Worst implant case I’ve seen: treatment options?
This is a real case and I think it’s the worst implant case I have ever seen. The patient (went out of the country for treatment) received implants in the mandibular anterior region which appears to have a diminished occlusogingival height. The implants are also very close together. From my perspective this case will be extremely difficult to restore as is. What kinds of treatment options are there for this patient? How can I best explain the situation to the patient?
![]worstimplantcase](https://osseonews.nyc3.cdn.digitaloceanspaces.com/wp-content/uploads/2013/03/worstimplantcase.png)
31 Comments on Worst implant case I’ve seen: treatment options?
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Dr. Alex Zavyalov
3/25/2013
Panoramic method gives not only horizontal, vertical but also angular distortions. Frontal teeth are more sensible to it and a discrepancy rate may vary up to 21 % there. So, based on this image only, I would not say that the situation is definitely hopeless. Moreover, no antagonists at that area and mastication forces will not be powerful. You can choose any type of prosthesis to restore lower jaw.
Eswar
3/29/2013
All posts are pretty doable, If we need to think out of the box for a minute.....
Considerations:
-Weak mandible,which may or not have been strengthened by the Implants
-Treat the case as if there could be a potential fracture
(Which leads to splinting the prostheses)
-Vertical ht of the Implants probably encroaches on the available VDO to restore the case with the least amount of physiologic interocclusal space as needed, but should be ok with a max denture.
So what would I do after all the investment on the Mandible and also on Maxilla-
Start off with extraction of remaining teeth on maxilla
Border Mold, Final Impression and Record base for maxilla
Fabricate record base for mandible to sit on the Implants
Jaw relations
Set teeth and fabricate maxillary denture on the maxilla.
Now, I will duplicate the ht of the lower rim
Fabricate custom abutments on each of the implants- yes-on all 8 of them
How would I deal with too close a distance between implants?
Not all implants are too close to one another, so the few that are...
I shall prep the implants with a fine diamond to gain just the needed space,
use UCLA abuts and prep them to be cast. For the rest of them I shall
use the same UCLAs unprepped.
Then, how do I duplicate the implants- well I wont.
Once all abuts are prepped/placed on implants-I shall adjust the ht
of the abuts to the ht of the occlusal rim that we preserved.
Then,all abuts will be cast and I shall go straight to the mouth,
Make sure I am parallel to one another on all abutments.
Then I shall treat it as C&B, make my final Impression,
mount my case, I shall get a frame,try in and get my FPD 1-8.
Reason to splint-because I would like to prevent any chance of fracture
It is better to overengineer in such a case than not.
Why would I not be scared with the FPD-because my opposing is a CD
and I shall have edge to edge occlusion, with probably just 1st bi occlusion
keep forces really minimal anteriorly and posteriorly.
Only reason to use all the implants if someone like this comes to me is because,
it is doable and we can better this ugly situation.
All other treatments listed from IS-OD to Hybrids are all valid.
I was just thinking if I want to do what no on else wants to do which is an FPD,
this is how I would do it.
All criticisms/advice most welcome.
Pynadath
3/25/2013
Am I missing something here?
Why is this going to be hard to restore? You do realie you don't have to restore every implant. Just restore the most distal ones and a few in between. Leave the others a sleeper implants.
As long as tree is no sign of failure or integration, what's the big deal?
naser
3/26/2013
i believe this mandible is going to get fractured .
Richard Hughes, DDS, FAAI
3/26/2013
There is a high probability that this mandible will fracture. This patient was abused.
Dr. Ikram BDS RDS MCPS C
3/26/2013
Its not a good quality OPG / or picture itself. although the implants are pretty close yet successfully osseointegrated, lets appreciate that. besides u may give any restorations to it. If the patient agrees, i would suggest a well made CPD may serve the purpose.
VR
3/26/2013
You are where you are with this case. The pan does not show bucco-lingual thickness, etc. Removal of the implants may only make the jaw weaker.
Restore only after using 3-D software to eval the whole situation.
I assume the patient has a max denture which can help achieve a balance between upper and lower for increased vertical dimension. This will also help the TMJs which are probably suffering from overclosure damage.
