Prosthodontic Solutions

08/19/2026

Go ahead and google "Dental implant or FPD?" or even "Dental implant benefits." AI will give you some fantastically biased answers. The one I most enjoy highlighting is the classic argument for the single tooth implant being 'better' than a fixed partial denture. Namely that the implant option, 'Keeps other teeth safe' or sometimes stated 'keeps healthy neighboring teeth untouched.'

Sadly, this is not always the case. In fact, the research is finally confirming what has been known clinically for some time, single tooth implant restorations result in a higher caries risk for adjacent teeth. For example see Clin Oral Invest 2026;13:120.

There are many reasons for this. Post extraction bone loss, post implant placement or grafting recession, opening of the proximal contact areas adjacent to dental implants, and failure to manage a patients pre-existing etiologic factors are among the most common.

The biased implant focused environment basically ignores this fact and continues to use 1990's marketing strategy that tells the dentist to 'not cut down the adjacent teeth.' Well. Maybe they won't need to right away. But based on the continued increase in the complication rates for patients receiving dental implants, the adjacent teeth are going to need treatment sooner rather than later. So what was gained? Or did the situation just get more complicated now that an implant is involved?

Based on the ability to control the proximal contacts, occlusion, restoration contour, and restorative condition of teeth adjacent to an edentulous space, conventional FPDs tend to be the more predictable option.

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07/29/2026

After seeing several comments, I thought it would be appropriate to demonstrate that we, as dentists, should not be trying to replace all missing teeth. Specifically wanted to show a shortened arch case. This is particularly pertinent with patients that present with extensive surgical or prosthetic risks in regard to dental implant therapy.

There is a good body of research (start by looking at Kayser and Witter) on this topic. Remember to also look at chewing efficiency studies as they demonstrate an objective value per opposing tooth unit.

This patient remains in our maintenance program. Has been a patient of mine for 18 years now. I restored two significantly debilitated mandibular premolars (28-29) with cores and splinted PFM crowns. She was not a good implant candidate as she had/has major surgical risks. Surgeons sometimes claim to restore those defects with no or minimal risk, but the risks are real and significant. Just ask the attorney's dealing with the growing number of lawsuits related to situations just like these.

Why take on surgical risk when patients often function just fine with a short dental arch? All the caveats of patient relationships and treatment planning discussions apply, but just because there is a missing space, doesn't mean the patient needs an implant.

This patient ended up needing a maxillary reconstruction (still on natural teeth) in 2019. The mandibular arch remains as I restored it in 2011. She remains on recall to this day with the splinted crowns on 28-29 now over 15 years in service. She eats what she wants and how she wants. Her muscle function is WNL and comfortable. Plus, after the maxillary rehabilitation she even loves her smile.

This was the safer, less costly, more predictable option to keep this patient comfortable, functional, and happy.

07/08/2026

This patient came to see me for this emergency back in 2013. Already in his 80's, one of his dental implant crowns had come out and his dentist had referred him to me to 'fix it.' Unfortunately, that was not possible.

The 3i implant had fractured just below the screw. It should be very apparent how thin the periphery of metal is around the abutment screws. This is an external hex implant. For many manufacturers this issue is compounded by internal hex designs. Traditional Astra for example. Another factor here is the fact that 3i used 'pure' titanium for their fixtures rather than an alloy.

Of course, this patient wasn't kind to his teeth and would definitely be classified as a heavy function patient. All the more reason to consider strength of the fixture when treatment planning.

In this situation - no treatment was recommended. The patient had an otherwise complete dentition and had more than adequate function. The remaining implant body, already covered by soft tissue, was left. As can be seen in the 2024 recall, this quadrant has remained stable since this fracture. Sometimes doing nothing is the best approach.

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06/20/2026

Sometimes dental implants make the situation worse.

We commonly receive referrals for tissue-supported implant-retained removable prostheses that aren't functional or that have chronic complications. More often than not, the cause is poor planning. Her is an extreme example.

I saw this nice patient in 2012. She had hoped that the four additional implants she just had placed would help her maxillary denture work better. Unfortunately, they were so poorly placed that they interfered with her ability to use the maxillary denture at all. One had already failed by the time she was referred to me.

A proper pre-treatment diagnostic tooth arrangement confirmed that these implants could not be utilized in any reliable way. The dramatic angulation and thin/soft maxillary bone no doubt exacerbated the progressive bone loss around these fixtures. The patient was very disappointed to learn that a prostheses, even by a specialist, would not improve this situation. The implants needed to be removed.

Eventually, when these implants failed, the patient returned to me and we fabricated a conventional maxillary denture. Despite the loss of further residual ridge due to the poor implant ex*****on and subsequent failure, the denture was very successful. The patient - pictured here after treatment in 2014 - was quite functional and pleased with how things finally turned out. But so much wasted time, effort, and cost!

