Implant restoration of a maxillary arch: Which option is better?

I have treatment planned a patient for implant restoration of his maxillary arch.Â Â One of two options that I am consideringÂ is to extract all his remaining teeth and do an All on 4 bridge on 4 implants without having to do a sinus lift.Â The patient does not have any problems with parafunction.Â Â The other option is to do bilateral sinus grafts and install implants in #3, 4 [maxillary right first molar and second premolar; 15, 16] #13, 14 [maxillary left second premolar and first molar; 25, 26].Â I would also extract #7, 8, 10 and install implants in those sites [maxillary right lateral incisor and central incisor and maxillary left lateral incisor; 12, 11, 22].Â I would then extract the remaining teeth and do a maxillary full archÂ bridge.Â During the interim I would make a provisional bridge fromÂ #5 to 12Â [maxillary right first premolar;14 and maxillary left first premolar; 24].Â During the interim the patient would like to wear his maxillary removable partial denture over the implants as they are osseointegrating.Â Which do you think is the better option?Â Do you think the patient can wear his maxillary partial denture while the implants are osseointegrating?

27 Comments on Implant restoration of a maxillary arch: Which option is better?

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Leal

12/10/2012

Think about / study the possibility to insert a mesial implant that would anchor in the mesial wall of the sinus right on top of that premolar and a distal implant that would anchor in the distal wall of the sinus. I can't see really clearly as that panorex is laking quality but with those two implants you could have a 3 unit bridge with two 30degree multiunits or two co-axis implants (if the 6 degree difference does not make a difference to you; I think it does). Worst case scenario is you would have a 4 unit bridge if the distal implant would be placed far away in the 2nd molar position. Anyway you would in these 2 cases have a mesial cantilever. Not the ideal case (as you don't want to graft the sinus) but...... I don't think you could ever consider extracting everything and do ALL-ON-4 in this particular case.

Leal

12/10/2012

I'm still sleeping, sorry. That would be a 2 or 3 unit-bridge always not a a 4 unit.

CRS

12/10/2012

What does the lip line look like? If you remove all those teeth you won't have papillae . Use an Essex not a partial. How old is the patient? Implants with small lifts in the first molar areas plenty of bone, first molar in the mandible also, occlusion. Replace th broken lateral and the premolars with implants. Get rid of the partial that's the point of the implants. You have enough bone not to cantilever the implants. Forget the all on four, you have enough bone to work with. Get help with the grafting and restore the case properly. I'd not even have anything provisional in the back while it is healing to prevent resorption, tell the patient what they need,and do the best site preparation. I'd restore the anterior teeth if stabl. Implants are not a panacea. This is an advanced case get some help.

Dr. Alex Zavyalov

12/10/2012

I bet, you would not choose these treatment plans for yourself. Some frontal teeth are rather salvageable, more stable then the â€œfuture implantsâ€, and can serve as a good support for future dentures.

OMS resident

12/10/2012

All-on-4??? Are you kidding me? Most of these teeth look salvable. It's the old "new hammer, only nails" story, again.

OMS resident

12/10/2012

...salvageable.. Sorry!

12/10/2012

I agree with Dr Zavyolov,why are you considering extracting all teeth?From what I see,only upper right lateral need restored,possibly with a post crown,if not a single implant.Looks like a good shortened arch.If pt wants upper posteriors replaced,I would go for bilateral sinus lifts and implants to replace UR6,UR5 and UL6,UL5 correct me if I am wrong.

sharon g

12/10/2012

Thank you for your comments. Much appreciated. In fact there are many details and x-rays ommitted from my original submission. The patient is in hins mid 50's and has an average lip line. #8 is hopeless as it has extensive subgingival decay as did #7 which had extensive decay and fractured below the gum line and hence was extracted. #12 has subgingival recurrent decay under the crownand has a grade 1 mobility.. #8 needs extracting. The periodontist I work with suggested an All-on-4 and the prosthodontist in the group suggested grafting the sinus estracting the remaining teeth; 6 implants and a bar retained overdenture or hybrid(which would involve removing bone in the anterior maxilla. My thoughts were to do a FPD from #6 to #12 (#7 and #8 are pontics) and place implnats in #3 #4 #13 #14 after sinus grafting.The editing of my case was wrong...the patient CANNOT TOLERATE AN RPD HE HAS NOW THE A U SHAPED PALATE!! So giving him a partial denture or anything removable will not work for him! Any further comments??? Thank you !!!!!

