Should I Redo this Case?

Here is what I what to explain, when you are watching generalized bone loss over time the bone level is flat and very difficult to graft. If I have the topography of the extraction sites I can rebuild what is being lost. My typical experience with my patients is "my dentist has been watching this for years" often by the time I see the patients there is not lot to be done. Holding off on needed treatment is not what I feel in the best interest in the patient and it is sad to see his these patients could have been helped at an earlier phase. Unfortunately many dentists like to kep the patients "in house" and watch the disease process progress. I get pushback like oh my patient can't afford it or it won't work or it won't be successful. It is sad to get the patients when they are referred at a late stage and it Is not good care. Hiding cases and needed work I feel is not what is best for the patient, bottle necking these cases is not to the patients best health. Fortunately patients do seek other sources to get the referral and care they need. Don't get me wrong I advise a lot of patients to keep their teeth per individual cases but often it is after they are retired and don't have discretionary income, " if I only knew sooner, my dentist was watching it " typically there is no "flight plan" or these patients and there is no future thinking . Cases are not being presented let's just watch I. Just my viewpoint when I see what is possible. Thanks for reading!

Yes I agree and I'm sure others would too. Leaving Perio too late compromises further implant placement due to lack of bone. But the above case doesn't illustrate that. If its stabile Perio then there is no need to take the teeth out and replace with implants as the Perio is stabile. If it isn't stabile boneloss then implants shouldn't even be considered!

What you just stated contradicts itself. If this stable then the bone can be regenerated if it is not then implants should not be considered. So keeping teeth with 50% bone loss as illustrated by the new implant and assuming this s stable then it is a good time to consider implants. How much bone loss do you want to allow? That's my point which your response just illustrated. Thanks for reading!

Sorry. I don't understand where I've contradicted myself. On another note the teeth do not have 50% bone loss. And if they did we wouldn't be assessing it from the bone around the implant (as you said).

The case was placed to deep near the floor of the nose because there isI not adequate bone, no site preparation period. There is palatal perforation in the higher ct views. You can 't see the labial plate. And yes "drifting" is BS. Dr. I totally agree with you!

Nope it's palatial look at images again , ie the camber of the anterior mandible.

hey, look where the bone lossis and follow the palate posteriorly - that is not a nose!!! I'M 100% SURE ITS THE BONY DEFECT IS PALATAL. WHAT DOES EVERYONE ELSE THINK!

Correct if these is a ten year result I agree. My point is if I have more to work with this could end up a fixed case( individual bridges) vs a bar or locator case in the future. The issue is the soft tissue which needs a good bone base. If the patent wants a final prosthesis which is individual crowns or bridges now is the time to jump. And true, I admit I am trying to predict the future! I just observe what this poor poster had to work with, a long narrow implant in the floor of the nose with palatal perforation it would be very interesting to see a cone beam! Actually I could maintain this with a LANAP procedure. Thank you for the discussion and challenging me! Best wishes.

It is a judgement call that I am comfortable with, always weighing all the options. Believe me often I talk patients into keeping teeth from my perspective I often hear from refered patients "I wish I had done this sooner" But who knows perhaps they did not follow thru on their dds recommendations. I just like to have a flight plan or algorithm for the case. Then when I see the patient again I refer back to it, I don't have the luxury of seeing the case every 3-6 months. However like the " frog in the slowly heating hot water" it is sometimes shocking to see the long term progression of the "watched bone loss". I guess it is a matter of perspective and balance. I also rely heavily on team treatment, benefitting from the patients own dds who knows them best, there is no substitute for that.

Also!!! you were wrong the implant is too palatal look at the camber of the lower jaw!!! In my opinion you would maintain the perio before extracting the remaining teeth. I.e maintain once you have performed your initial therapy and monitor. I suspect if you were to do this the teeth would last longer than any implant therapy. Its far more ethical, and hey if he / she doesnt do her bit they just dont get more implants in the future.

i might add i teach anatomy to undergraduates!!! (medical and dental students), besides when do you retrocline an implant tyhat much !!!! bone loss is at the platform palatally. I'm quite shocked at someones lack of knowledge when placing implants-scary! no sorry when practicising dentistry.

You know, I took a closer look at the ct scan, I bet this was an immediate placement after an extraction, I see space at the crestal edge and the implant was placed narrow and deep to the palatal which explains the odd look on the panorex. This was not a case for an immediate because of the bone loss, site prep 101. I don't think Maxillas drift as previous poster stated and there are teeth on either side of the implant site so there had to be some buccal plate interproximally. I actually like the roundhouse c&b ideas and treatment planning posts! And Peter NOBODY goes to Michigan in February, God bless you! Next time Florida! Safe travel! CRS

last time i checked we had genial tubercules lingually check it out and do some anatomy courses! very basic if you read other posts people think correctly its palatal bone loss!!!! geeze being a maxfax it scares me that apparently your doing le fort (not forte)-i dont think you are. If you were you wouldnt make such basic incorrect assumptions.

Since we are correcting spelling it is genial tubercles. I think the implant was done as an immediate with it placed too deep floor of the nose, too palatal with perforation. Not sure what the genial tubercles have to do with my comment about the maxilla, perhaps you are trying to point out something you can identify. It is still the floor of the nose and the turbinate just above the implant, not an assumption. I find that when posters become defensive it could be that you are taking this personally which was not my intent. I try to be respectful. And polite. The bone loss of the palate was a perforation since this was a recent post operative film. Practical operative experience always backs up a didactic anatomy course of which I have had several, I wish you great success in your teaching endeavors and thank you for reading, peace!

Well Said!

I agree 110%.

This is at best speculative without a ceph. The buccal plate is not fully visible on the ct scan and the anterior nasal spine is not visible to help locate point A. I bet if the poster showed the whole buccal plate it would be obvious how far palatal the implant is and we would not be having this discussion. I agree that there is flaring of the anterior with posterior bite collapse with a tendency for auto rotation but given the large width of the anterior maxilla, mesial/distal (diastema) I doubt think is an example of a deficient premaxilla. Interesting point however. Thanks for readin!

John I may have been misunderstood.. I used the term 'drifting' to describe the deviation of implant from the intended path during placement. This usually occurs due to different bone density (hardness), poor guide and big jump between the sizes of drills. Interesting read.