Thoughts on Retaining Patients Own Teeth

I'm curious why is the premolars implant so close to the natural tooth and why aren't the implants parallel to each other? Did you plan it that way or use a surgical stent? The molar crown does not appear to be along the long axis of the implant. Since I don't restore and I like to use a surgical stent keeping the implants as parallel as possible I ' m not sure if my protocol is correct. I do see improvement in the medial bone and I know that X-rays can be deceiving. Was there difficulty in the amount of patient's mouth opening causing the implant to be tipped? Any other constraints since seeing the pilot in that position I would have changed the angle, was the first implant already placed so it could not be lined up? In multiple implants with a stent I drill my pilots at all sites and try to line them up. Thanks.

Hi CRS , the anterior Implant was placed into the socket and grafted similtanouesly and the distal Implant was angled to optimise the bone to the floor of the sinus ( seen at the topof the x-ray ) . As I said the initial x-ray was only a pilot x-ray to check this angulation hence not ideal . Yes ageed the initial Brannemark protocol was always parallel implants in the early 80s but we developed a system of angled abutments ( using these Intoss Implants ) in 1987 and have seen many positive results since then . Agreed x-rays in this area can be difficult and misleading due to the shape of the roof of the mouth especially in some patients . Just showing the ability of the body to heal when the circumstances are improved . Happy X-mas Peter

We should preserve as many of patients' teeth as possible within reason. Dental implants can do wonderful things when they take the load of natural teeth. The natural teeth strengthens and even bone can grow back!

Are they Dio implants ? Nice case however i wouldnt be that happy with the mesial fit. It fits but there is ledge which could push teh boat towards periimplantitis in teh futre. Probably the lack of accuracy on teh lab tech but could also be a ngulation of radiograph. In these circumstances i always undo teh bridgework and remove ledge and convert back to screw retained even if buccal. Tidy access up sandblast, hf acid , silane , bond composite . Or alternatively use a multidirection abutment thus making it screw retained. I wouldnt be too worried about the angulation. just make sure its guided by teeth and on infraocclsion contact is light-you will know that!!!

For decades we intentionally angled two implants in the bi/molar area for greater stability in three unit bridges with great success. While this may not carry over to all designs, and may be more difficult to restore, the history shows reliable stability. I have patients who had this done over 30 years ago and still have the original abutments and bridges in fine function today. The first critique I hear from the young periodontist is them telling my patients these old implants should have been parallel. Since I now primarily aim for individual restorability, I keep the implants within about 6 degrees, but think one should be aware than non-parallel installation is not necessarily a bad thing if it was carefully planned and not an accident.

Also, as mentioned, it is better to use an available socket with Buccal bone, than to have a parallel bi needing bone grafting. As to keeping periodontally loose teeth, I have several cases with inadequate posterior support where only two or three implants, e.g. Central, Cuspid, and molar provided enough support that the rest of the teeth recovered, grew strong bone and tightened up. So, as long as they are placed to allow more options later, placing implants in the place of the worst perio challenged teeth and evaluating can be fruitful.

Although the parallelism is not ideal, the bicuspid implant in the upper radiograph clearly shows that the implant is not impinging on the natural tooth. In the lower radiograph, there appears to be a fracture line going through the mesial natural tooth that now has a crown on it....but adjacent to this tooth is another implant......which seems more parallel to the other implants .......so this should work well if there is in fact a fractured tooth. Dr. Gerald Rudick Montreal, Canada

I definitely agree with your intention of trying to retain patients' natural dentition wherever possible. I do not think the case that you are showing is a good example to try to give this goal validation as sequential PAX taken at different angles are of little if any diagnostic value. It would also have been informative if you could have included x-rays of the other maxillary anterior teeth.

