnu" uniqKey="Prabhu V" first="Vishnu" last="Prabhu">Vishnu Prabhu</name><affiliation><nlm:aff id="aff5">Department of Oral Pathology, Yenepoya Dental College, Mangalore, Karnataka, India</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26538957</idno><idno type="pmc">4606699</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606699</idno><idno type="RBID">PMC:4606699</idno><idno type="doi">10.4103/0975-7406.163528</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000177</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000177</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Prosthetic management of malpositioned implant using custom cast abutment</title><author><name sortKey="Chatterjee, Aishwarya" sort="Chatterjee, Aishwarya" uniqKey="Chatterjee A" first="Aishwarya" last="Chatterjee">Aishwarya Chatterjee</name><affiliation><nlm:aff id="aff1">Department of Dentistry, SMS Medical College and Hospital, Jaipur, Rajasthan, India</nlm:aff></affiliation></author><author><name sortKey="Ragher, Mallikarjuna" sort="Ragher, Mallikarjuna" uniqKey="Ragher M" first="Mallikarjuna" last="Ragher">Mallikarjuna Ragher</name><affiliation><nlm:aff id="aff2">Department of Prosthodontics, Yenepoya Dental College, Mangalore, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Patil, Sanket" sort="Patil, Sanket" uniqKey="Patil S" first="Sanket" last="Patil">Sanket Patil</name><affiliation><nlm:aff id="aff3">Department of Prosthodontics, Yogita Dental College and Hospital, Ratnagiri, Maharashtra, India</nlm:aff></affiliation></author><author><name sortKey="Chatterjee, Debopriya" sort="Chatterjee, Debopriya" uniqKey="Chatterjee D" first="Debopriya" last="Chatterjee">Debopriya Chatterjee</name><affiliation><nlm:aff id="aff4">Department of Periodontics, RUHS College of Dental Sciences, Jaipur, Rajasthan, India</nlm:aff></affiliation></author><author><name sortKey="Dandekeri, Savita" sort="Dandekeri, Savita" uniqKey="Dandekeri S" first="Savita" last="Dandekeri">Savita Dandekeri</name><affiliation><nlm:aff id="aff2">Department of Prosthodontics, Yenepoya Dental College, Mangalore, Karnataka, India</nlm:aff></affiliation></author><author><name sortKey="Prabhu, Vishnu" sort="Prabhu, Vishnu" uniqKey="Prabhu V" first="Vishnu" last="Prabhu">Vishnu Prabhu</name><affiliation><nlm:aff id="aff5">Department of Oral Pathology, Yenepoya Dental College, Mangalore, Karnataka, India</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Pharmacy & Bioallied Sciences</title><idno type="ISSN">0976-4879</idno><idno type="eISSN">0975-7406</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Two cases are reported with malpositioned implants. Both the implants were placed 6–7 months back. They had osseointegrated well with the surrounding bone. However, they presented severe facial inclination. Case I was restored with custom cast abutment with an auto polymerizing acrylic gingival veneer. Case II was restored with custom cast UCLA type plastic implant abutment. Ceramic was directly fired on the custom cast abutments. The dual treatment strategy resulted in functional and esthetic restorations despite facial malposition of the implants.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Duff, Re" uniqKey="Duff R">RE Duff</name></author><author><name sortKey="Razzoog, Me" uniqKey="Razzoog M">ME Razzoog</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wohrle, Ps" uniqKey="Wohrle P">PS Wöhrle</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Misch, Ce" uniqKey="Misch C">CE Misch</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Stacchi, C" uniqKey="Stacchi C">C Stacchi</name></author><author><name sortKey="Chen, St" uniqKey="Chen S">ST Chen</name></author><author><name sortKey="Raghoebar, Gm" uniqKey="Raghoebar G">GM Raghoebar</name></author><author><name sortKey="Rosen, D" uniqKey="Rosen D">D Rosen</name></author><author><name sortKey="Poggio, Ce" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Pharm Bioallied Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Pharm Bioallied Sci</journal-id><journal-id journal-id-type="publisher-id">JPBS</journal-id><journal-title-group><journal-title>Journal of Pharmacy & Bioallied Sciences</journal-title></journal-title-group><issn pub-type="ppub">0976-4879</issn><issn pub-type="epub">0975-7406</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26538957</article-id><article-id pub-id-type="pmc">4606699</article-id><article-id