Teeth Have Shifted Considerably: Make Space for Implants or Close the Space?

Better off replacing # 30 to optimize occlusion and if patient is opposed to ortho leave max arch alone, yet present argument of persistent food traps which could compromise periodontal heath in the long term.

i would remodelling this teeth in the same way in the two sites and place an implant per part, i think around 2,5 3 millimeters , not more. this is the simplest way to solve the problem and is economic too.

Heard at the OMS department: "Missing teeth or missing implants?"

I think osseonews reworded my case presentation pretty badly. Implants were already placed for #30 and #31 and #3 is super erupted. #19 appears to have a thin ridge. Obviously it cannot be seen in a 2 dimensional peri apical radiograph. The bone in the #4 location had adequate thickness.

I suggest that the best choice for type and location of prosthodontic care take into consideration his occlusion. His radiographs suggest significant cuspal wear suggesting habitual bruxism. What is the status of anterior teeth: occlusion, wear pattern, splaying, fremitis? You have not mentioned the missing lower right molars. I think that evaluation of his occlusion is key to what might be done within the patient's range of acceptance. Have you considered just an implant in the lower right first molar area with a fixed partial denture abutted on the upper right first molar and first premolar to restore his posterior occlusion on that side of his mouth? This of course should be co-ordinated with proper occlusal adjustment and use of parafunction habit pattern management. In the future, he may be willing to address his prosthodontic needs on the left side of his mouth.

So #19 does not have adequate attached gingiva nor bone thickness (so it seems). #4 DOES have adequate attached gingiva and bone thickness.

Space closure by ortho could also address the problems of tilting, over-eruption and to provide better inter-occlusal space for implant supported prosthesis.

I would evaluate the occlusion. Make a bridgework to correct & modify the occlusion.

OMS Resident: LOL, interesting perspective! Dr. Rhodes, all excellent questions, especially with the patient's young age. Treat the whole patient, not just a single (missing!) tooth. That's good advice I'll pass along. Dr. Carnazza, great thoughts also.

The key here is to clearly define your goals (and the patients) and find the best way to get there, not find a way to fit implants into the case. Without ortho this is not an implant case.

I just finished a case very similar. We extracted the left third molar and did a ramus graft to restore the buccal deficiency in the first molar area. 6 months of uprighting with fixed ortho to upright the 2nd molar while the graft integrated provided a great site for a simple, single stage implant (not immediate load). This type of treatment lends itself to idealization of occlusal scheme, great longevity, and only one complex surgical procedure. The healing on the graft procedure is not much more than the third molar removal, and the implant placement later on is simple. Having the tipping gone is a huge longterm plus for a young patient. For me it is very hard to tell what might be a "best treatment on the patient's right with the information provided. Photo of mounted models would be nice. Best of luck. t

I would consider resin bonded Zirconia inlay bridges instead of implants in this case

Orthodontic treatment would be ideal! Present to the patient all the options. Let them decide. Sometimes implants, sometimes bridges and sometimes nothing!