Complex Case: Comprehensive Treatment Plan for Maxilla and Mandible?

I would begin with removing upper left bridge. The second premolar might be saved. The restoration is supposed to be sequential: upper and then lower jaw with fabricating immediate temporary denture. I could not give a comprehensive treatment plan, because it’s based on not only clinical pictures, but also patient-realistic expectations and financial possibilities.

Impossible to diagnose from one picture and one panorex. I would start by finding out the patients chief complaint and then go to charting and perio with full exam. There is supra eruption of lower anteriors and obvious tissue discrepancies in the max anterior as well as perio possible elsewhere. The tissue in he anteriormakes for a challenging fixed case so that's where smile line and patient's expectations come in. Is the patient adversed to a removable full overdenture? Fact finding may find that, possible, she is not and that MAY be an option. Obviously, we, as dentists prefer to give our patients a fixed prosthesis but that is not always the case. If she is OK with an overdenture, that will somewhat simply treatment on the upper. Again, with that being said, there is obvious eruption if lower anteriors which indicates that treating the Curve of Spee must be addressed also. In that case, you may need to treat both arches at the same time or maybe address the lower first. Not ideal however. Just my thoughts from the limited info.

in my opinion i would do the mandible arch first because it has infection and the maxilla is ugly but stable. cut bridge distal to #29 and remove brige and extract remaining teeth leaving existing implants in place. fabricate a provisional acrylic prosthesis let bone heal and ct scan and now you can start treatment planning this case. bone grafting in my opinion should be delayed until infection is under control. the crown height space is going to determine what type of restoration is best for this case.. then worry about the maxillary arch

Start with a classic workup! Study models, facebow. Tx the perio, endo. Extract the hopeless teeth. Place the pt in provisionals (fixed or removable, then evaluate esthetics etc. Determine what the pt wants and can afford first. This case will be best served by starting over from scratch (Genesis).

Er... Uh... can anyone say Posterior Bite Collapse? Again? (lol) Uh... how about inflammatory periodontal disease? Er.. uh... would that be chronic, Dr. Kong? My educated guess would be that this patient suffered from PBC and it was, judging by the case as presented, not diagnosed prior to "reconstruction". By not accurately diagnosing this case in the beginning, the result has been predictable failure. I would hope someone diagnosis this properly and the case is treated by someone experienced in these cases. Dr. Hughes's comments above are accurate. I would bet that many would dismiss the diagnosis of PBC. It is interesting that none of the above comments note this fact. The focus on hypereruption as a cause rather than a consequence is a very common mistake. Treatment planning this case does not require treatment to see, it requires education and experience. Here is another case of PBC that has been misdiagnosed by the last clinician; let's hope it is not by the second.

All the great dentistry will not fix this smile. You also need to treat her musculature so she returns to a symmetrical natural smile. She does not know why she smiles this way but when you develop the ability to diagnosis the reasons for facial asymmetry and treat it patients like this will be forever grateful. Greg Steiner Steiner Laboratories

Send me a CAT Scan and I'll give you advice. How can you possibly evaluate this case without a CT scan?

Upper - if the pt wants correction, remove the bridge, leaving the existing implants in place, extract the teeth, place immediate implants, wait for healing and then give a implant supported bridge! Lower - cut the bridge leaving the implants intact, extract the lower teeth, wait for bone to heal, later place two implants in the anterior region, and two if bone permits angulated (45') like an 'all on four', give the prosthesis. you might need some block grafting on the lower arch.

Time to put on the brakes here!!! The patient has already had some implants placed, at least one of which is failing miserably. To follow up on all of the above comments, without any idea of why both the periodontitis and peri-implantitis are out of control and not managed even marginally, you are setting both your patient and yourself up for failure and very expensive misery. Back to square one here before you do anything for/to this patient.

It's difficult to diagnose from one panoramic pic and a cbct examination is necessary,I think. what about he patient's occlusion & TMJ? In my opinion ,the right side Maxilla and Mandible should treat as the beginning .remove the bridge & the implants cuz de bone around the implants seems inflammation . Control the inflammation first and then restore her smile . A removable denture may be suitable for her.

Ron: "How can you possibly evaluate this case without a CT scan?" A CT scan is only a tool. The overall case is apparent from the photo, even sans radiographs. You can easily see the inflammation, the bite collapse, suggest probable loss of vertical dimension, and that this case was "reconstructed" without addressing the bite collapse. One does not need a CT to evaluate the over-view which is where all reconstructive cases MUST start. A CT is necessary to evaluate exact parameters for specific treatment or to discover pathology that is not apparent with other sources of information, it is NOT necessary in a case such as this to create a diagnosis and overall treatment plan and to believe differently is to miss the overall global issues. This is a very common mistake and many patients suffer in the end because of a limited view. It is discouraging to see suggestions to treatment that, again, have no mention of the bite collapse and other obvious concerns in a case such as this. Far too often dentists only see their focus. There is a saying that applies.. it is a truism, not an egotistical statement: You Only See What You Know.

PBC is an issue. I did not mention but was thinking about PBC. I usually start pts in provisionals to evaluate the vertical, esthetics, phonetics and TM joint. I agree a CT does not seem necessary, just an added cost and a dog and pony show.

Musician, no I did not take it personal. It was a reminder to spell things out for the beginners. We all start as beginners! Experienced docs should help the new docs along the way. All is cool. Have a blessed Easter or Passover.

All above comments are acknowledged and have validity. However, it is obvios that this woman has had a lot of trouble with her teeth and has bad infection. I think trying to save any teeth at this point is not cost effective and inhibits a more ideal plan. I would plan as many implants as you can and then do immediate acrylic (3i DIEM). Once you have the VDO established in the interim acrylic prosthesis go with either zirconia or acrylic to titanium permanants. This patient is probably worn out already adn trying to do too much heroic dentistry on her again (GBR , etc) will not serve the patient best. Bring her back to function the esiest and Simplest way.

The most significant problems are, massive infection, pretty much everywhere.