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Medical Forum / General / Dentistry / August 2005

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Implant questions - Can this restoration be salvaged? Should we move on?

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pdurant - 23 Aug 2005 23:13 GMT
By way of background - I contacted this group two years ago about my
son who was about to have surgery for an upper right maxillary
ameloblastoma (which was discovered incidently during preparation for a
bone graft to reconstruct his upper front jaw which had been destroyed
in a bike accident 7 years earlier).

Following the surgery to reconstruct his upper front jaw we planned to
have implants placed to replace his four upper front teeth.  We also
needed to figure out how to deal with the gap left by the subsequent
ameloblastoma surgery which removed most of the upper right jaw,
palette and teeth from the eye tooth back.  (Search "ameloblastoma" and
see threads entitled "18 y/o son with ameloblastoma" for more details.)

So far, here's how it has gone since then....

Christmas break 2003 - Surgery to implant posts in my son's upper front
jaw. It was not possible to place 4 posts for individual implants
because part of the reconstructed jaw bone was not thick enough to
support the 4th post.  Thus we knew from that point that the proposed 4
implanted teeth would have to be connected.

Summer, 2004 - Implant posts are exposed and healing caps are placed.
Six weeks later, impressions are taken during which one of the
implanted posts pulled loose (painfully) from the jaw.  Two weeks
later, another surgery to implant a larger post to replace the failed
post.  Another 6 months of healing required.

Christmas, 2004 - New post exposed and healing cap placed.

March, 2005 - impressions taken again

June, 2005 - first try-in of implants - the initial fixed (4 teeth)
bridge seemed to be OK after a few adjustments and was sent back to the
lab for finishing.  The lab then added a partial plate (made of bright,
shiny metal and having 4 clasps - ugh!) which was affixed to the 4
implant teeth "bridge".  This metal partial had several cosmetic teeth
in the back to fill in the gap left by the ameloblastoma surgery.

July 12, 2005 - Final try-in and hopefully walk out with implants. The
finished appliance could not be made to fit. Our dentist, then told us
we had to start back at square one.  He did all new impressions that
week and sent the whole thing back to the same lab to have the entire
appliance redone.

August 19, 2005 - The appliance had been redone from scratch and did
not come close to fitting correctly this time either. Two of the three
implant posts could be made to seat well but the 3rd would not seat
correctly.  Then the attached metal partial plate would not fit right
either.  Then the 4 implant teeth and metal partial with clasps and
back teeth were separated and could not be made to fit separately
either.

Now....our dentist says we are back at square one again.....and has my
son scheduled to have new impressions taken the next time he is home
from college - which is the day before Thanksgiving.  The dentist says
he will not use the same lab....that he will "ask around" and find a
new lab.  BUT that's how he found this lab that supposedly had some
hotshot technician from Germany and was highly recommended.  The cost
of this was to be right around $6,000.  I know our dentist has hours in
it.  Presumably the lab has many hours and a lot of material in the
project.  BUT we still don't have anything for my son's mouth except
the "temporary" obturator with teeth made for him over two years ago
after his jaw reconstruction and tumor surgeries.

In addition, now our dentist is talking about doing the 4 front teeth
....then sometime later figuring out a way to fill the gap in the back
upper right area left from the ameloblastoma surgery. Perhaps by making
a separate partial plate that is never attached to the 4 front implant
(bridge) teeth.   My son is very concerned about that gap - right now
he has just one (non-functional) tooth (on his partial obturator/plate)
filling the space and he is satisfied with that but adament that he
does not want to spend days, weeks or even months with nothing filling
that area.

Initially,  the plan was to make the implant/partial plate device
removable - now the dentist is talking about making the implants
permanently attached, cemented in place - only to be removed when
having his teeth cleaned.  If my son has implants and also a partial
plate, we are all beginning to think the whole jaw reconstruction,
implant saga has been a waste.  After all, he had a partial plate with
teeth on it since he was 11 years old and lost his front teeth in the
bike accident. What is better about this scenario??? - to say nothing
about all the pain, trauma of bone graft, reconstruction, implant post
surgery and re-surgeries?

