Case Study
This case demonstrates the rehabilitation of a 75-year-old male patient who presented with a malpositioned anterior impl · Dr. Rodney Andrus
This case demonstrates the rehabilitation of a 75-year-old male patient who presented with a malpositioned anterior implant and severe loss of vertical dimension of occlusion following seven years of piecemeal dental treatment. Through comprehensive treatment planning including diagnostic mounting, provisional restoration, and full mouth reconstruction at increased vertical dimension, the patient achieved restored function, improved aesthetics, and renewed confidence with sustained success over four years of follow-up.
Patient GT is a 75-year-old male who was referred by his general dentist after experiencing ongoing challenges with piecemeal dental treatment over a seven-year period. The patient had undergone treatment by multiple providers including general dentists and surgical specialists, but the lack of comprehensive planning had resulted in deteriorating function and aesthetics. The patient's condition included a malpositioned anterior implant, posterior implants restored out of occlusion, severe wear with chipped porcelain restorations, and significant loss of vertical dimension of occlusion.
In the patient's own words, his primary concern was that "my front implant does not have enough space for the tooth." This statement reflected the functional and aesthetic limitations created by the malpositioned implant in combination with his collapsed bite. The patient was frustrated after years of attempting to address his dental problems through sequential treatments that failed to resolve the underlying structural issues.
Clinical examination revealed an implant that had been placed at improper orientation, rendering it unrestorable, particularly in the context of the patient's current collapsed bite. The anterior implant position did not allow adequate space for proper prosthetic restoration. Additionally, posterior implants had been restored out of occlusion, which eliminated posterior support and contributed to a cascade of problems.
The lack of posterior support had resulted in severe wear of the remaining dentition, chipped porcelain restorations, and a loss of vertical dimension of occlusion estimated at 10 to 15 millimeters. This significant collapse of the bite had created both functional limitations and aesthetic concerns. The cumulative effect of seven years of piecemeal treatment without comprehensive planning had left the patient with a deteriorating occlusal scheme that could not be adequately addressed through continued isolated interventions.
Two primary treatment approaches were considered for this patient. The first option was to continue with the piecemeal approach that had been followed by his general practitioner over the previous seven years. This would have involved addressing individual problems as they arose without fundamentally correcting the underlying structural and occlusal issues.
The second option was a comprehensive full mouth reconstruction that would address all of the interrelated problems simultaneously, including correction of the vertical dimension of occlusion, management of the malpositioned implant complication, and restoration of proper occlusal relationships throughout the arch.
The comprehensive treatment approach was selected due to the poor outcomes that had been achieved with the piecemeal approach over the preceding seven years. The patient's experience with his general dentist and various specialists had demonstrated that isolated interventions without comprehensive planning could not achieve satisfactory aesthetics, function, or longevity.
After seven years of sequential treatments that failed to resolve the fundamental structural problems, it became clear that a comprehensive approach would be necessary to change the patient's clinical situation and quality of life. The treatment plan needed to address the malpositioned implant, correct the significant loss of vertical dimension of occlusion, restore proper posterior support, and create a stable and functional occlusal scheme.
Treatment began with mounted diagnostic casts to analyze the existing occlusal relationships and plan the correction of vertical dimension. A diagnostic wax-up simulation was completed to visualize the planned outcome and establish proper tooth position, contour, and occlusal relationships at the corrected vertical dimension.
Provisional restorations were then fabricated and placed based on the diagnostic wax-up. These provisionals served multiple purposes: they allowed the patient to function at the increased vertical dimension, facilitated proper surgical planning to correct the malpositioned implant complication, and provided a functional and aesthetic blueprint for the final restorations.
Several teeth required cast post and core buildups to restore tooth structure that had been lost to severe wear. These buildups were necessary to create proper resistance and retention form for the final restorations. The cast posts and cores reestablished adequate tooth structure to support the planned crowns.
Following the completion of tooth preparation and any necessary endodontic and restorative foundation work, the full mouth reconstruction was completed with definitive restorations that maintained the corrected vertical dimension and provided proper anterior guidance and posterior support. For more information about treatment planning, visit our first visit expectations page.
The final restorations utilized high-strength zirconia materials specifically selected for their combination of strength and natural translucency. The restorations were fabricated from three-yttria, four-yttria, and five-yttria stabilized zirconia in monolithic crown form. This layering of different zirconia formulations allowed for the creation of restorations with the strength necessary to withstand occlusal forces at the restored vertical dimension while maintaining natural translucency for improved aesthetics. The monolithic design eliminated the risk of porcelain chipping that had been problematic in the patient's previous restorations.
