Teeth joined with implants resulted in open bite: which therapy?

Send her immediately to a trusted prostodontist, someone with more experience. Whoever did this violated several surgical principles and most of the natural teeth are failing as are the implants. The open bite did not happen overnight. Don't even think about the TMJ or diagnostic tests, this is clearly a restorative failure leading to decompensation. The prostodontist will know how to get them out of pain and get the treatment plan rolling, your paitent is in crisis. You do don't want to get piggybacked into a poor treatment which was perpetrated on this patient. Then watch how the prostodontist manages the case you will learn tons! Sometimes you have to know when to refer, I see this often in my practice and this is how it is managed. In later posts I can pick this apart an give feedback but get the patient in the right hands, you can't charge enough or treat this comprehensively and you will look like a hero to refer and work with a prostodontist Good Luck and thanks for reading

I am having some commenters remorse I hope I wasn't too harsh,but there are so many things going on here and I may have over-reacted, I want to clarify that going down the cranio-mandibular route may be fine later but this seems like the occlusion, dental pain and over closure/open bite need to be managed.. The prostodontist I use teaches me a lot about this and one needs to be careful and have backup other wise the last dds managing this is tagged. I feel that the patients dental/masticatory/tmj systems etc can no longer manage the situation so it is very helpful to have a set of accurate jaw relation records mounted case etc before treatment is started. A soft splint may help since it is reversable. I bet the first thing to do after this would be to diagnose how this happened, Any old xrays or records available? Was the open bite even there preop? What did the original occlusion look like and where exactly is the pain coming from? The mandibular thirds seem supraerupted and the mandibular anteriors seem intruded? Could that be the source of the open bite?

CRS , wow! you are a know it all.

Nice case to consider, thanks for posting.

PFM metal frames give us the distorted picture. We do not see a real porcelain occlusion to evaluate how bad the clinical situation is.

@CRS. it seems you are the only one here who makes sense. i agree that we have missing information, but only someone who is trained properly can extract the right information, process it well and put the pieces together to come up with a proper diagnosis and a solution to solve it, based on evidence based data and sound principles . One can be a hero and gamble with patient’s health, trying to find out what is happening, when really doesn't know the issues in depth. This restorative case is a good example of how wrong we can be when we don't know, that we don't know. This is a dentist who was probably saving patient more surgeries and money and decided to connect everything together, not knowing the consequences would be. it is very typical to make an impression and send it to the lab and what ever the lab. technician designs, eventually will go into patients mouth. If 4 years is enough to learn everything in dentistry from ENDO, PERIO, TMD, OS, PROSTHO, RADIOLOGY, ETC. imagine how much more you can learn by spending 3 years only studying prosthodontics. The era of being a super dentist and doing it all by going to dental school for 4 years plus AGDE is gone. Those who don't know when to refer to their colleagues are providing disservice to their patients.

I think you need to do a full case work up on this patient...there are multiple abscesses in this mouth so the failing implants are just one of the MANY issues in this case. Also, definitely a thorough, comprehensive occlusal analysis. You may want to refer this case out unless you have extensive experience in these areas

In my opinion it is inappropriate to suggest treatments for this case based on just an opg. To make a plan I would take casts, articulate, study and then move on from there.

I agree this lady's dentition and occlusion are a dog's breakfast, but you're surely not blaming the three implants for causing her anterior open bite? The fact of the matter is that in maxfac practice one sees an occasional patient who presents with a fairly recent onset of an AOB bite in middle life for no very clear reason. I don't have an answer, but I suggest it's a mistake to blame the bridgework - rubbish though it is.

This is tough. Not a problem I would like to inherit. I would be glad to refer this to a prosthodontist.

It looks like Eastern European dentistry. The implants may be failing but there is so much going elsewhere. Eg. #17, 18,24, 26, 27, 37. 48 ( Universal system). Overeruption could be caused by infection and could be at fault here too. This one is a doozie!!! refer to a prosths and get a 2nd opinion and get mentored on this one.The pain in the TMJ area could be referred from the molars involved..

Before condemnation of any dentists work is done one must understand what was present before the work was done and what was present when the work was completed. In my 30 years of GP I have seen people come in with open bites at a young age, a middle age and old age. Some have TMJ issues and some do not, which I find amazing. Bruxing and clenching are obvious factors in developing pain. Occlusion certainly is as well and such an open bite, as this is, if left untreated can have negative effects on the entire stomatognathic system. Some individuals I have seen developed an open bite which was not there before. Developing an open bite can occur from developing obesity. A fattening tongue may splay the teeth. A habit of biting on the tongue may do the same as may tongue thrusting. I have seen such situations corrected with orthodontics. I do have concerns about maintaining such corrections if the contributing factors remain. Of course there is TMJ treatment as well. You surgeons out there might even consider orthognathic surgery. If this person came to my office, I would contact the prior dentist and get his perspective on the patient, get any prior xrays and any models that could be seen or duplicated. This is no simple case and substantial consultation should take place. For immediate pain I would start with a simple appliance and any appropriate pain meds and/or sedatives. I suspect the appliance should initially disclude the posteriors and should not be in use long term. I hope this helps. Good luck

An appliance??? Are you serious?? What about all of the abscessed teeth? How is an appliance going to take care of these?? How about we take care of the of the acutely involved teeth before we get into occlusal therapy??

I agree with Dr. T. The first order of treatment is always phase I therapy, including proper diagnosis and treatment planning. From my view of this PAN there is not enough information to blame the splinting of the implants with the natural teeth for any of these problems. There are many causes of an anterior open bite, including joint pathologhy such as an osteochondroma. This is a tough case.

