Fixed Bridge or Implants?

Hello everyone,
First I want to say that I’ve learned a lot about complex cases here on OsseoNews than in any textbook or journal of implants, so here is one for everyone, where I am sitting on the fence. Your opinions and suggestions are welcome, as we need to get into replacement options sooner than later.

I have a 55-year old male patient in excellent health but a smoker with severe bruxism and clenching.  In September 2010, He sustained a vertical fracture in #13 [maxillary left second premolar; 25] which I extracted atraumatically and placed Osteograf LD 150 for socket preservation. The fracture most likely was from his severe clenching habit, but patient will not admit to it. 

Cut to January 2013. Now #12 [maxillary left first premolar; 24] has fractured resulting in dislodgement of the DO resin and another vertical fracture with necrotic pulp.  The fracture may not go do far enough to render this tooth non-restorable.  I want to extract #12 and place implants in #12 and 13 sites with single crowns.  Sinus is low and I may have to do a sinus lift.  Patient has some ideas about his treatment plan.  First plan is to extract #12 and do a 4-unit bridge from #14 to 11  [maxillary left first molar to canine; 26-23].  Patient also wants me to try to save #12 first with a root canal.  If this can be done successfully, he wants me to run a bridge from #14 to 12. 

To summarize, all our options right now are:
1) Extract #12 (24) and do two implants at the same sitting, then two joined crowns in 4 months time. Note that there is only about 8-9mm bone height in the #13 (25) area due to the sinus floor, and if an immediate is planned in 24 area, I could go with a 13mm here, but going beyond the socket apex is not possible, due to sinus floor.
2) Extract #12 (24), no grafting then wait 4-5 weeks, then place two implants in the #12 (24) and #13 (25) area. Delayed immediate placement.
3) Complete RCT on #12 (24), then using #12 (24) as mesial abutment, make a three unit fixed bridge to replace #13 (25) as well as hold #12 (24) together. Non-surgical option.
4) Complete #12 (24) RCT, crown it. Implant only in #13 (25) area with a single crown on it.

How do you think we should treat this case? Which of these treatment options do you think would have the greatest chance of success?

Case images (click any image to enlarge)

Fractured 25 in Sep 2010. Tooth surgically removed in two halves, socket preservation done with HA particles [OSTEOGRAF LD-150 -Dentsply]

Fractured 25 in Sep 2010. Tooth surgically removed in two halves, socket preservation done with HA particles [OSTEOGRAF LD-150 -Dentsply]

Split down the root into two

Split down the root into two

In January 2013, Xray of pain over 24, and OD composite lost on distal.

In January 2013, Xray of pain over 24, and OD composite lost on distal.

Image of 24 as remaining occlusal composite came away very easily, complete debond failure, rare with my composites.

Image of 24 as remaining occlusal composite came away very easily, complete debond failure, rare with my composites.

Close-up of Tooth#24, after pulpectomy and before placing CaOH dressing. To keep this tooth or not?

Close-up of Tooth#24, after pulpectomy and before placing CaOH dressing. To keep this tooth or not?

17 thoughts on “Fixed Bridge or Implants?

  1. I would remove the fractured tooth, trying to hold it together usually doesn’t work, I’ve seen this often. Now for the big question how does one get the Bruxism under control. I think this is important for any type of restoration. The premolar areas with two individual 10-11.5 mm length implants non- splinted crowns with an internal sinus bump (crestal lift) should work. I would hesitate to cut down the molar, a virgin tooth and splinting a bridge to a fractured tooth premolar is risky. When it fails you lose the whole bridge. If an individual implant fails it doesn’t affect the molar. What’s causing the clenching? I’d get this guy in a soft splint possibly some physical therapy(Tmj familiar practioner) while the implants are integrating. Check overall occlusion, balanced etc. This is tough since the patient is telling you what to do and he could destroy any work done so you need his buy-in.Most patient’s understand that clenching can cause tooth fractures, is there a financial or insurance reason why the patient wants to save the premolar. I have placed implants in bruxers with success if the occlusion is well balanced and a niteguard is used. I use proper consents and not guarantee anything. I just think trying to hang a bridge on a compromised tooth is asking for trouble.