pub-id-type="publisher-id">JPBS-7-740</article-id><article-id pub-id-type="doi">10.4103/0975-7406.163528</article-id><article-categories><subj-group subj-group-type="heading"><subject>Dental Science - Case Report</subject></subj-group></article-categories><title-group><article-title>Prosthetic management of malpositioned implant using custom cast abutment</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Chatterjee</surname><given-names>Aishwarya</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Ragher</surname><given-names>Mallikarjuna</given-names></name><xref ref-type="aff" rid="aff2">1</xref></contrib><contrib contrib-type="author"><name><surname>Patil</surname><given-names>Sanket</given-names></name><xref ref-type="aff" rid="aff3">2</xref></contrib><contrib contrib-type="author"><name><surname>Chatterjee</surname><given-names>Debopriya</given-names></name><xref ref-type="aff" rid="aff4">3</xref></contrib><contrib contrib-type="author"><name><surname>Dandekeri</surname><given-names>Savita</given-names></name><xref ref-type="aff" rid="aff2">1</xref></contrib><contrib contrib-type="author"><name><surname>Prabhu</surname><given-names>Vishnu</given-names></name><xref ref-type="aff" rid="aff5">4</xref></contrib></contrib-group><aff id="aff1">Department of Dentistry, SMS Medical College and Hospital, Jaipur, Rajasthan, India</aff><aff id="aff2"><label>1</label>Department of Prosthodontics, Yenepoya Dental College, Mangalore, Karnataka, India</aff><aff id="aff3"><label>2</label>Department of Prosthodontics, Yogita Dental College and Hospital, Ratnagiri, Maharashtra, India</aff><aff id="aff4"><label>3</label>Department of Periodontics, RUHS College of Dental Sciences, Jaipur, Rajasthan, India</aff><aff id="aff5"><label>4</label>Department of Oral Pathology, Yenepoya Dental College, Mangalore, Karnataka, India</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Aishwarya Chatterjee, E-mail: <email xlink:href="aishwarjo@gmail.com">aishwarjo@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><month>8</month><year>2015</year></pub-date><volume>7</volume><issue>Suppl 2</issue><fpage>S740</fpage><lpage>S745</lpage><history><date date-type="received"><day>28</day><month>4</month><year>2015</year></date><date date-type="rev-recd"><day>28</day><month>4</month><year>2015</year></date><date date-type="accepted"><day>22</day><month>5</month><year>2015</year></date></history><permissions><copyright-statement>Copyright: © Journal of Pharmacy and Bioallied Sciences</copyright-statement><copyright-year>2015</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms</license-p></license></permissions><abstract><p>Two cases are reported with malpositioned implants. Both the implants were placed 6–7 months back. They had osseointegrated well with the surrounding bone. However, they presented severe facial inclination. Case I was restored with custom cast abutment with an auto polymerizing acrylic gingival veneer. Case II was restored with custom cast UCLA type plastic implant abutment. Ceramic was directly fired on the custom cast abutments. The dual treatment strategy resulted in functional and esthetic restorations despite facial malposition of the implants.</p></abstract><kwd-group><title>KEY WORDS</title><kwd>Custom cast implant abutment</kwd><kwd>malpositioned implant</kwd><kwd>UCLA abutment</kwd></kwd-group></article-meta></front><body><p>With the advent of osseointegrated implants, restorative and prosthetic dentistry has conquered new horizons. The clinical success and outcome of implants are well-documented in the scientific literature.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref5" ref-type="bibr">5</xref>] Riding alongside this success story is another picture which is not very pleasant to look at. Complications have arisen which challenge the patient and the restorative dentist as well.[<xref rid="ref1" ref-type="bibr">1</xref>] All too often these complications are due to poor planning; poor case selection; poor communication between, the patient, surgical and restorative operator, laboratory personnel; faulty operator technique, to name a few.[<xref rid="ref2" ref-type="bibr">2</xref>] One of the most common and preventable complications is an error in placing the implant in a favorable position facially.[<xref rid="ref3" ref-type="bibr">3</xref>]</p><p>Malpositioned implants often exhibit facial bone dehiscence or fenestration.