Respecting all opinions, to discuss this kind of clinical cases, we should have: 1st, More detailed clinical examination of this patient. 2nd. Clinical photos of the case. 3rd. CBVT and report findings, and we will see some surprises inside there. And after all that, we can comment about all this with more common sense. Regards to everybody from Spain.

CRS is right on. If an inexperienced doc is asking how to start with this case then refferal to a specialist is needed. Once a doc starts on a case like this he should be prepared to carry it through as it then becomes his case and he becomes responsible for the out come. Please procede with care and CYA.

The thing with a case that contradicts everything you are taught in residency is that it confirms your professors were really correct. I see a case like this and feel thankful I was blessed to be educated by the best. 3 pier abutments Rampant periodontal disease Probably uncontrolled diabetes Occlusal dysfunction Lawyers dream.

DrT, Yeah, sure you need to deal with all those infections let's not belabor the obvious. This is a complex case and the patient as I understand it is in acute pain. Those infected molars need to be discluded and the joint unloaded. Abs. and pain meds. are needed of course. I would not get into any irreversible treatment without a treatment plan in place and specialist consultations are needed to be safe. Those consults in most cases could take weeks. What better way than to make an inexpensive non invasive appliance? There is a product whose name escapes me now that can be made in office by hand and light cured to effect relief from posterior hyperfunction. I have used it twice and both times were successful.

Wow! What a mess. If you are comfortable doing it yourself, then start all over. Remove all the existing fixed prosthodontics and give the patient a partial(with adjusted occlusion) in the interim. Clean up all the perio,endo and restorative issues and then you may have a reasonable basis for rehabilitation. Otherwise, refer! Good luck!

Interesting case. I would do the following:1) Take a 3-d scan of the condyles and see what if anything is going on and full upper and lower casts mounted with an earbow.2) put patient on full time splint therapy in CR Dujour to relieve pain and discomfort. The splint has to be checked weekly and relined.3) Once the pain and discomfort are gone and you have a reproduceable CR position, a panographic tracing is done, program a fully adjustable articulator, and mount your casts. 4) Determine from the mountings how you are going to correct the occlusion. As you can see this case is complex and need to be in the hands of someone you has experience with above technique. Probably a prosthodontist but not necessarily so.

I think the condyles are WNL on the panorex perhaps a ceph to see if the apergnathia is skeletal vs dental. It may be difficult to get a CR with this occlusion perhaps getting the patient on provisionals first with caries and infection control first

An interesting and complex, difficult case, fully agreed with Dr O. Bye the way could the appliance be the NTI appliance (neuro trigeminal sensory inhibitor.) I will appreciate very much if what is meant by craniomandibular dysfunction in the above patient be clearified, thanks.. Is the severe pain on the right or left quadrant and upper or lower jaw or both. When does the pain start,.is it intermittent or persistent. Has heat or cold or chewing hard food any effect on the nature of pain. Is it painful at night . These details will help us to determine the pain is dental ,periodontal or other causes. Tooth 27 has deep and large cavity on the distal, 33 left lower molar has some radiolucency and 17 has loss of bone and probably be and abcess. Treat these teeth and relieve the pain and it will be easier to asses the anterior open bite. The implants looks fine from the xray, especially 46. After four years there appears to be no bone loss. Most likely it could be a one piece mini implant 2.8 or 3mm by 12mm. All the best.

I hate to keep "beating this horse", but one must take care of the obvious disease before going after intangible possibilities . Bvinci

The initial poster seemed to imply that the implants joined to teeth might have been aetiologic. Cannot see how these implants have caused the open anterior bite. Hard to diagnose from OPG (rubber xrays). Maybe there is Pagets or fibrous dysplasia. Regarding the implants- It may have been the case that they were not cemented to the bridgework - they only function as intermediate stress-broken abutments - I have used this from time to time with long span bridges. I agree with the other posters - refer.

Definition of Craniomandibular Dysfunction CMD is a systemic disease of the Craniomandibular Feed-Back-System, a disease of the muscles and nerves of the head-shoulder region. It is mainly caused by malpositioned and malinclined teeth with resulting dysfunction during masticatory activities and swallowing. (G. Risse)

I am certain that this will generate a spark, but........The above definition is very debatable. There is little science to support that the position of the teeth or jaws has any correlative with some of the conditions that our colleagues are "treating". It is hard to suggest that a full mouth reconstruction, ortho, orthognathic surgery or a splint can cure some of the these conditions. We have a lot to learn and until we have some good science, we need to stick to what we know. Bvinci

Unless his open bite was present preop ie. skeletal I think that the implants caused compression of the natural anterior teeth splinted to the fixed implants according to the panorex. One could start by correcting the occlusion, the supra erupted posterior teeth, isn't that what an open bite is, not the tmj's or paget's. sometimes one has to concede that basic implant treatment planning just was not followed and this was what resulted. Duh!

This case deserves a classic work up. Treat the Endo, perio and carries. The anterior FPD should be all implant supported ( not good to have implants between the teeth on a FPD). Bathe span for the lower left FPD is to long and it to would best be managed by an implant supported FPD. I am no way against connecting implants to natural teeth, but do it correctly. The prosthetics most likely should be re done to establish an idealized occlusion. I would first do the classic work up, Endo and perio and place them in provisional bridges and work on fine tuning the occlusion and TM pain, while in said provisionals. Baker, go back to the red paper back occlusion book by Hoffman and Reginos. It does lead into the explanation of some of the pain. I agree with you that other non dental issues can cause head and neck pain and definitely should be R/O or treated.

There is literature on implant and natural tooth bridge connections. They have found that there are instances where infraocclusion of the natural teeth will occur. There are something different theories on why this occurs. This patients anterior open bite may be related to this, also due the nrumours other pathologies occuring at this time.