OsseoNews

12/11/2012

Hi Dr., If you want, you may post additional x-rays, by using the "Post a Case" link (top right of website), and referencing this post. Please post the case under the same contact information as the previous posted case. Thank you.

Peter fairbairn

12/11/2012

Yes treat the patient like you would yourself retain the maximum number of their own teeth as the future more balanced occlusion will stem their loss WE WiLL DIE ONE DAY BUt THAT DOES NOT MeAN WE COMMIT SUICIDE NOW! Peter

sharon g

12/11/2012

Hi Peter;thank you for the commnet.Please can you expand on the comment that the "future balanced occlusion will stem their loss"? I was not sure exactly what you meant by that? Thank you!

naser

12/11/2012

the natural teeth look fine, as well as the periodontium as we can see from the x-ray you attached, rehabilitate the natural teeth and do full fixed bridge and do distal cantilever 2units on each side of the arch ,and i bet it will survive for another 10 years , no bone to insert implants distal to the premolars

Richard Hughes, DDS, FAAI

12/11/2012

This patient can be restored several ways such as. Bilateral sinus lifts or unilateral subperiosteal implants. I would like to see a PA of #7.

sharon g

12/11/2012

we extrcated #7 at the time of initial presentation before I refered him to the periodontist as the fracture and decay was subgingival and the patient needed a flipper as an interim.I will post more x-rays. Thank you for the reply!! I look forward to your response. Here are the anterior periapicals that were not initially submitted: (click for larger view): anterior teeth

sharon g

12/11/2012

Here is another x-ray:

CRS

12/11/2012

Whew what a relief a team approach. In a male with a low lip line stagger the implant placement and use the natural teeth for temporary bridge or some minis. I 've done this with a prostodontist in two main steps, simultaneous sinus lift implant placement in the molar region, stagger the anterior implants so a provisonal can be used or use some minis. Second stage uncovering pace rest of implants and use initial implants for provisional. What dictates this case are the provisionals. You should end up with a set of fixed bridges I don't see the need for a hybrid if the extraction sockets are properly grafted and restored you are starting with a reasonable alveolar height so you don't need a hybrid to replace the bone. I love it when I get the patient at this stage you can do so much since you can control how much bone is preserved. Sounds like you may need a surgeon who is stronger with the alveolar ridge preservation and simultaneous sinus lift and implant placement. Have the team check out DentalXP online for the techniques. You have decent bone, perhaps with crown lengthening some teeth can be saved perhaps some good old perio treatment of the anterior teeth. It is a shame that these techniques are not used as much to save teeth, I use them as an OMS,they still work. Also the unknown is how the patient will respond to isseointegration. I like to keep natural teeth as long as possible, it's a safe bet. Great case I love the woman's touch you go girlfriend!!!

Dr. Alex Zavyalov

12/11/2012

I did not understand what you meant by â€œwrong editing.â€ Your team has a full set of specialists. Why are you asking for "any further comments"? The new focused X-rays confirm my opinion that the upper teeth (except #5,7) are restorable and more stable than the future implants, and to replace them with implants can be only financially motivated. Most of patients have unrealistic expectations and itâ€™s incorrect to do what they think is right

Peter Fairbairn

12/11/2012

Hi Sharon , sorry busy day but what I mean is the deterioation is benerally multi-factorial and by restoring the posterior occlusion with Implant retained restorations we can balance the destructive forces of the anteriior occlusion the patient currently has. The teeth look restorable and I have had many cases where mobile anteriors are restored to full stability for many years ( 10 ) later with both oral hygiene and occlusal balance. Sorry last Patient here but good luck and enjoy. As he is only young ( mid 50s like I am ) the best solution is important If he was 80 then all -on -4. Regards Peter

CRS

12/11/2012

I agree with posterior occlusion comment and keeping natural teeth. One other factor not mentioned, this is a relatively young patient who probably is still working and has discretionary income. Is it not better I'd definitively treat the patient with implants now while he can afford it and is healthier thn waiting 10 years and is living on retirement income. Also patient has to go thru more dental work on teeth that are marginal. In the USA I see this often when a 60-80 year old patient wishes that they had been given the option much sooner. Just thinking of the big picture and yes the patient's wishes are an important factor. It's good planning but of course I do not presume to be able to predict the future outcome patient's finances and health. You are the person clinically present and can make the judgement call.

