Atrophic maxilla: Recommendations?

Subperiosteal implants, while they can be a lifesaver for a case like this, are much more difficult to do than implants or even than mini implants (which are also tougher to do than implants). They require a very adept surgeon with experience in subperiosteals, excellent patient cooperation, and very skilled dental techs. The casting must be of the utmost accuracy. Subperiosteals have been around since the late 50's, but they lost favor due to the large number of soft tissue dehiscences they've suffered. I highly doubt that anyone is still practicing them in the US any more. I've seen a couple of cases of subperiosteals, but the dehiscences were a constant cause for concern and a constant OH nuisance. Still, I must say that surprisingly they did hold up long-term even with those unsightly dehiscences. It's a real testament of the resiliency of the oral tissues and the oral environment overall.

I am always a little weary of unsplinted implants in grafted sinuses with the in and out of a locator denture. Perhaps a safer idea would be heavy sinus grafting, at least 3 implants in each sinus and 2 bars (i.e. a bar in the UL and URQ's). This gives you the advantage of splinted implants. Not ideal, as we like to have cross arch stabilization if possible, but I think splinting all of these implants (R and L side) would have negative cantilever effect. Fun case! (not for the patient :))

I have a patient with severe atrophy max/md. Will work with oral surgeon. Implants 22/27 w locators. 6 implants on maxilla, sinus grafts will be done with locators. If lower was not over denture, splinting would be considered due to increased forces on maxillary implants. Full palate should help distribute forces. I would not use horse shoe maxillary denture. Your point is well taken . Btw are you a gp? How long have you been practicing? Respectfully, Dr.A

Saw your website thank you for your comments. What is your opinion all on four maxillary but the patient is a class 3 with natural dentition. Ty

Dr Ronald Receveur, have you ever done mini implants? What is your objection to them?

Abrams, I see you are an experience implantologist, do you refer The Cat Scan or also the surgical phase of Implantology?

Hi Raul, Irefer the surgery to an oral surgeon now. Busy as gp . Also member of Spear dental ed. Recommend it highly.

Dr Abrams, dentistry without surgery and implant surgery is no fun, man! I naturally did lots of oral surgery before implant surgery, but implant surgery just opened up this whole new challenging (and fascinating) world that goes beyond mere dentistry. All the advanced restorative and cosmetics I did became "mere" dentistry. Sure there are cases I refer to the OS occasionally, just as there are cases I occasionally refer to endo and perio, but there is no satisfaction like that of doing a challenging reconstructive implant case completely, from start to finish. None! And the smile of the patient when it's done and they say "thanks Doc, I can finally eat normally"? Priceless! My fave saying: "an implant a day keeps burnout at bay".

Matt, We are in the same boat, I do all my implant surgery and all of the bone grafting, of course that include perio surgery. The only cases that I wouldn't do are the medical compromised patients, that present a surgical risk, and in those cases why expose them to any surgery, so I don't refer. Of course I am not critical of any doctor that does't want to perform the surgical phase of implantology. By the way the surgical phase is the easiest one. Like you I enjoy being able to fully reconstruct my patients to full function, esthetics and phonetics. To each its own Raul

Dr. Ronald, please humor me. What exactly do you call large cases? Typically mini-implants are not large cases. Were these mini implants employed in other ways prosthetically besides stabilizing overdentures? Or for more than replacement of a single anterior tooth? Even more importantly, how exactly were they placed? Which dimensions and which type of threads have you seen fail? And in what type of bone? (They are all contraindicated in D4 bone.) Were you directly involved in at least overseeing their insertion? Do you know if proper protocol was followed? Not that there is actually one protocol that fits all, really -- one must have a very good feel for the bone one is working in, much more so than with regular implants -- but still, there is a protocol and it differs from that of implants in one key aspect, i.e. one must engage the opposing cortical plate with the tip of the mini implant. That is one of the keys to the stability of the mini implant. Success can be achieved even in the absence of that one criteria, but then the choice of size and thread of mini implant becomes critical, especially in D3 bone. Mini implants are actually much more finicky and harder to place than regular implants, and the margin for error is much much smaller. One important caveat is very slow insertion, due to more rapid overheating of the bone even in the presence of cooling. That can lead to premature failure even if all the other proper insertion criteria are met. But they can be a lifesaver for the patient with very resorbed bone who has neither the age, nor the financial means, nor the disposition for sinus lifts or substantial bone augmentation. I've placed more than double the cases than the 30+ failed cases you've seen, and I haven't had one failure! Still going strong 8-9 years on. Also used them in atypical applications, such as stabilizing Kennedy Class II full quadrant maxillary cast partials that had no hope of stability otherwise. So how and why did these 30+ cases you've seen fail? How long were they in place before they failed? Because another key of mini implants is that if one doesn't achieve at least 30 Ncm, and ideally 35-40 Ncm of initial stability upon insertion, the mini implant is a write off from the very start --it should be removed and placed in a new osteotomy. Also, they are not designed to sustain occlusal forces, only to retain the overdenture. I would be very curious as to your clinical findings. Many thanks.

