message board Missing Laterals, Bonded Maryland Bridges, Ribbond or Something Else?» A Townie seeks the best option for a young patient with missing laterals. Dentaltown.com > Message Boards > Cosmetic Dentistry > Missing Laterals, Bonded Maryland Bridges, Ribbond or Something Else? Heisman Member Since: 12/15/08 Post: 1 of 70 Keep the conversation about implants and Maryland Bridges rolling on Dentaltown.com s other message boards. Missing Laterals Not Enough Room for Implants Help! Search: Patient Blames Me I m looking for some guidance on a case. Patient is 22 years old and has missing laterals. He s had consults with two oral surgeons about implants and they both agree that there is not sufficient space needed for implants. He is not interested in orthodontics to try and create the room for implants and was told it would take quite a while and still might not be successful. Here are some pictures I took from hygiene. He is coming back next week for impressions and after that we will plan and then present the case to him. He currently wears a retainer and that has served him well for the last eight to 10 years. But he is getting ready to graduate college and wants to have something more permanent in his mouth. Of 6, 8, 9 and 11, he is only hitting on #9 and the rest of the anterior bite is slightly open. I am leaning toward bonded Maryland bridges, but I did not know if others would choose Ribbond or another option. Thoughts? A More Predictable Alternative to Maryland Bridges Search: Implants and Maryland Bridges Fig. 1 Fig. 2 Fig. 1: Pano indicating insufficient space for implants Fig. 2: Missing laterals Fig. 3: With ortho retainer in place Fig. 3 AJeziorski Member Since: 12/03/11 Post: 2 of 70 drrick Member Since: 03/19/00 Post: 3 of 70 I would like to know the dimensions of the bone currently. I think a CT would be a good second opinion so you know how much bone is there and then look into every implant maker to see if there is something that could work. Maryland bridges done well can last quite some time or you could you do a traditional bridge. That makes sense. Plus, if he only needs a little room that really shouldn t be that long of an ortho case (at least from looking at the records posted). Some distal root tip on the canines and mesial root tip on the centrals could do wonders here if we are look- continued on page 34 32
message board continued from page 32 ing at a mesial distal space shortage. If it is buccal lingual, will some grafting help? I don t know enough about that to tell you, but I am sure someone else here will. rundoc Member Since: 07/05/10 Post: 4 of 70 zdravkodimitrov Member Since: 08/30/11 Post: 5 of 70 scotts studio Member Since: 01/20/12 Post: 6 of 70 Looks like the roots are angled poorly for the implants, but it can be misleading. Is he finished growing? You sure? How? (cephs). There is room for the laterals as the retainer shows that, plus the facial tissue defect. Could do lateral wings cantilevered off the centrals, however, these are often a maintenance hassle with fractures, debonding and such. Plus, you will need some gingival augmentation to make them look better than the retainer does. Once you start going there, the big question is if the adjacent root angulation allows implants. If not, it needs to change. It s more of a soft-tissue issue than a bone issue, maybe. No one wants ortho or surgery, but no one wants fractured cantilevers either. At 22 years old, I would not be too keen on implants. This case is ideal for adhesive e.max cantilevers from the centrals, even without soft-tissue augmentation. Just take the time to form ovoid pontic on the soft tissues. They will look extremely aesthetic. I just did a case like this with Lava. No, you can t bond but with some retention grooves it works well. You can also get the zirconia much thinner on the lingual vs. e.max. doctored Member Since: 09/21/02 Post: 8 of 70 Before taking a handpiece to these virgin teeth, I would send the patient for a CBCT. The patient might be able to have 2.8mm mini-implants or possibly 3mm Astra implants. If these are not options, I would not prepare any of the teeth for full coverage. There are several options that can be used with bonded retainers on the lingual considering there is an open bite with only incisal contact on #9. Ed acemo1 Member Since: 10/21/03 Post: 10 of 70 Rubinsteindds Member Since: 08/15/07 Post: 16 of 70 zdravkodimitrov Member Since: 08/30/11 Post: 21 of 70 I am with Ed as well. This person is better off with the ortho retainer until implants can be placed. Cutting these pristine virgin teeth down for full-coverage retainers should never be done in this day and age. Bridges suck! A smile photo would be helpful in evaluating the lip line. Having done a number of these both ways, there are times where you have room for an implant, but the architecture might still leave you with an unaesthetic result, missing or misshapen papilla, emergence issues, etc. Though I usually favor the implants, I have occasionally looked back at one of these and wished I had given more consideration to a resin-bonded bridge. I ve just realized that I suggested cantilevers. What I meant from the beginning was Maryland-type-min prep on lingual and lingual wing on the abutment. (I would prefer the central bigger bonding surface, but canine is OK, too). continued on page 36 34
