Posterior Restorative Challenge.

104 Rating(s).


Posted on By Anton Andrews In Orthodontics

I'd like to present an interesting case for discussion.
26.y.o. female is at finishing stage of her ortho tx.
She presented to my practice with the desire to replace the upper missing molars.
The restorative space is only 2mm vertically, 14mm M-D
bone is measured 5mm vertical and 18mm BL!!
The orthodontist wants me to place an implant and to restore before removing the braces for stabilization purposes.
What would you do?


buccal view 2X14mm restorative space
lingual view

CBCT
upper occlusal view
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22 Comments

Anton. I would need to see lateral ceph and facial profile, but my instincts lead me to believe it is probably not best to restore at this vertical dimension. I would anticipate opening the bite with improved anterior guidance to be a possible solution. I am curious as to your thoughts. Best regards. Chuck


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I agree with Chuck....no restoring at this VDO and space unless open vertical dimension. regards Dr. S


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According to the orthodontist " the case is almost completed".
Permanent fixed retainer had been already placed between 8&9.
I also wondering, how would you increase VDO? Extruding upper posterior teeth? What are the other options if the ortho is not on the table?


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So the patient is wearing Orthodontic appliances and Orthodontics is off the table? There must be a diplomatic way of suggesting an Orthodontic solution. Other options would be less ideal and more invasive. Is your malpractice policy up to date?


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How about the least invasive and bio-mimetic without ortho? The ortho tx has already taken 3 years.


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Sure, but IMO additional Orthodontics would enhance and or expedite anything you decide upon. In retrospect, perhaps PAOO would have been useful for this case.


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I agree with you, Charles that there is a need for better teeth positions, arch widths and relationship. BTW #1 presents intruded on cbct.
Let me ask you a question, if another round of ortho is not an option, would you take this case ?


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Anton. Excellent point of discussion! We encounter moral dilemmas such as this on a regular basis. I reflect upon advise given to me years ago by Morton Amsterdam "'If we are to do anything we should do no harm". In reality I would consider less than ideal treatment, but never any treatment that would be inflict harm. So based upon the information at hand, I would walk away. It would be nice if you could post more diagnostic information to further discuss this case. Maybe this case can be restored at this VDO without harm? BTW did the patient understand the circumstances and potential consequences before treatment? I recently walked away from the case below at the start, because it was to be both treated with Invisaline and restored by a recently graduated "Super Dentist". Perhaps New Techology and Dental School education has eclipsed my diagnostic and clinical experience?


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Ortho is almost completed.

Either the parents and patient are happy with the incisal edge position of the anterior teeth for esthetics or they are not.

If they are then an increase in the VDO is not indicated.

The problem in my eyes is the sinus. The solution is to lift and place the implant.

A screw retained crown will work just fine IMO!

Emil


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Do you have clinical pictures? Gregory


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Hi Anton; You are becoming a wise man. There is more wisdom in this short conversation than I have witnessed in almost 20 years on online dental discussions. The orthodontist may claim that he has completed treatment but this case seems lacking in several areas: tooth position and vertical dimension. Wouldn't it be nice if no patient completed ortho treatment without a general/restoring dentist signing off before the appliances are removed? And how about no implant be placed without a restoring dentist stating that the implant is restorable in the proposed position. Something to think about. Regards, Gerald


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If we forget about VDO, ortho and limited vertical space for a moment, how do we approach 14 mm M-D space with such sinus anatomy? How many implants do we place? What size ?


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Hi Anton:
I would do Sinus lift, then implant insertion, leaving vertical distance enough for restoring.
Then I would ask the ORTHO, to mesialize the 2nd molar just to have 12 or 11 md width for the molar. So place the implant related to 2nd bicuspid distal part.
We cannot change VDO with only one restoration, must be adapted to the actual VDO.
Regards
Jorge


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Anton,
I would have sinus lift first and then place a large diameter implant (But not an 8....) and have a cantilever on second crown.
Implant placed deeper to have a good emergence profile.
No Ortho.
These patient may exibit a balanced occlusion that, if lost, could be an issue.
Great case to share the way you did it: future is to share file DICOM and .stl to be valued by anyone.
Best regards.
Armando


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Anton. If we are to compromise, I like all
solutions mentioned, as well as yours which isn't difficult to guess :-). I feel this case is best suited for the DENSAH lift with a 6mm implant. However, if you desire to go wider, I suggest UN-Osseodensifacation at the osseous crest prior to implant placement. Hey if your not going to perform ideal treatment what's the difference? Chuck


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Chuck, you have a great sense of humor, lol, i liked your comment and advise a lot. Regards.


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Let's put it all together .
A single implant 6-7 mm not 8 w/SL -Densah
Screw-retained crown with cantilever or limited ortho to mesialize #1.
Have I missed anything?


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Anton, you missed to put all this information into a planning with realistic items (implant, crown in occlusion) to see if distances and workplan are optimal before actual surgical procedure. It will demostrate, IMO, the clinical validity of planning over simple opinion and/or 'word of experience'. Best regards. Armando


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Very good point Armando!
So do you suggest to run it with something , like implant studio , to see the potential outcome?


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Anton,
You got the point and I know you can do it!!!
The 'new way' is in the planning: with surgical stent. placing an implant is simple enough, if initial data are correct. There will be a perfect match between plan and clinically execution.
So, looking forward to see your plan.
Armando


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Hi Anton;
I like to go back and revisit cases to either validate my original thinking or re-engineer the case based on a new perspective.

In the biggest picture, the orthodontist, like many specialists, tried to bully the general dentist into completing a less than ideal case so that the restoring dentist takes the blame for the final outcome.

The restoring dentist must remain the captain of the team and all on the team must agree that that they are subcontractors for the generalist. Unfortunately, specialists who generally know little about any of the other specialties in dentistry (especially restorative dentistry) routinely bully the restorative dentist.

This case will always be a failure, esthetically and functionally, unless you step up and demand that the case be reworked.
Regards,
gerald


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I appreciate your comment. Jerald, and I agree 100%.
But the life is not black and white. There are compromises. I don't feel right to set any doubt in patient's mind about quality of her ortho tx.
I am also confident that I am able to provide tx with long-term stable results. Please take a look at part#2 if you have not done it yet. I overbuilt the case. It can withstand any load, including parafunctional. Should the pt choose to redo orthodontics, the implant could be used for anchorage as well.


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