Extraction, Ridge Reduction and Immediate full lower denture

Thank you. You are absolutely right. I don't have as much experience in full arch cases (Beverly Hills patient keep their teeth or have them replaced one at a time). I love the guided process and wanted to get more accuracy. I will certainly get into immediate load (which I've done but not tons). Thanks!

Actually the sockets can be used as a guide since you can directly measure form the radiograph, you have an anatomical landmark. I personally in this case would not have done an all on four, would not want to remove all that bone. Once it is gone it is gone. The protocol for all on four is one step, graftless and fixed. It is an open technique, you can see the landmarks. The mandible will remodel and resorb now that it has a denture sitting on it and that can be unpredictable, some width can be lost. I do think extractions and the radical alveoplatsy is a lot to do in one step, now you need a reduction jig since the landmarks have been removed.

Thanks for the feedback. So how would you treat this case? Severe posterior mandible atrophy and not enough bone for 5 implants inter-foramina. I appreciate the help

Could you post a panorex? I would learn towards a hybrid. The all on four works but it has many drawbacks. It will be interesting to see some of these compromised cases in 10 years.

Thank you and you are right. I could have placed the implants at the time of extraction. I wanted to do it guided and didn't have a proper denture/wax up to work by. I could have done a conventional surgery and saved the patient a secondary procedure. I had a CT before. There were some issue to get a proper upper denture and a lower partial and to determine the proper occlusion and that's why I decided to delay. May not have been the best and hopefully will gain some more confidence to do it guided as a one step. One thing I respectfully disagree. The fact that there is a full upper denture doesn't guarantee that there will be no restorative space issue. The denture was deficient and the lower ridge had excess of bone and tissue. Thank you for the feedback and support

As per my observation of photographic details, Patient seems to be wearing Maxillary CD against Mandibular anteriors(including PMs) since long(??)as you have mentioned that posterior mandible is resorbed in one of your replies And ALSO in one last pic of Mx & Md CD ( Front View ) it seems as if patient had that harmful anterior contacts which we always avoid in ideal CD occlusion. Whole this made me to assume that patient must be having good restorative space as harmful anterior contacts plus his/her habitual protrusive mandible shift for mastication might have resorbed his/her anterior bone in Maxilla. . BUT obviously you are the best judge Thanks for sharing

Well said! Terminology is very important especially in communicating in regards to treatment plans and online as well., As much as I like to use the word hybrid, it is not the proper term any more. Refer to this article that became a key publication in implant terminology. That will really make your like easy. Thanks for the comments Abstract Send to: Int J Oral Maxillofac Implants. 2003 Jul-Aug;18(4):539-43. Terminology for implant prostheses. Simon H1, Yanase RT. Author information Abstract The use of systematic terminology for implant prostheses can simplify communication within the scientific community. However, a review of the current literature demonstrates the lack of uniformity in this field. It is the purpose of this manuscript to suggest uniform terminology based on conventional prosthodontic terms that will simplify communication in the profession.

Now in regards to the decision between 4 and 5. It's not obvious. It depends on your goals. The shape of the arch and the inter-foramina space are critical. The All-on-4 (which is a branded procedure) allows for an increase AP spread. Especially important for the severely resorbed mandible. once the distal implants are angled distally, they will impinge on the surgical space on their mesial aspect, hence there will only room for 4 implants. great discussion and thanks again for the comments

I have a question I thought an all on four described by Nobel requires a lot of bone reduction to allow 18mm of space for the prosthesis since it is prone to breakage. It is used as a graftless solution in atrophic jaws. I'm confused is the final all on four prosthesis reinforced with metal frame work like a hybrid? Personally I don't want to burn the bridge of removing all that bone. I will order the book. Thanks Happy Holidays

I believe these are all FP-3 prosthesis. Hybrid refers to the use of acrylic and denture teeth. Just a thought--When you do the surgery this way and pull the tissue together and suture after the bone reduction you loose your keratinized tissue that would have healed over the extraction site. If you extract and place the denture with no osteoplasty you retain the KT and increase your zone for later. The denture will allow you to work out the occlusion and esthetics before implant placement. After the denture is relined in 3 months you can measure the height of the occlusal plane using the denture with a boley gauge- that will determine your bone reduction. Your angle of implant placement will be clearer because of the change in the trajectory of the bone and you can be sure the implants emerge from the lingual. You want to loose bone on the lower unless you are going for FP-1or2 which is not this case. Many of these patients haven't had posterior support for some time and the position of the condyle will change once this is restored causing the lower anterior teeth to translate forward. That is a problem if the anterior teeth then make contact For me it is best to know where Im going than chase it later. We were trained to do osteoplasty for immediate dentures in dental school and it is hard to walk away from this thought but I think that with the dawn of implants we may need to rethink this. I just don't see the purpose.

Well taken!

Hi Gianmarco, Thank you very much for your opinion. Although you used less than friendly verbiage I can tell that you are very passionate about this topic. Things have evolved a lot since the beginning of implant dentistry and I agree with your true yet simplistic horse/car analogy. I wish you added some more details about what is correct biologically. We all want to know more about your opinion and the methods you use to treat the same situation. It would be great if you could post full documented start-to-finish cases and some more details about the proper treatment. If I'm doing something wrong biologically, that can jeopardize my whole operation not to mention my patients, I'd like to know about it. Please enlighten me. Delayed implant placement is currently still acceptable and is to the discretion of the clinician. There are many more factors that guide you in the decision making, except for available bone quantity and quality. We of course need to be biologically correct once you we know more about what it means. In the case I posted, immediate placement was certainly a very good option. I like the fully guided approach, and I should have made a bone supported guided, that is planned on a reduced ridge ahead of time. I decided on the delay because I wanted to do a proper virtual work up and plan after my patient approved the teeth position (as well as the treating dentist and technician). For that I needed to have a scan with proper markers and I failed to do this when I originally referred her. Immediate implants and loading would have been possible and unfortunately, my patient will go through a secondary procedure very shortly. I know that she healed well and is motivated to proceed with the second part. You may want to look at the definition of the word "Useless" you described my case as. Useless means not fulfilling or not expected to achieve the desired outcome. I think you'll agree, that the planned staged approach will be able to achieve the outcome of a fixed restoration and is therefore not useless. At the same time you may want to look up the definition of "Kind". Ciao!

Thank you. Makes total sense

No worries. My English is not perfect and I know you care to express your opinion. Best wishes for he holidays!