My son now wants me to find someone in the Chicago area and try to get
the implants done there (we live in PA - 10 hours from his college).
My question is - Is this drawn out process normal for this type of
complex dental restoration involving implants?   Or are we justified in
seeking someone else to do the job?  Would it be foolish not to change
providers at this point?

So far our insurance is covering everything and will continue to do so
until my son is 22 years old.  But I don't know if they will cover any
expenses incurred from these two failures (will the lab and dentist
bill for this?  I don't know.) or how they might view a change of
provider at this point.  Any advice or perspective (or alternate
approach) you would be willing to share would be greatly appreciated.
Vaughn - 24 Aug 2005 01:04 GMT
>(will the lab ... bill for this?

    It depends on the lab's policy and their relationship with the dentist.  I
have seen many labs "eat"' failed cases and they are sometimes happy to see a
"nightmare" case just go away.  Other labs claim "if the restoration fits the
model, you bought it".

Vaughn
pdurant - 24 Aug 2005 03:02 GMT
The professionals think they have the "nightmare"?  What about the
patient's "nightmare"???  Actually multiple, continuous and chronic
"nightmares"?

I have never understood why lab technicians and patients are separated
completely in this process.  The lab in question is 120 miles away.

The only dental lab in our town recently closed.  In the past, if my
son's partial plate broke or developed a problem....it was a simple
matter to run over to the lab and have it fixed in a few hours.  Now we
are completely at the mercy of a far away lab technician who does not
know and maybe does not care what happens with his "product".

So what should I do?  The process so far appears to be the equivalent
of trying to hit a bullseye while blindfolded.
Joel344 - 24 Aug 2005 14:27 GMT
Its even worse than that. The huge labs have constant turnover o
UNSKILLED technicians and what you get it what you get.

CONVERSELY, years back, when I found a good NEW lab, I would eventall
call for an appointment and bring over three or four tough cases.
would introduce myself and then explain what was needed.

Then, here IS THE CLINKER, I would tell the bossman that he needs to d
the case EXACTLY as I am designing it. It it fails or if MY DECISION i
no good, I will pay him a SECOND TIME to remake it.

Why? Because I am making the lion's share of the profit, while he i
working by the hour, or the technician is working by the hour so t
say.

That is fair. PLUS, I AM THE DOCTOR and the responsibility is mine. I
its my responsibility, then I AM CALLING ALL the shots. Now a LA
MISTAKE is another story, but guess what? After meetings like that n
lab would even send me crappy work!

They would call, ask, discuss, cajole, and plead first! I like al
that. I am never too busy to DISCUSS a case. So do the patients lik
this approach!

Joel

pdurant writes,

The professionals think they have the "nightmare"?  What about the
patient's "nightmare"???  Actually multiple, continuous and chronic
"nightmares"?

I have never understood why lab technicians and patients are separated
completely in this process.  The lab in question is 120 miles away.

The only dental lab in our town recently closed.  In the past, if my
son's partial plate broke or developed a problem....it was a simple
matter to run over to the lab and have it fixed in a few hours.  No
we
are completely at the mercy of a far away lab technician who does not
know and maybe does not care what happens with his "product".

So what should I do?  The process so far appears to be the equivalent
of trying to hit a bullseye while blindfolded

--
Joel34
Steven Bornfeld - 24 Aug 2005 03:06 GMT
> By way of background - I contacted this group two years ago about my
> son who was about to have surgery for an upper right maxillary
[quoted text clipped - 94 lines]
> provider at this point.  Any advice or perspective (or alternate
> approach) you would be willing to share would be greatly appreciated.

    I remember you.  I want to give your questions some consideration, and
right now my eyes are crossing.  I'll post tomorrow when I get a chance.

