Help with tx plan needed.

75 Rating(s).


Posted on By Jaroslaw Wrobel In Implants

Dr. Salama, I would be grateful to receive your help with a proper treatment planning with this case. Having attended your courses including the full mouth rehab cours - I am leaning toward the staged approach: extracting some teeth with implant placement ( I plan on PET-ing the sites of interest), temporizing with the round house temp bridge on the saved teeth, then performing the remaining extractions at a later stage with final multi unit abutments for a fixed implant supported prosthesis. My question is:
Which sites would you choose for your implant placement? My initial thought was: 4, 5, 8, 9, 12, 13.
1/I would extract 5, 7, 8, 9, 12, 14, 15. PET and implant placement at 5, 8, 9, 12. GBR at 14 only. 15 just XB. I was thinking optional root submergence at 7. Then temporary bridge with abutments: 4, 6, 11, 13.
2/ Stage two. Extraction of 4, 6, 11, 13 (root submergence 6 and 11?). PET and immediate placement at 4 and 13.
3/ multi unit/multi angle abutments.

Dear Dr. Salama and dear forum members, what are your thoughts? Any feedback will be greatly appreciated.

Adam Wrobel




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13 Comments

I would extract, graft and temp....and stage case. Keep 4 teeth ti support provisional. Test esthetics, VDO, phonetics etc
Then new CBCT at 3-4 months and plan FULLY GUIDED sx.
Typically I go with implants in 4-6-8-9-11-13 sites or angle distal implants if needed.
Good luck Dr. Salama


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So no implants placement at stage 1, just extraction and GBR, temp?


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Yes, one miracle at a time. Would allow for more precision and accuracy. Dr. Salama


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Hi, Jaroslaw,

I am not sure that all these teeth should be extracted. Molars on the left-yes, but all other teeth?
If you have decided to extract all of them and want to improve teeth positions, than staged approach, navigated surgery and implant positions as proposed by dr. Salama would be safer. For the implant sites I would go for socket shields (Glocker) and socket augmentation with dentin graft.
Spontaneously, not knowing all details and patient´s aesthetic demands I would prepare a provisional bridge from the right central to the first premolar on the left, PET plus implants for the left central and canine, ex first molar on the left and augmentation, late implant placement on this position. After implant osseointegration partial extractions and provisional bridge on implants.
Let us know about clinical findings on the teeth and patient`s expectations.
best regards and thank you for sharing
Snjezana


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Dr. Pohl, thank you feedback. I really appreciate you taking your time! As for the clinical findings: Teeth 6, 7, 9, 11, 12, 14 and 15 have root caries. 9 displays mobility and flares up labialy. 5 was already extracted with GBR last year (the pano and CBCT are from last year). Crowns on 4 and 13 broke off since then with compromised coronal/stump structure left. Perio: moderate generalized to localizedd advanced periodontitis with moderate gen. horizontal bone loss with mobility on #9 and 14. SRP was done last year with perio maintenance scheduled. Pt broke his maintenance appointments. He tends to show on an emergency basis usually when something fractures or he is in pain. Breaking the premolar crowns made him finally realize he needs complex treatment plan. He seems committed. Now, prognosis:
1/ hopeless to for: 9, 14, 15
2/ questionable for 4, 5 - we would have to re-endo both and rebuild them for single crowns
3/ relatively good for 6, 7, 8, 11, 12. Full crowns and most likely RCT on 12 and possibly 7 and 6.
-------
The original tx was similar to yours. Now, with #5 gone, 4 and 12 compromised - that leaves us with only 5 teeth with relatively decent prognosis. a lot of costly treatment is required to save them. Then selected implant sites, GBR, sinus elevation with placement at 3, 14. It all adds up. I started thinking about the full mouth re-hab at this point. Thus the posting.
--------------
Yes, he has an esthetic concern: flaring up of the upper left central, failing unsightly maryland bridge, root caries. He is also starting to realize his chewing function is missing. Incredibly, he is not in pain now but ready to start his tx.
One more thing: low lip line.


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Thank you for the detailed description.
Good thing is that you have some teeth for fixed provisional and a good bone to place implants. Centrals, canines and second premolars for implant sites would be my choice. PET wherever indicated.
If you are not going to place immediate implants but Glocker approach, I would recommend to fill the sockets with slow resorbable material, like dentin graft or allograft and cover at least with PRF. After many Glocker cases I realized that it is the only way to prevent soft tissue invagination.
Best regards
Snjezana


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Thank you kindly!


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Agreed!! Dr. Salama


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Thank you very much!


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For me, this is a perfect full upper extraction with immediate implants placement, tilted implants to avoid the sinuses, immediate fixed temporization.


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Yes, another option that is being considered. I like the idea of the staged approach though.


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You can always take teeth out, give immediate denture.
wait 2-3 months (depends on how much alveoplasty you need to do), place implants and bury them, then in 4 month , expose the implants and start the process of final Hybrid.
My success rate with a staged approach was great, the immediate temporization works as well, its just much harder to do.


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If you are starting to be envolved in the complex full mouth rehab , from the prosthodontics point of view tae it easy do not run or fail will make you feel frustraded so like Dr Salama said like Tarnow likes too " one mircle at the time" Prosth is not a hurry to make an exc Diagnosis and treatment planning my recomendation if it is possible keep strategic teeth so you would not loose the proprioception. Regards....


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