Vertical bone loss and possible grinder: Is a third implant over-engineering this case?

No, there is no #15. Please tell me what HNG is?

HNG = Hard Night Guard.

Got it. Thank you!

Remember that due to the Bruxism a patient actually gets pretty dense bone due to the forces on the bone, many even develop exostosis. There is plenty of bone there, if it were me, I would place two implants tenting up 2-3mm of bone with particulate graft probably a membrane over the top bury them and allow to heal. Then expose don't splint, hygiene issue, I like Zimmers due to the flat screw, often the bone will grow over the top and need to be removed at uncovering. Now here is the key, a balanced occlusion, bite splint and stress reduction for the patient. I would placed Botox if the masseter muscles are hypertrophied depending on your comfort level refer for that. That way you are treating the problem directly not relying on splinted implants in dense bone to fix it. And you're welcome!

CRS: My current plan, provided the anatomy, to put 11.5mm TSV. Are you suggesting to put may be 13mm and do GBR. Pardon my ignorance on the subject of grafting, but what type of material would you elect for this? Would FDB work. DO you think additional 1.5 or so mm of implant height would make a difference in the outcome. Would the quality of the new bone around the coronal part of the implant be better than native cortical bone around coronal part of the implant in current scenario?

Agree with everything that you have said but I am having a problem understanding the need for the grafting given the cross sectional films demonstrating fairly ample available bone height and width. What do you see (that I am not) as far as the benefit from the additional graft procedure and additional risks associated with it. Just curious - Thanks!

What your missing is the bone height relative to the natural teeth,a better restoration can be planned. The crown won't be as long and will be easier to maintain. The graft would be replacing what was lost and it is a small amount of grafting to replace it. Remember that crestal bone loss will occur over time and fixing it at placement is best. Think like a regenerative surgeon not a dental technician. I see many of this deeply placed posterior implants with perio issues down the line. Dentists tend to look at the wrong place, it is about crestal height lost not the implant length and small corrections make a difference in the long run. And hopefully you understand occlusion and bruxism. Lastly make a scan appliance it needs to be done at the time of the scan not trying without to eyeball it with the implant software you will avoid problems in the future. Dentist tend to ignore the golden opportunity of placing the roots of your restorations in an ideal location based on the individual patient not implant software theses implants look a bit buccal but I can't tell since a scan appliance is not there. We learn this stuff in dental school implants don't change those principles but are an aid to what you already know. Your question demonstrates that you need to focus on the replacement of what was lost and future problems not the implant length; with implants the restorations come first that's the key. If you don't get appropriate grafting concepts the results are compromised and you will be scratching your head in the future, not best for the patient. I see a lot of cases where these steps are missed by dentists that are learning, this case is not easy for a novice since the right side molars will fail in the future based on the film. I always suggest performing within one's strengths and teaming with an experienced surgeon it is best for all and mitigates future problems. It puts the patient first. Thank you for your honest questions implants are not easy and we sometimes don't know what we don't know.

CRS, thank you. That's profound that you just wrote!!!

Thanks CRS - an excellent answer. Hard to argue that we need to treat to the ideal if the patient will allow us to do so. Unfortunately, not all patients will allow us that luxury and sometimes a couple of millimeters is just not enough of a difference for them to justify the added procedure and cost. P.S. The SimPlant software will allow one to import an optically scanned model which can (at times) be preferable to a scan appliance. This would also negate the need to rescan this patient and allow for what you suggest (which I totally agree with.) Typically, one would take a PVS quality impression of the arch and make two pours (master and working model.) The master is optically scanned, imported into the software and indexed to the original CBCT scan via the existing teeth. This then becomes a virtual model which is used for the fabrication of the surgical guide. A clinically acceptable wax-up is then done on the articulated working model and this is also scanned and imported into the software. Both scanned objects (both models) are visible in all sectional views and in the 3-D rendition to assist with an accurate planning. There are many advantageous to this technique but that is beyond the scope of the space available and the interest of most. You probably were aware of this but Mark D may not be familiar with this option. Personally, I prefer this approach to a scan appliance in most cases.

The Straumann transmucosal is an excellent idea to help with the crestal bone height issue. They are technically more difficult to place for a novice but are great in dense bone. I wish I had thought of it!

Very valuable, thank you so much, Reg O'Neill!

A lot of ways to over engineer a case and increasing the implant diameter (where you reasonably can) is one of the easiest. I know that Zimmer makes a 6.0 diameter in the TSV series and would think about that for the molar. Watch your peri-implant bone density go up in the SimPlant stats as you approach the cortical plates with a wider implant. I don't personally like second molar implants but have done them to disperse occlusal forces over more teeth. I also don't like splinting if for no other reason than it creates the usual hygiene issues - I always try to look for a better answer. Lastly, if your patient is truly a bruxer, you could "consider" Botox in the masseter muscles as one of several remedies to reduce occlusal loading. Best of luck!