During the course of treatment, one of the prepared teeth experienced stress to the pulp and required an unplanned root canal treatment. This complication was managed successfully and did not compromise the overall treatment outcome. The need for endodontic intervention reflected the significant structural changes being made to teeth that had been subjected to years of adverse loading and wear. The root canal treatment was completed before proceeding with final restoration of that tooth.
The patient was very pleased with the results of his comprehensive treatment. He reported increased confidence and a restored ability to chew, which had been significantly compromised by his previous dental condition. His general dentist expressed gratitude for the treatment provided and stated that the comprehensive reconstruction had changed the patient's life.
Following completion of the full mouth reconstruction, the patient was referred back to his general dentist and hygienist for routine cleanings and examinations. This established a clear prevention and maintenance protocol to protect the investment in comprehensive treatment. At four years of follow-up, the patient has reported no complications, demonstrating the stability and durability of the treatment provided. The long-term success of this case reflects the value of comprehensive treatment planning and proper restoration of occlusal relationships.
This case illustrates an important principle in complex treatment planning: surgical specialists are trained to perform surgical procedures, but they are not trained or qualified to plan comprehensive treatment. When patients present with complex needs involving multiple dental disciplines, it is appropriate to refer to a prosthodontist first for comprehensive treatment planning before initiating surgical or other interventions.
The seven years of piecemeal treatment that preceded the successful outcome in this case demonstrate what can occur when surgical and restorative procedures are performed sequentially without a comprehensive plan coordinating all aspects of treatment. Implants were placed without consideration of the overall occlusal scheme and vertical dimension requirements. Restorations were completed in isolation without addressing the fundamental structural problems affecting the entire dentition.
By referring complex cases to a prosthodontist for comprehensive treatment planning before beginning surgical or extensive restorative treatment, general dentists can help their patients avoid years of unsuccessful piecemeal interventions. The prosthodontist can develop a coordinated plan that sequences all necessary procedures in the proper order and ensures that surgical work such as implant placement is performed in positions that will be restorable within the planned final occlusal scheme.
Vertical dimension of occlusion refers to the height of your bite when your teeth are together. When teeth wear down significantly over time or when dental work is not properly coordinated, this vertical dimension can collapse, leading to a shortened lower face height, compromised chewing function, and accelerated wear of remaining teeth. Restoring proper vertical dimension is essential for both function and facial aesthetics. In this case, the patient had lost 10 to 15 millimeters of vertical dimension, which contributed to his inability to properly restore the malpositioned implant and created severe wear throughout his dentition.
Piecemeal treatment refers to addressing dental problems one at a time as they arise, without a comprehensive plan coordinating all aspects of care. While this approach may be appropriate for simple isolated problems, it often fails when multiple complex issues are present. In this case, seven years of piecemeal treatment by multiple providers resulted in a malpositioned implant that could not be restored, posterior implants placed out of occlusion, continued deterioration of the bite, and ongoing functional problems. The comprehensive approach addressed all of these interrelated issues simultaneously according to a coordinated treatment plan.
An implant becomes malpositioned when it is placed in a location or angle that does not allow for proper restoration, often because the surgical placement was planned without adequate consideration of the final prosthetic outcome and the patient's overall occlusal scheme. In this case, the anterior implant was placed at an improper orientation and did not have adequate space for a tooth, particularly given the patient's collapsed bite. Correction required comprehensive treatment planning including diagnostic casts, wax-up simulation, and provisional restorations to establish the proper vertical dimension and occlusal relationships before addressing the implant complication surgically.
Cast post and cores were required to rebuild teeth that had been severely worn down over time due to the collapsed bite and lack of posterior support. When teeth are worn to the point that insufficient tooth structure remains, they cannot adequately retain and resist the forces placed on crowns. Cast posts are placed into the root canal space and cores are built up around them to reestablish proper tooth structure with adequate height and form to support final restorations. This foundation work was essential before placing the final crowns.
Zirconia monolithic crowns are fabricated from a single piece of zirconia material rather than having porcelain layered over a zirconia core. This eliminates the risk of porcelain chipping, which had been a problem with this patient's previous restorations. The use of different zirconia formulations—three-yttria, four-yttria, and five-yttria—allows for both the strength necessary to withstand the forces of chewing and natural translucency for improved aesthetics. These materials are particularly valuable in cases requiring restoration of increased vertical dimension where the restorations must be durable enough to maintain the corrected bite over time.
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