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Implantology Restorative Dentistry

A case of failing implants and crowns; how would you manage the aesthetic challenge? Un cas de défaut implants et des couronnes; comment voulez-vous gérer le défi esthétique?

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Crowns on teeth #1.1 and 2.1 are overcontoured and failing.  The mini-implants in the 1.2 and 2.2 areas have failed.  How will you manage the aesthetic challenge?  See the question video below (bilingual videos this week) followed by a review of the case by Dr. Wazirian in the next video.  Please leave us your comments about what you would do.

Couronnes sur dents # 1.1 et 2.1 sont surcontour et défaillants. Les mini-implants dans les zones 1,2 et 2,2 ont échoué. Comment allez-vous gérer le défi esthétique? Voir la vidéo question ci-dessous (vidéos bilingues cette semaine) suivie d’un examen du cas par le Dr Wazirian dans la vidéo suivante. S’il vous plaît laissez-nous vos commentaires sur ce que vous feriez.

From/Depuis Drs Berge Wazirian (Prosthodontist, McGill University), Mark Straus (GP, Stratford, Ontario),  and Ian Furst (Coronation Dental Specialty Group).

 (case presentation, english)

(case presentation, french)

(case review, french)

(case review, english)

 

 

14 Comments

  1. Mark Venditti January 14, 2013

    Interesting case. The patients chief complaint appears to be the appearance of the maxillary incisors. So, I would either recommend cantilever bridges off the central incisors to replace the lateral incisors. I would tell her there are esthetic limitations with this option as we are trying to work with the space that exists for the lateral incisors and the position of the canines. For the best result possible I would recommend a full mouth rehabilitation, likely including orthodontics in part to to make more space for dental implant supported crowns to replace teeth 12 and 22. Possibly dental implant supported crowns to replace other missing teeth and crowns or veneers to improve the shape of some teeth. This option would require more investigation.

    Reply
  2. Elizabeth Vella Caruana January 14, 2013

    Thank You for reference to the Featherstone Protocol!! And the excellent method of presentation!

    Reply
    1. Berge Wazirian January 15, 2013

      You’re welcome!

  3. LOUISE DESNOYERS January 14, 2013

    Interesting case. As far as this pictures show, there is no occlusion contact on the lower anterior group. If the patient can afford it and if there is no contraindication (medical or other), I would recommend to enlarge the space for replacement of #1.2 and 2.2; either move by orthodontic or/and by reducing the M-D width of the two canines, lateral to the edentulous sites. After,I would replace the two central defectuous crowns (advising the patient that we could find decay under and also endo + pegs might be needeed).
    The complete esthetic success of this case would probably involve a bone or a conjuctive tissue graft on Buccal mucosa sites of #1.2 and #2.2. During the healing process of those grafts, I would prepare and place two temporary cantilever bridges 21-X and X-11 (with Voco or any other composite temporary material)so the two edentulous sites sculpt the future pontic’s shapes. When the two graft healing processes are completed and after the patient is sure to like the shapes and the position of the temporary bridges, I would prepare and finalize the two cantilever bridges in Zirconium.

    Reply
    1. thanks louise – cost was a consideration (and treatment time) so the pt opted out of the ortho solution. why the connective tissue grafts; compared to bone grafting or in addition to? what are your thoughts on cantilever from 11/21 vs 13/23 with maryland attachments?

  4. LOUISE DESNOYERS January 14, 2013

    I think the decision for bone grafting or only connective tissue graft should be considered with a bons scan. The connective tissue graft is ok but has a limit for expanding the tissue. If there is a bigger leak than 3 or 4 mm(?) we should consider a bone AND a connective tissue graft.
    For your other question, the two caninces are completly healthy and as long as there are no occlusion contact on antagonist front bottom teeth, I still recommand cantilever instead of a any other bridge. For tree reasons: first the central are already reduced and there two crowns have to be redone, second a cantilever bridge is always more esthetic (gray shade from the attachment) and has a longer life time in mouth than a Maryland attachment. And third, a cantilever is easier to clean and much easier for personnal oral hygiene than a Maryland attachment; which means will keep oral tissue healthy more easily.

