Challenging Case

[Archives_Admin]

Dear Colleagues,
Hope everyone has started their summers nicely! Recently saw this interesting and challenging case. A few background details:

1. the implants were placed and restored 12 years ago
2. they are quite stable
3. in case it’s not totally clear from the photographs, the top of the implants are visible
4. 4+mm pocketing is associated with the implants
5. at the time of implant placement, she acknowledged that “additional grafting” was recommended which she declined–I do not know if this was hard or soft tissue grafting or both.

She is a very attractive, 31 y/o nurse who would like to know her options to improve her esthetics. I would love to start a discussion regarding the challenges and treatment options here. I think it would be especially helpful if anyone in the group has had experience with a very similar case. I imagine we will be seeing more and more of these types of cases as time marches on?!?

My best,
Bruce

[document redacted]

—————————————————————————————-

My first step would be to bury the implants with ct grafting. Then decide between a tooth supported bridge or an implant bridge with porcelain gingiva.

Chuck

—————————————————————————————-

Chuck,

I am merely a restorative dentist, but I wasn’t aware that you could add connective tissue to form a stable esthetic foundation in terms of soft tissue. Is there good clinical data to support that? If so, that’s great to hear. I would value the opinions of the surgeons on this message board.

If it comes down to it, I would humbly suggest that you try everything to keep this as it was, an implant supported restoration, rather than taking the patient one more step down the line by prepping adjacent teeth.

Glenn

—————————————————————————————-

Bruce,

Multi Unit abutments and a flange.

Not ideal, but likely your best option.

Rick

—————————————————————————————-

I agree with Glenn.
Big Giant CTG Tissue Graft and then…..see attached articles….
We have had great success with this approach but it requires a different “thinking” and plan.
By the way, it’s Pink Composite Resin not Pink Porcelain.

Bruce, I live less than 1/4 mile away from you, let’s get together sometime!!

Maurice

[document(s) redacted]

—————————————————————————————-
When dealing with a situation such as this, I would avoid using the words “stable” or “predictable”. Such expectations are not realistic for a clinician nor the patient.
The least likely way to suceed would be attempting to augment around the existing prosthesis.
As far as clinical evidence, we will need for Maurice to chime in.

Chuck

—————————————————————————————-

Bruce,

Great teaching case. I am sure that if you went through the history, there’s a great story about how she got to where she is now.

I have attached an image of a case I treated about 5 years ago that is by far, the best “Holy S$#T!” case you will ever see. (Maurice, I remember your reaction when I showed it to you a couple of years ago.) There’s a horrific story of clinical wrong turns that caused her to end up where she was when I met her like th eimage shows. The details of the cases seem somwhat similar.

In my humble opinion, I would suggest that you keep “heroics” to a minimum because of the liability, time and resources it might take. In this case, I would consider finding a great lab and getting some amazing pink porcelain which will serve her well (think Christian Coachman-like). The case lends itself to that and I think you’ll be fine. Best of all, you can test the case first in a pink/tooth colored acrylic screw retained provisional and see how it looks. In retrospect, the lab I used was a mistake and came by recommendation. I know the pink porcelain in the final “full face ” image could have been better, but once I showed it to her during try in (note this for yourself ahead of time) she wouldn’t let me send it back to the lab for color modification because she was so happy with how it looked.

If you want more pictures of my case, and the steps from a-z I will happilly show them to you. I photographed it every step of the way. It wasn’t what was done, but rather the treatment plan and the steps we took to ensure a predictable outcome that made this a “thinking man’s” case. I just figured that it was one of the cases that off the “top of my head” seemed to be similar.

Best Wishes,

Glenn

—————————————————————————————-

I agree with Glenn.
Big Giant CTG Tissue Graft and then…..see attached articles….
We have had great success with this approach but it requires a different “thinking” and plan.
By the way, it’s Pink Composite Resin not Pink Porcelain.

Bruce, I live less than 1/4 mile away from you, let’s get together sometime!!

Maurice

—————————————————————————————-

Thanks Maurice. I agree. My error. 5 years ago, it was pink porcelain. Now I would use the composites. Amazing control and good color selection chairside.

Thanks for the other info.

Glenn

—————————————————————————————-

Glenn and Maurice,
I was reviewing the emails back and forth today and wanted to touch base with you guys on the pink composite vs pink porcelian. I am a periodontist so forgive my ignorance but where can I get more information on HOW the pink composite is utilized instead of pink porcelian in cases like this?

Thanks so much.

Nathan

—————————————————————————————-

Nathan,

The technique is explained REALLY well on pages 24-27 of the third installment of the papers that Maurice sent as attachments earlier today. The one called prd_30_1_Coachman_3.pdf

Great articles Maurice!

Glenn

—————————————————————————————-

Sounds good, but what if you really wanted to fix this problem? Patient is 31. Do you expect thick connective tissue to alter the apparent tendency towards circumferential bone loss? Eventually, these implants will either lose bone up to the floor of the nose or break off. Pink composite and a new restoration sound like a reasonable short-medium term solution but can we do better?

If you really wanted to redo the case in a similar style, I would think that some form of coronally positioned segmental osteotomy or distraction osteogenesis procedure would be the direction of choice unless you thought an iliac crest graft were necessary. Obviously this would assume that you could cut apical to these enormously long implants without perforating the floor of the nose. If you could actually make the bony cuts apically and without nicking the apices of the lateral incisors, then you could use orthodontic mechanics to “erupt” the 8-9 implant segment. Once the bone was in place, then take out the implants, graft the holes, augment the ridge and see where you are at. With a great result and no additional deterioration of the laterals, you could consider new implants. Clearly this is a lot of work and carries significant risks of complications.

