Best treatment sequence for this implant case?

2 options for me: .1st option: appt. 1 - remove impacted canine and graft, sinus lift and graft, enlarge that crest with graft, membrane and passive tissue closure; appt. 2 (6 mths later) - install implants with help of osteotomes if soft bone is present and/or if crest enlargment was not good enough after GBR. .2nd option: appt. 1 - remove impacted canine; appt. 2 - ridge expansion and osteotomes, sinus lift crestal or direct approach and install implants with graft. Good luck.

This case of cosmetic and mastication rehabilitation of the patient can be successfully fulfilled without a complex implant treatment by means of traditional veneered telescopic crowns (as a rest element) imbedded into a prosthesis.

I would say that a simpler way would be: remove canine and graft, later date implant 11, distally angulated 13 following the mesial cortical of the sinusboth with a veneer graft, and mesially angulated 15 as a pterigoid implant.I would do all implants with expantion system. No real need for a sinus lift. Rehab would be a fixed bridge 11 to 15. Remembering to do correct connection with gingival management. Cheers

It is diffuclt to plan without diagnostic waxup, and seeing how much soft tissue is missing and where the smileline is. For control a staged approach would be much more predictable. But if lower snile line doesnt matter Will there be pink replacement and where will this transition be? Re: Telescopic crowns. Yes it can be done but high biologic cost, high laboratory cost and skill required and extremely high maintenance cost without fall back position. Implants reconstruction doesnt sound too complicated when compared with this

my surgeons usually like to rebuild the bony architecture first, then place the implants. Another option is to implant #11, make a crown, then use an RPD to replace the posteriors. It is less expensive and less invasive. I still like implant borne fixed restorations but sometimes a combination approach can work too.

I concur with Leal for option 1. You do not need to enlarge the crest as you can use osteotomes to expand the bone and place your implants after grafting.

I try to find out what kind of finesse px wants. Are they motivated to go through multiple surgeries, do they have the finances, what are their expectations. If px is motivated and then i am motivated. BUT the reality is 95% surgeries in my office are single stage where ext, ridge expansion, bone graft, sinus lift, sectg, BMP, impant placement, screw retained temp crown placement are done in one shot.....px's don't want to go through multiple surgeries . I love BMP. Sam Jain, DMD Center For Implant Dentistry Bay Area

I would tell you to first mount the models and do a wax up and see what type of restoration would be best for this patient. If a Hybrid is to be placed then your options change. Know the end before starting. All the ideas above are gret but what is your final restoration?

I would also consider orthodontically moving the canine into place. It can be done using miniscrews for bony anchoridge. This way you avoid the huge defect form extraction and get a good natural tooth in position.

Impaction removal, sinus augmentation, ridge augmentation, and implant placement all at one time is possible but not prudent. Best to stage the procedures. Grow a good ridge before placing implants. I like the idea of bringing the canine into position orthodontically if anchorage can be obtained. This would help keep hard and soft tissues, and would probably produce a more esthetic overall result.

The impacted canine is next to the floor of the nose and directly behind the incisors. it would be a challenge for an oral surgeon to remove without causing significant damage. The sinus lift should be done by a specialist since the floor of the sinus is so thin risking an o-a communication. You need width in the posterior with an onlay or expansion graft. Do a wax up to determine where you need the teeth send the patient with a barium scan appliance for the ct. The scan appliance can be used for a surgical stent I might consider doing this ct guided to avoid the impacted cuspid. Be careful not to go where you don't need to.

if this canine is erupted into the oral cavity then it should be treated either in position or extracted before sinus lift to avoid infection of the bone graft. if orthodontic correction is not possible, we can do extraction by orthodontic traction, to avoid bone grafting the area of #11. a one less expensive way, after a while during this phase may be we can do sinus lift, while waiting for complete extraction of #11. as for implants, we can use short implants, and splint them together after 6 months healing of the sinus graft.

I doubt that tooth will move!

Thanks for all the comments.I will offer her to do ortho first. However, considering the extent of all the surgeries, I am not sure she would extend the treatment even more. I will get a diagnostic wax-up in order to get my surgical guide. However, it will not affect my treatment planning since the bone level on both upper right and left side is the same. And regardless of the smile line, I won't attempt any vertical ridge augmentation in this case for cosmetic reason. I did try split ridge in the past with a 2.5mm wide crest successfully. However, despite full coverage of the implant, the bone was too thin (1mm.) and I had to go back for a GBR anyway. Implant placement #7 with GBR, extraction of impacted canine and sinus lift will be done altogether. If the bone allows me to place a membrane to do a GBR for the left ridge, I will also do it at the same time. If not, I will do it later on, during implants placement. Simultaneous implants placement 11-13-14 in the first appointment is too risky for me. I am afraid whatever left of the crestal ridge will break if I attempt implants placement. Let's not forget, we want ideal implants placement. Again, thanks to all.

Very very good plan The ortho needs to be ruled out as part of the workup. Very wise, please post completed case I'd love to see the out come I have a similar case!

Try to orthodontically move #11. Angled implants should work in the left maxilla and straight implants in the left max anterior. Consider the angled STR from Pacific Implant for the most distal implant. Actually consider STR implants for the other sites. They have to be immediate loaded.