Full mouth restoration case: treatment options?
This is my first post on Osseonews. I am a general practitioner, and I will be taking on 2 other specialists (prosthodontist as well as an implantologist) for this case. I would like to get your opinions on your evaluation of this case.
The patient is 57 year old female with no medical contraindications to treatment. She has been edentulous for 11 years, has had 3 sets of unsatisfactory complete dentures and hence does not want removable prostheses. In the maxilla, my patient has some spicules which I can remove and smooth out with an alveoectomy, and I am confident that I can make a retentive complete denture.
I have attached clinical records done on March 3. OPG made on March 19, and CBCT made on April 9.
Opinion I: All-on-6/8 on the upper arch and 2-implant supported overdenture on lower arch since the lower arch has resorption and placing 6 implants is not possible.
My doubt is whether an acrylic overdenture will be compatible strength wise opposing a castable/milled/hybrid upper fixed prosthesis or will it we better to have an acrylic denture opposing the overdenture?
Opinion II: 4-implant supported upper overdenture, 2 implant supported lower overdenture
Opinion III (from another implantologist): All-on-4 in the lower arch and All-on-6/8 in the upper arch using short implants in the lower arch, indirect sinus lift for upper left side and ridge split for maxillary anterior region. My doubt is whether implants can be placed avoiding the left maxillary sinus instead of a sinus lift or will the distal cantilever till the first molar region cause imbalance in force distribution.
Please provide any comments you have on the case, the scans, the treatment options mentioned above, any other solution you may have and the best probable options along with any other observations that can help planning prosthesis for the case. Thanks in advance and apologies for image quality, as these needed to be compressed to upload to the site.
14 Comments on Full mouth restoration case: treatment options?
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Alex Zavyalov
4/12/2018
A very good diagnostic approach. Plenty possibilities, including Bicon short implants to avoid the left sinus lift. The patient's finance situation is the key to choose appropriate treatment plan.
Peter Hunt
4/12/2018
A sensible way to start would be to do full upper/ lower wax ups for dentures to check for esthetics, occlusal vertical dimension, maxillary-mandibular relationships etc. This case looks as though part of the problem is that there may be a considerable Angle's Class 3 relationship.
Then you would be able to merge digital data from the dentures with the CBCT and to see if implants can be placed in the positions that you propose, whether a hybrid design would be needed, etc. etc. It can all be planned out ahead of time. I can assure you that this will help.
Good luck
mj dds, ms, facp
4/12/2018
Nice presentation of the data! Starting with the maxilla first:
1) your patient has quite a large ridge. This should be OK for a well made complete denture. If she wants fixed then do a diagnostic wax up without a flange, butting the teeth against the ridge. With a large residual ridge a crown and bridge restoration on 8 implants (sites 3, 5, 6, 8, 9, 11, 12, 14) with four 3 unit bridges would work. It is also the most expensive and most technically challenging way to restore the maxilla. It requires a well planned surgical guide to get the implants in the correct positions. It may also require sinus augmentations or short implants posteriorly. It then requires a well made provisional restoration to sculpt tissues and verify esthetics and phonetics before fabricating the final restoration.
2) remove at least 6-8mm of ridge crest (you need at least 15-17mm from crest of ridge to incisal edge) to fabricate a resin to titanium prosthesis or a zirconium based prosthesis. Don't worry about the sinuses. The definition of "all on 4" is to angle the posterior implants to maximize A-P spread and avoid the sinuses. I usually have my surgeons level the bone to nearly the floor of the sinuses. Place 4-6 implants for a one piece fixed restoration.
In the mandible, much easier! You have plenty of bone for 4-5 implants between the mental foramina. It is always nice to get implants in the 19 and 30 sites to minimize cantilevers (use short implants) but we have been placing implants between the mental foramina and using cantilevers to get to first molar occlusion since Branemark initially described the technique many years ago. And it still works today!
Good luck. The key to these restorations is interarch space. Decide which style of restoration you want in the maxilla then decide bone reduction and implant placements from there.
NY OMFS
4/12/2018
First - I am unfamiliar with the term implantologist. What is that? I know what a Prosthodontist is.
