I Am Concerned About Healing Time for Older Patient: Treatment Options?

A lower overdenture on locators sounds like a good plan if you're unable to save some of the patients teeth. Has a conventional partial removable denture been discussed as a long-term temporary/definitive solution? By the way, I think we are able to identify your patient.. Maybe you should look into that?

Thanks didn't realize that. He is coming in tomorrow to discuss options.

Keep the natural teeth dude. This is geriatric dentistry. Cant go subjecting a patient to that much shock. Simpler the better. Tidy everything up with endo in some areas, Composite, GIC etc Xla's only of the really bad ones. splint the others together. further xla when needed. Creeping Plastic denture. Sometimes caution is the better option. taking all the teeth out and placing implants is a massive thing for the body to have done, if you need to do implants, do them as an adjunct, but I suggest you try the prosthetic option first and see how he copes.

In this cases: extraction of the lower teeth and provisional prostheses a month later immediate loading with four implants with fixed prostheses. In the upper jaw: Treatment of the remaining teeth and implants.

Don't be the straw that breaks the camel's back. I would treat this case prosthetically or not at all. Be careful how much surgery you do in the geriatric population. I would only do what is necessary. How do you defend the fact that you had a 90 year old spend a bunch of money on implants and then he has complications that might lead to more severe issues. Remember "do no harm!" because the lawyers will hold you to that.

In this cases: extraction of the lower teeth and provisional prostheses a month later immediate loading with four implants with fixed prostheses. In the upper jaw: Treatment of the remaining teeth and implants. I don´t see any problem because the age.

A full lower denture is really tough to handle even if it is for 3-4 months. Ideally, if you can find at least one good tooth on either side, make a temporary strong partial and place 2-4 implants. After the implants have healed, place your locators and finish the case by extracting the at least 2 remaining teeth. Now another option, if affordable by your patient is placing at least 4 implants, tilting the distal most ones and converting an immediate denture to an immediate fixed implant prosthesis..such as described in the "All-on-4" concept..that is if you know how to do that. I would say that if you know what you are doing, this is the ideal way to go instead of a removable prosthesis.

How old is the patient? medical compromised? bone density consideration?

This is relatively straight forward. I agree with Dr. C., Extract the teeth, temporary max. denture, no lower prosthesis for 4-6 weeks. This clears up infections, allows soft tissue healing. He's not going to wear a temporary lower anyway. Then four implants and go straight to lower hybrid. Bar clip overdentures can sometimes be difficult for older patients since they may not be strong enough or dextrous enough to remove an overdenture, especially clipped to four implants. In this way, he's into implant retained lower teeth in 8-10 weeks. Any restorative work on his natural teeth should be palliative only due to the severity of dental, pulpal and periodontal disease. Age shouldn't be a factor, only health.

Based on your comment am gathering your planning on full mouth extractions. Since this gentleman has not worn a removable prosthesis before I would suggest upper and lower bar overdentures which will provide good stability and elimination of any palatal coverage. In the upper arch would consider implants at sites 3, 5, 6, 11, 12 15 (molar fixtures will be 10mm but can place super wide bodies in to get primary stability at the extraction time. On the lower arch will need to see how the orientation is for the IAN in the buccal-lingual dimension and may be able to place a standard diam fixture at the 2nd premolars bypassing the IAN. and also fixtures at the cuspids the a bar connecting the 4 with Locators on the bar with one cantilever distally and one just mesial to the cuspid fixture. Allow both arches to heal 3 months and restore. Should be sufficient bone to place temporary mini implants in the interproximal bone of the extraction sites and then lute a temp bridge to them in the interim.

Please dont get the poor man's teeth out.He is 90 years old...say that out loud once for you to listen to. Get two imps between in thelower incisor area and 2 on each lower molar side. You have enough space. In the upper left area get the roots out and do ridge preservation.

Okay I have a his man is 90 years old and while I have done implants on someone is age I see no reason to remove all of his lower teeth and place implants. There is nothing wrong with just electing to do a few root canals and place locators into his natural roots then deliver a denture and pickup the locators. Less trauma, faster, less expense, and better sensation. Then if you don't have adequate retention with two natural teeth locators add a couple of implants for more locators.

