Best prosthetic option in this situation?

This case really demands an implant at least in the 2nd premolar position, otherwise, you will be constantly dealing with prosthetic issues down the road. GBR in the area of the osseous defect, and delayed implant placement, straight or tiled, to be used as the distal prosthetic abutment. for a segmented or single piece bridge.

Without a sinus lift, I'd probably choose to do a fixed bridge on the implants you've got and do an RPD for the posterior teeth. Unless he is willing to do a very short cantilever on the UR.

Why not just angle an implant in the #3-4 area and restore with a fixed prosthesis?

Without the added cost of guide regeneration of the #4-5 area, or sinus bump, your patient is dictating a lesser treatment. You are limited to tissue born/implant retained overdenture or fixed bridge with an rpd. I think you lay it on the line with him and let him chose the “Chevy” or the “Bentley”. Hope he picks the latter, it would be a nice case. So far looking good

First your surgery looks good BUT there are so many things that are wrong with this from the beginning There is no treatment plan presented Also thinking that 2 implant and a locator retained upper denture is a plan. It is not in any text or any conversation - this is not the mandible and the same tx plans do not translate back and forth. What is your plan on the lower- is it a new lower partial-it will work great now with an upper denture but that will change and will not be adequate compliment for your implant supported upper. Hopefully you are not going to try and support the occlusion generated by implant supported prosth with soft tissue with the thought it will work -- after 3 months of healing it appears you don't have another plan or you would have started executing it. . So you end up with a great/expensive upper and the patient cant eat except on the 2 bis on the right. Because the occlusal plane is a mess with #31 Your prosthesis will have to be trimmed so the patient can translate and not hit your distal tooth on this high end upper solution Now what do you tell the patient about the lower and this possible esthetic issue from trimming the distal tooth. You have set up the occlusion with the remaining teeth that may not be where you would like them in an ideal situation. Now when the patient realizes that they can't eat and you tell them you will also have to do implants on the lower and redo the occlusion on the upper prothesis to get it to work with the new lower.-will they be prepared. I hope they are aware of the new cost of the upcoming treatment plan. I hope it does not involve a lower partial With this kind of plan on the upper you should be doing lower supported prosthesis. Because if you can't get implants on the lower then you may have to bury the implants to get him comfortable with his possible new lower denture/partial Im sorry but you have got to look at the total case or you are going to have at best a misunderstanding with the patient or at worse.....? Adding an implant is not the discussion you should be having now. Building adequate posterior support (not tissue support) on the lower should be your focus. Also you may not even have enough prosthetic space for an overdenture. I may be wrong but you may be looking at FP-1 on the upper also Hopefully you have prepared him for that cost difference also You only have to look at the impact of his recent occlusal scheme and what it did to his upper bridge and lower teeth to realize this apparent tx plan will do the same thing It just may take longer Hopefully this rant has been a waste of time on my part because you have a full tx plan disucussed and on paper If so let us know next time . Just trying to keep you out of trouble JMHO Bill McFatter

Your original treatment plan seems the best if your patient refuses any more surgery. But it seems you are falling into a situation of having the patient dictate to you what is best. I suggest you decide on 2 to 4 options: work out the cost, time and pain involved with each and present these to the patient. Then let the patient decide what option he wants and stick to it. If you use a bar to retain the denture, then the existing implants should be fine, but if you use locator retained then I would suggest not utilising all the implants – either place locators but not activate all in the denture, or simply leave healing caps on some (it is interesting how much a healing cap can assist retention and resistance). To some degree what you offer as the best option will be determined by what you and the patient want to do on the lower arch. Upper denture stability will be determined by this and as such it would be better to take this into account when generating your treatment plan for the upper arch.

Well you got off to a great start, and the case is beautifully documented. At the time you re-evaluated, three months following the initial procedure, you had the opportunity to go in all sorts of directions. But now you have six implants in place, but they are all grouped together in a line and the restorative options are now much more limited. Would it not have been better at the outset to plan for distributing six implants around the arch? Then the implants could be restored in several different ways, an All-On-Six, a fixed crown and bridge case, even an over-denture on a bar or with various form of clip-on-device. Yes, some time should have been placed up-front on educating the patient of the benefits of a sinus lift procedure on the maxillary right. You must have had good communication skills to get him into placing four more implants in the upper arch and then five more in the mandible. Perhaps a little more time explaining the advantages of an implant in that region would have paid off. The key to a complex case like this is what Axel Kirsch likes to call "Backward Planning". One has to develop a vision for the case, then start working to establishing the right foundations in the right place, then to building teeth on the foundations that have been established. It's very hard work bringing these big cases home. The aim is to get "Closer and Closer" to the final vision. You can still get there. Maybe you are not comfortable with sinus lift procedures, if that's the case then why not seek help from a colleague. With more posterior support in both arches you could have a marvelous case on your hands. You have come so far. You have helped the patient so much. Just consider the advantages of a re-think of your treatment plan at this stage, just like you did at the first re-evaluation. Take it home,

put pteyrigoid implant on rt side and give one piece cross arch bridge.try for double pty.