[<xref rid="ref4" ref-type="bibr">4</xref>] Several authors have reported multiple techniques for management of misaligned implants.[<xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref7" ref-type="bibr">7</xref>] Other than managing the malposed implant, restoration of the surrounding tissue also proves challenging especially if the patient has a high lip line.[<xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref>]</p><p>Two cases are reported showcasing prosthetic, nonsurgical management of malpositioned implant and one management of soft tissue due to patient's high smile line.</p><sec id="sec1-1"><title>Case Reports</title><sec id="sec2-1"><title>Case report I</title><p>A 27-year-old female patient reported to the Department of Prosthodontics, College of Dental Sciences, Davangere, Karnataka, India with a chief complaint of missing teeth. Patient history and clinical examination revealed missing maxillary left lateral incisor whish she had lost due to trauma 1 year back. She had then opted for a fixed dental prosthesis and the option of an endosseous implant was given. The patient had revealed no relevant medical history and results of routine investigations were within normal limits. Following this an endosseous internal hex two stage implant was placed in the edentulous area. After a seven month period of healing second stage surgery was done, the cover screw was retrieved and healing abutment (gingival conformer) was placed. The case was then referred to the Department of Prosthodontics for prosthesis fabrication [<xref ref-type="fig" rid="F1">Figure 1</xref>].</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>Implant with permucosal extension-note the angulation of the extension</p></caption><graphic xlink:href="JPBS-7-740-g001"></graphic></fig><p>During treatment planning for restorative options, sub-optimal implant position was observed in three geometric planes-faciopalatal angulation, depth and positioning. In the given situation, following options were presented to the patient:</p><p><list list-type="bullet"><list-item><p>Re-submerging of osseointegrated implant followed by a fixed dental prosthesis, with maxillary left central incisor and canine as abutments</p></list-item><list-item><p>Complete surgical removal of malposed implant followed by grafting and a second implant placement at a later date</p></list-item><list-item><p>Relocation of the malpositioned implant by segmental osteotomies</p></list-item><list-item><p>Prosthodontic management by fabricating customized implant abutment.</p></list-item></list></p><p>The patient did not opt for surgical procedures and consented for prosthodontic management by fabricating customized implant abutment.</p><p>A closed tray impression of the implant was made with addition silicone elastomeric impression material (Aquasil; Dentsply). The implant analog was placed in the impression and silicone resin was injected around the analog to mimic gingival tissue. Type III dental stone (Kalstone; Kalabhai) was then poured, and models were made. Materials available for fabrication of the custom abutment were:</p><p><list list-type="bullet"><list-item><p>Inlay casting wax</p></list-item><list-item><p>Pattern resin.</p></list-item></list></p><p>Inlay casting wax was chosen for fabrication for relative ease in manipulation and carving properties.</p><p>Die lubricant was applied into the internal hex of the implant analog. A drop of inlay was applied into the internal hex compartment, and the abutment screw was slowly screwed into place. This was done a couple of times till enough wax was visible around the abutment screw. Wax was then added to this incrementally so as to obtain a framework similar to the outline of a maxillary left lateral incisor. The abutment screw was carefully removed, and the obtained pattern was inspected for any deficiencies at the internal hex level [<xref ref-type="fig" rid="F2">Figure 2</xref>].</p><fig id="F2" position="float"><label>Figure 2</label><caption><p>Abutment access as seen from the internal hex aspect</p></caption><graphic xlink:href="JPBS-7-740-g002"></graphic></fig><p>The wax pattern was immediately invested and cast following standard casting procedures. Fit was checked of the obtained framework in the patient's mouth. Shade was matched, and ceramic build-up was completed directly over the framework. A bisque stage trial of the ceramic crown was done [<xref ref-type="fig" rid="F3">Figure 3</xref>].