Dr. Trevor
3/26/2013
I would place locator abutments on 4 implants and prepare an implant retained removable lower denture. I would make sure that the denture base did not contact the remaining implants. I am not sure what explanation you need to give to the patient other than a clear analysis of the situation (the bone is very thin and I am concerned that your jaw will fracture if we place too much force on it) and a review of the treatment options. I would not attempt to remove implants, the potential bone loss could worsen the situation. I would avoid a fixed prosthetic with the hope that the proprioception from the removable would help prevent excessive biting forces.
Opposing would be a full upper immediate. I once tried to make an upper removable prosthetic with unilateral retention, it was a complete failure. The reduced biting force from the full upper is working in your favor here.
Dr McFatter
3/26/2013
Qusetions after evaluation of the CT- are the distal implants in a location that if connected with a bar there will be torsion on the prosthesis and implants when in function? I can't see the mental nerve so it is hard to tel-l but if both distal to mental foramen you dont want to connect in one piece-I would think that would make this pt more suscptible to mandibular fx. distal to the terminal implant. Im thinking that in this case the wink link may not be the implants of the prosthesis but the mandible
I think if they are anterior, this may have been beneficial for this pt in that the mandible can be fixed and splinted together with the implants using a bar or hybrid type device Most fx's seem to occur with a body fx in combination with one at a condyle in trauma cases. I don't know if this is true with a fx of a deficient mandible and where the most likely fx is in the deficient case.
Im not sure about locators unless they are with low retention and any snap in snap out appliance would scare me if retention too tight. would be interested to hear other restorative options and opinions and if splinting of some of these implants could protect this pt from fx--Anyway get the max teeth out-they will be a problem with any tx choice
Tuss
3/26/2013
Like Dr Trevor and Pyandath said - its not all bad, sleep some of the implants, use locators with either red or orange inserts and restore. Remove all the healing abutments and place cover screws on the slept implants. yes the patient was abused, I would have no issues with telling t he patient they had been over-treated if they asked me a direct question.
toothdoc
3/26/2013
My Experience With Restoring An Edentulous Arch With Short Implants Favors A BaR Overdenture Rather ThaN Locators. Locators Work Great When There Is Some Load Sharing With The Ridge/Tissue. This Case Is Going To Be Entirely Implant Supported. Pick Your BeSt 4-5 Implant, Maximize A-P Spread And Sleep The Others.
Don Rothenberg
3/26/2013
There are too many things going on here. It's amazing that the mandible did not fracture during placement of the implants.
What kind of restoration does the patient have now?
I believe a fixture restoration("All on 4") would be better then a removable(overdenture-O-Ring)restoration to help strengthen the mandible.
And in all honesty, I would not like to restore this case, as it is...because the dentist that does restore this patient, will marry the case.
It is a shame that the patient was treated like this...and since it was done out of the country ...they have NO recourse.
mwjohnson dds, ms
3/26/2013
I did research in graduate school relating to fractured mandibles after implant placement. The fractures only occured during integration (never after unless there was trauma such as a pool cue to the chin). The likelihood of a fracture was not related to vertical height but to mandibular width. An occlusal film would give you a better idea of the fracture risk. That being said, this is an easy cast to restore. Use the implants you want to use (i.e every other one or 4-5 of the implants evenly spaced around the mandible) and make a fixed hybrid restoration, sleeping the rest. This helps splint the implants as well. Locators are a poor way to stabilize this mandible and should definitely NOT be used. If you are not familiar with hybrid restorations, refer to a prosthodontist. I see too many patients incorrectly treated by well meaning general dentists because they don't know all the options available to the implant patient. As a prosthodontist, this isn't anywhere near the worst implant case I've seen or treated.
Dr. Gerald Rudick
3/26/2013
There is no question in my mind that the surgeon who placed these implants was very skilled....... is there a paresthesia as a result of impinging on the mental foramina?
The case is certainly restorable, and I would favor a fixed screw on prosthesis, trying to create as many embrasure spaces as possible........thinner abutments to open the spaces.
I have such a case in my practice for more than 20 years, where the implants were placed in France....and I too marvelled "how come the mandible did not fracture?"...but as stated above, once osseointegration has occurred, the jaw seems stronger.....and the patient has absolutely no problems with it.
