Failed Bridge with Bone Loss Case: How Would You Place the Implants?

Dr. M asks:

This 40 year old patient (see case photo below) has a failed bridge extending from the maxillary left second premolar to the maxillary left canine as well as a single crown on the maxillary left lateral incisor. Although a chronic periodontal infection related to the canine and lateral incisor (grade II mobility) has resulted in moderate bone loss and a crater-like bone defect, the overlying soft tissue appears clinically in level with the gums around adjacent teeth and a CBCT showed it was about 6 mm thick over the alveolar crest. My plan is to have the canine and lateral incisor extracted to avoid more bone loss, the second premolar endodontically treated, and 3 implants placed in the edentulous area. Regarding this degree of vertical bone loss, would you consider placing the implants like 2 mm supra-crestal together with vertical ridge augmentation using a Titanium reinforced membrane to avoid having long crowns (but I am afraid of the deep pockets that would res ult around the abutments!!) ? Or would you place the implants in level with the available bone and depend on the good vertical position of the gums to give you nice looking restorations?

8 thoughts on “Failed Bridge with Bone Loss Case: How Would You Place the Implants?

  1. On the Opg the canine and lateral look to be viable-I’d fight to keep these teeth. I think you may have an occlusal issue considering the pattern of bone loss. I would consider splint therapy and some sort of regenerative periodintal therapy for these teeth and see what happens in the medium term. If that doesn’t work, do orthodontic xla to bring the bone down and buccal augmentation at the time of xla.

    the 15 looks to have a break at the gingival level, if this is the case I would consider xla, but that might just be artifact. It looks like you have a retained root in the 14 area but shouldn’t be a problem. If you can keep the adjacent teeth then the vertical loss should not be so much of a problem and could probably be delt with using vital at placement and a ctg at uncovering.
    phasing becomes a real problem if you extract the 12 and 13, so I’d save the teeth and place one implant if poss – you can always do the others later.

  2. I assume you plan on extracting and placing immediate implants and graft from the way you posted. I would break up the procedures. I would extract the 3 teeth. Put pt on antibiotics, wait 3 days to do ridge augmentation. Then reeval in 4-6 months. It will be easier to manage the case and the patient if you defer the implants until after you have your ridge set up. Dealing with failing implants from chronic perio infection or a bone graft that did not take and bone loss down to 1st or 2nd thread will be no fun. Too many things going on to do it all at once. You may have less soft tissue thickness after remodeling. You’ll get a better esthetic result using 2 implants(#10 and #12) with a pontic in between vs. 3 implants. You’re most likely going to have long teeth regardless of what you try with the degree of bone loss present. Just use as long of an implant as possible for good initial stability and to handle the load of 3 teeth on 2 implants.

  3. There are several considerations in a case like this. But with the small amount of info given I would say… First endo of the premolar, then removal of the bridge and individual temps(4-6-7), ortho extrution of the canine and lateral incisor(temp of 5 in the arch wire). After adequate time, eval of the incisor(most of time they get better and if so keep it, if not keep it for a while) canine extraction implant placement in 5 and 6 with gbr(fast overturn) and soft tissue graft(palatal soft tissue). After implants are ready, implant connection (second stage surgery with buccal displacement of the gingiva to gain some extra width)if you are keeping the lateral good if not, extract and site preservation with bone packing(slow overturn) and free gingival graft(preferably from the tuberosity)after healing final impressions and crowns in 4(individual),5 and 6 with ovate pontic on 7(or crown if you kept it),
    not so simple but straight forward.
    Best wishes
    Dr. Berg

  4. Would probably treat similar to Dr. Berg except without photos of the smile line etc. I don’t know if I would put the pt through the soft tissue grafting. If you do the extrusion and hard tissue aug and release enough for primary closure, you may have enough tissue there without it. It’s a nice case – best of luck.

    Ryan

  5. I agree with Dan P. I wouldn’t think of keeping the cuspid and lateral for bridge abutments. I would treat the 2nd bicuspid intending to restore with a new crown. Extract the root tip, cuspid, and lateral and augment sockets and ridge(#14) if needed. Later place implants #14 and 12 for a fixed implant supported bridge.

  6. To the Editors:
    Recently I posted a question regarding the placement of an implant in very dense bone. I erroneously wrote that the implant was being placed in the area of #19. It should have read, “in the space of congenitally missing TOOTH #20; NOT #19.” Please correct that before posting if possible. Thank you so much! It won’t make sense otherwise as there is no primary tooth
    in the first molar site.

  7. Dr. M,
    It looks like your patient has perio issues, #’s 1,2,3,5,6,7 & 10. Is that decay on #3, or 18 & 19? Hard to tell on panos. Are there apical lesions on 5 and or 6?
    Do you know what his “financial tolerance” is? You’ve probably looked at all this, but if not these issues may change your approach.

    Assuming you have considered all that, both sequence wise and money wise, let’s talk about 10,11,12 areas. Ortho extrusion isn’t a bad option, it looks like you may need some grafting in addition. I think I would extract 10 &11, and the root tip, then place 3 long small diameter implants centered on ridge in both ext sockets and in 12 area. Have a pre-made temp bridge ready. You can use your idea of placing the implants supra-crestal and tenting a membrane. I’d use tacks too. If you can use the 2.0 x 18 MDL one piece implants, that will leave a lot of area for vascularization of the new bone. They have crown abutments that fit over the top, 15 degree if you need it. Obviously you wont let the temp bridge on these minis function. Tell the patient that his gums may look worse, and that there is a good chance we will not be able to keep them where they are now. About 5 mm from the top of a papilla to the height of bone is usually the best you can hope for, you may get less. Don’t promise a fixed solution. He does have gum disease and may lose some other teeth that can be added to a implant retained partial. If he does have other dental work and money is a consideration, a removable will be more cost effective and will look better if you can’t maintain the gingiva. After 6 months you can see what you have. If you do get good healing and adequate tissue, I would place implant in the 5 and 6 spots cantilevering 7 off. Generally best to avoid cantilevers but laterals are often an exception. If you wind up not using a temp bridge for 10,11,12, use an Essix not a temp denture. Looks fun, good luck.

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