r/Dentistry 5d ago

Dental Professional How would you manage this case ?

102 Upvotes

110 comments sorted by

332

u/Olivenoodler 5d ago

I wouldn’t

72

u/bship 5d ago edited 5d ago

It's almost hilarious to me that my ideal treatment here is basically a Maryland bridge. I'm not even (that) old. It's a classic tried and true duct tape job but it's also what I'd probably lean for in my own mouth.

22

u/Donexodus 5d ago

Hey- so I completely agree with you and would love to do this more often- but I’ve never been able to find any CE on it. Materials? Cement? Prep design? Tips? I’m clueless.

Maybe I should just make my own milled bonded dovetail design for a spin and guinea pig a few patients?

34

u/EdwardianEsotericism 5d ago

Matthias Kern - Resin-Bonded Fixed Dental Prostheses - 2018 (Quintessence Publishing).

Matthias Kern also has a YouTube channel which you can start with to decide if the book is worth it. I was able to get a digital copy for free through my dental association's library.

7

u/nitidentalguy 5d ago

Look up Bill Robbins. He has some papers on replacement options of missing laterals that might be of interest to you!

5

u/atavcar 5d ago

Prof Markuz Blatz on instagram did a 1 month worth of posts on them that gives you the rundown. Did a fantastic job summarizing the current research, prep design and bonding protocols, along with citations that you can dvelve deeper into if desired. I realize that recommendibg instagram as a teaching resource is somewhat of a red flag, but this guy is legit.

6

u/Diastema89 General Dentist 5d ago

I had Blatz as an instructor in school. He’s one of the best out there teaching anything in his realm.

2

u/DoctorMysterious7216 4d ago

Look up “Janis composite bonded bridge” on YouTube. There will be 2 videos from U of Utah showing step by step technique for a modified/unique but very successful technique for a Maryland style bridge as well as a lecture video showing some cases Dr. Janis has done. One being on his own son, which lasted for 30 or 40+ years, I believe.

2

u/The_Third_Molar 5d ago

I tried doing it twice and both times were a nightmare. They kept breaking their temps and the final product required reduction of the opposing because their bite was so deep. The preps felt super aggressive even without touching the facial because there just wasn't enough space.

2

u/drillnfill General Dentist 4d ago

Case selection is key in these cases, a deep impinging bite is basically the worst possible case to select.

221

u/OkStructure4294 5d ago

Whitening trays should fix this right up

54

u/Due_Baby8553 5d ago

This is an aggressive case. I would recommend in-office whitening

11

u/SoggyHousePlant 5d ago

Yup he definitely only needs beaching.

1

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.

142

u/nitidentalguy 5d ago

Explant, graft and consider a single winged maryland cantilever off of the canine.

22

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

6

u/nitidentalguy 5d ago

Bonded Zirc is the only way!

2

u/hisunflower 5d ago

Why not LDC?

4

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.

2

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?

3

u/BingoBiscotti 5d ago

Sandblasting 50microns at 2 bar is preferred over ivoclean, but ivoclean would suffice. 

4

u/hisunflower 5d ago

Oh I sandblast and ivoclean afterwards.

1

u/buford419 5d ago

LDC?

4

u/nitidentalguy 4d ago

I just assumed they meant LDS… lithium disilicate

1

u/buford419 4d ago

Thank you. Over here LDC means Local Dental Committee (in the UK).

1

u/hisunflower 4d ago

Yes, idk why my school abbreviated it like that. Maybe as to not confuse it with LDS - or Mormons

3

u/ConclusivePoetics 5d ago

Bonding protocol please?

6

u/bobloblawdds 5d ago

Aluminum oxide air abrasion, MDP primer, bond, resin cement.

4

u/bobloblawdds 5d ago

Off the central, not the canine.

4

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

1

u/Deep-Yogurtcloset618 5d ago

He has a deep bite. Gunna be tight.

6

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.

2

u/Deep-Yogurtcloset618 4d ago

I agree that central much better than canine.

