All on 4, Implant supported denture, sinus lift?

Difficult to give a proper opinion as we do not see the condition of all his teeth.....but in the maxilla, from the xrays supplied, probably all of the teeth should be extracted and an implant supported prosthesis can be made. Restore the lower teeth ….and supplement the missing teeth with implant supported crowns. It would be useful to have the patient's health history, and a knowledge of his bloodwork.

There appears to be a lot of infection. I would opine: extract and thoroughly debride the sockets, graft and wait 4 months for healing. Then with surgical guide proceed with the implant placement. Even though it is possible to immediately place implants in debrided chronically infected sites the multiple sites may preclude a thorough removal of all infected tissue.

This is a great case to discuss. There is a lot of information missing so I will be more general in my comments. I think the upper is hopeless and will require full arch extractions, but the lower seems to be in better shape. You will likely need to remove most of the lower post teeth. You obviously need to give the patient several treatment options for both arches ranging from completely removable appliances to fixed implant supported restorations. Lots of people will recommend fixed hybrid appliances but I have had very good success with locator attachments and overdentures. They are much easier to clean and significantly less expensive as there is no titanium bar to mill. My biggest suggestion is if you are planning on a fixed hybrid on the upper you try and get 6 implants in the arch. Very interesting case and can go in infinite directions. Best of luck and make sure your patient is involved with the treatment planning!!

I agree that all must go on the upper. No, It doesn't appear to need sinus bone regeneration and I would use 6 implants ( 2 tilted) on the maxilla. The mandible could have 2 choices: If the anterior' s are sound, implant the posterior. Keeping those teeth will reduce the total force due to proprioception. You could do an all on 4 on the lower (same number of implants) yet you do give up a fair bit of healthy tooth structure and bone. The literature supports extraction and immediate placement with similar implant success rates. I've done countless cases just like this in the last 20 years with immediate loading. Either staging or immediate, you still need to remove all the diseased tissue. Putting a denture on top of a wound is much more uncomfortable than immediate loading for the patient and invites wound opening. Immediate loading gives you a chance to confirm integration of the implants before restoration. Even with a complete denture and phased treatment, a fixed provisional is the standard of care, so why the extra step of having the denture?

If he were my patient, i would extract the uppers and do socket grafting and make a denture. See how he does then in the future you can do dual scan or triple scan for implants for fixed or removable. The lower, yes, i would leave the cuspid teeth. I would extract and graft lower left and right. Then make tooth borne guide to place 1 implant on #19 and #30 sites for "snap in" partial(metal to valplast). See how he does. Maybe transition into future 4 implant locator overdenture or fixed. It seems like this patient has had some dental work in the past but probably not doing preventive appointments or great oral hygiene. So that being said, it is easier to unsnap an overdenture, clean 4 locator abutments and then soak your teeth if you are not going to make an effort for checkup and cleaning appointments. What is the point of buying a Lamborghini ig your not going to change the oil? Extraction and overdentures will at least help to change the bacteria biotype in his mouth. So a case done in steps toward a future goal if each step is maintained. Best of luck.

Obviously this is an interesting case and the treatment plan will depend on what you as the operator want to achieve and also what the patient wants. Clearly cost needs to be considered but also what sort of prosthetic outcome all parties want. As well (and of immediate importance) is how will you and the patient manage the transition phase? With such gross infection in the upper arch I would tend to consider a full clearance and wait for a healing period. If this is done then short term management is an issue. This could be solved with a temporary Full Denture. As pointed out above, this may end up being a perfectly adequate final treatment. Certainly most edentulous patients have reasonable success with a full upper denture. However you might like to consider a temporary (acrylic) Part Denture (retaining 23,24 and possibly place a preformed locator in 13 and or 14). This can help stabilise the new denture making the healing period more tolerable for the patient. Once adequate healing has occurred, then implants can be placed and after integration, you can proceed with whatever form of prosthesis you and the patient agree on (in this case I would tend towards a removable prosthesis to make maintenance easier – since it appears to me that the patient does not have good oral hygiene). At this stage, extraction of the remaining few teeth can be done but this will not affect the prosthesis to any great extent. I am not sure a sinus lift would be needed on the upper left - but obviously a 3D image is required to assess this. Similarly on the right, you might not need a sinus lift if you only place the distal implant in 15 position. Whether you need a molar implant would depend on whether you are doing a tissue borne implant retained denture or hybrid fixed appliance. Of course the patient might elect to go without any upper prosthesis during the healing phase (in reality he has not had much to eat with or look at recently). In the bottom arch, I think your suggestion of retaining teeth is a good one. I would tend to consider retaining 44 to 33 (45 might be viable but hard to say from the information supplied). 33 has an apical lesion but I suspect it is associated with an abscess on the 34. In any event I would aim to retain 33 (and treat endodontically if required). The posterior teeth can be removed and probably you could implant straight away. However given that there will be a difficult transition period involving the upper arch, I would think it unnecessary to implant the lower arch at the time of extractions. I consider the success rate will be dramatically improved once most of the oral pathology has been removed and healing has taken place. I would likely advise an implant retained lower partial denture (Cr/Co frame) sitting on single bilateral molar implants. However if surveying the lower model indicates there is not enough retention and resistance doing this, then extra bilateral premolar implants could also be considered. Of course lower implant crowns or bridges could be considered – but as mentioned, I am not convinced the patient’s oral hygiene will improve much so these may be difficult to maintain. In my view the important thing is not to rush this case and communicate extensively with your patient so you both have clear objectives in mind and agreed on – before you start on any treatment.

Right on with a lot of the advice given. We also need plenty more information; especially on what the patient wants and what they expect. Molar to molar implants for max with sinus tap on right side. Immediate implants in between where you get good torque. Debride really well and bone graft. Lowers may serve a challenge for max restorations if occlusion and positioning is off. I would extract 18, 20, 21, 30. #22 may be easily treated with endo but will risk infecting implant on 21. I would stage out the lower posteriors with proper bone grafting first and implants at a later time. The maxilla is more forgiving. This would be a first treatment plan option to present to patient and work your way to the lesser options. I think you have more than enough usable bone to have to resort to all on 4. Thanks for posting and keep us updated. Good luck.

Depends on what patient wants and what you can do... Remaining bone is obviously disease- resistant... Thought of Basal- Cortical Implants..? Thats what I would suggest .

All in 4 case. Or Basel plants will be the choice

It appears that the 22-27 have fanned into the necessary occlusal space needed for an all-on-4 and could severely effect a stable occlusal scheme for any upper Denture. Just a thought. Need more information. Articulated models would help any diagnosis and treatment planning.

Given the patient's history of poor oral hygiene, I would consider 2nd premolar-2nd premolar occlusion restoration with implants at positions 4,6,7,10,11,13, 20,22 with 4 bridges and retaining mandibular dentition #23-29 with maybe endo #29