Cleaning below pontics for anterior implant bridge: feedback?

Last Updated: Oct 05, 2012

I have recently placed a 4 unit screw retained bridge in the area of the 4 Mx incisors. The restoration is supported on 2 implants in the place of the maxillary lateral incisors. A gingivectomy was done to allow the central incisor pontics room to seat below the gingival for optimal esthetics. The pictures you see are on the day of insert and 2 weeks after insert. My plan is to leave the screw retained bridge for 2 month’s and then replace with a metal/ceramic final bridge.

My question is how do I manage the difficulty of cleaning below the pontics? My patient says it is to painful to floss there. Will it be better after the 8 weeks(or less) or do I need to modify the temporary before then. I already did a lot of resin work in office before I inserted it.Thanks in advance for your feedback.

![]day of screw retained temporary](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/day-of-screw-retained-temporary-e1349448985383.jpg)day of insert
![]](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2012/10/2-weeks-after-temporary-placement-e1349449014258.jpg)2 weeks post insert

13 Comments on Cleaning below pontics for anterior implant bridge: feedback?

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CRS

10/05/2012

The bridge looks beautiful, but I'd like to see an xray. I was concerned about the flatness of the buccal plate in the lateral areas, was any bone grafting or ct grafting done? Also the bite is very deep, how high does the lip line go when smiling? I guess what I'm getting at is are you happy with the occlusion? I'd keep the patient in temps a long time 6-12mo and make sure you are happy. As for cleansability how about an interproximal brush and flat floss in the pontic area? It is normal to be sensitive for at least 6weeks post op.

Brent. Macdonald

10/05/2012

Thanks for your comment. As for the laterals I did not do any grafting. Would there be any merit in a ct graft at this stage ? The smile line is not very high such that I haven't seen the gingiva with this patient unless he really forces it. As for the occlusion it is tight but at three weeks now the patient is doing well. The chip you see is from the screw access area. Thanks for the tips on cleans ability. Another dentist also suggested a watering. These tips are all helpful. If you send me your e mail I can send a pa today and a digital pan when the patient is in next. Thanks Brent

Leal

10/05/2012

I think it looks good and with time it will look even better. I would leave a "black 0,5mm (and later on more 0,5mm) interdental space" so that a mini interdental brush would clean those spaces and hope the papilla becomes more natural (if you have the bone for that sure). Make these kind of adjustment in whatever time you think it is necessary. 1 year is OK... don't rush with the final work. Also I would like to remind you that you should respect the metal and ceramics thickness in a metal-ceramic crown. Sounds to me that the access hole in implant #12 is way to buccal (the farthest I can go is between the cingulum and the incisal line). I honestly love screw-retained and don't really like cemented stuff on implants but sometimes one must choose what is better. Keep up the good work.

Leal

10/05/2012

To the final prosthetic work a micro interdental brush and Waterpik are just fine. All my patients absolutely love Waterpik and feel motivated to O.H. this way.

DrT

10/09/2012

The gingival texture appears noticeable fibrotic and unhealthy. Has this tissue appeared this way since the extractions or is it more recent? Also, is the patient a smoker? Thank you. DtT

Baker k. Vinci

10/09/2012

Not sure what the difference is, between this and a FPD on natural teeth. I kinda thought we encouraged implants to avoid this. All in all, I think it looks pretty good , considering the deficient bone. Bvinci

Baker k. Vinci

10/09/2012

He couldn't brush his teeth before the photo? Bv

DrT

10/09/2012

I am not sure I agree with you Bv....considering the likely deficient labial bone on both abutments, or at the least on the left lateral, along with the questionable health status of the soft tissue, I would anticipate the development of peri-implantitis in the not too distant future. I think more care and attention should have been given to site preparation, both soft and hard tissue aspects.

Baker k. Vinci

10/09/2012

Well dr. T, you maybe correct , but after decades of treating "the compromised case", our expectations and the expectations of our patients can not supersede the limitations posed by the scenario. I doubt this patient will be walking around with cheek retractors in, for the rest of their lives. I would need more information, before I could criticize this case. As of now, there is keratinized tissue ( regardless of the lack of buccal contour ) and sometimes that is the best we can offer. Bvinci

DrT

10/10/2012

I did not mean to raise any concerts about esthetics in this case. The unhealthy appearance of the gingiva in this instance suggests, at least to me, that it is not healthy, and may not be offering the kind of protection of the underlying osseous that is so critical. In addition, again in this case, it appears that the labial bone is quite thin, especially on the left lateral fixture....which will require even more optimal protection by the overlyng gingiva. As for your use of the phrase "compromised case"...I would only add that in cases such as this, it is all the more important to try to optimize the hard and soft tissue health. Thank you. DrT

Baker k. Vinci

10/11/2012

I totally agree, Dr. T, but I would discourage going in and trying to correct anything. Bvinci

Dr. JLD

10/23/2012

The tissue looks better in the 2-week post delivery picture. Maybe with more time and improved oral hygiene the tissue will look even better. Perhaps flossing will become more comfortable as well. Whenever you prepare the gingiva to receive an ovate pontic that is flush with the tissue you are setting yourself up for a long period of the patient struggling with hygiene. Thin, flat floss has the best chance for pain free use. Good luck to you and the patient.

Pankaj Narkhede, DDS; MDS

10/23/2012

If the question is regarding maintaining hygiene a water flosser made by water pik is a good choice. It has a speed control. There is a trick to use it - so let the patient be explained about it

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