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Case Conference Prosthodontics Restorative Dentistry

Your Opinion: How would you manage this case?

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This case is presented by Dr. Emad Girgis

Patient x-ray

I have a 66-year old patient, male Caucasian. Although on medications, these are not contributing to any health complications. The patient had a bridge, done on combined mini implants and teeth, tooth #42had been extracted prior to this X ray due to root fracture . #34 was extracted from under the bridge due to fracture as well. The bridge has been there for about 3 years and the gingiva seems to be healthy around the implants; so, I am assuming there is good integration. #33 has a large periapical radiolucency due to poor RCT and clinically the retainer of the 33 is off from the finishing line, suggestive of movement in the bridge, the heads of the mini implants has been reduced by the performing DDS (the lower bridge came off and was cemented temporarily), mandibular posterior ridge is wide enough to add implants as needed 

The lower bridge has to go and the patient doesn’t want a removable appliance. Upper bridges are OK .

 

Tell us how you would have dealt with this case. If you have other interesting cases, email those to us at oasisdiscussions@cda-adc.ca

 

 

5 Comments

  1. Kent Orlando November 15, 2013

    My associate and I see these cases all the time. We have an immigrant population of truck drivers here in NB from Germany, Romania, and other European countries. The underlying theme is “super ambitious ” dentistry coupled with inadequate oral hygiene. The old saying of superior German engineering doesn’t not apply to their dentistry.
    You have to be suspicious of the quality of the rest of the dentistry and when you say the upper bridge is ok, it can see some open margins there too.

    For the md, you could remove the FPD and hopefully save the Mini implants, place a few more minis or conventional implants and restore. If they refuse a removable appliance, then the minis can’t be used.

    For the md, after the impacted 13 is removed, you may consider replacing the FPD’s as well. Surprisingly, the endos don’t look that bad.
    Unfortunately, in my office the patients have no means to pay for the mess they got into with their “Euro dentistry” and we end up trying to patch and monitor.
    Good luck.

    Reply
  2. David Rose November 15, 2013

    I would remove the remaining teeth in the mandible, place one more mini in the anterior and place a temporary bridge on these mini implants. After suitable healing, place five or six real implants where appropriate, removing or cutting off the mini implants, place an immediate temporary bridge on them, and later restore it with a fixed or, preferably, hybrid screw retained bridge.

    I would also tell the patient to expect something similar for the maxilla in the future.

    Reply
  3. Tom Wierzbicki November 19, 2013

    Hello Dr. Girgis,

    Thank you for presenting a very interesting case.

    If treatment planning off of the panoramic radiograph only, here are my recommendations:

    Maxilla
    Problem list: open margins on existing FPDs, occlusal trauma on remaining dentition, 15 localized severe chronic periodontitis with poor periodontal prognosis (possible vertical root fracture), possible periapical lesion on 14, impacted 13 with possible external resorption of crown

    Option 1 – full clearance and immediate implant supported fixed restoration.

    Option 2 – a) temporization of FPD 11-x-x-14 and 21-22-x-x-25 (assuming no periodontal issues involving the retainers), b) 13 and 15 extractions and socket augmentation and bone grafting in the 12, 13, 23, 24 sites c) conventional implants and implant supported crowns in 12, 13, 23, 24 sites.

    Mandible
    Problem list: open margins on existing FPD, possible bone loss around mini implants, periapical lesion on 33 and 34, long cantilever in the anterior.

    Option 1 – full clearance and immediate implant supported fixed restoration.

    Option 2 – a) temporization of mini implant FPD 45-44-43-x-x-x-x-x-x-35-36, b) extraction of 33, 34 and socket augmentation and bone grafting as required, c) conventional implants in 42, 31, 32, and 34 sites d) implant supported FPD 42-x-31, 32-x-34, e) the minis can then be removed if the patient chooses and replaced with conventional implant supported crowns/FPDs.

    Cheers,

    Tom

    Reply
  4. JCDA Oasis November 25, 2013

    On behalf of Dr. Brian Show:

    Obtain thorough records.
    Photos, study models, bite registration.
    Remove everything and place provisional CUD/CLD to allow for healing.
    Sinus augmentation as required, likely would be 16 and 26 locations.
    Healing 4-6 months.
    Maxillary implants (non-mini) in the 13, 16, 23 and 26 areas, ideally 4-5 mm diameter and 8-12 mm in length.
    (Bone level)
    Mandibular implants 33, 36, 43, 46 areas ridge permitting as determined by tomo. (Same dimensions) Healing time 4-6 months to allow for osseointegration.
    Fabricate upper and lower implant supported and cement or screw retained full arch 12 unit hybrid restorations.

    Reply
  5. Emad Girgis November 25, 2013

    Thanks to everyone who helped its been very helpful. I am leaning to remove remaing mand teeth , temporization using the minis with CD , bone augmentation and 6 implants then fpd .Uppers will be dealt with after the patient recovers from the our bill

    Reply

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