Don't overlook this patient's chief complaint. Consider implants on the upper left and lower right where his perceived problems ("gaps") are. Discuss other prosthetic treatment to ensure function. One step at the time approach would benefit this patient the most.

I'm going to suggest you work on your editing skills with the pseudocanal feature on your scanner. Next I'm going to suggest attempting to save as many teeth as reasonably possible, and make this man a partial denture and do your patient a great service. Are you going to sedate this patient? Are you and your staff acls certified. Regardless of what you are doing, monitoring this man's ekgs in at least lead 2 and monitoring his bp is critical as well as providing Supplemental O2. Regardless of the local you use he will have a flood of epi in his system, either exogenous or endogenous. This is when you thank God, that there are many facets to what we do, but considering implants should be after all other options are exhausted. To the person that suggested edentulation and immediate restoration of mini- implants, you have got to be kidding! The level of viable osteoblast and blood supply is compromised in every aged adult, regardless of how healthy he is, this is just the nature of aging. Are you aware that every male over the age of 45 starts to develope carotid vessel plaques. Please don't forget regardless of your specialty, we are all doctors of dental surgery. Let us not forget to look at the big picture . Nothing replaces natural teeth better than natural teeth. Bv

It is scary to see such a wide range of suggestions. I'm going to guess those that suggest implants( especially early loading ) are the guys that haven't placed many. Don't practice on the elderly. What happened to the premise by which dentistry was founded. Aren't we supposed to be saving as many of our own body parts as possible. Why has dentistry turned on itself? I got to say ,some are seeing dollar signs , some are seeing a 90 year old father/ brother/ uncle.

The physiology of bone at this age,and surgical risk for such patients.is best considered not placed implants .is necessary to planning:estraction,root canal,post core and crown,and upper,lower partial denture.

On a different note, what Cone bean scan and software did you post? I am thinking of getting one and on the fence between gendex with Invivo software or Vatech pan duo.

I am definitely with Baker on that.I would never consider implant trt for patient in this age. I would be even very careful with the extractions of those broken roots and do them gradually.is what this patient WANTS really what he NEEDS?

Dear resident, if you are getting ready to take your boards, get ready! They will cook you, if you suggest this guy is a candidate for implants. Again, the number one contraindication for implants is active perio dz. . Do you really think a man that neglected his teeth for 90 years is going to take care of Implants. Forget MRB in this patient. In regards to the question about cbct units. This one is antiquated relatively speaking. They ask us on the web sight to avoid proprietary promotion, but the scanner I purchased 7 months ago puts this one to shame, and the soft ware is second to none. The scanner that I have was developed by terrarecon , a Japanese company that makes hospital scanners. You can look that name up and the brand will pop up in your search. Bv

I appreciate all of the comments. I've posted this because there isn't really a "best option" for this man. If he were 70 I wouldn't hesitate suggesting implants fixed or removable, but he is not. I'm not into raping his pocketbook either. We have decided to be as conservative as possible removing what we have to and preserving what we can. My main concern is this mans health. All of the suggestions here have validity and I thought the same things about each one. FYI, we always monitor EKG etc appropriately, the software is Invivo, God bless all of you.

Dr. C , when I respond to these questions , I make an effort to voice my " opinion" to all readers most of the time. As you will note I will let someone know if I'm directing a remark their way. You seem to take offense to the suggestion of " seeing dollar signs", I hope you don't think I was attacking you personally, if so , I apologize. The questions requested opinions on managing the patient . I felt like most readers should be reminded that regardless of wether we are putting these people to sleep or tx them under local, we should be prepared for any event. If we aren't injecting epi into this 90 yo, epi is getting dumped by his adrenal glands assuming they still function. By the way a lot of these cbct systems will mark the ia nerve for you, if you just dial in the mental foramen and the lingula. I have found this feature to be very inaccurate and dangerous. Bv

Hey resident, what are you the hippo Nazi ? This guys name is mr. Focal Trough Jr.. Damn, your worse than my office manager! Go remove those arch bars! Bv

Hippa , sorry

I didn't use the nerve feature but traced it out manually. I always do it that way. Thanks for the reply. This is the first time I've posted something on the forum. I really just wanted to see what others thought. Saw the patient today and he is pushing to have some implants placed to hold a RPD. I told him my concerns and sent him home with my recommended treatment.