DrT

12/11/2012

If the patient cannot tolerate a RPD as a final prosthesis then how can he be accepting the maxillary flipper that you made to replace tooth #7? I TOTALLY agree with the above posters who are suggesting that you do whatever is possible to retain this patient's own teeth. I have to wonder how long you have been placing implants, and how many All on 4's you have inserted? Please tell me that you are not seeing any complications with all of the implants that you have placed, and that the many All on 4 cases that you have already done have been functioning for many years. DrT

Dr G John Berne

12/11/2012

Under no circumstances would I consider an all on 4 for this case. If he can't wear removeable dentures, what is he going to do when the all on 4 fails later on-gum his food to death in the nursing home? I can't see why bilateral sinus lifts can't be performed and keep as many of his own teeth as possible-most appear salvageable to me. He certainly needs posterior teeth and that should be the priority.

dr nehal sheth

12/11/2012

dear on either side u can have one implant to replace 2nd premolar with either indirect sinfus lift or may be direct sinus lift with simulateous implants. as u have not mentioned any replacement options in mandibe i think this will suffice ur job or u can give a mini molar anatomy to this tooth instead of premolars (ie size between premoar and molar) so functions will be there. what about 1st premolar with rct and post is it symptomatic? if no leave it. best of luck

12/13/2012

It's never the same trying to analyze and offer suggestions over the internet without actually being able to see the patient in person and follow the progression in time with changes as they occur. However, in trying to give my best advice and after 40 years of practice, I would recommend to maintain as many of the front teeth as possible whatever it takes and in whatever manner you are most comfortable. Do bilateral sinus lifts and then place the implants. You might want to temporize the anterior section with a lab processed provisional pending the outcome of the success of grafting and implant fixtures. Obviously, the patient has to maintain good oral hygiene and be commited to the treatment plan and periodic monitoring. I know that's what I would want in my own mouth, regardless of age or finances. I don't think i will see stem cell regeneration of teeth in my lifetime.

K. F. Chow BDS., FDSRCS

12/15/2012

Dear Sharon. G.V. Black's basic rule for the conservation of sound tooth structure should be remembered and applied as far as possible. What would you do if this is yourself? We should preserve whatever we have as far we can and should not be so arrogant as to ever think dental implants are better than natural teeth! At best they are but a pathetically poor imitation compared to the supremely sophisticated gift of mother nature. But if you have lost a tooth, then a dental implant is the best possible replacement currently. Do the necessary sinus lifts and place in the necessary implants and leave viable teeth alone. WADR. http://smalldentalimplants.blogspot.com/p/the-rescue-of-dental-cripple-and-life.html

sharon g

12/15/2012

I have of course heard all your comments. i would if it was me want to keep as many teeth as posiible.However some of my other colleagues have pointed out that this patient has a very high decay rate..look at the subgingival and recurrent caries on #8 #9#10 #12 and the lower arch also #20 #28. If the patient has crown lengthening #9#10#; (I think #8 and #12 are non restorable as the decay is into the root..look at PA's!! #12 has a grade 1 mobility and crown lengthening will reduce attachment even more!!! ) and then has an FPD #6#-11 and retains #5 (needs reRCT and crown) he is likely to incur recurrent caries further down the line...then he has an extra expense to pay in the perhaps not too distant future? If we were to keep #5 #6#9 #10 and #11 and place implants #3 #4 #12 #14 ; how would you keep the patient in a fixed provisional and place implants in a strategic position (bearing in mind #6 and #11 are key implant sites) if and when these remaining anterior tooth abutments would fail again due to recurrent caries? Could you make a large fixed provisional on #3 #4 #5##10#12#14 whilst #6 and #11 have been extracted and implants #6 and #11 are integrating? Thank you !!

Baker k. Vinci

12/15/2012

Dr. Chow, thanks for bringing GV's name back to the "table". I was afraid, it was pure anachronism. I've been wanting to use his name several times, but thought maybe he had been de-sainted, as saint Christopher. Again, solid principals never change. Bvinci

Richard Hughes, DDS, FAAI

12/16/2012

Dr Sharon: You have to ask yourself why does this patient have such a high rate of decay? If they are taking meds that cause such a high rate of decay, then you should be concerned that these meds may also have an adverse effect ofnthe bone physiology. If it's due to neglect, then this patient may have difficulties with at home maintenance ofnthe implants and prosthesis. I suggest that young a little into the patient's history. As for the suggestion of an "all of 4" or fixed detachable case, I think it's a bad idea, unless you can help this patient turnnthings around. Younmay want ton consider an alternative treatment. You have to be quite frank with the patient and not worry about their delicate feelings.

Implant restoration of a maxillary arch: Which option is better?

27 Comments on Implant restoration of a maxillary arch: Which option is better?

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