</p><fig id="F3" position="float"><label>Figure 3</label><caption><p>Post ceramic firing showing abutment screw and access visible at full smile with marginal gingiva visible</p></caption><graphic xlink:href="JPBS-7-740-g003"></graphic></fig><p>The crown was glazed and inserted in the patient's mouth. The smile of the patient revealed a high lip line. The abutment screw access was showing at maximum smile as the patient had a gingival show. Hence, it was decided to veneer the abutment screw access with auto polymerizing acrylic resin characterized with pigments [<xref ref-type="fig" rid="F4">Figure 4</xref>].</p><fig id="F4" position="float"><label>Figure 4</label><caption><p>Gingival veneer on the abutment access characterised to match patient's marginal gingiva</p></caption><graphic xlink:href="JPBS-7-740-g004"></graphic></fig><p>Intra oral periapical radiograph revealed that the abutment screw had engaged the internal hex threads [<xref ref-type="fig" rid="F5">Figure 5</xref>].</p><fig id="F5" position="float"><label>Figure 5</label><caption><p>Post attachment Iopa radiograph showing abutment screw engaging the internal hex chamber</p></caption><graphic xlink:href="JPBS-7-740-g005"></graphic></fig><p>Acrylic resin was used to provide ease of access to the abutment screw access for future procedures. Ceramic pigments were used for characterization of the acrylic veneer. The patient was satisfied with the final outcome [<xref ref-type="fig" rid="F6">Figure 6</xref>].</p><fig id="F6" position="float"><label>Figure 6</label><caption><p>Post operative view showing smile line and prosthesis with gingival veneer</p></caption><graphic xlink:href="JPBS-7-740-g006"></graphic></fig><p>Oral hygiene procedures were explained to the patient keeping in mind the abutment gingival tissue interface, a dental floss and an interdental brush were recommended for hygiene around the acrylic veneer.</p></sec><sec id="sec2-2"><title>Case report II</title><p>A 25-year-old patient reported to the Department of Prosthodontics, College of Dental Sciences, Davangere, Karnataka, India with chief complaint “my missing tooth has been replaced by implant and now it is ready to receive crown.” Patient history, clinical examination, revealed a missing maxillary left central incisor which was lost due to caries during child hood. The patient had opted for endosseous implant, after rejecting removable appliance and a 3 unit Fixed dental prosthesis [FDP] involving maxillary left central incisor and canine. He did not want the adjacent teeth to be prepared for receiving the FDP. The medical history of the patient was normal as were the routine investigations. An endosseous, internal hex root form implant was placed in the edentulous region. After 6 months period of healing surgical re-entry was done cover screw was recovered and healing abutment (gingival conformer) was placed. The case was then referred to the Department of Prosthodontics for prosthesis fabrication. Clinical examination revealed that the implant was malpositioned labially [<xref ref-type="fig" rid="F7">Figure 7</xref>].</p><fig id="F7" position="float"><label>Figure 7</label><caption><p>Facially inclined implant abutment with ball top impression attachment</p></caption><graphic xlink:href="JPBS-7-740-g007"></graphic></fig><p>There was no hard or soft tissue defect associated with the implant. Following options were presented to the patient:</p><p><list list-type="bullet"><list-item><p>Re-submerging of osseointegrated implant followed by a fixed dental prosthesis, with maxillary left central incisor and canine as abutments</p></list-item><list-item><p>Complete surgical removal of malposed implant followed by grafting and a second implant placement at a later date</p></list-item><list-item><p>Relocation of the malpositioned implant by segmental osteotomies</p></list-item><list-item><p>Prosthodontic management by combination of customized abutment and hexed UCLA type plastic burn out pattern.</p></list-item></list></p><p>Patient did not opt for a second surgical procedure, and hence a nonsurgical approach was planned. Closed tray impression of the implant was made with addition silicone elastomeric impression material (Aquasil; Dentsply). The implant analog was placed in the impression and type III dental stone (Kalstone; Kalabhai) was then poured, and models were made. A hexed UCLA type plastic burn out pattern sleeve (Biohorizon) was fitted to the implant analog [<xref ref-type="fig" rid="F8">Figure 8</xref>].