Full Arch Reconstruction of Edentulous Maxilla: Will 6 Implants Suffice?

From the scan that you posted, your patient has very little bone, and you will be placing implants after a prudent healing period mostly within your graft. This goes along with a large interarch distance that would be amenable to something like a bilateral bar maxillary overdenture on the six implants rather than fixed bridgework. This is just one option of several. Good luck!

I agree with Dr Boudet. I would graft first and consider a bar over denture or at most a hybrid.

Dear Dr. C: I would consider these issues: 1) is this patient a candidate for an all on four? (no sinus augmentation) 2) would this patient benefit from vertical augmentation with BMP? (this allows the implants to be placed in de novo bone rather than a grafted hybrid bone -- and/or no sinus augmentation?) 3) will you be able to place the most distal implant at the most posterior tooth you want to restore (eliminating a cantilever) 4) will you be creating a facial cantilever in the final prosthesis (if the patient has resorbed to more of a class 3 -or worse- in the anterior) 5)Finally, the number of implants, and the position of them should be answered by working through #'s 3 and 4. Hope that helps!

the ridge is severely atrophic and the left antral membrane is thickened. It is prudent to treat the sinus infection first before grafting. Overdenture is your best bet as per Dr Boudet's post.

Dr. Chan, a slightly thickened sinus floor, does not an infection make! Remember; rubor, tumor, calor, dolar? It would be nice to know the thickness of the sinus floor,at your intended implant sites. He is not a good fixed candidate and he's probably not a good" all on four " candidate either, in my opinion. Remember how he got here. Simpler is better. He will be a patient, forever, if you take the more (sophisticated) complex route. Bv

Bad luck, when patients really want implants, they have no bone. I think this is not a good case for all on four. It is a complex case and is dificult to satisfy all the expectations of the patient. First I would do one or two stages for bone grafting on anterior maxillae and bilateral sinus lift, then the treatment can be planned because the bone graft surgery won't be easy too. The membrane looks thick, send the patient to an ENT specialist. Right now he is just candidate for grafting and waiting. And the patient must understand this.

Thanks for posting the entire CT slice set. Buccal atrophy has left you with Class III occlusion and the mx ridge smaller overall than mand. We restored a similar case and found that anterior support was critical; you should consider block grafting and implanting the facial aspect of the anterior segment in addition to the sinus augmentation. A cantilever to the front can be as damaging, long-term, as one to the posterior.

We get in the most difficult spots and give ourselves our own misery when we want to please a poor candidate. Be wise, from a poor denture to a removable over implants is like going to the moon for this gentleman! Be realistic, under promise and over deliver! Good luck!

Love it BV , sure will be a patient for life , as they say you will be "married" to this patient so think about it ....

Maybe best solution is all on four Zygomatic implants ......

Patient’s desires do not correlate with reality. I would limit implant insertion within anterior area and make a locator-fixed prosthesis.

Hello colleagues, In addition to some excellent comments made thusfar, here are some other related thoughts ... 1- What is the state of the mandibular dentition. 2- Focusing on the etiology of previous tooth loss, that is, dental history, may be a very key consideration here. 3- As some of you have already noted, there is very little alveolar bone remaining due to extensive sinus pneumatization and alveolar ridge resorption. 4- The request by this patient for a fixed maxillary implant-supported prosthesis requires very careful consideration and treatment planning ... it is theoretically possible to arrive at such a desired prosthesis ... however, I suspect that the final consensus here might be, especially from our most knowledgable and experienced colleagues, that a fixed prosthesis in this case would not be realistic nor practical. 5- If it must go towards a fixed prosthesis, a multi-disciplinary experienced and knowledgable team approach and fully educating and informing this patient is of utmost importance. 6- Thanks for posting this case. MM

graft the sinuses, give the grafts time to mature, place 6 root forms and restore with a bar OD. Way to much resorption to restore with a fixed bridge. Way to many hygiene issues.

In my point of view only 2 chances: 1st: overdenture with 4 locators - 2 implants in the canine pillars placed with osteotomes to expand as much as possible + 2 implants in the posterior maxilla in the 2nd mollar region with sinus lift I believe you have +/- 3mm of height for immediate implant placement (would like to see CT slices 1 - 6); wait 6 months and adjust the denture to overdenture. 2nd: zygoma

Leal, I agree with this option. I might encourage splitting the difference and placing the posterior fixtures closer to the first molar area, just from an oh perspective. His denture needs to be hijacked for at least 2 1/2 months and used only for cosmetics, for the remainder of the integ. phase. Scans, that deliver information in sliced format, such as this one, are soon to be a thing of the past. Patient's have a real difficult time understanding this and to be very honest, after 25 years of reading scans, I have a bit of trouble as well. When you are looking to get your scanner," because the times, they are a changin", you need to look at the soft ware as much as the unit. Bv

The use of Inter Mucosal Inserts are a very simplistic modality, that will give a maxillary denture excellent retention. The method is easy to learn and apply, and is cost effective. IMI's may not be what the patient wants. It is worth mentioning to the patient and has a less risk and moirbidity. The other options mentioned are just as viable but time and money are factors to consider.

Dr. C, I would be interested in what you have summized, from the advice given. What is your current tx plan? I am working up a case where 6 implants were placed, immediately after the removal of 6 healthy anterior maxillary teeth. They have all failed and now the patient has been left with a situation just as desporate as yours. Will I work him up for a fixed appliance? Hell no! The difference between the patient I'm bringing up and yours, is, my guy has perfect oh and a full compliment of teeth at the lower. This was the product of one of the biggest " implant gooroos" in the world. Bv

Carter, the procedure first suggested by Leal, can be done in an surgical office setting. This patient could get four standard implants, With a bit of work. I have had some good success, with just placing the implants and having the restorative doctor make the denture over the uncovered, integrated fixtures. These few cases were not planned this way, but as I have said before, when we as surgeons are treatment planning the cases, the plan doesn't always meet it's appropriate "end point". These few cases are all greater than 15 years old( the patient's maxillary anatomy has not changed a bit)and they are happy! These implants could all be restored now, they just choose not to proceed. Bv

Dr Hughes, what is an inter mucosal insert? Tried Googling it but no results. Would appreciate some pointers to get more info.

ktau, you can obtain the inter mucosal inserts from Park Dental Research @ 212-736-3765. You can learn the technique from Cranin's Atlas of Oral Implantology, Misch wrote a chapter for Clark's Clinical Dentistry. Park Dental Research may have reference material.