Second Opinion

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I have been asked to give a second opinion on a treatment plan that extracts #7,#8,#9,#10, places two implant fixtures #7 and #10 locations as a basis for a fixed bridge.

My concern is the deep impinging bite.

Orthodontic retx is out of the question as he was retx’d twice and now there is considerable root resorbtion.

My instinct is to attempt to keep the tx plan as simple as possible by extracting the maxillary incisors, modifying the lower anterior incisal edge and placing a fixed pd #6-#11.

Who wants to restore this with implants? What is your recommended tx plan?

Michael

[photographs redacted]

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I’d be afraid of restoring this case unless the occlusion is modified to manage the deep bite and flared anterior teeth – implant or natural tooth supported FPD. I think a comprehensive occlusal and periodontal evaluation should lead to a comprehensive, occlusal therapeutic approach as the basis for the small tooth replacement issue.

Karl

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Can the lower incisors be kept without compromising the occlusion?
pretty steep incisal guidance, maybe need a bridge on the lower
anteriors #22-27? or lengthen and crown 22-27, likely endo, embrasure
issues and difficult teeth to work with, i think depends on the skills
of the restoring dentist

Greg

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Hi Michael.

Unfortunately, I cannot locate images or radiographs of the case you describe.
However, trying to visualize this case the excessive overbite should be corrected by intruding either maxillary or mandibular teeth, whichever is appropriate, to gain appropriate space (Kokich). Although you describe previous root resorption, generally resorption will not re-occur if these teeth are treated with PAOO, as a totally different type of tooth movement occurs, based on a RAP effect and not a hyaline necrosis, associated with traditional tooth movement.. I am currently treating, a retreatment, of a case similar to your description – we are eight months into treatment, and all is going very well. No new root resorption is noted, and the teeth are moving very well.
Was this case previously treated with four bicuspid extractions? ( I have no images)
It is my fundamental belief that teeth should be, more or less in their correct position, before undertaking orthodontic treatment!
Please repost the images.

Best wishes,

Colin

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One of the key questions has to be whether it is important to maintain the patient’s diastema or not. If the answer to this question is yes, then you can’t consider a fixed bridge 7-10. On the other hand, you could consider putting implants in the central incisor sites and cantilevering lateral incisors.

I wouldn’t argue that ideal treatment would include orthodontic correction of his malocclusion and deep bite. Few patients in my practice would accept this recommendation. So the next question is what is the next best option? Do we avoid implants because of concern for high lateral forces? Do we insist that the patient must do ideal treatment or leave the practice? I don’t think so. Instead we design the case to withstand non-ideal forces using implants with adequate surface area in appropriate sites restored with prosthetics that can tolerate heavy loads.

I think it is very difficult to “overload’ an integrated implant with occlusal forces. So far most literature confirms this belief.

Jeffrey

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Karl hits the nail on the head! Having said that–and without additional necessary info–what about the strategic removal of mandibular incisors? Obviously there is an extrusion issue. How about some really nice study models/model surgery/diagnostic wax up? I know it’s sacrilege as a periodontist to consider removing teeth and not saving them, but maybe the needed prosthetic interarch space and verical/horizontal relationship can be achieved without orthodontics.

Nick

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