Now What?

[dmonwaxa]

Some more pics for evaluation.

 

[rkm rdt]

The diagnostic waxup should have been done 6-8 months ago. The only way this case could be made retrievable is with a partial over locators. The cost of any other option will help change the patient and dentist's mind.

 

[TheLabGuy]

The diagnostic waxup should have been done 6-8 months ago. The only way this case could be made retrievable is with a partial over locators. The cost of any other option will help change the patient and dentist's mind.

Very well stated!!!!!!!!!!

 

[kcdt]

kcdt, no no no the patient did'nt request set screws, he "demanded" esthetics. The doc's major concern was retrievability.

Gotcha my bad, it seemed to read that way.

 

[dmonwaxa]

A diagnostic waxup was done, a stone model was made from the wax up. Changes were made to that, and here we are. Patient did not want a partial, locator retained or otherwise; and the Doc also felt a partial was out of the question. The votes so far rpd,cementable or set screws: 1,4,3

 

[dmonwaxa]

Sorry for any mis understanding. My bad. I'm definitely gonna be put in the corner after this.

 

[kcdt]

The diagnostic waxup should have been done 6-8 months ago. The only way this case could be made retrievable is with a partial over locators. The cost of any other option will help change the patient and dentist's mind.

Your point on the wax up is right. What was that adage about planning to fail?
I think you have a valid point about an RPD over Locators, but if I'd dropped a serious chunk of change and only wound up in a partial I'd be really pissed. The lingual set screws wont be cheap, but it will provide retrievability with cement retained type of esthetics. I'll bet money the patient wont settle for anything that's not fixed.

If I had a preference, my first vote goes to cement retained, my second to the lingual screws.

 

[dmonwaxa]

I think you have a valid point about an RPD over Locators, but if I'd dropped a serious chunk of change and only wound up in a partial I'd be really pissed. The lingual set screws wont be cheap, but it will provide retrievability with cement retained type of esthetics. I'll bet money the patient wont settle for anything that's not fixed.

If I had a preference, my first vote goes to cement retained, my second to the lingual screws.

And right you are, patients look at it this way all that for a piece of plastic? (That brings up another question but I'll leave that for another discussion)
So things are heating up, any more ideas, Zr is not an option at this point; no locators and no cementable,,,Now what?I 'm leaning.

 

[JohnWilson]

Its absolutely frustrating to the artist in us all that our clients sometimes do not take our advice and plan accordingly.

This case EASILY could have been a home run esthetically. It will now have to be presented properly to the patient as expectation may never be able to be met.

Make sure your client knows the pros and cons of the plan before you start. These cases often come back to be YOUR headache when it is the clients failure, protect yourself now with communication before potential damage is done to the relationship.

 

[kcdt]

A couple of questions that come to my mind. since there was a wax up, was a guide made? If so, how did this ****ty placement happen? Was it even used? Did the OS find no bone for ideal placement and just go cowboy?
If it was bone, why wasn't imaging done first when the set up was accomplished? Did they quote some iron clad price and now augmentation is off the table 'cause no one insisted.
Handing off this kind of piss poor placement to the lab and asking for mental gymnastics to try and cover up crappy surgery is BS. THAT"S WHAT THE G*D*****D WAX UP WAS FOR, DOCTOR!

Sorry for the caps, but we should be WAY past seeing this lack of attention to the established protocols by now. It just reminds me of the early-mid nineties....

 

[BruceQuality]

I see a lot of this type of case go out of the lab. Angled implants seem to be more common than parallel... So it seems to be a cementable option in order to correct the angulation issue and get the esthetics desired.

Retrievability is a low priority at this point. Perhaps if it is such a concern for the doctor, he could attempt to use temporary cement when placing the bridge...

Rhetorical questions here, no need to respond in the forum: Why is he so concerned with being able to remove the bridge? It's simply a matter of cutting the bridge off and replacing it with a new bridge, esp if it is under warranty from the lab. What is the warranty on the bridge to the doctor?

Find out more about the doctor's concerns and deal with them accordingly.

 

[rkm rdt]

I see this type of situation all of the time.It is becoming the rule not the exception.

"If it was bone, why wasn't imaging done first when the set up was accomplished?"

Good question kcdt. Once again it comes down to time and money.
I would opt for custom abutments and a cementable bridge as well.

 

[Clear Precision Dental]

Temporary cement isn't that temporary when it is placed between an abutment and a crown (or bridge). Most of the time it is just as permanent as any permanent crown cement. I've heard that even TempBondNE mixed 50-50 with Vaseline still sticks like a banshee if the preps are even approaching ideal.

My vote: Fabricate custom abutments that correct the problem with angulation (Zr if possible). Make an esthetic restoration that everyone will be thrilled with [but keep the framework thinner over the location of the abutment screws].

