Which Should be the First, Ortho or Implants?

A 66-year-old man is partially edentulous (Fig.1,2,8).  Premolar occlusion is planned initially.  Two implants have been placed (Fig.6 **), two provisionized (P) and one restored (C).  The tooth #13 will be extracted and implant restored (Fig.8).  The biggest challenge is that the tooth #4 has lost crown; its lost coronal space is compensated by supraeruption of the opposing tooth #29 (Fig.1 arrow). 

It appears that an implant should be placed at the site of #30; using #28 and 30 as anchorages to intrude the supraerupted tooth (Fig.3 arrow).  Accordingly, an implant is to be placed at the site of #3.  More important is that the implant is used as an anchorage to distalize the teeth #4-7 (Fig.3,4, as compared to Fig.1,2).

The sequence of ortho is important. The tooth #29 should be intruded before #4 composite buildup/bracket placement and distalization.  The most effective method for intrusion is to use the neighboring implant-supported crowns as anchorages.  Therefore implants should be placed prior to ortho.

For implant placement, a second set of wax up without tooth movement is necessary (Fig.5,6), using the first set of wax up as reference (Fig.3,4).  The models with the second wax up are duplicated and stents are fabricated for implant placement (Fig.7).

Xin Wei, DDS, PhD, MS 1st edition 03/20/2014, last revision 03/20/2014