This is a simple all on 4 case. Upper and lower. Don’t make it any more complicated.
Funny
4/12/2018
Implantologist: a dentist who places dental implants but refers you the impacted third molars...
Kaz
4/16/2018
Implantology is a dental specialty. Therefore a person who is an implantologist is a dentist that is a specialist in implantology.
Pros specialist
4/16/2018
Actually, in the U.S. there's no such specialty. Maybe in Europe.
Kaz
4/18/2018
Having achieved a designation of Diplomate of the American Board of Oral Implantology allows doctors in Florida, California and Texas to advertise their credentials as specialists in oral implantology. Most states will accept that designation in the future as well because the dental boards do not want to lose millions on a fight that they cannot win. See ABOI.org
Pros specialist
4/18/2018
Non the less it's still not a recognized specialty.
NY OMFS
4/25/2018
A real specialty is one that has a clearly defined path (training) and a clearly defined need. “Implantology†has neither. It is as bogus as calling oneself a cosmetic dentist. The fact that some people got together to make an organization devoted to nonsense does not change the reality that it is still nonsense.
Greg Kammeyer, DDS, MS
4/12/2018
I agree with Peter Hunt on pre-op planning, esp being sure you have 15mm minimum of space per arch for the prosthetic to be strong enough if you use acrylic or Zirc. I prefer your implantologists view point from an overall case success point of view. The final prosthesis will have 4 x the biting power and 2-5x less proprioception which means your forces will increase dramatically over the 10% functional effectiveness of dentures. You didn't mention force factors which I would consider strongly given the size of the case. Acrylic does have maintenance issues much more than Zirconia. I especially like the maxillary 8 implant site treatment approach of mj dds, ms, facp, as IF the porcelain does fracture, it is easy to retrieve yet the literature shows 10x fracture rate of screw retained metal ceramic bridgework versus cement retained ( as well as 3 x the screw loosening and 2x the marginal bone loss). Proceed cautiously when someone presents with several failed dentures. If you make a maxillary denture then let the patient know in advance that it is a blueprint for the surgical guide, IF they don't like that denture. Paying for the better, longer lasting materials is such a small part of a full mouth implant case compared to the time spent to repair, the lost practice momentum & referrals when the patient is unhappy.....much cheaper to do it right the first time!!!
FRANK
4/12/2018
Nice case to talk about edentulous treatment!
First of all, the mandibule is perfect for easy and fast reconstruction. Place 4 implants in the anterior region between the mental foramens. Plenty of bone for regular implants. You can then restore with a fixed all-on-four type prosthesis or a removeble denture on a titanium Dolder bar. Because of the moderate bone resorbtion there is enough restorative space.
For the upper arch I am worried to read about ridge splitting. I do not think you need to graft or split the ridge. To make a fixed or hibrid prosthsis on 4, 6, or 8 implants, you need to reduce the ridge height in order to create restorative space. Otherwise you may have very nice intergrated implants, but impossible to restore esthetically and phonetically.
As previously advised, make new dentures, verify esthetics and teeth positioning. Then make a diplicate of the upper denture containing barium and re-scan. You will be able to evaluate restorative spce: abutment height, screws, superstructure, acrylic ou zirconium depending on treatment chosen. That will give you the crest reductioon needed and most likely, once reduced you do not need ridge splitting.
Be very very carefull about restorative space...
After that, 4-6 implants is a choice. mechanics, bruxism...
Finally, I would suggest you make a new upper denture and 4 implants on the mandible as explained. After that the patient will evaluate the need for upper implants. He will already be very well educated and able to understand your recomendations and make an infirmed decision.
Good luck!
Chris Smith
4/13/2018
I was wondering which prosthesis was unsatisfactory. Was it both the upper and lower, or just the upper or just the lower.
Invariably the upper denture for the majority is associated with a highly successful outcome, and it is the lower full denture that invariably is the problem.
Is it possible your patient would be happy with a well made full upper denture in terms of fit, comfort and aesthetics. If so, you would only need to consider implants in the lower to provide the support for a fixed prosthesis.
Kaz
4/16/2018
Maxillary and Mandibular Hybridge should work well for both arches.