I think explain to patient for treatment options and concern c aging and systemic disease.

Dr.c, just for fun, what branch is running vertically and then anteriorly? If you look at the most recent intnl. Journal of omfs , you will see an interesting study that proves the supposed loop of the ia nerve doesn't exist ,most of the time. Maybe your mapping the incisive branch! Bv

I agree with Dr. Vinci. You guys should not be so cavalier in this case. Take a minimalist approach here.

Dr. Kurtzman, your going to place implants at 3,5,12and14? Are you punking us? I placed implants in that region today in a fifty year old,and just barely got 35ncm at final seat. My patient, had to spend six months at the periodontist office just to get ready for this case. His oh is meticulous and I was still guarded ,as far as selling this case to him. This was after autogenous ridge grafting and management of a sinus infection on one side. Do you realize that the 90 year olds maxillary bone could be thumped out with a strong index finger. Please consider this before you suggest placing implants to someone that is asking for validated advice. Also, understand that as most patients age ,sinuses sometimes become more pneumatized and septated. Bv

Dear dr. Vinci, I've just removed the arch bars, but I'm still on call...:) I'm working long hours these days, but I'm still a couple of years short of getting ready for my boards. I think that my earlier post was a bit unclear. What I said (or at least meant) was that I think a lower overdenture on locators COULD be a good plan IF the teeth were unsalvageable. Then I asked whether or not a conventional partial removable denture had been discussed as a long-term temporary/definitive solution. I didn't get into discussions around the patients age and health since dr. C stated: "The man is is in good shape and pretty robust for a 90 year old". But if this was my patient I'd try to talk to his physician and get more data on his general health status before I would start any major treatment. One of the luxuries of working in a hospital setting is that it is easy to consult an in-house medical colleague regarding patients general health issues and how to manage them properly. The oh part and the perio disease is of course a problem, but as a novise I reckoned that it would be obvious to all of us that these issues need to be adressed before the start of any kind of elective therapy, whether it is conventional prosthetics or implants. This goes for all of our patients in my opinion. By the way dr. Vinci, are you going to Philly this September?

Agreed, im considering it , it falls smack in the middle of teal season. Nest and pond counts in the breeding grounds for ducks exceeds all counts since we started intensive studies Of such some fifty years ago. I unfortunately am just as passionate about my hobbies as I am about surgery. May come just for a day of meetings and an honorarium for R.V.Walker. Bv

Dr. Vinci has a point about doing nothing...Bottom line, what is the patient's chief complaint? Is he in pain? There are also active infections...well, that's not good for anybody anyway. Doing nothing about those infections is not recommended in my opinion. If the patient is healthy, and he is complaining about not being able to eat because of his teeth and he is in pain, age should not be a prerequisite for not doing implants if implants are the best option...even with immediate loading, considering he has never worn a prosthesis. Going straight to removable dentures after 90 years, in my opinion, is more traumatic than immediate loading four implants, if the patient can afford that type of treatment. 90 years and healthy is a wonderful thing..someone who has lived that long and is still healthy may live another 10-20 years. Why make those last years of his life horrible with removable dentures? And yes, if this were my father, uncle, grandfather, father-in-law, grandfather-in-law or opposite sex, I would do it.

Dr. Dan, I suggested saving every salveagable tooth. Do you not speak English ? That means, removing nonsalveagable teeth, doing endo or whatever you have to do that is reasonable to make this man function, free of infection and active dental dz. . You apparently don't like surgeons, can't read or are just looking for a fight . Would you like my address ? Give me a brake, dude . I'm just guessing when I say this, but you just finished a tough week. Hope your weekend is better. Bv

Dr . Dan , you don't buy the philosophy that active perio dz. Is the number one contraindication for implants. This guys teeth didn't fall out because he is taking care of them. I guess you will place implants anywhere, anytime. I have enough work, to allow me to practice within the standard of care. You and dr. Blah aren't going to refuse to place Implants in a patient with poor oh.. Good for you, this is why you have so many failures. Bv

Very classy response, baker. I suppose patients love you because if your wonderful bedside manner too. Have you every realized patients like this one refuse to see a dentist because of the possibility of wearing dentures? Why not offer the option of immediate loading with implants instead of laborious dental work which may be even more costly in the long term? You have such contempt for the elderly. That is disgusting. In your mind he's 90 years old and is not worthy of giving options and perhaps better treatment than a removable denture and endo on several teeth with a weak bridge? Why not offer an alternative? That's all I have been saying and here you are in you try and insult me. And learn to spell. It's not give me a brake; it's break....you shmuck.

