Complex Case Example–Tilted Dental Implant Used To Bypass Impacted Tooth and Bone Expansion for Missing Front Teeth

This patient presented to my office in Burbank by referral for dental implants from another patient. She had two dental problems. One was her 6 tooth front upper bridge was loose and had come out a few times and the second problem was her lower molar in the #19 position.

After examining her, it was noted that the 6 unit anterior bridge was only anchored by the two canine teeth. Both of those teeth had root canals and had broken off to the gumline. They are too weak to use for a new bridge. In this space where she had been missing the four center upper teeth (7-10) her bone had atrophied (shrunk) because the teeth have been missing for so long.

On the bottom jaw, her existing molar was cut in half by her previous dentist and a root canal was done through a very old procedure called a hemisection. She was walking around with basically half a tooth that wasn’t even re-crowned because of its poor prognosis. The complicating factor on the lower jaw was that she had an impacted premolar tooth stuck deeply in her jawbone. She was told an implant could not be done here because the impacted tooth was in the way. Generally speaking impacted teeth can be removed like wisdom teeth are impacted. This tooth is special because it is completely encased in bone and has a very high risk of nerve damage and jaw fracture to remove it.

In order to treat her in both the upper front and lower left #19 area several procedures in sequence were necessary. Her treatment took about 11 months to complete.

5 Steps to Successful Treatment

1. Extract the canine teeth #6 and 11 with simultaneous socket bone grafting and ridge splitting bone widening expansion.

Tooth #19 molar would be extracted at the same time as this procedure under IV sedation anesthesia.

I made her a temporary removable partial denture stayplate (some people call this a “flipper”) to be used as a temporary that was inserted on the same day of extraction and bone grafting.

2. After waiting 4 months for the bone graft for the upper front teeth to become strong bone , 3 implants were placed into the newly widened bone in the upper front area. At the same time, under sedation, a purposely tilted implant was angulated around the impacted premolar tooth.

The tip of the implant would be placed at an angle so that it would not hit the impacted tooth but the head of the implant would come out in a more ideal location for the molar.

3. The implants were allowed to heal for 4 months after placement.

4. A custom abutment was made for the angulated tilted implant in the #19 molar position. Custom abutments were also made for the 3 front implants so that their angle could be corrected and to be tall enough to support a bridge.

Custom abutments are able to correct angulation when implants are purposely placed in tilted positions such as the all on 4 procedure

5. The molar was replaced with a monolithic zirconia crown while the front bridge was custom fabricated from porcelain fused to metal with gum colored ceramic. Pink tissue porcelain was used so that the teeth would not look too long.

The pink porcelain edge does not show when she smiles, so no one can tell that both white and pink porcelain was used to make her smile looks much more natural. Both of these bridges are held by cement rather than by screws.

Keep in mind that her situation is compromised to begin with so a perfect result is not possible. She has an overbite from her upper jaw being too big which will always compromise the cosmetics of the front teeth. She is a very sweet woman in her 60s that just needed a healthy, confident smile that she would not have to worry about any more.

Every Dental Implant Case is Different

I think it is important to show cases to you that are real in every day dental practice. Nature made us all very unique and that is beautiful thing. If you have a unique case, and would like a second opinion, please contact our office and schedule your appointment.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry


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3 thoughts on “Complex Case Example–Tilted Dental Implant Used To Bypass Impacted Tooth and Bone Expansion for Missing Front Teeth

  1. Terry

    Good afternoon doc. I just read a post on the net and it really did informed me alot. I’m on warafin and I want to do a extraction on my tooth that hurts so bad. I went to the hospital and they be telling me that I will have to be admitted in the hospital for them them to monitor it. I’m my inr for last month is 2.47 n I’m taking 7.5 now every night. How can I Good afternoon doc. I just read a post on the net and it really did informed me alot. I’m on warafin and I want to do a extraction on my tooth that hurts so bad. I went to the hospital and they be telling me that I will have to be admitted in the hospital for them them to monitor it. I’m my inr for last month is 2.47 n I’m taking 7.5 now every night. How can I go along and do the procedure?

     

    Reply
    1. Ramsey Amin DDS

      Hello Terry,

      Thank you for contacting me. I’m happy to help. The more appropriate post for your question is this one:
      Blood Thinners and Dental Implants

      Warfarin is also known as Coumadin and is a blood thinner that prevents your blood from coagulating normally. So in essence, your dentist is worried that you will bleed to death from the extraction. Your INR which is called international normalized ratio seems to be in range. The INR is typically between 2 and 3 to be effective. Unless you have some very serious medical issues in addition to being on Coumadin, there isn’t a lot of reason to have this tooth extracted in the hospital! My guess is you have atrial fibrillation. Your dental implant specialist who will do the extraction may need to consult with you physician on possibly taking you off of Coumadin a couple days beforehand and then restarting it again about 24 hours later.

      In my own practice, I rarely takes somebody off of their blood thinner to remove just a single tooth. There are ways to manage bleeding without having to modify her medication. Sometimes the risk of coming off of Coumadin is higher than the risk of bleeding. Some patients can have a stroke, heart attack or pulmonary embolism during that 2-3 day period that there blood thickens.

      You need to find a dentist who is very comfortable dealing with patients on Coumadin. This would be my best advice. They need to understand your unique situation and medical history. You may want to consider having a same-day dental implant in order to avoid multiple surgeries and multiple bleeding episodes. Just a thought.

      Bleeding can also be managed using platelet rich fibrin which can be made from drawing blood from your arm. Good luck

      PRF can be usedto help blood clotting and enhance healing

      Ramsey Amin DDS

      Reply
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    Reply