Best Treatment Plan for 3-Unit Implant Supported Fixed Partial Denture?

Do the sinus-lift first achieve good bone height wait for 4-6 months ideally.. or u can also place implants immedietly after sinus lift but in this case i recommend to wait n watch for good prognosis... Always try to consider placing free standing implants and free standing single crowns ideally.. but depending upon occlusal & other factors u can also go for 2 implants and 3 unit bridge. All the best

I would concur with Dr. Habib. I would just add that you can mix some bovine in with Encore bone graft material that works well to preserve the height. Repair any perforations in the sinus membrane with a resorbable collagen membrane.

Dr Carl Misch who is a pioneer in implant dentistry, strongly recommends splinting implants together. The literature also supports this. In this case, since you are dealing with weak and insufficient bone in the maxillary posterior, I suggest you place three implants and splint them all.

Dr. Zaghi makes a great point. From the xrays, I would question why a 36 yo in today's society is missing so many teeth? May there be some undue wear in the occlusal surfaces? History of tooth breakage, paarafunction etc. If so then 3 implants isthe answer. As Dr. Misch would say iiiiiiiiiiiiiiiiiiiif you think you need "X"............... put "X+1"

I agree with Dr Zaghi. Do the sinus graft and delay implant placement for 4-6 months. Then splint implants together for the best biomechanical support.

you need to graft the site before implant placement because you will not get good initial stability at the distal site since the bone is so thin. To splint or not to splint, that is the question. I would splint to allow the occlusal loads to be transmitted better. You can place 3 implants that are at least 3mm apart. There is lots of room for most combination of size implants, say 2 4mm and 1 5mm implant. There is a possibility that you may need some lateral bone grafting (Bone block?) that can be done when you augment the sinus. Do not place the implants at the augmentation appt.

Since this will be placing implants into low density bone after the sinus graft heals then would strongly recommend 3 implants and splint them when restored. Also would agree with the comments about doing the sinus graft then allow to heal 5-6 months before placing implants as there is insufficient bone to get initial stabilization of the implants at time of grafting due to thin crestal bone thickness

First, I am a bit surprised by the question. Tx planning is key to succes. If you know how to do a sinust lift, you should know how many implants you need, and at what distance to place them. I also follow Misch criteria. Place as many implants you can. Patient is very young, so place 3 implants. Are you planing to replace the 2nd lower molar ? If yes, maybe you need 4 implants in the upper, just another option.

Dr. Gerald Rudick, Montreal, Canada We have some information as far as the height of the available bone, but we do not know how wide the ridge is, and therefore have no idea of what diameter implants to use; or the quality of the exisitng bone. If the ridge is wide, then it would be possible to place shorter implants into the #24 & #25 area; and a tilted longer implant into the tuborosity region. From the panorex, we see that the single lower molar has already began to extrude because it does not have an antagonist. For #24 area a 10mm tapered implant could be used because there is more than 12mm of available bone; for #25 area since there is 5.8mm from the crest of the ridge to the floor of the sinus, it would be simple to start the osteotomy by drilling to a depth of 5mm; and then with osteotomes, greenstick fracture the floor of the sinus and insert PRF (Platelet Rich Fibrin) as a membrane, or a collagen membrane to protect the Schneiderian membrane before pushing in the grafting material ( hopefully prepared with PRP); which will be followed by a 10mm tapered implant of adequate diameter for the ridge. A 13-15 mm tapered implant of proper diameter could be drilled on a mesial tilt to take advantage of the bone in the tuberosity. I would reccomend waiting 4 -6 months before loading, and a transmucosal abutment (TMA ) could be used to correct the angulation of the tilted implant and prosthetic abutments could then be placed; and a temporary 4 unit bridge made, with a pontic over the area with the least amount of available bone. At a later date, when function is restored with the temporary plastic bridge, a sinus lift could then be attempted to generate bone for #26; and possible future implant in that area. Realistically, sinus grafting does not always give us the optimal amount of bone needed to place an implantin the sinus ...but by placing three implants as suggested, will give the possibility of converting the temporary prosthesis to a four unit definitive ceramo-metal bridge should the graft not be successful. Judging by the depth of the restoration on #36, gives us some indication that this 36 year old male, may have been a very neglectful dental patient and we do not know if he is a smoker...where grafting may not be indicated. The ADIN DENTAL IMPLANT Company carries a full range of products at reasonable prices to get this case underway. I would reccomend that the implants should be splinted together for better stability.