  2. Exactly CRS , said it all perfectly and yes no splinting , stress levels have been up a notch over the last few years
    Peter

  3. Great advice so far. In addition to the bruxism guard, some analysis of the occlusal force directions would reduce breakage.

    Are the lower cusps forcing the B-P cusps apart by contact shape and hitting before bottoming out? He does not seem to show a lot of flat wear, but many microcracks are visible, indicative of clenching. So I’d advise re shaping the occlusal contacts, relieving B and L interferences, and an even centric stop to reduce the splitting forces.

    John

  4. I’d say extract and place 2 implants as well. As CRS said above, perform an internal sinus lift here where needed, if needed. As we all know, sometimes you get surprised when you clinically get in and you’re not where you thought you might be, aka, the sinus. If you haven’t done an internal sinus lift and have interest, honestly, they’re not difficult. You just have to get over perforating the sinus floor and perhaps sinus lining as well. Many of us have spent the majority of our careers avoiding the sinus as all costs so to perf it on purpose runs contrary to out very professional being! But do it. Make sure you are actually IN the sinus by holding the patient’s nose and having them blow. If you’re where you want to be and there are no air bubbles or noise, then just place the implant(s). If you do have one or both of those signs, place a collagen/bone graft sandwhich ahead of the implant (graft material (ideally the patient’s own collected bone) – collagen plug segment – graft material) and place the implant as you normally would. Give a round of antibiotic and things should progress nicely.

  5. All comments are right on. Let me add some things. The last thing I want to do after 41 years of practice is rely on a bicuspid with a RCT and post to support a 3-unit bridge on a bruxer. Even in a non-bruxing patient I don’t like the figure-8 root form of bicuspids. The chances of long term success are lower. The ideal situation by far would be two implants to replace #12,13. I would screw retain splinted crowns with a narrower occlusal table than usual and flatter triangular ridges. There needs to be no working or non-working interferences on the implant crowns. Cementing the crowns pretty much eliminates the possibility of any repairs. Screw retaining would allow removal in the likely event of porcelain fracture.
    I have a different take on some opinions above with respect to splinting. Splinting was the norm years ago as discussed at length by Misch. And as far as nightguards, yes advised, but remember that bruxing or clenching is a CNS phenomenon and the best we as dentists can do is to create an environment where the CNS does not win out over our dentistry. I have yet to see a study on patient compliance with nightguards, but I suspect it is low. One very old study showed that there was only a 75% compliance with patients taking meds that were required to live. 5-6% of patients floss according to perio dept. at USC. So I’d rather rely on well planned and constructed dentistry than nightguards.

  6. I am an NTI advocate. I have found a high compliance among my patients. A mandibular deprogrammer could work wonders. (there are many reasons NOT to use one as well)
    In cases without TMD, noticible clicks, etc, a hard full coverage guard is quite thin and easy to comply with.
    Refuse to treat unless patient gets a guard and complies. You’ll be suprised how much that conveys to a patient your adamant belief in a their parafunctional habit and the damage its doing.

    • I have made traditional brux guards forever and I have definitely found that many of my patients cannot accommodate to the bulk of these appliances. I would like to get into using NTI appliances. Can you refer me to a good link that can help me learn some of the specifics of the technic and/or do you have any other information on these appliances that would be helpful to a neophyte such as I am. Thank you.
      DrT

  7. In my practice, smoking is a contraindication for implants, especially in bruxers. If he won’t quit, smoking and he wants to retain #12, even given the very guarded to poor prognosis, you could double-abut a bridge anteriorally #11,12-14 and cut the root of #12 out surgically in the future when it fails. This patient is lucky to have #15, 16 to share the occlusal load as well. You can place implants in the future when he takes better care of himself!

    By the way, tooth #14 does have a composite, it isn’t a virgin tooth. I wouldn’t feel bad about crowning it since he will probably break it too and a crown my stall that from happening.

    I’m not against implants, but the only ones I have lost in my practice were in smokers who bruxed!

