From: Ahmad Tehrani
To: ROOTS
Sent: Friday, December 12, 2008 1:44 AM
Subject: [roots] WWID (What Would an Implantologist Do?)

all this talk about implants and funeral arrangement for endodontics.

here is a case for all you mavens of Titanium temple... fractured central...it is non restorable.
How and what to do now? - ahmad



probably extrude the tooth 2 mm and then extract and place immediate implant with temp to form gingivae
and maintain papillae.  thn follow with permanent restoration - Tarun

Hi Tarun: Absolutely your suggestions are on target. ...
but here is couple of additional information.
He has a very low lip line....esthetics and papilla preservation even though very important, is not critical.
He is anti ortho treatment, so extrusion is not acceptable to him. plus he is missing a front tooth.
He wants it fixed yesterday - ahmad

Ahmad, I think it's restorable, but is it worth it? There is a reason it broke. - Joey D

JD: Not restorable...it has a M-D crack when it broke....not worth it.
He is a prime orthodontic patient, but refuses to wear braces and not a candidate for Invisalign
( according to Orthodontist) either - ahmad

Well that crack makes a difference? - Joey D

First of all I'd take a much better angled radiograph...............
RESTORABLE - don't think so, not in this universe.........
Extrusion to correct poor distal bone position which will result in loss of papillae.........
Exo in time.......immediate placement with transitional to ensure emergence profile.
If you really want to do it right you'd use an ANKYLOS fixture, but I digress.
Radica temp preferably.  Reassess everything, posterior bite et al..........no rush to final.... Kendo

What about the other central? Will he be in less of a hurry when that one breaks?  Are the laterals vital?
Implantologists can't be doing single teeth---that's for the recreational implanteurs - Kendel

Kenny G:  Thanks for the heads  I have referred the patient for a full mouth extarction, since with every
implant placed they find another causing the failure....)))

I absolutely don't understand why you referred him for full mouth extraction. - Rafael Michiels

Hi Ahmad, Good to hear that you opted out from full mouth extraction, or was it a joke??? Caught me there.

Anyway, in my understanding and practice, the best protocol to follow in this case could be:

Immediate Delayed Protocol

1. Atraumatic Extraction of the tooth
2. Wait for 3 weeks for soft tissue closure
3. Place an Implant not disturbing the buccal plate taking care of the jumping distance
4. Wait for 2-3 months
5. Prosthetic Part

You may use Ankylos here for that emergence profile. You may have to do some soft tissue manipulation
with the provisional.

I may sound little old fashioned, but I think that's the safest option - Neil

I am quite surprised that the Impalnt pundits of this group are awefully quiet about treatment planning of
this case. I was expecting to see what graft material is used and what size impant to use, etc.
Oh well, forget endo and implants...bring on the full dentures and food blender. :-)  - ahmad

Ahmad - you raise a most interesting point...........one that continues to be raised, dazes and confuses.............
Treatment planning is off limits on the forum...........what file did you use is the cause celebre.

Repost the case Ahmad.............

There is a very linear or circular protocol that comprehensively defines any case............remember
I'm an endude, so this comes from the vaults of my memory, all alone in the moonlight
I can smile at the old days, I was beautiful then, I remember the time I knew what happiness was,
et the memory live again

Diagnostic records = Treatment plan.

Sequence: (each phase includes constant hygiene and OHI monitoring)

1. Clearance of untreatable teeth - with appropriate grafting
2. Elimination of all inappropriate restorations and decay - transitional and interim restorations
3. Periodontal treatment - soft and hard tissue correction
4. Orthodontic correction
5. Occlusal Equilibration
6. New transitionals
7. Implant insertion - healing and transitionals
8. Reassessment of occlusion
9. Various impressions and staging of placement of final restorations depending upon the school of
   occlusion of your choice
10. Final aesthetic restoration placement et al.

Please note that I have NOT INCLUDED ENDODONTICS because in all comprehensive treatment planning...........
ENDO IS DONE SHOULD BE DONE MUST BE DONE AND IS PARAMOUNT at each and every step to ensure that the next
step occurs without consequence.

I'd suggest that those who are derisive of those who are gaining an appreciation of the value that
implants hold to prevent bridge insertion or RPD insertion that is doomed to engineering impossibility
failure rethink.

I'd suggest that those who imply that the economy will dictate standard of dental care, work for a
capitation clinic or HMO............you practice what you believe, the market that you seek will find you.

Repost the case Ahmad..........FMX, clinical photos and models if possible..........
let's Seattle Slew the case or Seattle Study Club it, it's all a horse race lad. - Kendo

The patient is in your office asking for guidance and embarrassment of not having a front tooth.
what do you do?  - ahmad

Well in case a patient has too many terms and conditions for you to follow, it's the easier way out.
Either the patient takes your treatment plan or he is out! - Dr Sanjay Jamdade

On Tue, Dec 23, 2008 at 9:09 PM, Ahmad Tehrani  wrote:

I wanted to bring the case I posted to a closure.
It's quite obvious the "should've been single tooth" implant, now involves 2 other innocent teeth.
Look at the pattern of bone loss and complete destruction of precious bone ( not to mention tissue) in just
about a year. Someone dropped the ball and had no clue where to look for it.

What went wrong? My not so humble opinion is that those who believe in caulking every hole with a
graft material have closet full of this stuff. Then the dogma prevails... there is no way it could be the
technique , naturally they have to start blaming other teeth,. This graft never integrated, was taken out
and another crap ( errr, I mean graft ) was put in, that didn't integrate either and now it is the other
centrals fault since it has had endo. Mean while 2 different implant systems used, neither one worked,

The way I see it in implant world is this.
Those with surgical prowess and sophistication who truly understand what it takes to do implants at
excellent level don't need grafting as a crutch. Of course it is ludicrous to say ALL grafts are bad and
should never be used at all, but it takes true understanding of when, what, where and how to use it to avoid
outcomes like this.

of course it is preaching to the choir and you all knew that anyway - ahmad






yikes. I hope this patient has a successful outcome soon, thanks for sharing Ahmad - Kendel