Implant restoration options w/ re-establishment of VDO?

Please post radiographs

It has been my experience that insurance companies rarely cover anything related to occlusion or TMJ procedures. When planning a case, if a change in VDO is required I consider it part of the treatment plan. I do not know why there should be a charge to the patient for this. You can of course charge a fee for articulator mounted models, diagnostic work-up, photos, and a consult if you like as there are codes for all of those procedures. Of course there are fees for interim prosthetics or orthotics/splints. There will be no insurance coverage for these.

I assume the implants are integrated and are healthy. It looks like your soft tissue profile is acceptable. So in terms of proceeding with prosthetic treatment, here's how I would approach this occlusal wear case. Mount the case and send it to the lab for "over temporaries" that you can place before actually preparing the teeth. Get a diagnostic wax up and clear restorative stent for placing your abutments within the planned crown positions. Open the patient's vertical by 3mm+ and check phonetics and freeway space. Go ahead and open them another ml if they tolerate your first opening. Let them wear this for two or three months. Also test them for oral hygiene by letting them know they can't get their teeth until they prove their hygiene is acceptable. When you are satisfied their hygiene and vertical are correct, proceed with the upper arch first, then the lower arch afterward. Definitely splint your implants where you can based on the parallel draw path. Cemented restorations will probably give you a better draw path for splinting. Use Lava with cut back and build-up porcelain. They have to accept a staged program for such a difficult case if they want it right.

#12 will not be usable. Plan to remove it ASAP - the question is do you graft and leave it alone for a while, or do you go for immediate replacement? Otherwise it is as you say: restore VDO and build prosthetics. Hint: Build bite rims that fit over what he has now or some new healing caps. Line them with a tissue conditioner (flexible, fairly stable). Now play around with them until you have VDO that you are both OK with (he has a freeway space at rest, you have the interarch clearance you need to restore the case). The trick is to get enough vertical, but not TOO MUCH (consider Crn/root ratio of remaining teeth here). You will have to build up the existing anteriors in composite before you commit to crowns on them and on the implants (more likely the implants will support a hybrid FPD because of the crummy placement; possibly you will need a mesostructure). Take your "open bite" registration (made with rims as described above) and mount your master models with it. Do a "mock up" by waxing and/or setting denture teeth to exactly how you want the case to end up. Fabricate an all acrylic upper RPD to fit in around the natural teeth (I would place 5mm "healing caps" on upper implants (except #12 - just skip that one) and take the imp for the interim RPD with those healing caps in place - they will retain it nicely if you block out around them on the model and then do a chairside reline with a soft liner). Purpose of all this is to develop a working interim prosthetic occlusion/esthetic solution that is proved to function well and be accepted by pt. When this is done you will know your VDO, know your occlusal plan, and you can follow the usual path to fabrication of the finished prosthetics. You won't really know how you want to finish the case until you have the interim set-up done. Mesostructure? Custom abutments? bury #12 or remove (replace?). You might even find that a good upper overdenture is more cost effective then all the screwing around you will have to do to make the unfortunate implant placement functional. Lowers are routine - do custom abutments and you are home free. Further advice - as this case has potential for litigation you need extensive and immaculate documentation of his existing condition before you touch him. The photos you showed don't cut it. Mounted models, radiographs, etc must all be "board quality" or you risk being sucked in to a black hole. Think hard before you take this on - at the end of the day you will spend more time than you get paid for; i.e., do it for love if you must, but you probably will not make all that much money (per hour). Referral to a prosthodontist would be a really good move, IMHO (I am a GD; I disclose no conflicts). Good luck. Now do a Siltech or PVS putty "stent" of this and use it to guide your placement of composite on the remaining natural dentition (don't just "freehand" it - that leaves too much room for error).

Are these healing caps or per mucosal extensions. How tall are the caps? If pme's were used and they are 3 mm in height and planned on single phase surgery, the implants are in a better position to be restored. I can not tell without radiographs.

I would make an implant level impression and get a set of mounted casts at the current VDO, see exactly what space is available for restoration and then sit down with the patient and go over all your concerns.

You probably already know this, but inheriting any case at a midway step is complicated at best, and highly risky at worst. Make sure you set the bar for expectations at a reasonable level. Wanting to "get teeth ASAP" is a big red flag. As soon as possible might be 12 months from today. Make sure the patient understands that. Make sure he understands that this will be expensive. Don't sugar coat anything. This is starting out as an already "less than ideal" situation. Don't make any promises or guarantees. Do you have expeience with restoring VDO? If not, this may not be the best case for learning how. Consider partnering with a Prosthodontist and being there step by step throughout the procedure. A diagnostic wax up is recommended, temporary dentures for 3 months to confirm the new VDO is accurate/acceptible, and NOT rushing through this is going to be key. Good luck, and be sure to show pictures/radiographs throughout. We'd all love to follow this one.