Failing bridge due to internal resorption: thoughts on treatment plan?

Failing bridge #3,4 to #9,10 retainers, the rest are pontics. #3,4 have internal resorption. Patient is missing first bicuspid(#5). Alveolar ridge vertical and horizontal deficiency. My plan is to place #6,7 guided. Ridge split, Densah bur, protocol for ridge expansion. Veneer graft on buccal. Extract #4 and possibly place immediate, if I can get primary stability which is not likely( no apical height to grab on). Leave #3 for now to hold a temporary bridge in place while #4,6,7 are healing. After three implants integrate extract and cantilever #3 for a final implant supported bridge#4,6,7,8(#3 is cantilever,#8 is cantilever. Compensate for vertical deficiency of the alveolar ridge with pink acrylic. The reason for not replying #3 with implant is to keep a bridge as a temporary and not get him into a flipper and also to shorten treatment time . While there are many ways to augment or compensate for the vertical height deficiency that seems to be a good balance of TX length and predictability. Please provide a critique and some advice on this plan. Thanks.



8 thoughts on: Failing bridge due to internal resorption: thoughts on treatment plan?

  1. Howard Abrahams says:

    Fun case.
    prep and temp 2-15 with metal reinforced temporary .
    Extract bad teeth and bone graft where needed (including sinus if needed).
    Once healed, place implants.
    Once healed, restore with crowns and implant bridges.
    If you’re keeping 11-15, you may want to consider splinting units for mechanical reasons.

    Totally possible I’m missing something here but with the info I see, that’s kind of the direction I would head.

    Good luck!

  2. Carlos Boudet, DDS DICOI says:

    Very difficult to see any detail on the posted scans. What you call internal resorption I would call rampant decay under bridge abutments, which often happens on these bridges (long bridge with a large edentulous span. I do not like the idea of a molar distal cantilever. You could use minis to help hold a temporary while you wait. I would also do a ridge augmentation before placing any implants.
    Good luck.

  3. Peter Hunt says:

    Be careful, the amount of ridge loss in the #6, 7, 8 regions seems considerable from this limited radiographic view. This would cause two problems. First, the implants would be way up high. Second, as there is considerable resorption to the lingual, it would most likely not be possible to get three implants in the #6-8 region. You might land up with a biological and aesthetic nightmare on your hands. With the Densah burs and labial augmentation you might get better B-L width but it would be tough to get any vertical augmentation.
    This would make me look closely at where the remaining teeth are, particularly in the #4 &9 regions, as these might be the best sites for implants. I would be concerned about placing a distal cantilever for #3. This would better be replaced by an individual implant.

  4. Timothy C Carter says:

    IMHO, if you have the confidence to perform this type of treatment on your own then you need to avoid posting on this site. You will get a lot of different opinions and they are all just that….Opinions. I am a biased periodontist so I prefer the team approach but if your plan is to carry out the treatment alone then you should have the confidence an necessary skills to move forward without requesting too many opinions.

  5. Dr Bill Woods says:

    There is really little to go on to give long range sdviceceith some exceptions. A molar cantilever isn’t an option to me. Shortening treatment time in this case seems very shortsighted given the case as it appears. Take the time to analyze the available bone. I agree with a full arch metal reinforced provosional bridge. Then look at available bone to place implant for support. We don’t have a 3D look at anterior bone width, and the width, length and density will determine what you need. I just think you can’t say “2 implants here or there, one here and a cantilever and call it a day. Overengineer it first in your mind then go from there. In my area of the country a provisional removable appliance isn’t off the table. Just my thoughts. Good case to get many thoughts on reconstruction. Bill

  6. michael johnson dds, ms says:

    OK, I’ll try to be as tactful as possible. I’m a prosthodontist. And this is not a “fun” case. It is an extremely difficult case. There are multiple carious lesions, long span bridges and significant bony defects. What part of this is fun? I promise you it won’t be “fun” when things go sideways. Therefore, follow Dr. Carters suggestion. If you’re not an accomplished surgeon then get help. This is a very complex treatment plan both from a surgical perspective and restorative perspective. Use your local specialists. I also think you’re asking for trouble making a temporary FPD from 2-15. Another long span FPD which will torque the incisors and come loose on #2 and cost the patient a lot of money. I subscribe to the KISS principle, keep it simple. Therefore, the molar and premolar sites are prime implant sites. Use them. Make an essix retainer or a temporary partial denture to fill in the edentulous spaces while the grafts consolidate. If the patient has a low lip line, pink porcelain or acrylic will fill in the defect nicely. How picky is the patient? If he/she is picky or they have a high smile line then you’re in trouble. No amount of hard and soft tissue grafting will make this defect go away. You may also think about removing #9 propylactically and placing an implant there since there’s plenty of bone. Then bridging 4-6-9 for better esthetics keeping #3 as a single unit.
    Long story short: If you need to ask for help on such a complex case then get help, from your local specialists.

  7. Dr Dale Gerke, BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    You seem to want to treat this case in a hurry and this is definitely not a case you can hurry.
    There is not enough information given for anyone to make meaningful comments about a final treatment plan.
    I agree with most of the previous comments. Some excellent advice has been given.
    With respect (and I sincerely mean this because I do not want to sound rude), this is a very difficult case (which others seem to agree considering the comments from some very experienced specialists). I firmly believe you should at least consult with local specialists and probably have them do the job. I would think this is an ideal case for you to learn from – by assisting the specialists you refer to. You can be with the patient every step of the way and observe how to go about this.
    It has been quite rightly pointed out that this is not the case for you to be asking questions about – you should know everything that needs to be done if you want to do the surgery.
    Having said this, I repeat that in my mind there is not enough information for me to provide a definite treatment plan. I would say that I have doubts about some of your proposals and if I was doing this case I would CADCAM design this treatment and have a surgical guide prepared.
    It seems there are many other problems going on in this patient’s mouth. So what is your proposal to treat everything else? Start with the end in mind. I always treat the whole mouth and eliminate all other pathology and get the patient’s hygiene to a satisfactory level before I undertake complex restorative work. Otherwise, what is the point of massively restoring one section of the dentition only to have the rest fail soon after? Establish a stable base line for the whole dentition, then proceed to the complex work.
    It has also been pointed out that this is not a fun case. This is a patient who needs your respect and care. “Above all else – do no harm.” I am not convinced that this motto will eventuate with what you have proposed.
    It seems to me that those who know have advised you to go very carefully. I hope you take their advice.

  8. Wes Haddix says:

    Respectfully, abort your proposed plan. Design an ideal prosthesis first, then modify the mouth or patient expectations.

    Concerns I immediately have:
    1). Having trouble seeing details of the scan on my screen – perio defect 2M/3D?
    2) Deficient ridge height/width (especially height) in area 4-8; grafting can restore width but only limited height. Flap mangement will be challenging.
    3) Lateral/anterior disclusion will be completely borne by implants. The models appear to show group function.

    This case has a high degree of difficulty; based on the records I see, I concur with others here that there are significant biologic problems that are not addressed in the current plan and present a reasonable expectation of complications during/after treatment. I can’t offer any options as I don’t have the privilege of seing the patient firsthand, but I can see enough red flags to cause me concern. – especially a distal cantilevered molar in a prosthesis that will already bear lateral and anterior guidance forces. The anterior cantilever is beyond the pale in light of apparent existing bone volumes.

    I sincerely wish you and your patient all the best: consult with a prosthodontist and oral surgeon if you are not comfortable with advanced soft/hard tissue grafting. A successful case makes a pleased patient.

    I

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