Then, make a guide that fits over the bridgework (and a few adjacent reference teeth) that will give information as to the location and angle of the screw-access holes via holes drilled in the guide and cross-checked with some longer screws from a transfer coping.

Have the Doc torque everything down, and cement the bridge. In the future if there is a problem, the Doc places the guide over the bridge and "punches through" the bridge porcelain and framework in the areas where the abutment screws are located and UNSCREWS the bridge. This is much quicker to remove than trying to section the bridge while dinging up the custom abutments. He would then need to place healing abutments and a provisional (aka "flipper").

The bridge can then be placed in an oven (600 deg for 40 min) and the cement will break down enough to separate the components. Then things can be repaired or remade on the original casts, if needed.

In reality, the biting pressure and vector of forces on the anterior teeth are less (at least in psi) than other locations. In this case you have 3 abutment screws for 4 teeth, so the predictability is high that the restoration should have longevity.

We get a lot of these "RESCUE ME" cases where some untrained dentists or oral surgeon/periodontists are trying to jump aboard the implant restoration bandwagon without thinking through the entire process. Then the lab has to come in and make the dang thing clinically successful. Without some conversation, they will do it to you AGAIN thinking this is the standard way to get the best result. Conversations and education will result in a paring that is favorable for the dentist, the surgeon, the patient and the lab!

 

[TLA]

For what it's worth, Mr. Wilson's technique is the best choice for this. Barring the fact that you may not have access to all the materials, I'd at least recommend milled abutments (2degree tapers) and have the Dr. cement with temp cut 1/2 and 1/2 with vaseline for retrievability. Anyone ever try to screw/unscrew those tiny lingual set screws, especially accessing from the lingual/maxillary? I have... you practically have to stand the patient upside down to get to them! If you want 'lingual screws', then go with tube and screws from AI...case like this doesn't need but 1 or maybe even 2 if you have the room (i.e. open bite!). Lay them in the interproximals so the Dr. can play with his screws from the incisal edges. At least they're not in the midline and coming out in the vestibules like my last case!

 

[kcdt]

I still say an imaging appliance and a cone beam are within reach of most any clinician- if not to own, then to refer for planning. Trial and error at the patient's expense is not acceptable. If the Dr is such a newbie, then how about a display of character instead of forging ahead in ignorance?
Sacralogos in a crustum, I live in the middle of nowhere and I can name at least a half dozen offices with cone beam.

 

[kcdt]

It seems apparent to me that the OS never got the message that Restorative wanted screw retained. Love the Dr to Dr teamwork....

 

[dmonwaxa]

Wow so many ideas on how you would approach this, and you all make strong arguments. For the record the case is completed and I just want to say thanks to all those for sharing their thoughts. We see cases like this every day, they are challenging and we’re expected to work miracles. Results are usually directly related to the amount of communication one is provided and one’s ability to interpret what’s being said. But before you put me in the corner let me say this.

We can all learn something from this opportunity. When initially presented with a situation like this we either have a knee jerk reaction shouting out expletives or sigh and maintain our professionalism. Effective communication should be the pinnacle of any relationship. Not having all the information necessary to effectively solve a given problem can be challenging technically, and even more so when maintaining interpersonal and professional relationships. In complete fairness the restorative clinician inherited this case due to the relocation of the patient. The patient showed up with cover screws and a flipper; that was it, so we basically had to start from scratch.

At the time of presentation by the patient there were no notes in his records identifying the type of implants used, nor were there any diagnostics casts, wax up available. I was called in, we met with the patient and I was able to ID the implant. At that point an impression was taken to provide a diagnostic wax up and a starting point. As stated before esthetics was a priority, the doc’s requests were adhered to regarding retrievability. A decision was made to negate individual abutments and cementation. Options narrowed, we opted for lingual set screws over a cast sub structure.

This case was done about 4 years ago but I think there are some good learning opportunities to be had, not only technically but professionally. Forgive me if I led you to believe it was current. But I do appreciate all the input given by all. BTW there were some front runners. You’ll soon know who you are. Now there are more than one ways to skin a cat, but given my restrictive options this is what I came up with.

As an aside, this was due to the patient’s desire for aesthetics with an aggressive approach to ortho, bone never remodeled and teeth had to be extracted , the surgeon had to place implants in what was left of the bone. Aesthics? No, Irony.
I’ll go to the corner now.

 

[JohnWilson]

I kinda of knew it was a done deal, just was seeing how it would play out. The diag. with the plastic parts was the clue

Looks great, I would like to see the ling view if you have one.

I enjoyed the convo/thread, great job.

 

[dmonwaxa]

Thank You, John. You're way too exrerienced to slip one past you. But like you so early suggested; a telescopic type restoration secured with set screws.

 

[Al.]

Nice case!

If you wanted could you have made the screws on the occlusal for easier access or are there negatives to doing that?