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Treatment planning this difficult implant case: any ideas?

This landed in my lap on Thursday, patient is seeking a better smile and wanted the missing teeth filled in somehow. He is from Riyadh, Saudia Arabia, where the implant in question was placed almost three years ago. I have sent him for an endodontic consult first on the premolar and molar on both sides, but especially here to see what course of action we may take. The patient tells me that the space was larger three years ago and has been slowly closing up. We immediately extracted the retained roots on the palatal and grafted with CaSO4 and RCT to follow on the first molar in that area as well.
My concern is treatment planning this case. The Nobel implant is in very close proximity to the canine and the premolar has drifted to about up against the implant making restoration very difficult, certainly not a fixture level impression?!?!?
Any ideas I would love to hear them thank you.


Periapical radiograph of canine showing superimposed implantPeriapical radiograph of canine showing superimposed implant
Periapical radiograph showing implant and adjacent teethPeriapical radiograph showing implant and adjacent teeth
![Mirror shot of the palate intial pic]https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/10/IMG_5233-e1382473010555.jpg)Mirror shot of the palate intial pic
Front shot with teeth apartFront shot with teeth apart
Side shot of mouth closedSide shot of mouth closed

16 Comments on Treatment planning this difficult implant case: any ideas?

New comments are currently closed for this post.
CRS
10/22/2013
Resin bonded bridge and tell the patient that the implant will preserve the bone. Otherwise do nothing it is cleansable and doesn't look that bad. Anything else to create space involves extracting the premolar.
domis
10/23/2013
That's a good suggestion and most conservative!
Cliff Leachman
10/23/2013
Thought I might crown the premolar and fit a pontic and bond it to the canine. That way I could gain a little room for the pontic. Definitely the least invasive using the Maryland, thanx for the suggestion
naser
10/26/2013
crown the 2nd.premolar and the molar on the same side install the implant using 15 degree abutment
CRS
10/26/2013
Just a note, with the two periapicals the shifted shot shows the the implant is palatal probably like the opposite root. Perhaps that is how they do things in Arabia! But beware I'd you open this thing up it will be a hygiene problem and the adjacent teeth will be compromised. I really don't get the 15degree thing unless you are ridge lapping the crown, go with your first option! In the long run it is best, crowning the premolar is a great idea, this is really an esthetic issue. Good luck!
Steven Hai Qing
10/26/2013
For better treatment planning, you might want to take an implant level impression to really see if the implant can be savaged. Right now with customized abutment, with possible crown/extraction of # 4 and 3, the implant might be useful. Otherwise, as already been said, bury it to maintain bone.
Cliff LeachmanL
10/29/2013
Thought about the fixture level impression, but how do you take it with the proximity of the premolar? Also it seems palatally positioned making it near useless=,except as a space maintainer???
michaelwjohnson dds, ms
10/29/2013
If molar is questionable how about extracting the molar, distalizing the premolar to open the space then place another implant #3 position but it would actually be more of a premolar by the time #4 is distalized?
michaelwjohnson dds, ms
10/29/2013
PS, #4 not so hot looking. If #5 implant is usable remove both 3 and 4 and make a little 3 unit FPD on implants 3 and 5
Ben Manzoor
10/29/2013
The only point I will make at times PA is deceptive in premolar and canine area in terms of space it shows or the proximity. Its no denying that angle is not ideal. However, I would measure the clinical space and compare that to radiographic measurement. There is a good chance clinical space is wider then what you see on PA. I would do an informed consent and open the implant for stage 2. At the same time patient will benefit from 2nd premolar crown as it is a post and core. If you think that impression pickup can be inserted if 2nd premolar is prepared for crown i will be tempted to do that. However, consent is important in this case in my opinion. If agree to non then taking CBCT with modern machine such as Vatech or accuitomo which can reduce the metal artifact . This will help you to assess the implant position.
CRS
10/29/2013
Get out your implant shoehorn and try to place the healing abutment! You'll end the argument. Then pretty please just restore it with resin bonded bridge with or without a crown on the premolar and let's move on. I 'll bet you a coke this will work God bless!
Richard Hughes, DDS, FAAI
10/29/2013
The first thing I would do is sanitize the mouth and treat the salvageable teeth with good old fashion restorative dentistry. See how the patient responds and maintains the newly partially rehabilitated mouth. If they do a good job then move on.
Dr Bob
10/30/2013
Both the molar and the bicuspid would benefit with crowns. Splint and do a pontic to replace the 1st bicuspid. Let the implant sleep in place. First diagnostic wax up to be sure that it will look OK. This patient needs other treatment as well.
Cliff Leachman
10/30/2013
All comments are much appreciated! Px certainly needs a full rehab, but his interest is in the missing Maxilary teeth and smiling. Funny that the surgeon left the rotting palatal premolar roots to place an implant in the premolar site. I really like the resin bonded bridge or cantilevered pontic off the molar premolar. Happy to hear very few wanted to restore the implant, I think its going to be Rip van Winkled!
KGhia
10/30/2013
How reliable are the the cantilever first premolars as a pontic? I have seen three or so of my old partner fail. I don't if it was due to occlusal mismanagement or some other factors? Any thoughts?
Dr Hillel Baruch
10/30/2013
I would use orthodontics to move the pee molar and molars distally. You can use the implant to push the teeth .Make sure the first molar is restorable.
triangle of bone concept utilizing cbcttreatment planning implant placement narrow mesiodistal space

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