It would be interesting to see a Cone Beam CT scan of this case, to see exactly where these implants are sitting, and how many of them as actually osseointegrated ....but if it is working.......let the patient enjoy his or her life with this case.
Gerald Rudick dds Montreal, Canada
Randy
3/26/2013
The restorative choice should be predicated on what will best lend itself to maintaining the implants. If peri-implantitis develops with significant bone loss, the mandible will fracture.
dinnymick
3/27/2013
Impressive array of Implants.The fracture concepts that have been mentioned would in engineering terms be minimised by fixing of these implants with a rigid prostthesis avoiding crossarch flexure.A mandible fracture could actually be restored this way.
Pretty simple case to restore from what is presented.
DrMILAN KUMAR
3/27/2013
As suggested by Dr Gerald Rudick a CBCT is a must on such case to locate the exact placement of implants,no dbout the Osseointegration in all are quite stable n intact.................... .2] but such a skilled surgeon why placed so many implants on such a low height mandible is really an interesting observation and quite questionable........................3] now on such case a ALL ON FOUR approach can safeguard making rest of the implant as sleeper and occlusive stability is going to be in harmony as VDO is normal..........................4]a occlussal radiography is also necessary ..........................................5]now instead of handling self the surgeon should be responsible enough to give rehab to a prosthodontist for a fixture load.............................................................even its a blunder but rehab is absolutely possible in a proper fashion......................................but the real challenge will arise in making upper planning for loader in ideal occlusion keeping the lower bone depth of mandible ....................................................thanks
CRS
3/27/2013
Yikes! I know this is not much help but I think the mandible will fracture at the distal implants bilaterally and it will require a iliac crest graft with a bone plate to fix. This almost reminds me of the mandibular staple implant since the implants are through the inferior border. I would not restore this, it will be a nightmare when it fractures , I would refer it to a prostodontist. So much for the team approach.Good luck.
CL KOAY
3/27/2013
It will be good to ask the patient what was the treatment plan the dentist and him or her have decided on. Was it for fixed or implant supported overdentures.
For such a severely resorped and probably D1 type of bone ; to place and to have the implants integrated which can be ascertained clinically by tapping with the handle of the mouth mirror and getting a solid metallic sound and no pain on percussion is really a feat and I take my hats off to the dentist.
I fully agreed with Dr. Alex on the analysis with OPG'S. What Gerald Rudick mentioned makes a lot of sense.
I may not agree with the dentist to place 8 implants. 4 implants with and overdenture will be my choice . This will allow easy hygiene and allow the patient to brush the other implants with healing caps on and for the restoring dentist to have easy access to manage of any complications should it arise. Thus as many colleagues have suggested to select some as sleeping implants is definitely a wise choice.
We need to remember that we are to care and help whenever we can for the patients and also for fellow dentist.
Dr. Gerald you must be in your 60's for you to have the implant patient from France under your care for 20 yrs. Correct me if I am wrong.
Have a good and enjoyable practice. Good day.
mahendra azad
3/28/2013
As suggested by others CBCT in this case will be of great help in planing the further treatment. The OPG appears to be not accurate and does not give the correct picture in this case.
Dan
3/28/2013
Its a bit over engineered but that's not a bad thing, right? If 1or2 fail there are still options. Some can even sleep. I don't think this atrophied mandible has been necessarily weakened by 8 osteotomies esp with integration unless there's a lousy failure that occurs. I certainly had successes with very atrophied mandibles esp in grad school. My question is how's the pt's mental nerve? Can she still feel her lip! The pan distorts like a colleague said. We can make bettr judgement and advice if we saw clinical photos? Take it too the fixture level impression stage, pour a cast, then decide
CRS
3/28/2013
Help me out on my logic, the eight implants rigidly splinted together are a solid inflexible unit with the weak points just distal on an atrophic mandible , hence the possibility of fracture. An over denture which would be implant retained would have force distributed back to the retro molar pads and the denture would not be rigid. I don't understand how a root form implant can make a mandible stronger? I do heartily agree that a cone beam is essential to see the width and how much lingual plate is present for continuity which could be the only thing holding this mandible together. Just how many edentulous pathologic fractures has this group personally treated and had experience with? It is really easy to sit back and give advice how "we need to help this patient and our fellow dentist who placed theses implants" and no problem to restore, put implants to sleep etc. If this mandible fractures with or without restoration of the crowded implants it could be very strongly argued that it was an iatrogenic fracture due to the implant over placement and restoration, if you want to help this patient towards that end take heed you have been advised. Personally I would send this patient to a university based prostodontist with an oral surgery back up in case the patient requires a free fibula or bone tray graft when this mandible goes. It is the prudent thing to do, since I doubt any of the implantologists have experience in this regardless of their posts. It is the right thing to do. You can't fix what you don't know and both the patient and the dentist who posted this need to be protected, also some of the senior more experienced posters have expressed concern about fracture. I think the other posters just want to express restoration to sound smart they are not giving wise advice. Nobody trains for these unfortunate situations, we just try to salvage what was poorly done, this patient was abused probably for the money or out of ignorance. A set of minis or bone grafting prior to 2-4 anterior locator implants would have be better with removal of the remaining upper failing teeth. I don't want to offend this is my advice and opinion, good luck and as always thanks for reading!
