How would you treatment plan this case?

[AshleyMarkDMD]

Folks,
I realize that this is a dental lab network - however - how many times have you received cases and wondered what the hell is the doc doing? Probably on a daily basis.
In 4 years, it's extremely difficult to teach students to treatment plan patients well. Students are just trying to learn the basics - cook book style -and get out. Probably, just like any other program, including CDT. It's not until you have a few years under your belt and go back for advanced training, where you can finally have that ah-hah moment. There is no place that I"m aware of where folks can go online to learn how others treatment plan cases...with assistance from not only other docs - but you folks - the dental lab techs. Collaboration, virtually. The capabilities of materials have changed in the past few years, and most dentists, unless they are taught otherwise - learn nothing more than PFM crowns....that was me until 1 year ago. So, please take a look at this first case that I put up on a wiki site and chime in with your perspective. It will help the clinical folks......trust me...

Once the case is submitted, they only see what returns - and no nothing of what goes on behind the scenes.

Thanks

Ashley

https://allthingsdentistry.wikispaces.com/My+Implant+Sucks

 

[TheLabGuy]

Any pictures with the patient at 'lip at rest', occlusal photos, natural smile, at centric, buccal with mirrors. I would be more than happy to walk anyone through a Treatment Planning Quint (Aesthetics, Perio, Occlusal, Restorative, TMD) but I really need those particular photo's (and x-rays) to move forward. I do these type of cases everyday, which includes the treatment planning so I'd be more than happy to comment with the added info. Good Stuff!!! Any idea why that implant dehis'd?

 

[Jo Chen]

Zimmer 3.5 platform type implant. Pain at the apical of the implant and exposed from the bone that extensive? X-ray? Any paresthesia? Implant should be taken out in my humble opinion. Bone graft and start over.

 

[marvel]

I love LOVE my zirconium implants!

Oh! Dr Ashley, thanks for posting this photo.
https://allthingsdentistry.wikispaces.com/My+Implant+Sucks

I love LOVE my zirconium implants! For reasons I won't go into, I first needed extensive bone grafting and healing time to ready my mouth for implanting bicuspid replacements 4, 5, & a smaller graft for 21. An A+++++ perio/implantologist biologic Dr in San Antonio, TX, who also teaches seminars, performed the surgeries and I healed well.

From a distance this looks to be a healthy young woman with overall good bone, pretty gingiva, and nice teeth. Does she know an oral bone graft done expertly can be less traumatic than the needle pricks to numb the area? And is she aware of the zirconium implant alternative?

As p/ts we rely on our Drs, who sometimes don't tell us all that's needed to know to make well-informed decisions together. This can be especially true with an anxious p/t who may be over talkative (like moi at times).

[Edit]: Looking at the website closeups her gums are inflamed. Taking these daily supps could help her mouth heal, and may help her feel better generally: 500mg-1000mg Vitamin C BID AM/PM, 5000 IU Vitamin D3 daily, and a daily multiple vitamin/mineral tablet with plenty of B vitamins. These are minimum. Add'l Vitamin E 400 IU - 1000 IU daily, and an extra 10,000 IU A (not Beta Carotene) daily likely would help, too; as would adding 400mg magnesium. And she needs to eat nutritiously before caving in to junk; you are the doc.

Also, before drilling those multiple pre-caries lesions, you might wanna see if putting her on Squigle Tooth Builder Sensitive Toothpaste starts them remineralizing; it's good for the gums, too. See a description of how it works here: Buy Squigle - Tooth Builder Sensitive Toothpaste - 4.4 oz. at LuckyVitamin.com (I do not profit from this link). The detailed 5* reviews on Amazon.com are especially impressive.

[Edit]: Thanks to patmo141 below for pointing out previous unclarities in this post; I appreciate it.

 

[patmo141]

pretty gingiva

@marvel
I have to respectfully disagree. Check out this picture of the patient's diagnostic cast (in the link). See how the papilla look 'inflated' or 'bulbous.' That's a (halmark) sign of inflammation/ginivitis and maybe periodontitis (other objective measures needed to confirm periodontitis).

https://lh5.googleusercontent.com/-...M/9hl1Qq8yuHs/s912/AllThingsDentistryAS-7.JPG


AshleyMark:

Where did you go to dental school? This format seems very, very familiar.

