Good morning!

14 yo rising 9th grader with congentially missing laterals. New patient to me so I was not part of the ortho and original restorative planning. She has misplaced her Essix retainer with pontics, and eventually found the retainer each time, but after much duress and stress, she would like a fixed option. Previous consults with 2 other dentists including her "usual" dentist and a "friend who is a dentist" [image:IMG_1170.jpg][image:IMG_1185.jpg][image:IMG_1186.jpg][image:IMG_1183.jpg][image:IMG_1182.jpg][image:IMG_1181.jpg][image:R1.jpg][image:R2.jpg]include implants now (!!!), conventional FPD's (!!!) and resin -bonded bridges. I discussed the importance of waiting for implants. My preference, when I initially think of any of these situations, is to get these patients into their early 20's before implants are placed. How we get there is their option. I have a few male patients who don't mind the risk of losing their retainer and stay in the retainer/ pontic phase until ready for implants. I even had one male patient who chose not to use or wear anything, leaving spaces where the laterals should be, much to the dismay of his mother. Others, including the current patient, do not want to deal with a retainer, so I recommended a single-wing resin-bonded bridge.

The space for the implants will be tight and will benefit from a CBCT and guided approach to get the implant precisely where it needs to be. Grafting will also be necessary.

As you can see from the pictures, the lip line is not "too" high during full smile, which is beneficial for emergence of the pontic from the tissue. But I have a few questions:

1. Inter-occlusal space is tight, especially on the mesials of the canines, and especially #6 M. It looks like I will have to reduce the cusp height of #27 and possibly #22 to get enough restorative room. Any thoughts on this?

2. The canine should have less movement, due to root structure, than the centrals, so it seems logical to attach the wings to the canines. But then the wings will likely be in direct contact / directly in the path of canine guidance. So maybe I should attach the single wing to the central incisors?

3. (both #1,2 are affected by the moderately deep OB of the canines, and shallow OB is best for RBB's) Is this case a candidate for RBB's at all, due to the OB?

4. What material would you recommend? In the past, I have used zirconia frameworks with layered Emax on the pontic and Emax on the wing for adhesion. One ceramist I recently spoke to said he is moving back to a traditional metal framework. The patient and patient's mother do not want metal, and until I spoke to the ceramist, I had not heard of many problems with the zirconia framework, other than the debonding, which seems to be much less since adding emax to the wings and bonding to just one tooth has become more popular.

Thanks for your help and any / all experiences / recommendations are welcome.

Bill