Your treatment plan: oversized crown or remove and replace implant?

Looking at the radiograph the implant wall is very thin at the crest and it will not handle an oversize crown. I would consider a buildup of the distal of the bicuspid and then place an implant in the second molar area and bridge together. I have made the big crown mistake and it failed. Greg Steiner Steiner Biotechnology

I would recommend a normal size crown with a diastema easily cleansable between the premolar. It is a non esthetic area, and nothing is going to drift. Explain to the patient it is the best way to restore vs removing the implant or placing an oversize crown to accomplish what? They can live with the space and keep it clean, I would not try to fix this just restore.

I have seen many reports in the literature where a bridge between a natural tooth and an implant worked just fine, provided the occlusion is managed. I would caution against using an over sized crown on the implant as this will most likely compromise the health of the implant. I recommend you check the literature and I am sure you will see that this is the case

see what gordon has to say about connecting implants to natural teeth and this should give you the answer you are looking for.

Make a full-crown tooth preparation on the abutment tooth. The preparation should be parallel and as long from the occlusal to the gingival area as possible. Place an appropriate abutment on the implant. The abutment should be as parallel as possible with the abutment tooth. Make the fixed prosthesis. On the cementation appointment, make relatively deep rotary-diamond scratches on the tooth preparation. Make sure that the abutment is securely attached to the implant. Cement the fi xed prosthesis with strong bonded-resin cement. Adjust occlusion carefully, placing heavy occlusal forces on the articulation marking ribbon or paper, and reducing the marked areas to allow equal load on the implant and tooth-supported restoration and the adjacent natural teeth. The implant will not move apically, but the tooth can move slightly apically. Inadequate occlusal adjustment can cause premature failure. Expect successful service from the natural tooth/implant-supported fixed prosthesis. Dr. Christensen is a practicing prosthodontist in Provo, Utah. He is the founder and director of Practical Clinical Courses, an international continuing-education organization for dental professionals initiated in 1981. Dr. Christensen is a co-founder (with his wife, Rella) and senior consultant of Clinical Research Associates which, since 1976, has conducted research in all areas of dentistry and publishes its findings to the dental profession in the well-known“CRA Newsletter.” He is an adjunct professor at Brigham Young University and the University of Utah. Dr. Christensen has educational videos and hands-on courses on the above topics available through Practical Clinical Courses.

This is the other DrT here. I don't recommend a bridge for this patient at all. He has obvious caries on both premolars, so home care is poor. He'll never floss under a bridge so it will fail. Just crown the implant as is. When he loses the premolars to decay you can replace them with implants in better locations to close any spaces or bridge the implants.

Another alternative would be to place a second implant in the second molar position and restore as three premolars (or one molar and two premolars, or two molars and one premolar, etc.) with an anterior cantilever adjacent to #20. Also would have addressed the caries #20M and #21D before placing the implant. Priority question.

Agree with CRS' plan. Please do not overlook the obvious proximal carious lesions on the adjacent premolars. Oversized crown is definitely a cantilever. Regards

Restore the caries on #20,21.

Do not connect with natural teeth. Do not explant. Crown the tooth in front. Make a larger crown on the implant. You can extend the distal margin of the crown on the bicuspid to touch the molar or you could even consider splinting the two bicuspids and extending back. Make sure contact area is large and broad.

I have connected implants to natural teeth for years. It's not my first choice but, when there's no other option, it has been very successful, i.e. no failures in 20 years and at least 20 prostheses. Make a crown on #21 with a tapered arrowhead type of semiprecision attachment on the distal of the premolar with the pointed end up. Make an implant crown any way you want for the molar with a pontic #20. The female portion of the attachment is internal of the pontic and not visible from the occlusal surface. When I do the framework try in I have the FPD in three pieces. The implant crown, the pontic and the natural tooth crown. Try the crowns on then slip the pontic onto the semiprecision attachment. Use duralay or GC pattern resin to lute the pontic to the implant crown then presolder this joint. Finish the porcelain and that's it. I cement the natural crown with a permanent cement and the implant crown with a temporary cement or use screw retention. I have done it this way for years and am very pleased with the results. Rangert, an engineer with the Branemark group, wrote an initial article on connecting teeth to implants back in the 90's so this is not a new concept. Best of luck, you'll like this treatment option when full implant support isn't an option.

Thanks for all the comments. Yes I'm very aware of the caries problem, that's my first concern for this patient. He also has a failing FPD #7-10 that needed immediate attention. Not sure when he will allow me to address the LLQ. Thanks again for all of the great feedback! Justin

The second bicuspid needs reatoration - possibly endo once you have removed the decay. Consider elective endo on the premolar with a a crown restoration and use that to take up some of the space between the implant crown and the premolar. Get an implant level impression and have the lab wax up the premolar and molar so you have contact between the teo crowns and see what you would need to do. An slighyly wider crown (meisal-distal) on the poremolar will be m ore stable than an oversized implant crown - think back to what we can on a hemisectioned tooth (they usally end up with wide crowns)

Place a small diameter implant mesial to the existing implant. ( 1.8 - 2.5 mm ) and connect the two implants. There will be no cantilever and proper contours can be established.

Hi I think the best thing would be to do a single crown with normal size preventing any future complications. But if the patient has no option for one more implant; then you can think to do a mesial cantilever small bridge on the implant with small occlusal table. Considering the factors of loads such parafunctional habits or hyperactive muscles. A mesial cantilever is the best shot if you want to restore the mesial space; as it considered less catastrophic than implant-tooth bridge. Always the loads reduce toward the center of the mouth; utilizing this principle is the best what you can do. Although I would restore the implant with single crown.