  8. As already mentioned , all your collegues are offering good advise.
    Some interesting points to note are that if the patient is able to brux and break his natural teeth which had no restorations in them, then you can be sure the bone in his maxilla is definately not balsa wood or pine quality….it is probably more like oak, and implants would work well.
    I try to discourage smokers from opting for implants, but people do quit smoking, and quite frankly there are many people walking around with perfectly healthy implant situations who were not truthful with their dentist and do smoke……but in the consent form, they take full responsibility if they are going to smoke.
    There is adequate space between the crest of the ridge and the floor of the sinus to place 13mm implants, by gently lifting the Schneiderian membrane ( if required) and using the Summer’s Technique using osseotomes when the floor of the sinus is approached….do a pressure test as suggested above.
    Recent articles have been published, and lectures are given, that bruxism can be greatly controlled or eliminated by using Botox injections into the masseter muscles bilaterally to reduce the forces applied to the teeth…..look into it, and you will have more control of the patient, because these injections have to be repeated with some frequency.
    If the crown and bridge options are seriously considered, there exists the possibility of broken joints and fractured porcelain by the excessive occlusal forces.
    If implants will be used, it is always better to splint them together to stabilize the antirotational forces, and avoid screw fractures that are more likely to occur on single units.
    Gerald Rudick dds Montreal

    • Dr. Rudick,
      Thank you for the information! Who does these Botox injections clinically at this time? Do you know if Botox has been approved for this use? If it works, without causing any facial dysharmony, or interference chewing hard foods, that would be amazing.

      I think most of the practitioners I know, including me, are bruxers and wish we weren’t!
      You are right about the use of consent forms as well and informed consent is the key.
      Thanks again!

      • The problem is you need a lot of units of Botox in the massester given fairly often every4-6months to atrophy the muscles. If the patient has money to burn if may help but it is more practical to get to the cause of the Bruxism and correct it. Botox has many applications in treatment of muscle hyperactivity I have heard good things about NTI appliances also. I think the treatment needs to be multi, stress relief, education, physical therapy, and dental, which we are trained in.

  9. Hi, why it is #? Wt is the condition of other dentition same as well as contra lateral Side? Have u evaluated crackes, abfractions, loss or assessment of vertical dimension, occlusal interferences in all the movements of jaw. Placing implant is not going to be any issue. If this case is a case of full mouth rehabilitation that should be ruled out before loading the implants. Rest I’m convinced with crs.

  10. Hello
    You got very good advices from all the good practitioners.
    I would just like to advice you to give the patient a nightguard or a TMJ appliance for few weeks before doing anything so that patient is adapted to the nightguard for future use after treatment.
    Implants should be splinted and also free from occlusion.
    Also try to balance the occlusion from both the sides if they do have any deformities.

  11. Good planning approach and great advice, but I doubt that these teeth were broken because of bruxism, which itself might take place. I would insert two implants and splint them with crowns, eliminating from occlusion 0.5-1mm. So, night guide is not necessary.

  12. Please please please never bridge virgin teeth. Why destroy a perfectly healthy tooth? If the patient declines an implant, use a removable appliance. Don’t cut healthy teeth.

  13. My practice is exclusive to patients over 50. we see this all of the time. this patients occlusion is setting up stress concentrations through engramming. full mouth occlusal analysis and correction will be key to long term health. also, if he is smoking, is there additional information? maxillary implants will be suspect if he is >1ppd. what does he do in his diet and supplements to counteract the effects?
    first in foremost in our planning is to make it clear that ONLY dental implants can strengthen a mouth. i have seen these bridges placed and last only a year or two! you will own this problem if you dont refuse to do it ‘underengineered”!
    I would recommend (after above considerations) the following:
    remove 12, place a bicon implant (probably 4x8mm) and place a bicon in the position of #13, either 4×8 or 4×5 depending on specific measurements. bury them for 3 months minimum, then load singly, you do not need splinting as Wolff’s law will increase the bone density after loading on these implants. proper bite timing will load them at terminal intercuspation of the natural teeth. this will strengthen his bite without sinus lifting. the Bicon shelf design encourages maximum non-woven bone interfacing under load (see Bicon.com), the swedge-fit abutments are super strong in vertical loading, and there is no screw to break under load as in standard two stage implants.
    Good Luck!

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