Mr.Dan, contempt for the elderly. Are you kidding me,you Jack ass? Immediate loading on a 90 year old with active peri dz.. Have you not read the preceding post? Sorry my spell check, creates a few inadvertent typos. Come to my home town and check out my bed side manner. I'm surprised I have stuped so low as to entertain you senseless nebbish. There are a lot of good minds on this website that can retain what they have read,but you are most likely swimming in something that has rendered your limbic system useless. Go ahead and place your mdi nails in this man, and a qualified doctor will bail you out. I'm certain it will not be the first. Have another drink, snort,puff, or whatever your doing. I have a golf game tomorrow with two 70 plus year olds with 0 handicaps. Enough with you. Bv

Learn to spell? To not too.

Dude, what mdi nails? I'm taking about real implants, dummy. All on 4 nobel external hex implants conversion of immediate lower dentures into a fixed prosthesis. have you ever heard of it, dummy? Mdi nails....what idiot like you would use something like that on any patient? As far as periodontal disease..once your remove all the teeth there is no more periodontal disease in that arch. I wasn't advocating placing implants next to endo teeth like you were our in infected sites. And fyi, I'm not a general dentist. I'm a periodontist and board certified your shmuckhead. Get a life.

Dr. Dan, seriously , if you are going to engage on this website , you need to remain current with what has been said previously. While you bust me on s single spelling error, I can barely make sense of some of your responses . So you are going to edentulate this guy, and just like that his habits are going to change. Not likely. Most 90 yo guys are pretty set in their ways. By the way if you bag this guys nerve, fx his jaw, create a sinus communication or heaven forbid have a serious bleed that requires hospitalization, are you going to admit him to the hospital and treat all of his complications? You attacked me first, and god only knows why a waist time communicating with fools like you . The Nobel products that I use are not external hex, by the way. I have a pretty good grasp of that system. I Have been placing branemark/ sterio. Since they began. Again, I can't continue to go back in forth with your non sense. I hope you have a good weekend. The end! Bv

Geriatric dental tx option is always to treat active disease and then minimize doing invasive treatment. I would treat any current infection and if any teeth are loose and painful due to perio, will extract them and then make partial. Of course, all these will have to be explained to the pt. before the tx starts. I noticed that after some of newer members got on this site, it has become hostile at times. lots of offensive sarcasm and even name calling. Get out or suck it up and modify your behavior. I wouldn't think any inexpereinced docs will refer any of their patients to rude docs. I don't care how much you try to say " I'm not like that in my practice" . I heard it all before..