 

[marvel]

Agreed 100%

@marvel
I have to respectfully disagree. Check out this picture of the patient's diagnostic cast (in the link). See how the papilla look 'inflated' or 'bulbous.' That's a (halmark) sign of inflammation/ginivitis and maybe periodontitis (other objective measures needed to confirm periodontitis). ...

Agreed 100%; thanks for pointing out the unclarity despite the edit. The Vitamins C and D are for helping heal the gingivitis and/or periodontitis, also better nutrition should help, plus the toothpaste says it fights gingivitis as well as remineralizing the teeth.

 

[AshleyMarkDMD]

@marvel
I have to respectfully disagree. Check out this picture of the patient's diagnostic cast (in the link). See how the papilla look 'inflated' or 'bulbous.' That's a (halmark) sign of inflammation/ginivitis and maybe periodontitis (other objective measures needed to confirm periodontitis).

https://lh5.googleusercontent.com/-...M/9hl1Qq8yuHs/s912/AllThingsDentistryAS-7.JPG


AshleyMark:

Where did you go to dental school? This format seems very, very familiar.

I'm an Army AEGD-2 resident - hence the format.....

 

[AshleyMarkDMD]

Any pictures with the patient at 'lip at rest', occlusal photos, natural smile, at centric, buccal with mirrors. I would be more than happy to walk anyone through a Treatment Planning Quint (Aesthetics, Perio, Occlusal, Restorative, TMD) but I really need those particular photo's (and x-rays) to move forward. I do these type of cases everyday, which includes the treatment planning so I'd be more than happy to comment with the added info. Good Stuff!!! Any idea why that implant dehis'd?

Before I move on, the rest of the photos are at the bottom of the wiki page (For the next case, I"ll have to make this more evident). I've posted the slideshow here.
https://picasaweb.google.com/105920053692011871275/PatientAS?authuser=0&feat=directlink

 

[Xydorf]

Agreed 100%; thanks for pointing out the unclarity despite the edit. The Vitamins C and D are for helping heal the gingivitis and/or periodontitis, also better nutrition should help, plus the toothpaste says it fights gingivitis as well as remineralizing the teeth.

WHERE ON EARTH are the studies to support this claim about the vitamins??

 

[PCDL]

Someone fire that implant in after a few martinis??

First off, is this a dehisence of bone or just a massive buccal fenestration? In either case, I agree with the above post recommending trephining the implant out. At that point, you may consider using a block graft (Zimmer J-block?) to regain some of the buccal plate. After some healing, lots of healing, use a stent to guide that implant in a bit more lingually angled. The big question you will face is how much the bone will resorb, and where your soft tissue will settle. You will have to get a bit creative, and use a temp and temp abutment, as well as some selective crown lengthening to even things out.

Once that is done, the rest should be a cake walk; comparatively.

 

[marvel]

Study Trail: Vitamins C, D3, & A1 Nutrition Can Heal Perio Problems

@marvel "Vitamins C and D are for helping heal the gingivitis and/or periodontitis, also better nutrition...." WHERE ON EARTH are the studies to support this claim about the vitamins??

Gosh! just saw this Q, and thank you for asking. Here is a general article with refs at the end, and in the right menu are links to more articles with more study refs, etc., etc.

This is only one treasure map; am leaving y'all the fun of following trails.
What Vitamins Are Good For The Gums? | LIVESTRONG.COM

There also are anecdotal stories on the web and in books.

And you can experiment with yourself. If you have any hint of gingival inflammation try even a min of 500mg vitamin C BID AM & PM, 5000IU vitamin D daily, and, especially if you don't eat well, a multi vit/min tablet. Clean teeth and mouth well once daily, ideally using a remineralizing, non-fluoride toothpaste or powder--I am not discussing fluoride in this post--scrubbing with a super-soft brush while gums still are tender, and see what happens.

If there is infection you might wanna swish now and then with warm salt water in heavy concentration, or baking soda, both of which kill oral bacteria. Salt dehydrates them and soda makes the oral environment too alkaline for them to thrive.

For active infection one my fave Drs has his perio p/ts paint their gums with Lugol's iodine, which one can get by prescription, or buy as a food sup.

Clean teeth and mouth well once every 24 hours

It does help most folks to keep their teeth and mouth clean. Breaking up plaque along the gumline and interproximally, cleaning teeth and oral cavity well even once every 24 hours will do it, according to my dentist friends, and from what I've read too.

