A reader asked. You all answered. This is why this forum works, and this is why I do what I do.
The question: “Why is it that after I deliver a single-implant molar crown, the patient sometimes returns months/years later with a diastema between the implant crown and the adjacent natural tooth? I know for a fact that they didn’t leave that way when it was delivered, and yes, an occlusal guard is always recommended. No one seems to know why this is happening.”
We call them “drifters.” And in the dental world we don’t like drifters, do we? No, we don’t. Interestingly enough, this very conundrum crossed my path last week when a patient who was in for a recall was concerned due to the sudden food packing that was occurring on her lower left side. Clinically, there was a small diastema between teeth nos. 18 and 19. No. 18 was the implant, which was placed two years ago. My first thought was, “What did I do wrong?” My next thought was, “I didn’t do anything wrong,” because the teeth anterior to the implant drifted, creating an interproximal space.
One reader phrased the collective responses I received perfectly: “A developing diastema after placement of an implant is almost universally seen on the mesial aspect of the implant, and I believe it is due to the continued physiologic mesial drift of the dentition throughout our life. This physiologic mesial drift is the reason why many patients experience lower anterior crowding in their 40s–60s. Since the implant is osseointegrated and does not ‘move’ due to occlusal forces like a natural tooth would, as the adjacent teeth drift mesially, the contact point opens up. Unfortunately I know of no way to predict this, or on which patient type this may occur! Certainly, bite splints are recommended for all implant patients and may be of some benefit in reducing this phenomenon, but not in every patient.”
Solutions/protocols to consider
- Prescribe rigid bite splints; make them a standard part of the treatment plan.
- Use screw-retained restorations whenever possible so you can add to the restoration or have it remade. Some labs may even do this repair at no cost. Talk to them.
- Have an informed consent for the patient to review and sign; that way, if this issue does happen, the patient is aware of it and any fees that may be incurred.
Here are the codes I mentioned in the video that could be billed out for this service. I personally have never used these, so I’m unsure as to how “insurance friendly” they are. Maybe you could just charge for a new screw? Eat the cost completely? Any thoughts here?
D6090—repair implant-supported prosthesis, by report (repair or replace implant-supported prosthesis)
D6092—recement/rebond implant-/abutment-supported crown
Here are the articles I mentioned in the video as well. They’re good reads if you have a few minutes:
PubMed: pubmed.ncbi.nlm.nih.gov/26562738/
Spear Education: speareducation.com/spear-review/2015/08/implant-dilemma-unwanted-open-contacts
If I’m honest, and I’m being bluntly so since this topic came up, I’ve always thought I was the one who did something wrong, because, you know, the buck stops with the doc. I never (hand to forehead) gave it a second thought as to why that space was created. I always told the patient I’d fix it, that it was my bad, and that I’ve got their back.
But no more. Better discussions will be had with my patients when I’m restoring implants, because the body changes from the day we are conceived to the day we die (and even then, it arguably changes). The oral cavity is not exempt from this process.
And now you know the rest of the story.
A huge thank you to everyone for reading, watching, and responding! I appreciate YOU!
Lastly, don’t forget…shoot me emails with your questions, thoughts, and insights into anything dental and clinical. I read all of my emails and try to respond to as many as I can.
Cheers! S
Related articles
- Reader question: Diastema after single-implant molar crown
- Class V resins be damned (no pun intended!) I've got your back.
- How to get a better contact with dental implants
- Technique for delivering local anesthetic on lower first and second molars
Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles at this link and subscribe here.
Stacey L. Gividen, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Hamilton, Montana. She is a guest lecturer at the University of Montana in the anatomy and physiology department. Dr. Gividen is the editorial codirector of Through the Loupes and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. She serves on the Dental Economics editorial advisory board. You may contact her at [email protected].