message board continued from page 34 Heisman Member Since: 12/15/08 Post: 23 of 70 Thanks for the suggestions. Here s a little more information. The patient had a consult with his previous dentist and oral surgeon around age 18 about placing implants and was told it was not an option. He moved to my city and started seeing me as a dentist last year, and I felt the implants would still be the best option. So, I talked him into getting a second opinion and cone beam to re-evaluate for implants. Well, the oral surgeon had a couple problems with the case. First, the interproximal space was insufficient (he uses Astra mainly) but he and I both felt the inclination could be improved with ortho. Second problem is a little difficult to see with my photo. The buccal bone is deficient I will take photos after we get full models and see if I can get that to show better. In talking with my oral surgeon, the combination of these two issues was going to complicate the case to the point where he felt we should explore other options. Also, just for clarification, I would not prep these teeth down and do full coverage either, especially at his age. I ve only done one winged Maryland Bridge and it was about three months ago, so I really don t have any anecdotal evidence of success. I will check our schedule and see when he is coming in for records. I know my next question for you all will be what material you use. I m interested to see who would do it in Lava and who would go with e.max. Let me see if I can get him in this week and I ll take a few more pictures and models and then hopefully that will give you all the information you want about this case. Thanks again! gmoor Member Since: 02/05/04 Post: 26 of 70 My ortho guys would open that much space in three months: strip contacts and open. I ve done it a dozen times on bilateral missing laterals and unilateral. Often when we say the patient refuses ortho, then we have not explained it to them correctly. This is a case where I d give it as his only choice if he wants long-term results. Resin-bonded bridges can last a long time but only if you groove the teeth. This is 2013. You open the space and do implants. Guy continued on page 38 36 FREE FACTS, circle 41 on card
message board continued from page 36 Uwe Mohr MDT Member Since: 01/10/05 Post: 34 of 70 velogeek Member Since: 04/15/10 Post: 37 of 70 A mini-implant with an e.max crown for now. They can last quite a while. Then when ortho is finished, revisit. E.max is contra-indicated when you do a cantilever, but for a single crown on here it would be good and as much as I dislike mini-implants, it would be a good long-term temporary/semi-permanent solution. I agree, ortho, grafting and implants are the best treatment plan, but if restorative is the only option, how about a 3/4 pin ledge crown on cuspid and cantilever a lateral pontic? doctored Member Since: 09/21/02 Post: 38 of 70 Too difficult to prepare and patients hate gold! I did a fair number of these years ago. I have not in awhile. The last patient I did one for was thrilled. It was cemented with ZOP. Ed John Nosti Member Since: 02/23/04 Post: 47 of 70 I would not use zirconia. In the example of a single wing on the abutment with a cantilever pontic, nearly any material can be used in that situation if your prep design is correct. E.max fracturing at the connector is a lab fabrication issue, not a material issue. That is plain and simple. I have many e.max cantilevers where I replaced fixed bridges from 38
message board canine to centrals with a lateral cantilever off the canine and a single crown on the central. The aesthetics of these are much higher from the loss of a connector between the lateral and central. Hygiene is better and the forces on the anterior arch are no longer splinted between the canine and central. I am not saying a full crown on the canine is an option here, because it isn t, but a properly prepared wing on the lingual of the canine could work in this situation. I follow David Hornbrook s R-prep design protocol for this situation because traditional wing prep wasn t sufficient. Personally, I would push this patient into ortho. Like Guy, Ed, Lane and the rest of the crew suggested, ortho could be very fast on this patient. I would ask this kid if he has an extra 20K lying around to replace these fixed options every 10 years. Kids this age need to be told they only have one option (the best option). I would throw in the discussion, If you were my son this is how I would do it, and I wouldn t do it any other way! JAN 26 2013 Find it online at: www.dentaltown.com search Missing Laterals Small Mouth» FREE FACTS, circle 12 on card dentaltown.com «APRIL 2013 39