Matt, The main reason that I don't refer is that I evaluate the patient with and consult with their physician. I did a one year hospital training after graduating from dental school and years later a 3 year hospital base residency on Oral-Cranial and Maxillofacial implantology, under Anthony Wolf MD Reconstructive and Craniofacial Surgeon . If I evaluate that the patient should not go through the surgical risk I tell the patient that personally I don't advice the surgical procedure, but that they are welcome to a second opinion. At the same time I think that the way you handle those cases is also the right way. Only different ways of handling the situation, and I think that both options are Ok. Raul

Raul, I commend you for taking the time to take the training! I also eval patients and discuss with their physicians before referring to OS. I also study their latest blood lab reports. And I also tell them in no uncertain terms when I don't think they should undergo implant surgery. It's my s.o.p. However, I found in all my years of practice that most physicians will very rarely be completely unequivocal about absolutely contraindicating implant surgery (except in the most dire cases) and, that patients insist on exploring the option even when their physicians, and I, clearly lean against it. So after clearly exposing the risks to the patient and restating my opinion that I'm against it, I let them make the decision of whether to consult the OS. I feel that the patient deserves the chance for that consult and, that it is also the OS's decision if he can mitigate the risk. Many OS's feel that they can mitigate the risks, and they have done so successfully quite often. I just feel that I should not be the final gate-keeper, because I may exclude someone's chance from ever eating properly again, specially when I can see that the patient clearly is suffering (be it mentally, physically, or both) from not being able to eat adequately. I'm not there to make life or death decisions, and I also feel that quality of life is truly important. Because let's face it: eating is not only life sustaining, it's one of the only 3 real pleasures in life. Since most elderly and/or medically compromised people are down to only 2 real pleasures in life... Well, you get the idea. I also feel that implantology and bone augmentation (not to mention imaging) have come a really long way, and much more can be achieved today much easier than a mere 15-20 years ago. No longer do we have to harvest mental bone (or superior anterior iliac crest bone) with a hammer and chisel like we had to as recently as in the mid-late '90's. We have bone augmentation materials and techniques that surpass our wildest imaginations of back then. And although still not what one might call simple, implantology has become at least a bit more seamless and certainly less traumatic. Your way is quite fine also. We all have a set of principles we stand on when it comes to our patients' welfare, and we must be true to those principles. Matt

Dear Richard, I hate to contradict your opinion, but this is not a subperiosteal case. In my opinion this is the worst selection for a subperiosteal implant, and I have done many. The same goes for Mini Implants, without getting in to the discussion of their positive or negative outcome, they don't belong in this case. Let me start by congratulating the doctor that took such a nice Panorex, that is a high quality Radiograph. There are a few things that need to be done before starting treating this case. Upper and Lower Impression Bite Registration Is this a class I or a class II case? Upper full temporary denture (well done) Lower temporary partial A CT including the mandible and the maxilla. Bilateral sinus elevation 4 posterior implants on each sinus with the most mesial implant placed with a reverse all on 4 angulation. Meaning that the the incisal of the right and left mesial implants are going to be angled toward the mesial and the apical portion angled distally. 2 short implants on either side of the mandible, that will help with the occlusion and prevent the trauma of a combination case. Once the implants have integrated construct an upper temporary fixed bridge with a high lingual bar so it will not interfere with the grafting. Proceed to graft the premaxilla with block graft either with an open technic or with the Mena Digital Tunnel Technic. Once the graft has mature place implants in the premaxilla wait for integration. Final step is to finish the upper splinted fixed bridge and the lower posterior bridges. Another alternative will be to skip the grafting of the premaxilla and use multi unit attachmets or QFit fix attachents. All this can be done in a private setting under Local Anesthesia. Duration time from 2.5 to 4 years. I am sure that many will disagree with this treatment, I will be more than happy to listen to other suggestions.