Recommendations for Restorative Options for Multiple Implants in Patient with History of Facial Trauma?

It would be good to get a photo, to see the tissue dimensions but definitely leave the 12 as a sleeper, you wont get a good aesthetic result otherwise.

A clinical photograph would be helpful to determine aspects such as lip line, smile line, clinical position of implants, availability of soft tissue drape, etc.. In cases like this I assume the final restoration was already planned before implant placement. If you are not the dentist who originally placed the implants, I suggest you make a diagnostic wax-up and fabricate a fixed provisional restoration for the patient. Having the provisional fixed restoration installed gives you the opportunity to detect potential prosthetic, occlusal or esthetic problems. Also important, is determining the patient's ability to keep optimum hygiene with a fixed multiple unit bridge versus unitary crowns. This should help you decide with the patient what restorative option might work best in his case. Bets regards

Best I meant

I disagree with the need for a diagnostic wax-up. It's the esthetic zone where the mirror side and opposing side are present....So just match it up. That takes care of the esthetic issue. As for the occlusal issue, it comes down to whether you want it in full function or not. You have to splint them (if you can that is) for long term sake. Lateral forces will be a bitch especially in the front. Pretty sure those aren't Bicons. I wouldn't do unitary crowns unless they are Bicons. To evaluate whether a patient can maintain optimum hygiene is ridiculous. Who the heck maintains optimum hygiene????? And let's be honest here, it's not like you are not going to take the case if the patient has terrible hygiene. Provide a long-term, stable prosthesis is the key here. NOT whether you can clean/floss the damn thing!!!! It's not a furcation!!! Best esthetic result can be achevied if you can do a telecoping prosthesis so you can maintain the interdental papilla. Key to ideal esthetic isn't the crown or the prosethesis for that matter. Crowns are crowns. Worry about the gingival margin + gingval embrassures + incisal embrassures. Key to success everytime.

What kinda implants are those?

I must re iterate, I think the aesthetic success will be determined by the use (or lack thereof) the lateral incisor implant. Putting it simply, you will never grow tissue between these adjacent implants and hence the gingival level will be very asymmetric when compared to the contralateral side. You have enough implants with 3 in this case. place a bridge missing out the 12. If there is not enough tissue, do a soft tissue graft over the 12 and develop the pontic site over implant, but do not put an abutment on it under any circumstances.... pretty please...

I agree with Dr.mike ainsworth.

I disagree with Dr. Mike ainsworth. I have done enough cases to know that tissue will grow between those adjacent implants. Key is the prosthesis. Create enough embrasure spaces on the prosthesis and the tissues will fill in. Get a good lab and add gingiva porcelain to eliminate the "long tooth" look. This saves the patient additional surgeries, shortened treatment time, takes the variable of the soft tissue graft (it's not a 100%" thing you know" and you will still be in full control of the case. Do not short change the patient and the treatment by eliminating the 12 without trying. Utilize every implants for long term sake. 4 teeth on 3 implants is shit compare to 4 teeth on 4 implants. Force/load distribution and continual resorption on 12.......

Looks to me like there is a big lump of tissue over the implants from the shadow on the opg. (so you probably wont need a st graft. Alloderm double layer has always been good for me in this type of thing). I know that I personally couldn't get it to look natural using the 12 implant too thats all. I'm unfamiliar with the continued rates of bone around a fully integrated buried implant - I always believed that the slight negative charge helped bone density and quality around implants in fact have restored implants buried for 26 years before-they still had bone. As to the force distribution, I also thought that from a biomechanical point of view a bridge from a canine to central incisor position was quite a good way of doing things. Just my opinion thats all.

Blah sure is a class act! Four teeth on three implants makes total sense. It's not.... I suspect, if it's a trauma situation, that there is significant alveolar bone loss. It will be virtually impossible to make the restoration look cosmetically ideal from a dentogingival perspective. Therefore, pink porcelain will be needed for blocking out the defect as well as cosmetics. Pink porcelain can only dependably be used in multiple implant situations when the implants are splinted together and the lab has freedom to make ideal papilla forms interproximally. This is tough to do when you're trying to fit individual crowns. Also, Blah states the need to create enough embrasure space so the tissue will grow into papillas. If he would read some of Tarnows work, the tissue will not dependably fill in a gingival embrasure if the embrasure is more than 5mm above the crest of bone. with the severe bone loss, it is very doubtful that tissue will rebound satisfactorily. Dr. Ainsworth has a better biomechanical and esthetic model than Blah and I too would recommend sleeping the 12 (#7 for us north americans)implant for ease and dependability of fabricating an esthetic restoration.

