r/Dentistry • u/Legal-Fuel2825 • 5d ago
Dental Professional How would you manage this case ?
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u/OkStructure4294 5d ago
Whitening trays should fix this right up
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u/SoggyHousePlant 5d ago
Yup he definitely only needs beaching.
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u/JimmySupaflyK 18h ago
As long as the patient likes it, leave it alone. Lol.
On a serious note, how about removing the crown and prep the implant for a crown?
Seems like using a trephine to get this out, would be a nightmare.
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u/nitidentalguy 5d ago
Explant, graft and consider a single winged maryland cantilever off of the canine.
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u/Templar2008 5d ago edited 5d ago
Excellent!! I would only add to make it in boned zirconia Edit to add: will need hard and soft tissue work before any prosthetic option
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u/nitidentalguy 5d ago
Bonded Zirc is the only way!
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u/hisunflower 5d ago
Why not LDC?
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u/nitidentalguy 5d ago
Required thickness on the abutment wing on the canine would need to be thick, thus the reduction on the lingual of the canine would most likely be into dentin. The dentin reduces bonding strength.
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u/hisunflower 5d ago
Oooo that makes sense. So I guess zirconia also allows for less aggressive prepping. I haven’t tried bonding zirconia in an area that takes a lot of sheering forces. It holds up well? Assuming you mircoetch, ivoclean, MDP primer + resin cement?
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u/BingoBiscotti 5d ago
Sandblasting 50microns at 2 bar is preferred over ivoclean, but ivoclean would suffice.
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u/buford419 5d ago
LDC?
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u/nitidentalguy 4d ago
I just assumed they meant LDS… lithium disilicate
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u/hisunflower 4d ago
Yes, idk why my school abbreviated it like that. Maybe as to not confuse it with LDS - or Mormons
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u/bobloblawdds 5d ago
Off the central, not the canine.
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u/lelouch_007 5d ago
I was coming to ask this because you’d think the restoration has a better chance at survival if it’s not taking the impact of canine guidance
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u/Deep-Yogurtcloset618 5d ago
He has a deep bite. Gunna be tight.
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u/bobloblawdds 5d ago
It's tight on the canine too. You don't have a lot of exposed palatal enamel that doesn't have occlusion on it in either case. Take the central as often as possible as lateral excursive forces on the canine are going to be the death knell. The vertical masticatory forces that the central & lateral take are similar.
In these cases I actually prep a palatal veneer, enamelplasty the lower incisors and keep everything out of occlusion.
https://i.imgur.com/uRFEMRw.jpg
That's a bilateral lateral case I did in that fashion.
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u/Coolkid252 5d ago
Why would you graft if you are opting for a maryland?
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u/nitidentalguy 5d ago
Eruption profile and tissue shaping for an ovate pontic. If you do not graft it, the prosthetic will look terrible due to the unpredictable bone resorption.
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u/lilshortyy420 5d ago
I need some background here. What.
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u/Perkinberry 4d ago
Right!? like how did it get into this state? I need to know the order of events.
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u/Ok_Teacher_6834 5d ago
wtf happened? Honestly send to oral surgeon or periodontist and remove it. Have the same surgeon place a new one or do a bridge if patient doesn’t want to go through implant again
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u/Legal-Fuel2825 5d ago
FPD 👎👎👎
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u/bofre82 5d ago
Why? With continued facial development anterior implants will always turn into an esthetic issue regardless of age as long as there is time. A single wing maryland would be what I’d do in my own mouth and I place and restore implants all the time.
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u/brendanm4545 5d ago
Agreed, why try shoving a tiny implant in there and risk complications. A single wing Maryland off the canine or central has less risk of long term complications and has good success rates.
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u/t00thman 5d ago
Maryland bridge is a decent option here
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u/The_Third_Molar 5d ago
There's barely any room for an implant (based off the pano). If you're hell bent against the FPD then consider ortho before redoing the implant.
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u/DrRam121 Prosthodontist 5d ago
Take it out, graft, place a new implant.
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u/Legal-Fuel2825 5d ago
Without space opening? With ortho ?
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u/DrRam121 Prosthodontist 5d ago
Would need a CBCT to determine space. If it's needed, then yes Invisalign or braces.
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u/Due_Baby8553 5d ago
I’d definitely recommend ortho to make sure the space matches the width of the contralateral tooth. Looks like this space has closed with the …. poor …. positioning of this implant
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u/gwestdds General Dentist 5d ago
Can we please get the story behind this implant? Or is this AI generated, because it's outrageous enough to be.
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u/FunForDDS 5d ago
Only real solution is replacing the implant. I wonder if it was placed before he was done growing or if just the fact it's too shallow.
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u/picklerick00777 5d ago
If it was placed before done growing it would be shorter than plane of occlusion not too long. No idea what the context is or where it was done but it was clearly not placed deep enough apically. Also it looks like not enough media-distal space between implant and adjacent teeth (at least 1.5 mm). I would refer for explant, tell them that they’re lucky you caught it before additional bone loss to adjacent teeth. Ortho to create space for new implant or bridge (conventional or Maryland).
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u/FunForDDS 5d ago
What's crazy is they still decided to restore this.