</p><fig id="F8" position="float"><label>Figure 8</label><caption><p>UCLA type plastic abutment attached to implant analog in type IV die stone cast</p></caption><graphic xlink:href="JPBS-7-740-g008"></graphic></fig><p>The angulation of the sleeve was adjusted by trimming and molding. Inlay casting wax was added incrementally to obtain a framework, similar to a central incisor [<xref ref-type="fig" rid="F9">Figure 9</xref>].</p><fig id="F9" position="float"><label>Figure 9</label><caption><p>Wax pattern fabricated on the trimmed UCLA plastic abutment with provision for abutment screw access</p></caption><graphic xlink:href="JPBS-7-740-g009"></graphic></fig><p>Necessary carving was done, and it was immediately invested and standard casting procedure was followed.</p><p>The obtained casting was tried on the implant in the patient's mouth and checked for fit, angulation, and clearance from adjacent tooth [<xref ref-type="fig" rid="F10">Figure 10</xref>].</p><fig id="F10" position="float"><label>Figure 10</label><caption><p>Custom cast abutment with the abutment screw in place</p></caption><graphic xlink:href="JPBS-7-740-g010"></graphic></fig><p>Shade matching was done, and ceramic build-up completed. The abutment screw access was left intact. Trial seating of the crown was done for verification of esthetics, fit and interferences. On confirmation, glazing was done. Postglazing, the abutment screw access was closed with visible light cure (VLC) composite resin. The VLC composite shade was approximated to that of the ceramic crown [<xref ref-type="fig" rid="F11">Figure 11</xref>].</p><fig id="F11" position="float"><label>Figure 11</label><caption><p>Post ceramic firing with access concealed with VLC composite of same shade as ceramic</p></caption><graphic xlink:href="JPBS-7-740-g011"></graphic></fig><p>However, the patient did not report for revision of the composite resin for gingival mask. Hence, superior esthetics was not achieved.</p></sec></sec><sec sec-type="discussion" id="sec1-2"><title>Discussion</title><p>Implant malposition is an avoidable problem. Proper diagnostic mounting with wax up, use of surgical guide, meticulous planning, good imaging techniques, and a good communication between the operator, restorative doctor, and the laboratory personnel.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref2" ref-type="bibr">2</xref>]</p><p>Few criteria are to be followed for optimum implant restoration:[<xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref>]</p><p><list list-type="bullet"><list-item><p>Ideal hard and soft tissue morphology</p></list-item><list-item><p>Adequate interarch space</p></list-item><list-item><p>Optimum implant type and position</p></list-item><list-item><p>Arch relationship</p></list-item><list-item><p>Arch form</p></list-item><list-item><p>Existing occlusal relationship</p></list-item><list-item><p>Existing occlusion</p></list-item><list-item><p>Existing prosthesis</p></list-item><list-item><p>Number and position of missing teeth</p></list-item><list-item><p>Lip line.</p></list-item></list></p><p>Axially malposed implants are the most common avoidable error. However, when the malposition is mild to moderate, they can be restored adequately with angled or customized implant abutments. Commonly, this is seen in the maxillary anterior edentulous segment.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref><xref rid="ref4" ref-type="bibr">4</xref>] But a compromise in the above-mentioned criteria will result in a compromised restoration and esthetics, especially in the facial gingival contour.[<xref rid="ref2" ref-type="bibr">2</xref><xref rid="ref3" ref-type="bibr">3</xref>]</p><p>Numerous procedures for restoring a malposed implant prosthetically abound in the literature.[<xref rid="ref1" ref-type="bibr">1</xref><xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref5" ref-type="bibr">5</xref><xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref10" ref-type="bibr">10</xref><xref rid="ref11" ref-type="bibr">11</xref><xref rid="ref12" ref-type="bibr">12</xref>] Mild to moderately misaligned implants can well be restored with prefabricated angulated abutments, individualized framework, customized abutments and UCLA type abutments.