It's a numbers game! If you have done 20+ implants buried for 26 years then I will agree with that statement. On the flip side though, if it's there for 26 years then of course there will be bone (otherwise it would have came out already) That aside, base on the information on the given pan, i bet the patient is a relatively young patient. This is extremely important in coming up with a correct/long term treatment. Say the patient will live for another 40 years (very likely in my opinion), we simply do not have the raw data to support any long term "biomechanical point of view of a bridge". We don't have the numbers!! When I do my cases, I go long term. My experience tells me that more is better in the long run. Most of the time it's due to cost and amount of bone and ability to restore, but here we already have an implant. To say "I can't restore it" base on a radiogragh and throw your hands-up without even trying is malpractice in my book. Especially to do whatever grafting to improve the "Pontic" area is absurd. I like how people can determine the need of soft tissue graft base on a radiograph.

the pano is 2D and the relation of the implants to each other can not be appreciated fully from this film. after 2nd stage surgery you will see what can be done. this case will work with splinted or single crowns or a combination. evaluate after you see the actual position of the implants and the gingival tissues over them. a provisional restoration will serve for evaluation of esthetics and to provide for loading of the implants in a gradual fashion to allow the bone to strengthen.

For Blah,using every implants for every missing teeth is not a good idea and not every embrassure will come to the points you want. Carl Mich ,3mm between implants ,can you find that space between implants if you place every implants for every missing teeth.. Carlos Nemcovsky,2 implants for 4 missing anterior teeth is the best choice ,...

Quoting others don't make you an expert. Quoting Tarnow/Misch = you read their stuff and probably paid for their lectures right?? Very good! I can quote Shakespeare but that doesn't mean I'm a playwright. You do know that the 3mm between implants is a prosthetic/restoration issue, and not because of the biological/soft tissue/papilla right??? People always throw the "3mm" without know the real implication. Amazing!

I also like the "gradual loading to strengthen the bone" statement. I like how some thinks gradually loading in a year or two can give you comparable bone to those which have been in function for the past 50 years or so.

Create a splintted prosthesis. Telescoping. Open embrasure space 3mms. Pink porcelain to emulate gingival margin. Screw retained will look like shit.

Last comment of the night. What a waste it is to do a provisional!!! What meaningful good does it do other than charging the patient more money. Tell the patient that the crowns will be a mirror image of the other side and it will occlude with the teeth on the bottom "correctly", and the fact that he shouldn't lift up his lip to show people because the gingival margin/gum line and papilla will look like crap. Don't talk to me about esthetics when you can't even get the gingival margins and Interdental papilla/embrasures to look normal. That 3mm remark still cracks me up though. Hahaha. Amazing how people don't even understand that but regurgitates it like it's the word of God or something. Amazing indeed.

no one was born with the implantology knowledge ,son learn from fathher ,father learns from grand father...the unexperienced learn from the experienced ,..

Blah, you are remarkably arrogant in your quest to discredit the work of hard working researchers. Most scientist that I know are honest and to make such an assinine broad sweeping generalization regarding their work reflects your poor judgement, most likely. From someone that does almost all the facial trauma in my capital city , I can tell you first hand , that a lot of our patients are glad to have any teeth at all after a large avulsive injury. Yes , getting the best cosmetic result is critical , our job is to assure adequate function first. Without assessing an accurate study(cbct or models) and tooth to lip measurement we are waisting our time spouting unfounded dogma. It Seems like a lot of these responders do have a good grasp on some options, but blah; blah blah blah. B. Vinci

Splinting , gradual loading ,in an allready compromised case . First of All , why can't you wait for adequate integration , what's the big hurry . Splinting, give me a break, if your implants aren't strong enough to withstand occlusal forces, then , well you know the answer to that. Cleaning around splinted implants is a recipe for disaster. My patients with multiple side by side implants have to agree to regular ,sometimes every three month recall with there gp or perio guy. I got on this websight because I want to Improve my skills as a surgeon, not to engage in senseless banter with an apparent self taught " implantologist". You said it yourself , all the journals are bunk. You were born with implant skills?? Bv

The suggestion of provisilization is " standard of care" in a case like this , as well as pre- surgical wax ups. I am under the assumption that this not a rhesus monkey, but someones mother/ daughter or son .This is no time to base this patients care on myopic anecdote. The focal trough of the unit that the panoramic came from doesn't allow any of us to make any accurate suggestions. You certainly can't be serious , when you suggest that no implant other than bicon, can accommodate a tooth per implant option. B.Vinci

i totallly agree with B.vinci..

