Implant supported bridge?

[luckytooth]

Hi,

This is the first time I would be treatment planning an implant supported bridge (as a new graduate) and would like some inputs/guidance from fellow dentists. The patient is a transferred case from another doctor and is highly interested in implant supported bridge (#14-16). Implant for #14 is already uncovered, #15 was extracted with possible sinus perforation couple of months back and #16 is a healthy tooth. I will be seeing the patient first time tomorrow but I have this information from previous notes.M/H was mostly non contributory but will confirm tomorrow if anything specific.

I would like to know how to proceed with the case and what should be discussed with the patient before starting the case? I have learnt implants in DS so have basic idea working with it. I also understand that #16 should be perio sound if I have to use it as an abutment (although I would be using a wisdom tooth as abutment for the first time) and would also check #15 area to make sure that there is no symptoms of perf from ext.

Is there a good article that I can read up on this or some one can guide me through the clinical process briefly ( prepping #16 first , taking impression with abutment on #14, metal frame work tryin?) . Any help would be greatly appreciated.

Thanks.

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[CMistry]

You're trying to bridge an implant to a natural tooth?

 

[LilFalafel]

My faculty would freak out with the thought of that. We're taught to never have an implant and natural tooth as abutments for the same FPD, like you're planning. I would trash that idea asap and think about leaving the patient in first molar occlusion (what's opposing on the LL?) or placing an implant at site #15 and having two implants side-by-side

 

[luckytooth]

yes, that is the treatment plan.

 

[luckytooth]

As I mentioned, I have not done any implant supported bridge so I wasn't sure about it. I have done implant supported crowns and familiar with it.

 

[djeffreyt]

This is an unreliable treatment plan and I'm sorry you inherited it. The forces of occlusion against a natural tooth versus an implant are very different and you are about to try and connect them together. While in the short term, this will probably be okay, long term this we probably cause some problems.

Assuming #16 is in good shape, I would leave the patient in 1st molar occlusion and explain that the patient, if they wanted, they could put the money saved toward an implant in #15 if the bone height is there and the sinus isn't just laying all over. Otherwise, leave it at 1st molar occlusion.

 

[CMistry]

yes, that is the treatment plan.

Then you need to adjust the treatment plan. Due to the physiologic differences between osseointegration and a natural PDL, they should not be adjoined. The other options, as I'm sure you know, are single implant placement or a partial/flipper/nesbit.

 

[Mackchops]

Then you need to adjust the treatment plan. Due to the physiologic differences between osseointegration and a natural PDL, they should not be adjoined. The other options, as I'm sure you know, are single implant placement or a partial/flipper/nesbit.

+1... there are few hard and fast "rules" in dentistry. This is one of them.

 

[luckytooth]

Thanks to all.
I am going to discuss #14 and #15 STI restoration with the patient tomorrow instead of putting the bridge and implant at risk due to unbalanced occlusal forces. I'm glad I discussed the topic in advance.

 

[luckytooth]

Came across an interesting suggestion for a similar case on an implant website:

"I reccomend you cantelever a fake tooth off of the crown that will be attached to the implant. Have the lab make a "distal rest" off the floating, fake tooth that will rest on the chewing surface of the wisdom tooth (3rd molar). You get a bridge without having to cut the heck out of the wisdom tooth. This will allow the natural movement of the wisdom tooth in it's ligaments, but still allow full suport of the fake tooth."

What would you say??

 

[CaliDDS1986]

Yes it's possible, but your putting double the forces on that one implant hence making it more likely to failure. I wouldn't do it on one of my patients. Either 1st molar occlusion or save up the money for implant/sinus lift at 15.

 

[Halcion]

My faculty would freak out with the thought of that. We're taught to never have an implant and natural tooth as abutments for the same FPD, like you're planning. I would trash that idea asap and think about leaving the patient in first molar occlusion (what's opposing on the LL?) or placing an implant at site #15 and having two implants side-by-side

Ditto.

Never do an FPD with one abutment as an implant and the other as a natural tooth.

 

[ziptree]

Does the patient have #17?

If #16 is in occlusion and all indications are to save it, then keep it, place an implant in #15 and restore #14 and #15 separately. Otherwise, do the same except extract #16.

You'll get yourself in trouble if you do any type of natural tooth/implant supported FPD or cantilever FPD.

Another option is to place a Locator on #14 and attach an RPD to it if the patient is missing any other maxillary teeth.

Oh, and a FYI to everyone mentioning leaving the patient in first-molar occlusion. If you do this with your patients, **make sure you treatment plan an occlusal guard to prevent supraeruption of any remaining second molars without an opposing tooth.**

 

[jacksonkelly]

Theres a literature review by Greenstein and Tarnow about connecting implants to natural teeth I suggest that you should go through it.
We dont connect implants to natural teeth because the fpd will cause intrusion of the teeth and/ or decementing of the prosthesis, precision attachment makes it even worse. I also dont recommend cantilevering a pontic on #15, with a posterior cantilever, with this method you are increasing the forces on the implant by 8 times.
Another note, Im not sure how someone can prep #16 and capture the finish line accurately.
As others stated its either place an implant in #15 or ext #16 and have pt in first molar occlusion. There are other factors that come into play that you should be aware of like the condition and type of opposing teeth and parafunctional habits. For example If the pt is a female with opposing denture or rpd and no parafunctional habits first molar occlusion would be adequate. But if pt is a male with severe clenching/bruxism i would recommend placing implant in #15 and connecting crowns of 14 and 15 together.
Carl Misch has a great book that will answer all your questions.

Keep it simple 🙂

 

[caffeinehigh]

Theres a literature review by Greenstein and Tarnow about connecting implants to natural teeth I suggest that you should go through it.
We dont connect implants to natural teeth because the fpd will cause intrusion of the teeth and/ or decementing of the prosthesis, precision attachment makes it even worse. I also dont recommend cantilevering a pontic on #15, with a posterior cantilever, with this method you are increasing the forces on the implant by 8 times.
Another note, Im not sure how someone can prep #16 and capture the finish line accurately.
As others stated its either place an implant in #15 or ext #16 and have pt in first molar occlusion. There are other factors that come into play that you should be aware of like the condition and type of opposing teeth and parafunctional habits. For example If the pt is a female with opposing denture or rpd and no parafunctional habits first molar occlusion would be adequate. But if pt is a male with severe clenching/bruxism i would recommend placing implant in #15 and connecting crowns of 14 and 15 together.
Carl Misch has a great book that will answer all your questions.

Keep it simple 🙂

Greenstein, Gary; John Cavallaro, Richard Smith, Deniis Tarnow. Connecting Teeth to Implants: A Critical Review of the Literature and Presentation of Practical Guidelines. Compendium 30(7): 440-453, Sept 2009.

Interesting article....

While you're at it and considering the cantilever....
Greenstein G, Cavallaro J. Cantilevers extending from unilateral implant-supported fixed prostheses: A review of the literature and presentation of practical guidelines: J Am Dent Assoc 2010;141; 1221-1230.

 

[BryanD]

You will end up intruding the natural tooth in the long run, if you connect an implant to a natural tooth through an FPD. Save yourself from the trouble and don't do it.

 

[drtre1]

Have you thought about ortho to move #16 in to site of #15 (Assuming #16 is sound)? Not sure if this is a realistic option, I just didnt see this mentioned yet.