[<xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref5" ref-type="bibr">5</xref><xref rid="ref10" ref-type="bibr">10</xref><xref rid="ref11" ref-type="bibr">11</xref><xref rid="ref12" ref-type="bibr">12</xref>] For severe malposition of the implant, surgical procedures have been advocated, ranging from sub apical osteotomy to segmental osteotomy. All these procedures reposition the implant to a more prosthetically restorable position. Removal of implant entails the reconstruction of implant site with block graft, advanced regenerative procedure or submergence of the mal-aligned implant.[<xref rid="ref6" ref-type="bibr">6</xref>] However, the patient might not want to undergo a second surgical procedure, as was the case in these two cases, plus with added morbidity of the recipient tissue bed, alternative restorative procedures should be explored.</p><p>Case I reported with labially placed implant. The implant was restored with a custom cast abutment. Ceramic was directly built up on the abutment and attached to the implant with abutment screw. Case II also reported with a facially placed implant. A UCLA type plastic abutment was used as framework to design a custom abutment. Direct application of ceramic was done on the custom cast abutment and attached to the implant with abutment screw.</p><p>Hard tissue in misaligned implant often shows fenestration and dehiscence.[<xref rid="ref4" ref-type="bibr">4</xref>] Management of soft tissue around malpositioned implants is a challenge to the restorative dentist more so when the patient presents with a high smile line, or with melanin pigmentation in the gingiva.[<xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref13" ref-type="bibr">13</xref>] Prosthetically, numerous techniques are reported in the literature for improving soft tissue deficiency. Gingiva colored acrylic resin façade, flexible silicone-based tissue colored material, or removable prosthesis like Andrews Bridge are a few examples of the various techniques attempted. Peri implant tissue correction can also be done, by adding gingiva colored porcelain on the cervical portions of implant supported metal-ceramic restoration.[<xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref><xref rid="ref13" ref-type="bibr">13</xref>]</p><p>Case I presented with a high lip line at initial examination. The abutment screw access was visible when the patient smiled. The gingiva of the patient had melanin pigmentation. Auto polymerizing acrylic was tinted with ceramic stains and veneered on the prosthesis. The final outcome was satisfactory to the patient as it camouflaged the access to the surrounding gingiva. Case II did not show such aesthetic deficiency. The abutment screw access was covered with VLC composite resin. A revision of the composite resin was planned at a later dated.</p><p>Both the prostheses were fabricated with inlay casting wax. Inlay casting wax possess desirable properties, such as ease of manipulation, predictable coefficient of thermal expansion, absence of residue on burnout.[<xref rid="ref14" ref-type="bibr">14</xref>] However, if not invested immediately, they lead to distortion as residual stresses are released a long as they are outside the mold.[<xref rid="ref14" ref-type="bibr">14</xref><xref rid="ref15" ref-type="bibr">15</xref><xref rid="ref16" ref-type="bibr">16</xref>] Auto polymerizing acrylic pattern resin and VLC pattern resin provide an alternative to inlay wax in the fabrication of patterns. But proper manipulation technique and immediate investment of the wax pattern tips the balance in favor of inlay casting wax.[<xref rid="ref17" ref-type="bibr">17</xref>] Inlay wax was used in this study for the fabrication of the wax patterns. It was observed that for both the custom cast abutment the fit was adequate, and the abutment was stable.</p></sec><sec id="sec1-3"><title>Summary</title><p>Two case reports are presented, reporting the prosthetic management of malpositioned implant. Custom cast implant abutment was used for case I and a UCLA type plastic abutment was used for case II. Both were fabricated using inlay casting wax. Auto polymerizing acrylic gingival façade was fabricated to mask the abutment screw access visible during the patient's smile in case I. VLC composite resin was used for merging the exposed abutment screw access with the rest of the prosthesis in case II. 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