Yuup, Perio tx. does work! This patient is much better off, with the natural dentition mixed in with the implants, in my opinion . Bvinci

Keeping the teeth and instilling improved oral hygiene. The simplest form of Perio treatment is education. Grafting the extraction site upon placement of the implant, not only provides bone for the new fixture, but it also improves the bony architecture of the retained dentition. You do not always have to do "FLAP SURGERY ". A simple deep cleaning and patient compliance will regenerate bone. Bvinci

Hi Gerald , no issues from the patient on that premolar , may be x-ray issue ,but will have another look when he comes in again. As to perio treatment as you know when patients have spent a bit most become more aware of oral hygiene. Alas not all and sometimes cases come back a few years later with calculus everywhere which is dispiriting . One patient despite being routinely told felt that as they were not "real " teeth he did not need to clean them . And such is our chosen job... Peter

Excellent results. This case I feel will stand the test of time. I specially like the idea of placing implants at reasonable angle wherever the bone permits go for parallelism but not a must. The reason why there are angulated abutments speaks for itself. Fully agreed I do have cases like these that have function and still functioning for 15yrs . Thanks for showing cases like these. As for the bone growth I can testify to it. Syabas and a happy and prosperous New Year and may you have a wonderful and joyful implant experience and journey.

Hi Mike usual delayed 2 or 3 weeks for a bit of soft tissue closure . Hope you are well. Peter

Thank you Peter for just showing the ability of the body to heal when the circumstances are improved. We often give the human body far less credit than it deserves.Dennis Tarnow in the link below said, "This case report provides clinical and histologic proof that the immediate placement of implants into extraction sockets with an intact buccal wall allows healing and osseointegration despite a large gap distance and without primary flap closure, a bone graft, or a barrier membrane. (Int J Periodontics Restorative Dent 2011;31:515–521.)" My observation is that alveolar bone will grow back with direct stimulation by an implant even against granulation and epithelial tissue. Check this case:-

Hi Dr Chow , yes it is very encouraging to see some of the positive directions that bone regenration is going in and I will read that article . I have seen some research using a syncotron CT where we can shoot "through " the Implant to achieve a very high resolution scan of the surrounding bone and the increased density of the bone adjacent to the Implant is marked . It will be published soon and should help dispel the old comcepts of restoring the bone and then placing an Implant into the site. The Implant is the best graft itself and there is a number of surfaces and new surface concepts to further improve this effect on the adjacent new bone which comined with earlier loading principles with earlier fucntional re-modelling are showing some interestings outcomes. With over 1,300 grafts ( membrane free and autogenous free ) when the Implant is always placed even with only 1 or 2 threads in the bone have shown the benefits to me. Happy X-mas Peter

Peter, read what Tarnow said and also look at the before and after xrays of my patient. Just click my name. It may blow your mind. Joyful Christmas and a Prosperous New Year!

In many previous postings regarding implants placed close to the roots of adjacent teeth, the recommendations have overwhelmingly advised removing of the implant, grafting the socket and replacing the implant at a proper angle. Perhaps we sometimes jump a bit quickly to judgement. This case demonstrates the resiliency of the body to heal in spite of our little misadventures. So, put that trephine back in the drawer and wait a bit before getting aggressive.

Had a look Dr Chow you do some adventutous work with minis and great results , in 2011 I did a lecture on "the Body wants to Heal lets help it ! " and your cases show that . Dr Leal I use a number of products but they are not important it is more the techniques that have been developed . I use some orthopedic materials , Easygraft and Bond Bone with Adbone . Dr D I agree but tgis case was placed in a socket after 2 weeks of healing with minimal osteotomy and pri-implant grafting with BTcp and CaSo4 mixed . Regards Peter PS So the world is to end tomorrow ? , may as well take the day off and go fishing.

this patiet will be back for more implant treatment in the future hopefully you won't have to remove existing implant crowns because if you do you'll have a potential upset patient.. the angulation is of no concern to me, that bridge can be there for years to come..and xrays can be deceiving

Dear Peter. Adventurous in a way, but basically pushing the limits of what we know and understand. Ever since Professor Cochrane, evidence based medicine is the catchword nowadays, spoken as if one is totally logically scientific. Actually, EBM is but a mix of some inconclusive scientific studies, clinical experience and individual subjectivity.... otherwise known as "a hunch". But no, no, no. We must appear totally scientific which none of the best "scientists" are in fact. So, unless we humbly push the limits, which our predecessors unapologetically did so to our benefit... of course without endangering life.... we will not make much progress. The world has not ended.... so play on! May the coming year bring us a little bit more mercy and enlightenment!