My pros says after eating it's good to swish out food from around teeth with water and swallow. Wait 20 minutes to brush cuz during that time the body is remineralizing the teeth, which have lost nanoparticles at the CEJs from chewing. After 20 mins the repairs already have hardened and it's safe to brush, even with a firm toothbrush. That's from my pros; so far I haven't researched further but makes logical sense to me.

He says it's good for the teeth, too, to swish with water after drinking acidic stuff like soda, coffee, and tea.

If you eat refined starches like breads and cakes and crackers and have dry mouth, cleaning well once daily can be critical to restoring a healthy mouth and keeping it. Refined starches turn to sugar in the mouth and are sticky.

But thorough cleaning is not enough to regenerate tissue or even halt gin recession. Give a body the nutrients it needs, including enough protein to build a strong bony matrix, and see what happens.

[Edit:] Repeated bite trauma can cause bone loss in the absence of periodontal disease, too; research it and see.

 

[droberts]

Folks,
I realize that this is a dental lab network - however - how many times have you received cases and wondered what the hell is the doc doing? Probably on a daily basis.
In 4 years, it's extremely difficult to teach students to treatment plan patients well. Students are just trying to learn the basics - cook book style -and get out. Probably, just like any other program, including CDT. It's not until you have a few years under your belt and go back for advanced training, where you can finally have that ah-hah moment. There is no place that I"m aware of where folks can go online to learn how others treatment plan cases...with assistance from not only other docs - but you folks - the dental lab techs. Collaboration, virtually. The capabilities of materials have changed in the past few years, and most dentists, unless they are taught otherwise - learn nothing more than PFM crowns....that was me until 1 year ago. So, please take a look at this first case that I put up on a wiki site and chime in with your perspective. It will help the clinical folks......trust me...

Once the case is submitted, they only see what returns - and no nothing of what goes on behind the scenes.

Thanks

Ashley

https://allthingsdentistry.wikispaces.com/My+Implant+Sucks

Ashley,

What information is your lab giving you for assistance on these cases?

 

[marvel]

Implant angles Q

Someone fire that implant in after a few martinis??

Ha ha looks it, doesn't it.

... After some healing, lots of healing, use a stent to guide that implant in a bit more lingually angled. The big question you will face is how much the bone will resorb, and where your soft tissue will settle. ....

Once that is done, the rest should be a cake walk; comparatively.

What about the surrounding natural tooth root angles?

In the X-ray on the blog site they sure seem at odds with the plumb bob implant alignment. --I know this is not a consideration for anterior implants, which can be quite forgiving. The body will integrate bone around a well-placed anterior implant that is stable during healing. Once the implant is healed and being used the body will remodel bone around it, altering the dental arch profile accordingly.

But with the much greater chewing forces acting on the bicuspids and molars I am wondering if surrounding, natural tooth root angulation might be a consideration for posterior implant success?.

Response within quote.

[Edit:] Some dental implantology online CE classes are happening right now via Online Dental Education, Dental Learning - Dental XP. They also will email a newsletter letting you taste tempting bits of their offerings, which tend to be geared to Drs but not exclusively.

 

[PCDL]

Response within quote.

[Edit:] Some dental implantology online CE classes are happening right now via Online Dental Education, Dental Learning - Dental XP. They also will email a newsletter letting you taste tempting bits of their offerings, which tend to be geared to Drs but not exclusively.

Although the root angulations are at odds, I don't see anything that is overly problematic. The implant has to sneak in there somewhere, and as long as they lingualize it into the bone, there should be less of a problem.

Im not sure what you are referring to as far as the added forces applied to the bicuspids and molars, but the root angulation isn't too big of a deal as far as masticatory stress. The PDL takes the brunt of the load there, assuring a bit of a cushion. If there are future implant restorations planned for the posterior, I would design them to be of an occlusal scheme that they immediately disclude in lateral excursions, and have point contact in centric using 40 micron paper.
One of the only cautions I would have is if the lower molar missing (#30?) is recent, do not place the implant in the distal root socket, as this often times creates a cantilever in the restoration itself, and can be attributed to undue stress on the implant, and loosening of abutment retention screws over time **In certain instances**.

I know the dentalxp site, its run by the Salama brothers and Team Atlanta, right?? Good clinicians, they have a lot of knowledge behind them.