Some days, I feel like I’m the dental version of a fireman. On Monday, I saw a new patient who had been referred to me by a colleague in Ohio (who knows me through the Dentaltown message boards). The patient is a “snow bird” who spends his winters in Florida. It happens a lot, as it seems there is a rule that most patients up North eventually end up in Florida. I share many patients with my northern colleagues.
The patient, a 75 y.o. male with a history of multiple myeloma, had a chief complaint of a loose bridge. It was implant-supported with abutments in the position of #9 and #13. Interestingly, rather than pontics, there were crowns on natural teeth in the positions of #10 and #11. There is a pontic #12. So, it was combining natural teeth and implants. Except, the natural teeth were no longer really part of the equation (as you’ll see below)
The patient was planning to return home to Ohio in a couple of weeks. Normally, I’d recommend replacing the screws with new screws (and I told him so). The old screws have been stressed cyclically and are prone to breakage. But, he wanted a quick fix, and I thought I’d just tighten the existing screws enough to get him home to Ohio. And, so that’s what I did. I recommended that he see his dentist ASAP when he gets home. I also mentioned that the entire bridge may need replacement.
Yesterday, the patient called to tell us the bridge came out completely. Rut-roh! I knew the screws did not likely loosen themselves all the way out in a couple of days. And, I was right. Both screws broke off in the implants. Oh, crap. I saw him this morning, and this is what I found.
So, now what? OK… let’s see if we can get those screws out. I explained to the patient that it may not be possible, in which case, we could make him a temporary partial denture. If I could get them out, I would contact someone at 3i Biomet (a big implant company that is nearby) to see about getting replacement screws. But, first I need to try to remove the broken screws. I rescheduled my next patient (a crown delivery) and worked through part of lunch.
The first screw (#13) was closer to the surface, so I went for that one first. I was able to use an explorer and back it out in small steps. Hooray! My confidence was up.
Reality check! Not so easy!
Then, I tried the same approach with #9, which was deeper inside the implant body. I could see it barely moving, but it wasn’t rotating. So, I VERY carefully attempted to cut a little slot in the top of the screw without boogering up the implant’s internal threads. Then I modified a screw driver’s blade to a smaller size. It moved! A little. And, then it didn’t. Back to the handpiece. And, then the screw driver again. It took me at least an hour to get it out. But, I got it! It was a good feeling. The patient said, “You worked your butt off to get those out!”
I called my contact at 3i Biomet and sent him an email with the same photos you see here (and a few more). I sent the patient home and told him that we’d give him a call as soon as we got any news. In a couple of hours, I was told they had the screws, and at the end of the day, I drove about 30 minutes north to their headquarters and picked up the screws. I’ll be seeing the patient tomorrow morning on my day off. (I’ll update this article after I see him tomorrow.)
Update on Fire #1
I saw the patient this morning – by myself, as the office is normally closed on Fridays. I was relieved to see that I had the right screws (they fit). It was obvious that the ONLY thing holding this bridge in place was the screws. The bridge is destined for failure. But, we pressed on. The patient is in town only a few more weeks, and then he’s heading home to Ohio. I urged him to see his dentist there ASAP. While the patient is concerned about extracting the two roots because of his diminished ability to heal (multiple myeloma), I explained that the teeth could become a source of infection.
This was a new patient coming in for a consultation / 2nd opinion. He was a 20 y.o. who came with his mother. They found me via a web search. And, they drove SIXTY MILES to see me! There are probably a few hundred dentists between their home town and my location.
His chief complaint was that he had a crown done recently (1 week ago) that he didn’t like. The tooth had been previously restored with “bonding” multiple times. He stated that the new crown felt big, and there was a sharp spot on the back. The patient mentioned that the crown was done in a day with a “scanner.” Mom said she didn’t know that he’d be getting the crown the same day, so she wasn’t there to approve the esthetics. He came home with it cemented in place. Upon examination, I could see that it was a veneer (or 3/4 crown).
Apparently, there was a small diastema between #8 and #9, which was closed with the CAD/CAM veneer. From this front view, it doesn’t look so hot, but I’ve seen worse.
The patient’s biggest complaint is that it “feels big.” Let’s look at it from another angle:
Mom, patient, and I looked at these same photos on the iPad. Mom asked if I could just “take it down.” Patient explained his biggest fear was that if he went back to the treating dentist, and he wanted to re-do it, that there would be no tooth left to restore. He read it on the internet. I explained that the veneer could be removed without further reducing the tooth underneath. Not a problem at all. I also explained to Mom that most dentists, myself included, would not want to reshape the veneer placed by another dentist. I described that it likely had surface stains that, once “sanded down” would cause a color change.
The wheels on the bus…
I explained that some dentists would insist on restoring BOTH central incisors, because it would be easier to match. I said, “Your dentist was conservative on two levels. First, he didn’t insist on restoring the other incisor just to make it easier. He attempted what we know as the most difficult cosmetic procedure, which is to do just the one tooth. And, sometimes we don’t get it perfect on the first try. Secondly, he did a veneer instead of a crown. He saved a lot of the good natural tooth structure.”
I recommended that he return to the treating dentist and give him a chance to make it right. I re-emphasized that the patient need not worry about his tooth being reduced to “nothing.” Both he and his mother were VERY relieved and thanked me profusely. They said that if they couldn’t get it resolved, they would return to my practice. I smiled and said, “I’m here if you need me, but I bet you’ll get fixed up with no problem.”
So there’s a dentist in a town 60 miles north of me that will never know who saved him from an oncoming bus. It is a good feeling!
So, those were today’s fires. What say you? Comment below!