What is the big deal with a cleansable diastema in a non esthetic area? A well designed proportional crown in that area should be okay. The implant will not drift or tip over. And it appears on the bite wing to be well lined up with the upper teeth. Am I missing something? If a cantilever or a bridge to a natural tooth is placed I feel a problem is being built in. I feel that there is such a strong urge to close the space. I think a decision with the patient on hygiene is key, also what did the original tooth position look like? If the space is big and cleansable I don't see a problem, place a screw retained temporary crown and see how it goes. Please educate me I don't restore and want to learn Thanks!

What kind of case planning was done before the implant was placed? Was there a surgical stent? Why was an implant placed when there is active caries and other major restorative needs in a questionably compiant patient? There would be no need for this question with proper planning. I would not use a structurally compromised, endodontically treated bicuspid as a bridge abutment even with natural dentition.

jmkk - if you read the original post the Dr asking the question did not plan or place the implant so questions about stents etc are a bit mute. He's got this patient now and asking for options. decay is present in both lower bi's but the upper look sound so it might be localised just to that quadrant. yes, all primary disease should be treated beofre implants are placed but the dental history of this patient looks patchy at best (placed 5 years ago - whats the patient been up to since then? - not the current dr's fault)

What kind of case planning was done before the implant was placed? Done by prior a Dentist, at least a few years ago. Was there a surgical stent? My guess is NO, due to poor final placement leaving a hard restorative decision to make... Why was an implant placed when there is active caries and other major restorative needs in a questionably compliant patient? Excellent point, it's possible that caries developed after placement. There would be no need for this question with proper planning. I AGREE! I haven't excavated caries #20/21, but they are both vital. They may NOT require endodontic tx. I agree on their compromised status. Thanks again for all the great feedback/comments. At this time I'm leaning towards crowning #20/21 with an extension of the distal margin on #20 and a single implant crown with slight extension on the mesial of #19.

Implant seems very nicely osseointegrated. I think removing this Implant is not a good idea, better to think of making a good restoration that will work well for long run. First, measure the bone between root and implant. If more than 7 mm bone is available than install a narrow ridge implant (3 mm diameter) and make a 2 implant supported molar. second, you can install another implant on 2nd molar position (approximately) and make a 3 unit bridge. One premolar will be cantilever and leave the premolar bite free, hope that will also work well. Since he has upper 2nd molar, this option is more acceptable.

If this were my case, I would remove the implant and start over, with an appropriate wide platform implant. Most implants can be turned out of the bone with the corresponding placement tool with not too much fuss, the lone exception being a Straumann Roxolid implant. It's what I would want done if this was in my mouth. Anything else is a compromise, and those have a way of coming back and biting you in the butt, usually many years later, at which point it will be (mostly) your fault. Not fun. Good luck, let us know how this case turns out

MDI or another narrow diameter implant at reduced cost

Val, Perhaps I misunderstood your question. Were you asking about charging a reduced fee when using a narrow implant? The "mini" implant must be placed with the same care as a larger implant and many times with a greater risk to the treating doctor considering the attitude of some of our fellow dentist toward the use of small diameter implants. The small diameter implants when considering abutments, impression parts, and what is needed for restoration are not a great deal less in cost than the larger implants. Some of the small diameter implants can cost more than many of the larger implants. With the cost of the implant fixture itself being a small part of the entire restoration how much do you want to reduce your fee? Maybe $50 - $100. We are free to charge what ever we wish this is the USA.

Considering that the bicuspids (20 & 21) have decay and mandibular bicuspids have successfully served as abutments in the past. I would consider a three unit FPD from the implant to the second bicuspid. I've been abutting natural teeth to implants for decades without any adverse effect. One should place a coping over the natural abutment. The desired reduction and decay removal will require a root canal for #20. Also, one could remove #20 and place an implant and restore with a three unit implant supported FPD. The occlusal plane of the opposing teeth requires correction. The patients ability to maintain proper oral hygiene is of paramount importance. The patient will have to improve in this area.

The patient is on a limited budget which means cost is a concern. Presumably, since the patient is having other dental treatment elsewhere in the mouth, would prefer something cost effective and speedy. Val and Dr Bob's suggestion of a one piece implant may solve the problems of cost and speed. A one piece can be placed flapless at high torque distal to the existing implant that will allow for early loading with a two unit bridge and avoid adverse cantilever forces. I did a similar case successfully for a different reason.

Hi, very interesting comments. I took advantages of all of those. I do not like to go radical to bicuspid, just filling is enough, except need endo. I like CRS' and Dr. J Kanter's ideas at most. Appreciate for all comments. God be less you all Good luck

This discussion seems to ignore the upper 7 which is the key to the patients future. A correctly contoured implant crown on the lower can prevent the super-eruption of the 7, thus maintaining the contact point and preventing/reducing future root caries @ the 6 or 7 embrasure. That would have been the placing dentists priority - to load the 2 upper teeth? More chew for your buck. Certainly an open embrasure between the lower 5 and the implant is no liability as if it is wide enough, the patient can clear any food with a flick of the tongue. Lazy tongues? .. that is a book not yet written?

It looks like the patient could benefit from an additional implant posterior to the subject implant. Assuming that the patient considers that alternative than a cantilever could be considered mesial to the existing implant considering the two implants were splinted. The cost of removing and replacing the existing implant would be greater than just adding an implant.