Baker vinci, yes i have suggested placing implants in those maxillary site. I did not advise about loading those immediately they will require months of healing. Once can also improve the quality of the bone by using osteotomes and graft material developing the sites then threading the implant in. The super wide body fixtures work well in these immediate molar sites and we have had good success with these and have treated patients in their 80-90's this way. You stated "I placed implants in that region today in a fifty year old,and just barely got 35ncm at final seat." I personally have no issues placing an implant that torques to 35ncm doesnt mean it will be loaded immediately. My criteria is if we can get 40ncm then we can immediately load the case but only if we are doing a full arch and can get cross arch stabilization. single fixtures only in the anterior and out of occlusion (there for esthetics only) But lets look at the literature. Here are just a few articles and the consensus in the lit is 35ncm to immediately load but we prefer a protocol of 40ncm. J Oral Implantol. 2011 Apr 11. [Epub ahead of print] Survival and success rates of immediately and early loaded implants: 12-month results from a multicentric randomized clinical study. Grandi T, Garuti G, Guazzi P, Tarabini L, Forabosco A. Source a University of Modena and Reggio Emilia, Adjunct professor, Odontology and Maxillofacial Surgery, University of Modena and Reggio Emilia. Abstract Abstract Objective: to compare survival and peri-implant bone levels of immediately non-occlusally versus early loaded implants in partially edentulous patients up to 12 months after implant placement.Materials and methods: Eighty patients (inclusion criteria: general good health, good oral hygiene, 30-65 years old; exclusion criteria: head and neck irradiation/cancer, pregnancy, uncontrolled diabetes, substance abuse, bruxism, lack of opposing occluding dentition, smokers >10 cigarettes/day, need for bone augmentation procedures) were selected in five Italian study centers and randomized into two groups: 40 patients in the immediately loaded group (minimal insertion torque 30 Ncm) and 40 patients in the early loaded group. Immediately loaded implants were provided with non-occluding temporary restorations. Final restorations were provided 2 months later. Early loaded implants were provided with a definitive restoration after 2 months. Peri-implant bone resorption was evaluated radiographically with a software (ImageJ 1.42).Results: no drop out occurred. Both groups gradually lost peri-implant bone. After 12 months, patients of both groups lost an average of 0,4 mm of peri-implant bone. There were no statistically significant differences (evaluated with t-test) between the two loading strategies for peri-implant bone level changes at 2(p=0,6730), 6 (p= 0.6613) and 12 (p=0,5957) months and for survival rates (100% in both groups).Conclusion: If adequate primary stability is achieved, immediate loading of dental implants can provide similar success rates, survival rates and peri implant bone resorption as compared with early loading, as evaluated in the present study. Eur J Oral Implantol. 2010 Winter;3(4):285-96. Immediate positioning of a definitive abutment versus repeated abutment replacements in post-extractive implants: 3-year follow-up of a randomised multicentre clinical trial. Canullo L, Bignozzi I, Cocchetto R, Cristalli MP, Iannello G. Source [email protected] Abstract PURPOSE: The aim of this randomised clinical trial was to evaluate the influence of restoration on marginal bone loss (MBL) using immediately definitive abutments (one abutment–one time concept) versus provisional abutments later replaced by definitive abutments. MATERIALS AND METHODS: In three private clinics, 32 patients with 32 hopeless maxillary premolars were selected for post-extractive implant-supported immediate restoration and randomised to provisional abutment (PA) and definitive abutment (DA) groups, 16 sites in each group. After tooth extraction, 7 patients had to be excluded for buccal wall fracture at tooth extraction or lack of sufficient primary implant stability (or=30 Ncm. Implant stability measurements (ISQ) and radiographs of the marginal bone level (MBL) change were performed at prosthesis delivery and after 1 year. RESULTS: One implant in the test group and one implant in the control group failed, giving a cumulative success rate of 98.6%; the prosthesis survival rate was 100%. At the 1-year follow-up, no statistically significant difference was found between the control and test sites with respect to MBL change (0.47 +/- 0.18 mm versus 0.57 +/- 0.27 mm) or mean ISQ values (62.24 +/- 1.92 versus 61.34 +/- 2.15). CONCLUSION: These preliminary data suggest that immediate loading of implants placed immediately after extraction may be a viable treatment option for edentulous arches when implants are stable at insertion and are rigidly splinted with screw-retained titanium-resin prostheses. I have to say your responses come across in a very condescending manner. It's ok to disagree but do so in a professional manner. My opinions are based on clinical practice and knowing the literature. Your comment "Are you punking us?" is better suited for Aston Kuchers show then a profession implant list.

Dr. Kurtzman , I apologize if the statement offended you,I feel like a little levity keeps things bright . I did not intend to speak down to you, and while tempers have apparently flaired , it is inexcusable to act as such. With that being said,i read a lot ,and the science supports this type of tx in an appropriate candidate. This man is not one of those patients,and I would only offer this option with a very guarded prognosis,and if he were to choose implants ,I would encourage a second opinion from another boarded omfs. This man would be educated and fully informed that the best care would be removal of hopeless teeth, restoration of the others and partial dentures. He has proven he cannot clean his teeth and suggesting sophisticated implant care makes no sense, in my opinion. Have a good weekend. Bv

I agree with Dr. Kurtzman. The only other issues that have not been mentioned are the shape (conical vs straight) of the implant and the surface texture of the implant. A conical implant may be better suited in softer bone, thus using the concept of osteocompression. I would also grout the osteotomies with Osteogen. This would increase the bone to implant interface. I would also stay away from immediate loading.