Dr. Samir Nayyar
3/28/2013
Hello
I agree with CRS that send the patient to a good university with full backup.
Don't try to do more wrong things to the patient which you don't know as the patient has already suffered a lot.
Best of luck..........
CRS
3/28/2013
Thanks Samir!
mwjohnson DDS, MS
3/28/2013
by loading the implants with a fixed prosthesis you are placing the posterior mandibular periosteum under tension. According to Wolfe's law, this tension creates bone apposition. Placing the periosteum under compression with a removable prosthesis stimulates bone resorption. During my pros. residency 20 + years ago it was thought that in resorbed mandibles a removable prosthesis should be made to decrease the force to the mandible. This has been disproven and in fact a fixed restoration is a better choice in severely resorbed mandibles. Those of us who have made hybrid style fixed prostheses over the last 25 years have seen actual bone growth of the posterior mandible over time and it can impinge on the underside of the hybrid cantilever. In this patient is there a concern about mandibular fracture? Yes. If a fixed prosthesis contraindicated? No way. In fact this helps splint the implants and creates a more favorable load characteristic to the body of the mandible.
CRS
3/28/2013
I think this case is a little extreme for Wolfe's law probably Murphy's law is a better bet!
OMS resident
4/1/2013
Implants placed in atrophic mandibles will NOT strengthen the bone, neither before, under or after osseointegration! C'mon guys... This is at best "a recon plate through the neck"-case waiting to happen... I guess CRS has a good point; send it to a University based prosthodontist with OMFS backup. Good luck!
Sb oms
4/3/2013
This has to be photo-shopped. It's just not possible to place this many 4+ mm diameter implants into an atrophic mandible. The placement angles do not look natural at all if you think about the shape of an atrophic mandible.
I'm calling your bluff osseonews, I think thus x-ray is fake.
Additionally, for all of you who recommended a cbct, it would be a useless radiograph. Think about the beam hardening, scatter, and artifact you get from one implant. Now stack 8 into the area of two inches. It would be non-diagnostic for the surrounding bone.
OsseoNews
4/3/2013
We rarely comment on the website, because it goes against our policy to interfere in discussions by our users who are practicing dentists, while we are not. However, the implications of this previous comment warrant a response, because it provides a good avenue to once again clarify how this website works and doesn't.
In short, there is no grand conspiracy. OsseoNews is simply a third-party platform, based on questions and cases submitted by dentists worldwide. We do not modify any case images whatsoever that we receive, except to resize them automatically so they fit on the website, as more fully explained in our Terms and Conditions. Basically, what you see is what we get.
Has some dentist duped us by submitting a fake case photo? We guess it's possible, but also much too unlikely to warrant any further investigation (does a dentist have nothing better to do than photoshop case photos and publish them on websites for no obvious benefit?). More importantly, suggestions of some mad dentist case photo manipulator are irrelevant to the discussion, which we think has been has been educational and helpful. Now back to dentistry...Sorry for the interruption.
Sb oms
4/3/2013
well said osseonews,
back to business- sorry for the mindless diversion
CRS
4/4/2013
It is not such a crazy comment since I would have thought the mandible was compromised since several of the implants are thru the inferior border and they are so long and wide. Also the inferior alveolar nerve is exposed on top of the bone, who does this?
