Implant Supported Bridge vs Apicoectomy?

Keep your natural teeth as long as you can. Complications with natural teeth are generally more predictably treated than are complications with implants, which are rough surfaced screws that extend into the oral cavity and do not have a periodontal ligament, the associated osseous support and blood supply and do not have the complex of elastic fibers around their necks that natural teeth have. Implants are thus subject to greater and more rapid plaque induced inflammatory bone loss. I place lots of implants, when I have to and have found, after 37 years of practicing periodontics, that natural teeth are more resistant to bone loss than are implants. YMMV

Hi...now as a Periodontist, I always want to try to save teeth if I can, but in your case, with regard to 12,13 and 14, there is a lot to consider... especially cost/benefit. These teeth have SO much going on, a simple 'Apicio" is not the answer. First off, 12 and 13 display significant breakdown where crown length would be needed. This poses a problem as there appears to be periodontal bone loss associated with these teeth. Basically, they are REALLY compromised. With regard to #14, I'll bet if a CT SCAN were done we would see a bone loss pattern that points to a vertical root fracture. So...if you are someone that wants to take a chance with the understanding that the prognoses on these teeth are poor, then you certainly can try but realize that it's more than a simple Apico that is needed. If you are not looking to spend money on what I would consider a very poor choice, cut to the chase, extract 12-14. Have these properly debrided and properly grafted. CT Image the area again and then place implants, probably 2 for an implant supported bridge. You are a young guy...go with a long term solution and not a series of procedures with a big question mark. Neil Zachs Periodontist, Scottsdale AZ

Dr. Zachs is correct. I am a restorative dentist who has been placing and restoring dental implants for 40+ years. Apicoectomys are one of the least predictable procedures in dentistry. Piled on that are several teeth that are restorable only after periodontal crown lengthening. You must eliminate the periodontal disease before dental implants are predictable. Your way out of this problem is costly, so spend wisely and keep your preventive appointments after you are done.

I am a restorative dentist only. No implant placement or perio surgery . I also agree with the two above posts. Those teeth are very compromised. The molar has a large radiolucent are mid root. I don't think it could be predictably saved. You could spend a LOT on saving those only to be in the same predicament in a few years. I like the two implant and three unit bridge approach. Not sure you need three implants. Of course three is not wrong, just more costly. You have periodontal disease apparent on these xrays that needs treatment before implants are placed. Good luck

Firstly please understand this format is really for dentists to discuss techniques and philosophies rather than different treatment plans for an enquiring patient. The reason for this is that a considerable amount of information is required before a reasonable diagnosis and treatment plan can be provided – certainly much more than you have provided. EG, medical history, clinical exam, your desires in regards to what you want, your expectations, your budget, technical issues and engineering possibilities and probabilities. Secondly, I think you might end up more confused after getting different opinions on this post. The old dental joke is that if you put 100 dentists in the room you will get 100 different opinions on what to do and no one will agree with one another. The extra joke with that is that if you tell that to the 100 dentists, they will all probably say, “I don’t agree with that!” Thirdly, my objective is to always help my patients keep their teeth for a lifetime. This is usually possible, but not always. In an effort to help, please let me aim to provide some information for you. Understand that I feel it is prudent to save teeth if possible. Implants are great to use if teeth are missing but they have faults. Statistically between .5% to 5% fail outright. But more importantly only 55% to 65% can be classified as “successful” (using various criteria to measure “success”). So there is a large “grey” area in regards to implants. There are also extenuating circumstances to consider (smoking, diabetes, heart disease, osteoporosis medication, etc) – all of which influence the possible success or failure of implants. Therefore if a tooth can be saved, I feel it is always best to do so (you can always extract later if needed and implant). Once extracted you cannot put the tooth back. In my opinion, a well restored natural tooth is always a better alternative than an implant. In your case, when I look at your radiographs, my first impression is that your teeth seem to be viable for a life time. My expectation for a patient is that they will live to about 85 years old – so my expectation and question for you would be; “Can these teeth last another 40 years?” At first glance my answer would be YES, albeit there are other issues that need to be evaluated (see my points above). The main consideration for tooth longevity is bone support for your natural teeth and it seems that your teeth have good support. Further, there seems to be plenty of root and tooth structure to use as a foundation for good restoration. So from a restorative point of view I see no real problem restoring your teeth – BUT there seems to be a lot to do and I would advise you seek the expertise of a prosthodontist not a general dentist (not being critical of general dentists but some of your teeth need extensive treatment and if you are going to aim at a lifetime job, then you would be wise to get an expert to do things properly first time – not needing to be redone every 5-10 years). My general impression (albeit without a proper consultation and evaluation) is that your case is easy but hard (if that makes sense). So really I think you just need to find the right dentist. Having said this, where you have teeth missing, I would definitely investigate the possibility of placing implants (as mentioned, implants are definitely a great substitute where teeth are already missing because they are generally a better alternative than partial dentures or bridges). I hope this helps you and does not confuse you too much.