    Reply
    1. Berge Wazirian January 14, 2013

      Thank you for your comment! Interesting point of view! My only worry with a cantilever fixed bridge is the lower survival rate of the latter. Studies show (pjetursson et al.) that the survival of such design is much lower compared to a 3 unit FPD over 10 years and the most common reason for failure is caries. As for a cantilever Maryland Bridge, studies show (Goodacre et al.) that the survival of the latter is also lower than a 3 unit bridge but the failure of a cantilever Maryland bridge is less involved (i.e. usually debonding) and could be corrected in a simpler fashion (i.e. rebonding). This is something to keep in mind when looking at survival rates. The reason for failure could make one option better than the other even if both have similar survival rates.

  5. Hannu Larjava January 15, 2013

    Plan:
    1. Assuming that ortho to make more space is out of question
    2. New splinted crowns on 11 and 21 and cantilever pontics to replace 12/22 with potential veneers on 13/23 (need wax-up and potential crown lengthening of 11/21 needs to be addressed)
    3. Obviously ortho and more space for implants wound be ideal

    Reply
  6. Waji Khan January 17, 2013

    Excellent presentation. I would highly agree that the high caries risks needs to guide the direction of any treatment options. In some of these cases I like to have the patients wear fluoride trays in order to help assist in remineralization and also to help avoid future caries. Great presentation.

    Reply
  7. Paul Witt January 19, 2013

    Very interesting case and excellent presentation. Is there any reason, considering the high caries susceptibility, poor hygiene, long-term poor prognosis for two 3-unit briges, and limited finances, that a treatment plan involving replacement of the crowns on 1.1 and 2.1 followed by placement of a cast partial denture was not considered, even as a relatively temporary solution to the esthetic problem, until the patient can prove that he can maintain adequate home-care to improve the prognosis of fixed prosthetics.

    Reply
    1. Berge Wazirian January 20, 2013

      A cast partial denture would be another option for this patient. I was not involved in this case but from what I know this patient wanted a fixed option. The issue with replacing 11 and 21 with definitive crowns and the fabricatin of a cast partial denture until the patient proves adequate maintenance of oral hygiene is that once the patient is ready for FPDs, the recently made crowns on 11 and 21 would need to be removed. My approach would be slightly different, as mentioned in the video, before moving forward with any of the options, the patient should demonstrate an overall improved oral health. During that period, I would either modify 11 and 21 by recontouring or consider fabricating in lab provisional composite crowns and a provisional all acrylic partial denture. This way the cost for the patient is not high and he will have a temporary esthetic smile until he proves that he is ready for more definitive options.

      1. Paul Witt January 20, 2013

        Berge: your treatment suggestion involving a temporary acryilic partial is probably even more realistic than the treatment that I was suggesting. The only concern that I would have with it is that I am somewhat concerned that the patient would look at the acrylic partial denture as a “permanent” solution and return years later with the gingival damage inherent to long-term temporary partial wear. Having seen too many patients with a history of poor hygiene and lapses in dental care, I am not optimistic about the patient turning things around any time soon. If we all practised by performing treatments that the patient wanted with disregard to the reality of the conditions presented by the patient, we would need to stop calling ourselves professionals.

        1. Berge Wazirian January 20, 2013

          Very good point. I think that if the patient is one that is not able to correct his oral condition, any treatment option (even a cast partial denture) will be at risk of abutment teeth failure. That’s why I would refrain from moving forward with any definitive treatment option until the patient is ready.

  8. Robert Piedalue January 22, 2013

    With all the wear facets showing on the models occlusally, restoration needs to be done in CR as per Dawson, Spears, Phelan etc. The occlusal interferences have probably been a contributor to the caries rate. It would be interesting to see the articulator mounting of CR. Also a truly esthetic result would need the bicuspids built out facially to give a fuller smile. No doubt the cost of doing it right will be prohibitory and a sad future is potentially the result.

    Reply

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