Around 1993, a periodontist in Rhode Island removed my canine #11 and
simultaneously gave me an osseous bone graft. The bone graft didn't take
but a few weeks later he proceeded with his plan to install an implant.
There was not enough time to stay for it to heal completely, since I had
to move to France for a year or so. At the time I left, there was still a
gortex barrier in place. At the time I had the implant done, I did not
have a primary dental care provider; I only had the periodontist and he
knew that. However, he somehow forgot that when it came to planning the
implant and related procedures and informing me about what was involved.
In particular, he just ASSUMED that I had already made arrangements with
a regular dentist to have an artificial tooth placed on top of the implant,
something I didn't realize until after the surgery. He said something about
wanting to write an article about what he was doing and took some photographs
for that purpose; he was also a photographer operating under a different
professional last name, which didn't bother me since he was up front about
it and it made sense that he would want to keep his dentistry and his
photography separate. He said he would give me a copy of the photos but
never did.

Since it was obvious that I was going to need continued care when I got to
France, he looked in his list of periodontists with the proper training in
Paris and referred to me to an old school chum of his whom he described as,
"a crazy kind of guy" (henceforth, CKOG). This old school chum is a big fan
of a technique that involves taking a piece of bone from the patient's chin,
for example, and simply installing it in the relevant spot that needs bone.
Accordingly, he told me I had to contact the periodontist in Rhode Island,
ask for my money back and give it to him so he could rip out the implant
and do it all over his way.

I needed some of my old records and, in any case, wasn't too sure about the
advice he was giving me. I wrote to the guy in Rhode Island and eventually
received X-rays. Meanwhile, I went to CKOG for cleanings and also started
buying chlorhexidine over the counter, which one can do in Paris, and using
it. The gortex barrier kept protruding further and further through the gum
and eventually I understood that this was because the gum was getting thinner.
Finally, I went to the CKOG and asked him about it. His response was to take
a pair of pliers and just try to rip out the barrier, which he largely
succeeded in doing, but not completely, and a few weeks later it was infected.
By then, I had received a letter from the guy in Rhode Island, containing my
xrays and a letter telling me how glad he was that I had not allowed his
friend, who he now realized was just as crazy as he had been in dental school,
to remove the implant. He provided me the name and coordinates of another
periodontist in Paris. I went to him and he fixed the problem: the infection
was only on one side of the gortex that and could be removed without
complications. After I healed from the new surgery, the gum over the
implant was thin but it did cover it.

When I returned to the US in 1995, I went to Berkeley, CA, and found a dentist
through some phone referral service. I told the dentist that I wanted to have
a tooth put on the thing. He told me that he didn't think there was enough
bone support and recommended against it. When I moved to Bowling Green, KY,
my dentist there agreed with that opinion. When I moved again, the dentist
also agreed with that opinion. However, he apparently forgot that he had done
so, since a year or so later, when he got interested in putting a tooth on it,
he told me that there was plenty of bone support. For that inconsistency, and
also because he did something to the canine #27 that caused pus to start
gushing out of the gum the next day, without telling me that there was any
risk of a reaction like that, I decided to find another dentist and soon found
a practice consisting of a regular dentist and a periodontist.

This new periodontist told me that there was definitely enough bone support
but that the implant was pointed in the wrong direction. He also told me that
the implant was poking through the gum but that there wasn't much risk of
infection. I took a look at it when I got home and I could see a kind of grey
disk a couple of millimeters wide, that I hadn't realized was exposed bone,
instead of oddly colored gum tissue. During a subsequent visit, we discussed
the implant again and he explained a little more to me. There is, apparently,
plenty of bone support in the sense that the implant is not just standing
like the Washington Monument in the middle of a valley: it is solidly supported
by bone on all sides. However, the implant itself is only about 6 mm long
and goes right up to the sinus. Due to the complications of dealing with the
sinus, he wouldn't want to get involved in removing and replacing the implant,
although he doesn't necessarily think there would be anything wrong with
someone else doing it. On the other hand, the tooth that would be placed on
the implant would probably be more like 9 mm long, since it is a canine.
He told me that in general, one wants the implant to be about 1.5 times
as long as the tooth that it will support, whereas in this case the ratio
is reversed. In that sense, it seems to me, there is not enough bone support.
I don't know what the implications are of having something like that break,
particularly right next to the sinus, but I think it is risk I should not
take. So, I'm against this procedure, based on what I think I know about it.

Last time I went to him for my regular clearning, he told me that the
problem with the misdirection of the implant could be solved by using
what he described as an angled abutment. So, now he thinks there is enough
of a plan to proceed.

I have various reasons for not being convinced:
(1) The one I mentioned above about the recommended ratio between the size
   of the canine and the size of the implant. It occurs to me that I don't
   HAVE to have a 9 mm tooth put on it just for cosmetic reasons and that
   perhaps a tooth of ordinary size, would be perfectly alright. So what if
   my mouth is asymmetrical? That might improve the ratio of the lengths to
   about 1, which might be more tolerable.
(2) Another complication is that I no longer have a record of the exact size
   of the implant, although I am pretty sure it is a Branemark implant. The
   periodontist eyeballed it to one of two possibilities but says he can't
   tell without trying out the abutment to see which fits better. That would
   involve ordering two abutments, trying one and sending the other back if
   the first one fits and, if not, trying the other and, I think, paying
   for both of them. That sounds like abou $400 to measure a screw and I
   would hope there is a better way to do it, especially since we don't really
   know if either of the conjectural sizes is correct. I am unable to locate
   my old periodontist from Rhode Island. First of all, he retired shortly
   after giving me the implant. Second, I've gone to perio.org and entered
   the town where I had the work done and can no longer find the practice in
   a 50 mile radius.
(3) I am chronically unemployed and have no medical insurance. I'm basically
   living on charity. Even if I could convince someone to pay for the work,
   which is a possibility, do I really need a cosmetic false tooth more than
   I need a colonoscopy, which I've never had, and which is recommended to
   people my age?

I agree that I need to do something about the implant poking through the
gum. Now that he has a plan to install a tooth on it, he's changed his mind
and decided that there really is a risk of infection. I do believe that there
is and, in any case, I think that as long as it is untreated, the area of
exposed bone is likely to get larger. That is probably undesirable. So I do
think it makes sense to try to cover up the exposed bone using a gum graft.
That probably costs a lot less and, for the same total expenditure, also lets
me get a colonoscopy.

Let's assume I'm right about that. This still leaves the question of what
to do with the implant itself. I don't know what the implications are of
leaving it under the gum, pointing up as it does now. Maybe that would result
in thinning of the gum and having it eventually poke through once more. If that
is a problem, maybe it is a good idea to grind it down, but maybe not, since
it is conceivable that there could be more bone loss in the future that would
leave the implant sticking up again, so the effort of grinding it down would
have been wasted. Maybe removing it is a good idea (except for cost).

Another possibility that I am seriously considering is registering as a
patient at a dental school. I could be mistaken, but I think my case has
enough unusual features that it would be of interest to people teaching
periodontics and implants as an example for their students. They would
consult with each other about the best way to do it, the work would be
supervised and it would cost a lot less.

At the moment, I'm only using Listerine and brushing to protect the exposed
bone from infection, since that is all that the periodontist recommended.