JIACD
The Journal of Implant & Advanced Clinical Dentistry
Patient missing teeth #8 and 9.....What is best two implants or one and cantilever?
Sun, 01/24/2010 - 19:53 — Dr. Cohen
I have a patient missing teeth #8 and #9. I am always vexed on whether to place two implants or one implant and cantilever.
I know the tarnow study says to place one and cantilever. What is your opinion. What parameters to you look at in determining when to place two or 1 implant?


Comments
Implants #8 and #9 or Cantilever
There are many factors that need to be taken into account. Not Knowing the details of your case, the manner in wich the teeth were lost, the lenght of time since the teeth were lost, the gingival type,the amount and anatomy of the residual/existing bone,the type of implants you use and many more things need to be assessed and evaluated.
I would first ensure there is or reconstruct enough soft and hard tissue; if by any chance #7 and #10 need crowns, then I would graft and give the patient a long term temporary bridge with ovate pontics at #8 and #9. Later at approximately 4-6 months I would place two implants (in my case most likely Astra or Hiossen)and either have custom healing abutments or immediately temporize them in order to preserve/enhance ginigival contours. In some instances a second soft tissue graft might be necessary.
The option of cantilevering should also work,never tried it personally. The worse prognosis for papilla maintenance/regeneration is between two implants and with this option you definitely minimize your risks.
Anterior implants: two implants or one and a cantilever
This is an interesting subject and a good one because it takes a lot of creativity to make implants esthetic at times, but that is where the challenge is: fun when it works and not when it doesn't!
Just from my perspective and having approached it both ways with excellent results and sometimes several degrees less than excellent results! But I think this is the way to look at this issue:
As Sammy mentioned above, there are many factors. Fundamentally however it comes down to lip line, force vectors and quantity, and most importantly, the distance available to work with. Less space, the poorer result with side by side implants, more space, the more you can get away with.
Now, if the lip line is low no matter how hard you tickle the patient, then, really, who cares? Other than you and me? As long as it is hygienic and the restorative can prevent air blow, then it really does not matter. Does it? But on the other hand, if there is any gingiva showing at high smile, then the situation is some degree of critical.
If that is the case I tend to go with the cantilever bullet pontic and one implant for papilla. Tarnow's perspective does seem to work better for developing a more natural papilla. I have even gone to the length of sleeping an implant in favor of one and a pontic with improved results.
Just some thoughts along this line!
Michael
Dr. Herndon and Sammy Question on cantilever????
In this scenario of replacing #8 and 9 what local parameter do you look at in deciding to place two vs 1 implant and cantilever?
There must be some situation where you look at a case and you say definitely one implant only?
Cantilever...Depends on defect size.
Basically, it all comes down to how much space you have. If you have a huge guy with a huge space, you can probably place 2 implants side by side with at least 3mm between the platforms. Do this with a platform switch and you will be fine.
If you do not have at least 3mm between implant platforms, forget about it! Do the cantilever.
To Gretzky: Local parameters for two implants or cantilever
I have to assume that you mean by "local parameters" the clinical and radiographic information the patient presents with in order to decide cantilever or two implants at #8 and #9.
1)I would first assess the patient expectations, smile line, occlusion, gingival type, the size of the space; because more often than not most patients I have seen that with such cases have lost the teeth for a while and as a result there is a strong possibility of tooth movement and bone loss that even in ideal conditions two implants might only be a part of the solution for good results,you might even have to address the adjacent teeth (crown/veneer).
I would also look at the mesial bone levels of #7 and #10 because once you raise that flap and healing occurs, tissue shrinkage might pose a challenge for you at restoration time.
2) I obtain a CAT Scan of all my patients in order to determine the quantity and quality of bone. The treatment planning software I use is InVivo from Anatomage and some of their rendering features allows me to evaluate the height of soft tissue above the residual bone, this is particularly useful when you try to determine how much vertical height you have or might need to reestablish.
The scan also allows me to plan implant placement, make more detailed space analysis and order a CAD generated surgical guide.
3)For such cases I have drifted away from immediate placement, I prefer site preparation with adequate temporization. Implants are then placed later in better bone and soft tissue environment. Custom Made esthetic healing abutments are placed on the implants during integration time.
4) Based on some "local parameters" implants might not even be an option, then look at a conventional bridge with ovate pontics sometimes back that up with a Connective tissue graft where needed.
In closing it squarely comes down to soft tissue and supporting bone especially in the areas of #8 and #9 where aesthetics are a primary concern.
#8 and #9 Replacement....Adjacent Implants??
Of all areas to place adjacent implants in the esthetic zone, the 2 maxillary central incisors offer the best potential. The reasoning is the following;
1. Anatomically you have adequate spacing at the midline to segregate these 2 adjacent implants by 3mm or more.
2. You can get away with a slightly longer contact and shorter papilla because there is no other to compare this one to regarding form, balance and harmony.
3. Buccal-lingual dimensions here can be well preserved and placement can be made towards the palate as long as there is no excessively large incisive foramen.
The worst scenario for 2 adjacent implants is clearly the maxillary central-lateral followed by any of the mandibular incisors.
Hope this helps
Dr. S
mosalama what is your thoughts on Tarnow 1 implant?
Tarnow lectures all over the place on placing 1 implant and cantilever. What is your thoughts on tarnows study and his reteric on 1 implant and cantilever in the esthetic zone?
Dr.Salama what are your thoughts on Tarnow 1 implant? Response
I agree with Dr. Tarnow's thoughts on 1 implant with cantilever pontic in the "Esthetic Zone" only, except for the 2 Maxillary Centrals as I mentioned why on my previous post.
In the posterior regions behind the Canines, I would prefer no cantilvever as we get closer to the power musculature and higher occlusal forces. In addition, we have a flat gingival scallop in this region and esthetics is not an issue. So in this region, I would be in agreement with Dr. Misch from a biomechanics standpoint.
Hope that helps
Dr. S
1 or 2
Depends on how much space is present. You need 3mm between implant fixture (minimum) and 2mm between the implant and natural tooth, so if you going with 4mm fixtures you need 2+4+3+4+2=15mm to place two fixtures. or using 5mm fixtures 17mm.