Limited surgical space and increase restorative space: thoughts?

Removal primary teeth, ridge aug. follow by place only one implant. Even the spacing with restoration on adjacent teeth. May be one of solution

Hi Ziv , Hope you and Ari are well and having fun in Beverly Hills . Yes these cases are always challenging due to the lack of ridge formation where no adult tooth was present . Have done many cases and have a set protocol for dealing with them . But an interesting solution is a distraction orthodontics route by moving a tooth to create more bone , but patient has had enough. My standard solution involves ridge expansion and grafting but this can be more difficult on the lower jaw . Maybe best to post a case ... But could tunnel graft here first and the have a nicer ridge later but agree 1 implant two teeth may be best Regards Peter

I would consider extracting the retained incisors, flattening the ridge crest to gain a 2mm buccal-lingual width and expanding with osteotomes with a single implant plus further bone augmentation. I would try to place at the time of extraction as you have a lot of soft tissue to work with. I have restored multiple lower incisors like this with a single implant and 2 teeth, the best results routinley are with a strauman NN connection implant (3.0mm)

how about no implants? Not everyone's a good candidate. Place an e.max resin bonded bridge with layered pontics. The lithium disilicate etches nicely and bonds well to enamel. Minimal tooth modification, no bone graft or surgery. Simple!

There is about 8 mm of space between the lower laterals. Too much for one tooth, not enough for two teeth (assuming you wish an esthetic outcome and not just a chicklet). First you must solve that esthetic/prosthetic problem. Mock up a 4 tooth bridge 23-26 and a 3 tooth bridge in same site and see which you and the pt like better. This will guide your treatment plan. If 3TB then you need to make each tooth the same width. You could do some limited ortho to retrocline the teeth and break up the space more evenly. Suggest bonded bridge to start and enable site preparation. Particulate onlay with fenestrations and membrane to augment the ridge, then 2 stage implant placement (why rush, you can remove and replace the bonded bridge for a provisional) and restoration on a custom abutment. If pt likes the bonded bridge you may not even get to do the implant ;( 4 tooth plan would involve stripping both laterals and M of canines, pushing laterals wider (simple ortho using open NiTi coil) to make space, then bonded bridge followed by one implant supporting 2 central incisors using same sequence as above. Looking forward to seeing your solution...

Thanks George. What you are suggesting makes perfect sense.

I was just looking at the patient's upper arch. I wonder how concerned or motivated they are when we see diastemas, peg laterals , and a cuspid in the lateral position? I do feel that George had the best idea of a moch up to see what would look the best for this pt. I know as dentist we want to see nice gingival contours but it is too hard to tell right now with those primary teeth. Implants don't answer that question in regards to the esthetics. Good case....

This case can probably be accomplished with two, 2 mm diameter mini implants after extraction of the deciduous teeth. I routinely treat these cases like so. A splinted 2 unit restoration would probably do well over many years. The bone here may be very dense. The primary blood supply is via the periosteum supplied from the facial artery. Narrow diameter implants do not block remodeling. The lab is instructed to apply 3 coats of die separator to insure a passive fit of the PFM splint. Dennis Flanagan DDS MSc

Hello dr Ziv I always love your presentations. Thanks In this case if we desire most conservative and yet esthetic restorative solution then I think You may consider Single Implant supported Sort of Andrew's bridge although we are not taking any direct support from laterals but yes we are overlapping our removable part of the assembly on adjacent laterals to satisfy the proportions. U can mock up and see how it looks!! Will Love and be Eager to see the result whatever best You choose for this patient. All D best ""

For a long term functional and esthetic outcome the facial bone should be at least 1.8mm (Spray). A standard diameter implant may not allow this. Two 1.8 or 2mm minis will likely be the best course. Dennis Flanagan DDS MSc

I have published several articles on appropriate mini implant treatment. Go to PubMed and type in Flanagan D. I truly believe that minis and small diameter implants will be the standard in the near future. Dennis Flanagan DDS MSc

I too watch Ziv's videos and love them. Thanks Ziv. I agree with Dennis. Two 1.8 mm minis keeps it simple for patient and the dentist. Also they are more economical for patients. I would make the space a little wider by shaping the adjacent teeth. It is my opinion that 2 minis with splinted crowns will be stronger than one wider implant and a cantiliver bridge. Minis save more bone around implant which is more important than having a thicker implants (specially in lower anterior). Imagine placing a wider post at the cost of tooth structure making post stronger but tooth weaker. There is no problem of bacteria at abutment connection as there is no connection in mini implants. Also we can restore the mini implant almost immediately in most if the cases. I have done quite a few of minis for the narrow spaces, restored them immediately, and I am very happy with the results.

One implant in middle now here is the difference have the crown match the double lateral on the left it is a congenital one and one half crown that should solve the custom space issue in this patient.

CRS, Could you explain a little more? How would that improve the esthetics?

I have done many mini implants with crowns with great success. Haven't done one for a while as traditionals have more to offer. But in the lower anterior area they are excellent and look very natural if the crown is done properly by the lab. To do a mini here, I would find many problems with the placement. You would drill your hole and the knife edge ridge would make it impossible to get a straight line without perforating the cortical bone. And if you remove the knife edge then the head of the implant is too low. So the length of the crown is then too great. MIni implants are like any implant. Nice bone, acceptable crown length. Otherwise watch them fail. In this case, if you want perfection, what about ortho to open up the MDwidth. The proclination of the teeth can be accommodated or just reduce the width of the others to stop this. Then do your traditionals and fit in 2 teeth. You are the expert at working out the width of teeth for the ultimate appearance.

Yes the narrow ridge would need to be split and expanded with a scalpel and channel former before the mini implants were placed. There is a potenttial for an excellent outcome. Dennis Flanagan DDS MSc

I would exhaust all means of fixed adhesive or Maryland type bridges before telling this patient I could fix this with implants. I've seen cases like this before- and here are my thoughts: 1. At 20 years old, what ever you do especially with implants needs to last a very long time. 2. You already have no bone here, so it's not like the site is going to atrophy any more of you get 10 years out of a fixed bridge. 3. I have found that most patients appreciate trying conservative approaches first- And then if this fails, and there is no other option, consider grafting and implants. 4.Prosthetically a very challenging case.

Good points. I missed the 20 yo part.

Hi, Bone graft, mini…not likely. Mini split and one implant, looks like a solution. If anybody remembers old good blades! Custom blade could have 2 abutments or one, and long body 1,8mm thick. Regards mike

Ortodontica drive to the mesial of the lower lateral incisors and distal movement of the canines. now you have enough bone to place the screws on the side created space. if necessary re-anatomizes central and canines.

CRS makes an important point regarding the two forward places lower cuspids. These lower cuspids working against upper lateral incisors cause massive damage over the years to both laterals and centrals, not counting that due to no cuspid guidance. I have done a similar case, but was blame to squeeze out 10 mm space for two lateral incisor implants ( Bicon 3.0 X 8 mm ) with a precision placement deeper into the basal bone and extended, wide based 4 mm abutments with flattened I Prox surfaces. Was done with GBR on young man and needed connective tissue graft at 3 years to thicken up the tissue.