These teeth are not missing because of para function, I can almost assure you of this. Therefore suggesting second molar rehab., is contraindicated in my opinion. Graft success, in my hands is better, with implants acting as a scaffold. A wide body implant can have quite a bit of initial stability, with less than 5mm of bone, if the osteotomy is slightly underprepared . I would plan on placing three fixtures and if the third one is not going to be stable, then graft it and come back. You will at least have two good implants and a more predictable site for the third one. OH has been an issue for this fellow. I would discourage splinting. Another consideration would be two wide diameter implants. Bv

I'm a little perplexed at the previous comment. Why is second molar replacement contraindicated if no parafunction? If you are going to do a sinus lift then why don't you restore it adequately following the lift? Second molar occlusion is fundamental to normal occlusion and if we can restore to second molar occlusion we should do so. My advice is to do a sinus lift and restore as nature originally intended, which will mean placing an implant in the lower second molar region as well.

I think we need much more info on this case. Can we get a full mouth panorex ? About the second molar option, at 36 y.o., in my mouth, I would like to try to get 2 molars in all four corners. Why limit it to only one molar for the next 40 years of function ? Will the occlusion be stable for that long with only one molar ? In this kind of implant case, we need to ask this question, we are not planing for the next 5 years.

With this question, I'm not sure you should be doing the case. If you do, you got to do the sinus lift and wait at least 5 months. What do you gain in placing the implants sooner? Five months? Hardly worth the risk versus the time savings. You can't do 2 implants and a 3 unit bridge, if one implants fails at any time, and it probably will with only 2 implants, the case will fail. You need at least 3, I'd place 4, even if I had to give one away for free. Don't even consider NOT splinting. Again, if you don't splint and one fails, what then? Throw the other crowns away and pay for a 3 unit bridge? Besides, you don't want the implants to be exactly parallel, but at slight angles to absorb the occlusal load, look at the roots of a natural tooth. Also, what's the occlusion on the other side? If it's natural teeth, be really careful in the final occlusal adjustment. If both sides are balanced, upon hard biting, the implants will be end up being overloaded due to the natural mobility of the teeth.

I have to agree with the above comment! Splinting makes little sense. One fails and all other impants are comprimised . Three or even four(???) splinted fixtures will be very difficult to clean. Bv

Three good posts BV ,said it all ,whilst Carl may state that I too have seen many splinted case showing excessive bone loss on one due to co-axialforces possibly and as BV said then there are issues. Best here 3 implants , 3 separate teeth and yes I always 1 stage the sinus caes even with only 1mm of residual bone , it all depends on the graft material used . Then load at 4months for earlier re-modelling , again the bone regenerated when using a fully bio-absorbed graft material in the sinus is generally of greater density than the surrounding maxillary bone. So keep it safe ,keep it simple and help your patientsbody to heal itself. Peter

Regardless of bone grafting and implants number, the patient's expectations have to be limited to cosmetic rehabilitation only, because of problematic artificial bone quality at posterior maxilla. Mastication overloading of implants from powerful antagonists is most likely.

This is what I would do. Place the first two impants with a osteotome sinus lift,PRF, and push up the sinus with particulate bone, mixed with growth factors from the PRF,PRF, and liquid Metrodnidazole mix and wait. Then if I am "lucky" I will see the distal area of bone thicken enough to later osteotome this area in 4-6 months. You see when you lift one area the membrane wil lift distal and give you more than you expect.

I would certainly do the sinus graft and then allow to heal. Regrading splinting ...yes it is clearly biomechannically favorable but hygienically unfavorable. A case like this could have a single anterior unit as a separate crown and splint the posterior 2 implants.This is a decent compromise between the 2 camps addressing the meachinic where they are needed the most. BTW odd questions coming from somebody planning a sinus graft

I want to study msc implantology ,I have msc oral medicine can you give me more information .thanks

Stand in line. The " good Shepard " is waiting! Bv

Guys and Gals. We are talking about treatment planning here. Treatment planning is based on three broad areas, namely: 1. Patient's expectations and budget, 2. Patient's oral and general health, 3. Dentist's expertise and the materials available. The final treatment plan is a computation of all these held in a sensible balance with each other. In other words, due consideration must be paid to each of the criteria mentioned and then only...... then only can an optimal treatment plan be worked out. We should cease talking about whether we should place one or two or three or four implants, with or without bonegrafts, splinted or unsplinted etc.(all of them work!) until we have run bravely through the gauntlet... the above three broad areas..... then the optimal treatment plan will become crystal clear. Its like "Chef in the Wild".... the chef is let loose in the wild and he/she has to collect all the data, I mean cookable plants and catchable creatures and then put them together into a palatable dish for the judge who in this case is the patient. The patient is going to give the final assessment on a scale of 1 to 10 whether it can bite, looks good, easy to clean and overall satisfaction. Let the patient decide. 'Nuff said.