Another alternative could be to cut off the 2 implants at the osseous crest and then augment vertically with something like a bioOss block and connective tissue to create a stable edentulous ridge. Then consider a tooth supported fixed bridge 6-11 or implant bridge 7-10. This is a much simpler and more biologically stable approach than bulking up the ridge around the implants and planning to use them.

Jeff

—————————————————————————————-

I agree with Jeff that stability of the bone at the current level is questionable. On the radiograph there appears to be a 2 mm space between 7 and 8. The same distance is not true for 9 – 10. Yes, the gingival tissues around the teeth appear healthy and hopefully stable. As Jeff pointed out, the risk of removing the implants is significant in terms of possible increased bone loss. IF the bone loss is stable, then possibly trying to bury the coronal portions with a hard and soft tissue graft leaves open the option of a fixed, tooth-supported prosthesis for the future, however long that lasts.
Has a cone beam/CT scan been done? Is there any bone on the facial of the implants? If not, it may be easier to remove them than we, far away, would otherwise believe. In that case, an onlay block graft/mesh with BMP/regenaform or some other cocktail may give some more hard tissue to support gingiva instead of pink composite.
As a periodontist, my concern about changing the restoration on the current “fixtures” would be limiting the space for oral hygiene, which appears pretty close to optimal at this time, around the restorations if they are made as ridge laps.

Bob

—————————————————————————————-

Bob and Jeff,

We are lucky to have your clinical experience and knowledge of the literature. I sincerely mean it without trying to sound patronizing. I have watched both of you make exceptional points as I have sat back and read the threads on this message board that I am fortunate enough to be a part of. I have never met either of you personally, but value your opinions and hold you in the highest regard and hope to one day thank you personally for what I have learned as a result of your posts.

Although I completely agree with every single point that you both made, I am obliged to ask myself “what would I do if this was my daughter?” As a result, I wouldn’t consider anything else until I proved to myself that a pink porcelain/acrylic restoration couldn’t adequately do the job. Sure, the bone may deteriorate over time, and sure, the prosthesis might be tough to clean, but…If I can make it look good and buy 5, 10 or even 15 years, I would be willing to wager that our restorative options and surgical approaches/products will be superior at a later date. In the meantime, I can watch the area for what we might consider a catastrophic failure in the making, and best of all, it’s reversible and has an “out”. We can always become more aggressive, but we can never become more conservative.

This poor patient finds herself in the current situation for a number of reasons (that we do not want to exacerbate) and she is in the prime of her life. If a well made prosthesis could solve the problem right now, why not go with it? I don’t know about you, but as I become more experienced I am trying to de-complicate my clinical life and reduce my liability (no, not because I am hopefully going back for ortho training next year.) This case, treated in any way other than a prosthesis makes both the complexity and liability go up. Moreso, creating a scenario where a 31 year old wont have to be living at the surgeon or restorative dentist from ages 31-34 is a plus to me.

Anyone who knows me also knows that I am not afraid to “pull the trigger” on some of the “cool” (although somewhat unpredictable) options that we can throw around, but I was once reminded in a treatment planning session as I was getting really “gung ho” on some cool interdisciplinary approaches…”We make false sacrifices on the alter of academic perfectionism.”

I’m just a simple country dentist….

Glenn

—————————————————————————————-

Unfortunately, in the aesthetic zone, there’s rarely a slam-dunk.
Yes, I too, tend towards conservative therapy when available. Seeing her ability to maintain the proximal tissue between the teeth and implants (not between the implants themselves) in a healthy state is a good sign. Knowing if there is any remaining bone on the facial of the implants would possibly give the surgeons in the crowd more reassurance that there is nutritional support for the gingival tissues.
Yes, the tincture of time will lead, hopefully, to more predictable options to regenerate missing bone, allowing support for the gingiva to be maintained.
Some times, knowing the probability of losing bone and/or soft tissue after a regenerative procedure leads us all to be a little gun shy.

Bob

—————————————————————————————-

Glenn;

I couldn’t agree more. Perhaps the best post yet! Such empathy is rare.

Well said and Happy 4th Country Dentist,

Maurice

—————————————————————————————-

Bruce,

Do you have any additional information, such as the stage I surgical notes and sequential radiographs?

In my experience, although the original Brånemark “machined screws” weren’t as fancy and didn’t have the same integration / success rates that we enjoy today, they really tended to hold up well with few issues such as “peri-imlpantitis.”

You may see little to no change in bone levels over time in contrast to treated surfaces.

Rick

—————————————————————————————-

Bob and Jeff,

If it would be helpful, I will happily have this patient return for a complimentary CT scan and post some critical screenshots, which I did think about for the original posting. However, I would be surprised if bone on the facial extended any further coronally than it does interproximally and probably not even close to that much…..which is why this case prompted me to pause a bit and post it. I guess if nothing else, it would be interesting to see if the 3D technology will change any of our clinical “hunches” above and beyond the clinical and plain film presentation. After all, I’ve got the damn thing–I may as well use it! 🙂

Bruce

—————————————————————————————-

Rick,
I do not have the additional information you mentioned. Excellent idea and I will pursue it! I agree that her implants are most likely Branemark or clones with machined surfaces and her bone levels are probably stable however past radiographs may indeed verify that. I will attempt to retrieve some and additionally, when she comes in for her CT, I will get more information from her regarding changes in tissue levels or is her clinical picture more or less the same over the last 10 years.

Bruce

—————————————————————————————-

Roger that!

Rick

[Author]

Posts