Teeth Have Shifted Considerably: Make Space for Implants or Close the Space?

Dr. N. asks:

I have a 42-year old male patient who presents with missing #4 and 19 [maxillary right second premolar; 15 and mandibular left first molar;35]. These teeth have been missing for a long time and the teeth have shifted considerably. The attached gingival, bone height and bone width are adequate and healthy. I have recommended that these sites at #4 and 19 undergo orthodontic therapy to either close the spaces or open them up more for increased access for placing implants and crowns. Patient does not want to do ortho. My question for all of you is what you would do for #4 and #19? Would you make space for implants or close the space? How to present options to patient?

BW Right:

BW Left:

PA Left:

PA Right:

13 Comments on Teeth Have Shifted Considerably: Make Space for Implants or Close the Space?

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Guy Carnazza DMD
10/10/2011
Better off replacing # 30 to optimize occlusion and if patient is opposed to ortho leave max arch alone, yet present argument of persistent food traps which could compromise periodontal heath in the long term.
dr.med. dr. dent Alessand
10/10/2011
i would remodelling this teeth in the same way in the two sites and place an implant per part, i think around 2,5 3 millimeters , not more. this is the simplest way to solve the problem and is economic too.
OMS resident
10/10/2011
Heard at the OMS department: "Missing teeth or missing implants?"
Dr. Dan
10/11/2011
I think osseonews reworded my case presentation pretty badly. Implants were already placed for #30 and #31 and #3 is super erupted. #19 appears to have a thin ridge. Obviously it cannot be seen in a 2 dimensional peri apical radiograph. The bone in the #4 location had adequate thickness.
Paul Rhodes, DDS, MSD
10/11/2011
I suggest that the best choice for type and location of prosthodontic care take into consideration his occlusion. His radiographs suggest significant cuspal wear suggesting habitual bruxism. What is the status of anterior teeth: occlusion, wear pattern, splaying, fremitis? You have not mentioned the missing lower right molars. I think that evaluation of his occlusion is key to what might be done within the patient's range of acceptance. Have you considered just an implant in the lower right first molar area with a fixed partial denture abutted on the upper right first molar and first premolar to restore his posterior occlusion on that side of his mouth? This of course should be co-ordinated with proper occlusal adjustment and use of parafunction habit pattern management. In the future, he may be willing to address his prosthodontic needs on the left side of his mouth.
Dr. Dan
10/11/2011
So #19 does not have adequate attached gingiva nor bone thickness (so it seems). #4 DOES have adequate attached gingiva and bone thickness.
k.c.chan
10/11/2011
Space closure by ortho could also address the problems of tilting, over-eruption and to provide better inter-occlusal space for implant supported prosthesis.
Pankaj Narkhede DDS MDS
10/11/2011
I would evaluate the occlusion. Make a bridgework to correct & modify the occlusion.
mike stanley, asst.
10/11/2011
OMS Resident: LOL, interesting perspective! Dr. Rhodes, all excellent questions, especially with the patient's young age. Treat the whole patient, not just a single (missing!) tooth. That's good advice I'll pass along. Dr. Carnazza, great thoughts also.
ttmillerjr
10/13/2011
The key here is to clearly define your goals (and the patients) and find the best way to get there, not find a way to fit implants into the case. Without ortho this is not an implant case.
cavekrazi
10/20/2011
I just finished a case very similar. We extracted the left third molar and did a ramus graft to restore the buccal deficiency in the first molar area. 6 months of uprighting with fixed ortho to upright the 2nd molar while the graft integrated provided a great site for a simple, single stage implant (not immediate load). This type of treatment lends itself to idealization of occlusal scheme, great longevity, and only one complex surgical procedure. The healing on the graft procedure is not much more than the third molar removal, and the implant placement later on is simple. Having the tipping gone is a huge longterm plus for a young patient. For me it is very hard to tell what might be a "best treatment on the patient's right with the information provided. Photo of mounted models would be nice. Best of luck. t
Gregori M. Kurtzman, DDS,
11/11/2011
I would consider resin bonded Zirconia inlay bridges instead of implants in this case
Richard Hughes, DDS, FAAI
11/12/2011
Orthodontic treatment would be ideal! Present to the patient all the options. Let them decide. Sometimes implants, sometimes bridges and sometimes nothing!

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