Dear Alex as I said the graft material must be fully bio-absorbed ,we do not want a good x-ray but good natural host bone which is generally more densethan the surrounding maxillary bone . Regards Peter

Dr DuCon, hit the nail on the head. Graft and place an implant per tooth to be replaced. Remember, grafted bone in not the same as natural bone.

I think you should gaft the sinus e place one implant per tooth. But remember, those implants must have at least 10mm lenth. Less than that you´ll have to splint them all together. No dought three implants with three teeth are better than two implants and a three crowns bridge. Good luck.

It might be a classic case of using subperiostal implant to avoid bone grafting and sinus lifting.

All the suggestions work. Please ask the patient for his/her preferences, giving the pros and cons and then get an informed consent. That will be the best treatment plan...period.

Hi BV I know back to the 70s , by the way saw Jimmy Page outside his house the other day , another rare sight. A lot has been said and maybe mis-understood in this post . In the maxilla grafted sites with an good bio-aborbable material have better denser bone than the surrounding maxillary bone which has been shown by many studies ( we have many cores as well )and with Sinus augmentation being made safer , faster and less traumatic with the introduction of Dask and SLA systems these options are the better solution. Other areas have changed such as implant length , I remember when 14 mm was considered short , now 10 or even 8 mm length is acceptable ( research by Anitua Atigua ( BTI ) and Bicon ). Then there is the issue of bio -mechanics and the use of commercially pure Ti which has a modus of elasticity allowing for reduction of occlusal forces ( especially co-axial )on the crestal plate . Hence the presence in good systems of a stress riser at the point above the crestal plate. Splinting may negate these benefits as well a reduce the functional re-modelling of the bone adjacent the implant at loading. So as well as being more complex to clean it removes some of the benefits of using Ti Implants on the surrounding bone.We have all seem splint case where 1 implant has extensive bone loss due to "peri-implantitis " but there are many factors at play and these can be coplex situations to rectify. These are just some of our thoughts having made Implants since 1986 , merely to think about, after many years do we know , no, we are always learning. Regards Peter

sceletal prosthetic only no implants no sinus lift , enjoy your life!

Sorry, after you said you saw jimmy page, I couldn't read anymore. He's your neighbor? Do you talk to him? I've been within rock throwing distance of him three times, just before Bonham died. I would have to borrow a cup of sugar from him. Had the oppurtunity to meet Jerry Garcia, Bill Graham, John Popper, Phil Lesh, Bob Weir, John Bell. Those are the only names I can drop. He's still playin, isn't he? Bv

Yes lives ( London base since the 70s ) down the road in a gothic mansion in Holland Park . Has kept it origional , last time he played publically was the closing of the Beijing games, strange to think the 2012 games are soon on here. Back Dentistry , why the fear of sinus augmentation? One the most consistent safe graft procedures. Peter

Dr sengupta, a maxillary unilateral sub is a viable treatment option. If and only if, one knows how to render such a service!

Two options: Option I: Sinus lift, three implants (Osseo integration) with splinted crowns. Option II: No sinus lift, Maxilla: three implants – the distal most angulated implant, splinted crowns. Mndible: One implant with crown.

I don't know what teeth he has in 1st and 4th quads, and what plan is for 3rd quad as well. If scenario is similar then make a reduced oclusal table... place 2 implants, and a 3 unit bridge with 3 premolars. fertig!

Very simple do a lateral wall lift use prp or pgrf with bottle bone. Let heal six months. Be very careful at 2.6 floor site if you perf place a resorable menbrane. Use a surgical guide to place three spinted or three indiv crowns depending on how much bone you get. It will work fine!

Dr SenGupta, the main advantage is that the patient can be restored ASAP. This particular case, I would place a root form just behind the cuspid, then follow four to six months later with the sub. The bridge would be abutted to the sub and root form. The max unilateral sub is a good house in bruxers!

I agree with Peter and BV. Three implants-no splinting. If you feel they are too weak to stand alone, then you must feel there is something wrong with one or more of them. In general, splinting is bad-with teeth or implants. One strong tooth splinted to one weak tooth equals two weak teeth. One weak implant splinted to one or two strong implants equals a lost prosthesis after several months or years of recurrent infections.