Implantology should be a rhesus monkey!!!! Why shouldn't it be??? The implantologist should be well trained enough to treat it as routine. If you are not then you are probably not doing enough. Also, whos the one really doing the provisional??? The doctor in charge or the lab tech?? I wouldn't have that much of a problem if the the doc in charge is doing all the 'standard of care' bs. Sending it to the lab is not 'standard of care' in my mind. Other than 'selling' and 'showing' to the patient, there shouldn't be any reason for a provisional. All the parameters are there already. The only thing you can change is the bite/contacts. Length/esthetics are all predetermined by the existing dentition. What a perfect pt. Coming in with integrated implants. All we have to do is take impressions. Can't be any simpler. But peeps here have to re-invent the wheel.

Implantolgy is not a recognized specialty, according to the Ada or AMA . But must I assume, your not a member of either? Bv

Standard of care is not established by what is in your" mind ",but by what is considered to be best for the patient as practiced in your geographic area. There's a lot of deep philosophy coming from a shallow well, I'm afraid. All in good fun. Do what you need to do, just not on me. Bv

Cooler heads seem to be editing our non - sense. Thanks, bv

Dear Sir, let me say some of my point ,I saw some radiolucent area around fixtures and and which methods of surgical guide did you use for fixtures positioning and another is what type of bone did the patient graft.As for me honestly I don't want patient to face the trauma again. with respect,

Wal, I hope your wrong about that. I feel like I see the same. Maybe just a poor X-ray ,or still in integration phase. This is one reason , I would never early load these. Good day sir, bv

Hi guys, I have been watching this discussion develop with interest. It seems that we have a couple of schools of thought. Some of us think that sleeping the 12 implant would be a good idea and some think that loading all 4 would be better. I understand the thought process behind wanting to use al of the available implants. In a case where the patient has a low lip line and gingival aesthetics are not paramount, it would be a reasonable option. However, more and more patients are becoming very fussy with regards to pink aesthetics also. The issue with using all of the available implants, is that you can not achieve a peak of bone and attachment to the abutment crown complex, in the same way as a tooth. This renders a much lower papillary peak. It is healthy, it is functional, but is it aesthetic-no. When there is low aesthetic risk you can get away with this. When placing 2 centrals, you can get away with this by lowering the contact point and emphasizing the line angles on the restorations. In a young patient with a high lip line, in the papilla between the central and lateral and lateral and canine who has natural teeth on the contralateral, this tissue is simply not going to come back. Will this be acceptable to the person sitting in your chair? The key here is that no one is wrong per se. The case has to be analyzed on its merits, we just do not know what the lip line is, or indeed how the patient will feel about the asymmetry when fitted. I do believe that we have a duty to explain the pros and cons to the patient in easy to understand terms. Do you want to have single teeth, easy to floss etc, utilizing all of the implants, the crowns will look great but just don't look too closely at the emergence or do you want a bridge which will take a bit more time to make, possibly necessitate temporary stages, be more difficult to clean but will look more natural. Its then up to them. We can get caught up in surgical and medical risk factors and ignore the aesthetic risk factors associated with a case. In many ways, now implant dentistry has such a solid success rate and we can do many things predictably this has to be a prime consideration. In my assessments, I offer a simple choice, does the patient want a) prosthetic implantology for example, couple of implants to turn a bilateral FES into a bounded (one of my favorites!) b) prosthetic implantology, following Blah's philosophy, where function is paramount, if there is enough bone, place the implants and restore. or c) reconstructive where we aim to place a restoration which is all but invisible to inspection by replacing soft and hard tissue as well as tooth. I will admit that most of my cases fall into the first 2 categories, but where we can achieve the third, with no real detriment, why not?

Blah , .certainly you are aware that healthy mucosa( papilla ) will only grow where there is bone. It doesn't matter where the implants are if there is no bone at the embrasure or just below the cej,there will be little or no healthy keratinized papillary tissue . Bv

Sorry for the run on sentences. Bv