The only other issues that have not been mentioned according to the last entry was implant shape! I might suggest some other points of concern. There is an absolute decrease in tissue perfusion, oxygen tension,vascularity,osteoblastic,osteoclastic and collagen formation in everyone past the age of sixty. Not to mention neoangiogenesis and immune health. We are essentially performing orthopaedic surgery of the facial skeleton ,so anecdotally the risk of dvt's or pulmonary embolism is increased. The initial inquiry mentioned concerns regarding nutritional maintenance ,and the way I see it ,if implants are placed and a slightly longer integration phase is allowed we are looking at a year of supplementation. Are you going to asses the guys renal status,because as you know his creatinine clearance decreases significantly with age. Even a slight disruption in k and or na levels can be catastrophic at this age. If the more conservative approach of restorative dentistry is chosen this patient will resume a normal diet immediately. Is this man ready to be married to one of us for a year and God forbid,longer, if he has complications. If you must proceed with this ,please make sure you involve a nutritionist and the patients pcp. Bv

Dr kutzman, sorry that you misunderstood my entry. I fully understand the premise of torque values, and never suggested that there was some scientific threshold that correlated with implant success. I have had excellent success with implants that had extremely low torque values and even values greater than what some of the loose science suggest. Albiet, the information you provided is useful,it really has little to do with this particular case. Have you considered the effect of the unusual crp levels that this patient will have on integration success . There is a lot we don't know, so I will always keep a relatively open mind. I sure hope this man has a good experience . Bv

I have to add one more thing,and then I'll drop the subject . When I do a major reconstruction case ( this does not necessarily fall into that category ,relatively speaking ), I find the absolute best results come when a strict clear liquid diet is maintained, even going to the extreme of nasogastric tube feeding or less dogmatic,clear proteins such as resource fruit beverage. I advance to full liquids only after complete soft tissue closure has occurred . Anything Short of tube feeding carries with it a real likelihood of electrolyte/nutritional imbalance . Bv

Based on the original posters entry all we know is this pt is 90, no mention was made as to his health status. I am sure we have all treated patients who were 90 that were in good health and healed well. The oldest pt we treated implant wise was 98 and she did very well. We have also seen patients who were 50 that didnt heal well so IMHO age is relative and not a contraindication to implant placement we have to look at other factors. Why does it have to be another boarded OMS to make the decision and not some other type practitioner who is experienced with implants?

Dr kurtzman, would you like me to list every factor.I felt I gave a fairly comprehensive summary of some of the important concerns. Your right , I would actually get the second opinion from the restorative guy , either gp or prosthodontist,then another boarded omfs. That's right,would you get a chem 7 or chem 20 during and after his care. Did you ever consider the c- reactive protiens,do you have privileges in your local hospital to manage any complications. We can't ,for a second ,take this mans care for granted! I hope my opinion doesn't offend you ,because that's all we have, at the end of the 24 hour swath. Have a pleasant day. Bv

Age is really not the only factor. Am I missing something ? You did look at the cbct scan. One thing has remained constant, from the time I started operating with Kent and Block's residents and private practice 18 years ago,and that is ,the NUMBER ONE CONTRAINDICATION FOR IMPLANTS IS ACTIVE PERIODONTAL DISEASE. Why is that so difficult for a perio guy to understand. Please tell me you believe in scaling and aggressive oh.. There are perio guys in my town , that admit idly suggest otherwise. I feel like a serious conflict of interest ensues with this philosophy. I'm terribly sorry to keep hammering my opinion. Bv

Actually just a single peio guy! Bv

Does anyone know how to disable spell check?

The state of his mandible you will be lucky if implants work at all. Some heavy infection going on in there, especially under those root canals. All his lower back teeth probably need removal + heavy debridement of the adjacent bone. You can't even think about putting implants in that. I would do that plus give him some partial flexible dentures.