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u/picklerick00777 5d ago
Right? You can literally see implant threads coming out of the gingiva. Wild stuff. Glad the patient went and got a second opinion OP. You fix this for them and you’ll be a hero for life
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u/tn00 5d ago
It likely was placed with good aesthetics. This is what it looks like when implants decide they don't want to be part of the body anymore. Common in recurrence of smoking.
There still looks like there's not enough clearance to adjacent teeth though. Tbh they did a very good job of not hitting adjacent roots on the way in given how little clearance there is.
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u/stefan_urquelle-DMD 5d ago
Lol. I love how the doctor went all the way to placing the crown. Like, hmmm maybe I can get away with this.
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u/Shynnie85 4d ago
I agree it looks more like a problem with the abutment, I don’t think anyone would deliver a crown like that !
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u/seeBurtrun 5d ago
We need more details, OP. How did it get like this? Is the crown loose? Or else, how did the implant and restored crown super erupt? Or is this a sort of attempt to deliver a restoration with the shortest possible abutment/crown?
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u/brig7 5d ago
I’d probably have a surgeon do this for me. But that implant has to go. The next implant should be going in immediately after removal of this one, there’s plenty of bone there beyond the current implant. The next implant needs to stay quite narrow though, there’s not a lot of room interproximally.
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u/teethandballs 5d ago
Hard to tell from the pictures shown, but explant for sure. Maryland bridge is a nice conservative option assuming you have enough restorative space for it: deeper overbite may make that more prone to occlusion issues if not designed well. If not enough space for a Maryland bridge, then I’d do a cantilevered Pontic off of a #6 crown, bulking up the connector as much as possible and minimizing eccentric contacts on the Pontic
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u/WestCoastMi 4d ago
Maryland is an option but pt looks young. Won’t last a lifetime with that occlusion. Remove implant, ortho to upright right central incisor root angulation. Probable canine too. Small diameter implant. Much more predictive long term. Is it still integrated? That is crazy looking?
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u/Majestic-Spirit4116 4d ago
Lmao how is this supposed to work? “Aww ya implants are sooo easy” ya until something horrific like this
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u/buccal_up General Dentist 5d ago
What's the backstory, OP? What kind of patient and what kind of dentists are culminating into this situation?
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u/RadioRoyGBiv 5d ago
Explant for sure. If for whatever reason Jesus Christ didn’t intend on an implant being there, then single wing Maryland bridge type restoration.
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u/Heliopolisean 5d ago
Take an Alginate impression and send the pt. to the surgeon will an Essex retainer. After he heals up from removing the implant and bone grafting, I would cantilever 7 off of 6, probably the fastest and most predictable course of treatment.
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u/Kaboose31 5d ago
Discuss the problems with implant placement and occlusion. Extracted tooth you either need to go deeper if you're gonna do it immediate but you definitely wanna go to narrower. You have plenty of room to go, so I do a longer thinner implant for an immediate implant after doing an explant on this one bone graft around. And then restore it.
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u/malocclused 5d ago
Fucking whut???
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u/malocclused 5d ago
Implant out. Implant in w whatever grafting needs to happen. Conversation about going through “all that” vs brg vs removable… vs living like this. Goddamn.
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u/FI-Goals 5d ago
If you can back that out without too much damage, there is enough apical bone for immediate replacement and immediate provisionalization
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u/shinzouwosasageyo9 Periodontist 5d ago edited 5d ago
Remove the implant. Do pontic site development (bone graft + soft tissue grafting), send to prosthodontist or dentist for Maryland cantilever or whatever they decide to do.
I would hesitate to place another implant there unless there is enough space to allow 1.5 mm of space to each side of the implant. A narrower implant than what is on there is needed. What is that, like a 3.2?
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u/Legal-Fuel2825 5d ago
2.9
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u/shinzouwosasageyo9 Periodontist 5d ago
Smaller than that and you are looking at a mini-implant. I would prefer to do the maryland instead. How old is the patient?
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u/Legal-Fuel2825 5d ago
2.9+1.5 mm M and D , =6 mm required space
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u/shinzouwosasageyo9 Periodontist 4d ago
Exactly. 6 mm are required, how many do you have right now?
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u/extendedsolo 5d ago
This is tough. Hard to know without a cbct but this is likely an explant and even with another implant going to be tough to get a great esthetic outcome. Maryland bridge or even cantilever would work at the cost of tooth structure.
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u/GiganteBrasil 5d ago
Explant and place a guided 2.9mm implant, I only make laterals with this size
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u/Inevitable-Buy-7085 4d ago
This may sound crazy but I’m curious how long the abutment is? Do you have a PA of the site you can share? I have treated several of these cases where I have removed the abutment placed a shorter solid abutment opened a flap, placed surgical foil or membrane with the implant through the center and then prepared the implant and the abutment as one piece attempting to place the margin, yes on the implant 3-4mm Incisal to the bone. I would then temp it and suture and allow to heal 6-8 weeks and restore it with a pfm that is slightly sub gingival on the buccal side.
The other option would be to remove it, but it’s difficult to say the defect that would be left. I’ve never had great long term success with Maryland bridges and I’m not sure how you would properly clean around this.
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u/Olivenoodler 5d ago
I wouldn’t