I believe that Dr. Gerke’s comments are the most reasonable and well thought out. I’ve been practicing for over 45 years I’ve been placing implants for over 20 years. This patient needs to understand that in the right hands he should be able to maintain all of these teeth for a lifetime. But without being condescending this patient is not being honest. It is clear that he has neglected himself or herself for many years. No amount of dentistry even under the most expert hands will survive the neglect that is apparent in this case. In my career I have witnessed the most amazing advancements in the field of dentistry. I’m so proud to be a member of this profession. It is very likely that this patient can find a doctor who will take all things into consideration and deliver a treatment plan that will be long lasting and in most respects successful. Implants are a wonderful alternative. But so are apicoectomy‘s, root resection’s, periodontal therapy, and crown and bridge. Find a dentist you trust and stick with that doctor.

Nossa profissão não é uma ciência exata como a matemática, física ou a própria química. Muitas vezes o insucesso de um tratamento tem origem mista. Ou seja, do profissional e do paciente ao mesmo tempo. Nunca devemos perder o tempo para intervir e quando feito no tempo certo a solução para o cliente provavelmente será encontrada. Porém não esqueçamos que grande parte da solução dependerá das instruções ofertadas ao nosso paciente, principalmente quanto à higienização e ao tempo, para detectar problemas precoces e mais facilmente solucionáveis.

I guess we can all agree to disagree. As for the few comments made before the last one, the ONLY aspect that I agree with is where Dale Gerke points out that this can be confusing for a patient based on so many opinions...some from surgical specialists and others from General dentists. I vehemently disagree with the blanket comment that in the right hands he should be able to maintain his teeth for a lifetime. Come on. I’m a board certified periodontist and have been for almost 30 years. That statement is completely false and unfair for someone to hear. Things happen...even with strict care. There is no question that this patient’s #14 has a root fracture and a hopeless prognosis. No magic wand will help this. As for the other teeth in question, we live in a world where there is cost/benefit. I save Teeth for a living...but there is a time to say Stop! I won’t repeat my thoughts on this case...no need.

If the patient is willing to invest several thousand dollars in teeth with a guarded prognosis I would recommend extraction of tooth #14, an apico on #13, crown lengthening on teeth #12 and #13; re-eval in 4-6 months and if all is healthy restore with fixed bridge to replace tooth #14 and crowns on teeth #12 and #13. If there are any questions about teeth #12 and or #13 then remove and place implants. I like the idea of a phased treatment plan rather than jumping in full bore.

Probably, if we educate the patient with- 'Cause and Effect' phenomena of their clinical conditions, and our treatment plans which suits patient's willingness to look after OH, should make some sense. Like in the above comments ' I don't agree, with my own treatment plan, if the patients comes back later'.... [say after 6 months]..

Your current dental condition is poor overall. How did you lose so many teeth at such a young age? Your current periodontal conditiion is poor. When was the last time you had your teeth cleaned? If it was recently the hygienist lest tons of calculus. I would focus on getting your periodontal health in order. I agree that trying to salvage #14 is hopeless. The periodontal infection and bone loss will not respond favorably to a root amputation. All three furcartions are involved.

Decent endo retreat and why don't all the guys advocating extraction ask : how long is the underlying subideal condition going on, and if say, 5/10 years+, then retreat to eliminate the bugs ( xp 3d files anybody? ) and see how that goes? Maybe another 5/10 +years??? A good endodontist consultation would be next imo....all bets off if CT shows fracture of course.... No guarantee implant delivery will be hugely successful here, lots of bugs down in the bone....

You lost these teeth years ago. They are still hanging on, but it looks like you need a new plan. I have only been placing and restoring implants for 18 years, but I have had great success with them, especially Bicon and Ankylos implants. My opinion, shuck those teeth, heal a bit- like 6 weeks, then get 2 or even 3 Bicon implants placed and restored after integration. Unless you have some underlying medical issue that will work great.

Just a quick comment... the patient's mouth appears to show at least long gaps of sheer neglect, even after obvious dental treatments to address past issues. Those bad habits are difficult to overcome, regardless of best intentions. Of course unknown threats to success such as, smoking, vaping, and other unhelpful habits can add to the lack of positive progress and to eventual failure of even the most expert and advanced treatments. The wide knowledge shown by the responders is excellent information put down in black and white for professionals to weigh for their patients. I'm concerned that this patient will assume that the possible solutions offered are a cornucopia of permanent answers to his/her present issues rather than a discussion of professionals, who can differentiate due to years of experience and study. A little knowledge can be a dangerous thing, especially when the apparent background of neglect will work against success.

Dr Zachs beat me to my opinion. We want to save natural teeth when there is a reasonable prognosis. The clinical/radiographic presentation as it pertains to #14 does not warrant in my opinion spending any time, finances and effort as there is "a lot going on" as Dr Zack states intra-radicular bone loss due to possible fracture/failing RCT, periodontal isssues no amtter what the determined etiology of the problem is I do not feel it is a viable alternative to keep 14.