Steve

Signature

Cut the nonsense to reply

W_B - 24 Aug 2005 16:07 GMT
>My son now wants me to find someone in the Chicago area and try to get
>the implants done there (we live in PA - 10 hours from his college).
[quoted text clipped - 9 lines]
>provider at this point.  Any advice or perspective (or alternate
>approach) you would be willing to share would be greatly appreciated.

Hi p,

Have some thoughts on your son's treatment but don't have
the time right now to respond in detail.

You can contact me privately as always.
--

W_B
Take out the G'RBAGE
wubbabubbazG@RBAGEyahoo.com
ninefournine - 24 Aug 2005 17:09 GMT
Dear pdurant,

I feel sad when hearing of such cases. Im a maxillofracial surgeon
practising in Malaysia where Ameloblastoma are more of a common
occurence than it is in the United States. Through my humbling
experience, reconstructive surgery and implant can tremendously change
a patient's appearance as well as function.

I believe the problem here may be the location of these implants. They
maybe in a non favourable angulation or are too close to each other.
However I believe there are ways and means to overcome such problems.
We would be enlightened if you could provide a picture of the position
of your sons' implants either in the form of radiographs or clinical
pix. One obvious way is to involve less implants in the final
prosthesis as this will lessen the angulation problem ie. use only
three of the four implants in the final restoration

Dr Firdaus
doktorfirdaus@hotmail.com
http://maloms.tripod.com
Joel344 - 24 Aug 2005 17:15 GMT
Hello sir!

Any idea about the epidemiology of ameloblastoma? Would
it be increased awareness or some intrinsic factor?

Joe

--
Joel34
ninefournine - 24 Aug 2005 17:33 GMT
Ameloblastoma is a benign neoplasm of the enamel. However it is locally
invasive and this could be a problem as this will cause to recur. There
are many types and its 1 am here in KL so im not about to elaborate!

However in occur more in Asian and African and less common in European
races.

We see lots, 3 a month in our department. We believe we saw one of the
youngest, diagnosed at eight yrs of age. Its non lethal but can be
severe debilitating
Joel344 - 24 Aug 2005 17:39 GMT
Thanks. Some ameloblastomas can be so extensive as to shut off th
airway and of course lead to death. That would be a rare occurrence an
might occur an area of the world that is poorly served by the medica
and dental community.

Welcome to our little group!

Joe

--
Joel34
pdurant - 24 Aug 2005 22:21 GMT
Vaughn, Joel, Steven, W_B and Dr. Firdaus - Thanks to everyone for your
comments and offers of help.  I have x-rays of the pre- and post-bone
graft and ameloblastoma surgeries but nothing else showing the implant
post placement.  I do have the x-ray taken when the implant post failed
last summer and was half-in and half-out of his jaw bone but that
wouldn't help now.    I'll try to see if I can get a more current x-ray
and then figure out how to upload it.

Starting tomorrow, I will be traveling for a week but will try to check
this forum and my email while on the road.  I know this is not an
emergency but last Friday's disappointment was hard to take....  I
thought my son would have the front teeth he lost at age 11 before he
started college and, gosh, he's a Junior already.

Peggy
Joel344 - 24 Aug 2005 22:52 GMT
Okay, here's how.

1. Bring the image into your computer either through scanning, throug
a digital camera, through processing film at Wal-MMart and then gettin
a CD-ROM, or whatever ... digital.

2. Open image in Paint which is on everybody's computer.

3. Save As ......... jpg (this compresses the file).

This file was 2 megs compressed down to 103 Kb ... 1/20th the size.

4. Upload it at www.tinypic.com.

5. Here I am doing that.

6. Copy the code in blue and paste it into your message.

Joel

.

[image: http://tinypic.com/b4git5.jpg]

.

http://tinypic.com/b4git5.jp

--
Joel34
NineFourNine@gmail.com - 28 Aug 2005 03:33 GMT
thanks joel

Firdaus
 
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