OK, very good! I'm certainly considering at least 4.7X11.5. What do you think about increasing osseointegration time?

Increasing the osteointegration time beyond the manufacturers recommendation will probably not do you to much good from what I have read and seen. Progressive loading "after restoration" will increase the bone density around an implant but that won't do you much good if your patient is bruxing hard on the implant prosthetics from day one. One option is to initially place provisional restorations slightly out of occlusion to prevent bruxing on them for a period of time, but still allow for some functional masticatory loading. After a few months, these can be converted to traditional restorations. This can backfire if the patient won't tolerate the lack of occlusal contact - but since he is missing these teeth currently it has a good chance of working and might be worth considering. Another option, from a loading standpoint, is not to place two implants (bicuspid and molar) - place "three" implants spaced for bicuspid sized teeth and restore them individually. In effect you now have three implants supporting roughly the same occlusal table area as two with the single bi/molar scenario. Placing a bicuspid and "two" molars can do roughly the same thing. Unfortunately, the only way to take advantage of the additional second (posterior and unopposed) molar for loading support is to splint everything together. Again, splinting is something I personally try and stay away from if possible. Just some thoughts IMHO.

Yes, in the 90's it was commonplace for many to "oversize" implants which would cause the sequelae that you describe. That is different from "optimizing" the size of the implant for the existing anatomy. With existing CT imaging and software, one should not have to guess and use a sub-optimal diameter implant just to be safe. Why would that make any more sense than placing an extra implant just in case one fails which you criticize? Mark D has the CT, the software and the responsibility to determine what that optimal implant diameter is. Given the case description, why would it be wrong to maximize the implant diameter, loading tolerance and thus the ultimate success potential? I would feel that we need to learn from past mistakes and do things because they are reasonable, predictable and relatively safe. Larger diameter implants are, indeed, sometimes indicated. And yes, I do agree, the integrity of the buccal plate is paramount.

I know it looks drastic on CT but the right side is in relatively good shape. I think you see apico done on #30 that throws things off.

Melissa, your comment prompts me to think about getting more training.

SILENT NITE a snoring device (there are others also) that many dentists provide for patients that have a spouse that complains about the noise keeping them from sleep. It does work. Similar devices are available that are for sleep apnea. Be careful because sleep apnea is a medical condition that can kill. SILENT NITE is not specificly for sleep apnea and should not be sold as such. It does provide airway opening by positioning the lower jaw slightly anterior. It also serves as a night guard at the same time. If sleep apnea is suspected please refer if you are not trained to test for and treat this condition.

Richard help me out on this one, when I look at a case with a discerpancy in the crestal height is there a rule if thumb if how deep you can place an implant without added bone to correct the crest discrepancy with the natural tooth. I'm not talking about the implant length but the loss of crest when restoring the implant crown. I get the crown root ratio but I'm concerned about the hygiene and perio issues with the natural tooth. Am I stressing out about this seemingly minor amount of bone I add which I roll into my implant fee? I love it when I see bone almost covering my cover screw at uncovering and I know with some implants we get some dieback over time. What are your thoughts?

CRS, I'm not sure if I understand the question. There is no rule of thumb per say. Yes , implant/crown ratio is a factor! I look at the potential success of the bone grafting. Duration of treatment and cost. I know Hilt Tatum with his concepts of vital segmented osteotomies is changing treatment methods and goals. But this is catching on slowly. We do not always get patients with ideal conditions. If your considering placing the implant and then tenting ok. But grafted bone is not the same as real bone and bone has its epigenetic potential. I too am concerned with perio and hygiene issues. I am also concerned with phonetic issues. On some cases I do add a particulate (OsteoGen) atop the implant and a slurry of OsteoGen in the osteotomy prior to implant insertion. It's nice that you care about quality. I do too. As per the loss of stress when restoring the implant crown, I think its an implant design issue, some is occlusion, some is cement, some is due to the occlusal table width and cusp height and inclination. As a surgeon some issues are out of your control. They are influenced by the restoring doc. I perform both duties, so I am dogmatic about the occlusion and prosthetic design. You can perform great surgery, all to have it compromised by the restorative phase, not to mention the patient. I have a patient that bruxers like the dickens ( broke three bars, broke his overdenture numerous times, the same healing collar always backs out when his OD is in the lab for repair. He is an outlier. I recently sent him to an OMS for Botox. I have ruled out hyperocclusion. He has a most over active parafunction. He owns this! So we as Doctors have to accept that we can do out job as best as possible but the patient is going to do their thing. Don't be so hard on yourself.

Thanks for your insight and wise words, I appreciate your advice.

Garald, very valuable, thank you!

Yes, I see the teeth on Ct, i didn't see it before, sorry.