Tell Me What You See

The surgeon who placed the implants was right handed? But seriously, were the implants placed without a surgical guide or is that just where the patient had bone available? Paul

Hi Paul Yes the surgeon was right handed. Funny thing is I really didn't notice it until I poured the model. He is an exceptionally talented surgeon yet, just like my preps lean to the right because I am left-handed, even though I check them constantly, surgical procedures can be affected the same way. The answer to your question is twofold. You got it right when you pose the question about a surgical guide. The prosthodontist who referred the patient told him to just do the best he could since he knew where the bone would be. The second part is that without a clear understanding of where the teeth will be, the surgeon is left to place the implants where the best bone might lie. So, my question to you all, is who's responsibility is it to provide the surgical guide?

The responsibility lies with the surgeon and the restorative dentist. The surgeon might know where the bone will be, but a surgical could have helped in the orientation of the implants. The prosthodontist knows where the teeth should be and could have assisted the surgeon in aligning the implants to support the denture by making a surgical guide or a mock up of the denture. It looks possible to align the implants with custom abutments, and with the different attachment options it looks like we can expect to see a creative solution!

I'm assuming that this patient had a full denture and possibly still has one as these are being restored. If the teeth were in acceptable position esthetically and the teeth positioned correctly over the ridge, it would make sense that they could have duplicated it with clear acrylic and used as a surgical guide. The implants still may be in the right spot with repect to the bone but at least you could visualize the challenges of this case when trying in the clear denture/surgical guide prior to surgery and prepared the patient. And I would say, it's the dentists responsibility to prepare the surgical guide in most cases.. In my opinion..

it may be the dentist that supplies the guide but ultimatly the professional that holds the handpiece and places the part into the bone is totally responsible to place them correctly. Like lab work we must communicate our needs to have a predictable outcome.

i also believe this case is restorable and fairly good placement, there are so many restoritive options. anaxdent has a great system to do temps from screw retained dentures to substructure with crown and bridge.

Steve, Thanks for sharing a great case. My thought in this case is from experiencing this type of case from both the clinician and the surgical side. Clinically, as the "quarterback", I need to develop the treatment plan as well as develop the tooth position for the case along with the patient. I then need to develop where I believe the best sites for surgery would be based on my "needs" to deliver an excellent end result for the patient. That needs to be shared with the surgeon prior to finalizing the surgical guide to look at the final placement of the implants and to avoid post placement issues such as dehisciences, poor soft tissue development, etc. and make any corrections to the final surgical guide fabrication. Then, it is up to the surgeon to get things placed appropriately for the restorative side. Like it was mentioned above, communication is key. The implants on the patients right side should be pretty straight forward to restore as they appear lingual and affords more room, but the left ones look to be buccally inclined/placed. If you have an opposing mounted model or a photo of the abutments in place in the patients mouth-retracted, this would be great information. Thanks Steve for sharing..

All of the implants are restorable. While the implants aren't in perfect orientation, they are fine for restoration. It really isn't fair to be overly critical of the placement unless you know what was the planned restoration. Most prosthodontists, if they are restoring this as an all on six type of case, will give a denture with a large channel cut down the center of the occlusal or palatal surface and ask that you get the implants into the channel. They know that if it is that area, they can easily restore the case. If this case was to be restored with individual crowns (which there aren't enough fixtures here) the alignment and the placement becomes more critical. It sometimes seems trite, but these are severely compromised cases. This patient lacks alveolar bone and you're kidding yourself if you think you are going to condition the soft-tissue. It would be interesting to see this case with the denture in place and providing lip support to the upper left. The fixtures then might be through the occlusal surface. It terms of surgical guides, I try to have one whenever I do surgery. The less things I have (teeth) to orient myself, the more complicated of a stent I would like. This is a great application for CBVT guided surgery, particularly when you're placing this many fixtures...the cost becomes less of a factor.

The orientation of the implants on the cast means next to nothing without reference from the intended prosthesis. Mock up your intended restoration, then critique the placement.