Note the mandibular arch, with extensive aged restorations, was maintained. This made for a very economical treatment for this patient.

If you are prescribing dental implants for use with removable prostheses, make sure you are completing a proper diagnostic work-up. Assuming they will 'fit' under an overdenture is a risky bet. Likewise, assuming the teeth should go where the current worn prostheses have them often leads to chronic issues with component failure and other technical complications.

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06/04/2026

Here is a follow-up image from the failed Nobel Perfect implant situation I posted about (case 6) in April.

This is another example of the dramatic defects that often result from failed dental implants. The consequences to the adjacent teeth, seen here, turn a single missing tooth problem into a problem for an entire sextant (or more). Failed implants are rarely 'simple' to remove and replace. It is definitely not as simple as just remaking a restoration. The ability to safely, efficiently, and effectively retreat edentulous spaces is a major limitation not often considered when dentists recommend dental implants.

Add to this the fact that these patients are usually emotionally and financially exhausted. Note how clean this patient's provisional FPD is. This was not a failure via neglect. Many of these patients aren't interested in the many months (years?) and multiple appointments that are required to make another attempt.

If this site can be improved via connective tissue grafting, an FPD will be fabricated. The current provisional, seen here in preparation for this grafting (devoid of pontic contact), is being monitored for functional issues. When other factors are controlled, this test period will confirm the expected prognosis in this situation (which is fair).

6b

05/28/2026

05/26/2026

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05/15/2026

It's not supposed to rotate like that is it???

A case I dealt with in 2014. This patient was referred to me due to a 'loose implant crown.' Unfortunately, it as the implant itself that was mobile. The implant and veneers where completed about 10 months prior in Texas. That dentist reported to me that 'the implant was well integrated' when he last saw the patient. I did not receive a specific diagnostic reason why tooth #9 was lost other than 'it was broken and they recommended an implant.'

The treatment plan the patient received their was one that did not address the major etiologic factors. In fact, it appears to have increased the patients risks. Specifically: untreated malocclusion, grafted implant site, and maxillary bone. The 'graft' particulate can be seen on threads of the explanted fixture. So while a dental implant may have been a reasonable choice for this situation, it was not the fail-safe option the patient was led to believe.

Implants are less forgiving than natural teeth. Especially in the presence of significant malocclusions and heavy function patients. Conventional restorative therapy, even on debilitated teeth, is generally more predictable.

In conclusion, a conventional FPD was fabricated - after the patient again declined orthodontic therapy. It was cemented in 2015. He was turned over to his local general dentist at that time.

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05/01/2026

When an implant fails - early or late - it is very rarely as simple as 'graft and try again.'

Here is a good example of that. By the time this patient was referred to me there had been two failed implants (both early failures) and an additional failed grafting procedure. Not only is the edentulous site completed destroyed, but the adjacent teeth are severely damaged as well.

All the while, the treating surgeon saw tooth #24 was already crowned (poorly I'd add). This case should have been treated with a fixed partial denture from the get-go. Mandibular incisor sites are almost never candidates for a dental implant (in a partially dentate situation). It is nearly impossible to meet the anatomic space constraints of these narrow teeth. With the success rates of bonded restorations and FPDs, taking on these anatomic risks with implant therapy is not logical.

The challenge in treating this site now is the difficult pontic site. The horizontal defect is only partially visible in the clinical photographs. A provisional (shown in image 3) is used to train the patient on oral hygiene around the susceptible root surfaces. Due to the extent and volume of recent surgery, further surgical modification of this site was not an option at this time. This compromise is acceptable compared with extraction options and managing a larger edentulous area. Fortunately, this patient is fairly caries resistant.

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04/23/2026

A case referred to me back in 2018, when I use to take pictures of everything.

A great example of the limitations of 2D imaging and a demonstration of the fact that implants do not in fact 'preserve' bone.

This situation is quite common in the mandibular posterior. Typically seen in thin alveolar/gingiva anatomy patients. This astra fixture was placed by a very good oral surgeon. I was not involved with the planning or details of placement. It was an immediately placed implant. However, what I was told from this oral surgeon I trust, was that a complete alveolar socket/housing was present, the gap between the implant and buccal plate was grafted, and the implant platform was placed at the appropriate 3mm distance sub-crestal.

Notice the anatomy distal to site #30. The entire quadrant appears as it would for typical thin anatomy post-extraction residual ridge resorption. Grafting, especially with the limited amount of gingiva present, would have been futile (I'll show some of those in the future btw). If the plan was delayed placement, there would likely not have been an implant placed at all because of the amount of residual ridge resorption and challenges inherent in fighting against a patients underlying genotype/phenotype.

So while this implant was integrated and looks 'good' on a radiograph, the majority of the buccal surface is only covered with a thin layer of mucosa. Notice how close an impression coping is to the buccal contour. That was likely soon the recede and expose the buccal threads, leading to mucocitis and other long-term concerns.

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