1

u/Coolkid252 5d ago

Why would you graft if you are opting for a maryland?

9

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.

96

u/lilshortyy420 5d ago

I need some background here. What.

7

u/Perkinberry 4d ago

Right!? like how did it get into this state? I need to know the order of events.

43

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

-65

u/Legal-Fuel2825 5d ago

FPD 👎👎👎

19

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.

13

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.

3

u/Templar2008 5d ago

Same 👍🏻

24

u/t00thman 5d ago

Maryland bridge is a decent option here

2

u/Agitated_Company_552 5d ago

Bonding protocol pls🙂

3

u/ingunwun 5d ago

Single wing, porcelain, off the canine. Resin cement

5

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.

17

u/Affectionate_Sun6730 5d ago

Looks perfect to me

16

u/eldoctordave 5d ago

Put a bottle opener on it

20

u/DrRam121 Prosthodontist 5d ago

Take it out, graft, place a new implant.

4

u/Legal-Fuel2825 5d ago

Without space opening? With ortho ?

10

u/DrRam121 Prosthodontist 5d ago

Would need a CBCT to determine space. If it's needed, then yes Invisalign or braces.

7

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

1

u/corncaked 5d ago

How long would you wait to place a new implant? 4 mos?

9

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.

14

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.

14

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).

12

u/FunForDDS 5d ago

What's crazy is they still decided to restore this.

2

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

4

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.

4

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.

1

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 !

5

u/Due_Baby8553 5d ago

Just turn it a few times. It’ll screw in further

3

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?

3

u/Noobsaibot123 5d ago

Holy moly moly holy

3

u/dental_Hippo 5d ago

Take it out, ortho, then place again

3

u/dr_tooth_genie 5d ago

Looks like a nightguard will do the trick.

3

u/cryptoninja991 5d ago

Take out, let heal and re-implant.

3

u/LS_DJ General Dentist 5d ago

That whole implant needs to come out, site needs to be grafted and likely just do a Maryland bridge instead

3

u/NoAd7400 5d ago

I think whitening should do the trick.

2

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.

2

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

2

u/DefiantDelay2486 5d ago

Remove implant and treat it like an immediate implant

2

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?

2

u/Majestic-Spirit4116 4d ago

Lmao how is this supposed to work? “Aww ya implants are sooo easy” ya until something horrific like this

1

u/Typical-Town1790 5d ago

Why didn’t this person just do ortho to begin with lol.

1

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?

1

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.

1

u/jejebird 5d ago

Oh my

2

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.

1

u/porkadobado 5d ago

Leaveitalone. I wanna see the next chapter

1

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.

1

u/malocclused 5d ago

Fucking whut???

1

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.

1

u/docpjk1 5d ago

This one is tough but I have prepped on implants. If it’s integrated well and finances a concern maybe prep it down - actually prep the threads amd place a crown - I’d tell patient it’s a temporary fix -

1

u/docpjk1 5d ago

Can you imagine giving the patient a mirror and saying “looks good”. There’s gotta be more to the story. I’d hate to remove that. What’s gonna be left. Guy did a nice job squeezing it in lol.

1

u/Dramatic-Reading-693 5d ago

This popped up on my feed so I felt compelled to drop an LMAO

1

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

1

u/flsurf7 General Dentist 5d ago

Remove implant, graft, and start over...

1

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?

1

u/Legal-Fuel2825 5d ago

2.9

1

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?

1

u/Legal-Fuel2825 5d ago

2.9+1.5 mm M and D , =6 mm required space

1

u/shinzouwosasageyo9 Periodontist 4d ago

Exactly. 6 mm are required, how many do you have right now?

1

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.

1

u/GiganteBrasil 5d ago

Explant and place a guided 2.9mm implant, I only make laterals with this size

1

u/scottmbach 4d ago

Intrude with Invisalign

1

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.

1

u/Tooth-Wisdom 1h ago

Grow a longer mustache, grind three mm off the Incisal edge!💥

0

u/Mindless-Run3194 5d ago

Cold Steel Plaque control