Implants in all 4 posterior quadrants: thoughts on the case?

Restore the VDO that is lost and do e-max crowns on the 6 upper anteriors. Implants 46 and 47 are too close. Might loose some interprox bone but nothing to do at this time. Looks like you wanted to do 2 roots for the 1st molar (46) but then I looked at 36 and 37 and they are prepared for two crowns so not sure about your treatment plan. Go ahead and restore it.

OK, I'm gonna be a pain right now. What do you mean "how should I proceed with this case?". Are you kidding! You put in 10 implants and don't know how to restore them or don't have a restorative plan? Really?! The first thing in restorative dentistry is treatment plan then treat. This patient has just spent 15,000-20,000 dollars on surgery without a plan? Now, on the bright side. Your implant placement looks surprisingly good for not using a surgical guide. This case is actually quite easy. I'd get rid of #20 (35) and place an implant then restore the posteriors with FPD's UR and LL and single crowns on the implants UL and LR. Use custom abutments to align the implants ideally for path of insertion and draw. Restore the anteriors if patient wants to. We can't tell from a panoramic radiograph if the VDO is overclosed or not and whether the remaining dentition is in decent shape. In the future, when you treatment plan a patient, generally I don't replace second molars with implants. Patients do 90% of their chewing from first molar forward so it's hard to justify the cost of replacing 4 second molars to add slightly to the function.

I agree that placing implants without a restorative plan is not the standard of care. With that being said a pan does not give an accurate picture of distance and angles of the implants . Do what's in the best interest of the patient and take another Ct and then re-group

I agree with Dr Johnson! I can't believe that some doctor would place implants as they have in this case and not have a clue as to how to restore! The very first thing one thinks about is how to restore a case, then the requisite surgery. If your approaching cases like this, then you have to reevaluate your thought process! Evidently you have some talent, now you need some education. This has to be a fictitious case!

Kind agreed with Dr. mwjohnson's post. You should have a restoration plan before you start to place the implants. I think more info needed for coming up a restoration solution. What is pt bite? How much is the inter arch space? Also just curious what is the length of #3 and #14 implants? Are they inside sinus? or did you do sinus lift? #30 is too close to #31, maybe bury #31 and restore #30 with single crown? How far away is #19 to #20? Maybe splint #18, 19 and make a little cantilever mesial to #19 to close the gap? UL looks nice, either single implants or splint together. UR kind concern about angulation, definitely custom abutments. I am concerned about the crown to implant length. Look like you have a big interarch space. Would like to hear some suggestions on how to solve this with fixed restorations. pink porcelain? Will this be too heavy? What is the prediction for long term prognosis? Thanks

in implant dentistry,i think u should determine the type of prosthesis before u start in your procsdures. i think this is the best treatment plan.

dear surgeon i do appreciate ur implant placement . ideally u should have given removable partial denture to pt before planning for surgery . in ur case the main imp is to restore the lost vertical height . followed by it u need to achieve proper occlusion plane so that u can restore the lost dentition . at time of cementation plz do check the timing of occlusion contacts.

Please refrain from ad hominem attacks. Not everyone who posts on OsseoNews.com is a native English speaker and sometimes the intent of an original case is "lost in translation." As it stands the original poster, has clarified the case in the comments. Sometimes it's more helpful to first try to better understand the case, then immediately judge. And if need be, blame it on the editor (who occasionally also makes mistakes), not the doctor. Thank you.

"Implant dentistry is a RESTORATIVE treatment modality with a SURGICAL component". You work out where your final restorations are going to be relative to the patients current presentation and plan the surgery accordingly. If you were planning on incresaing the VDO then you should have done that by now as you have enough anterior teeth to do that plus you could have verified any increase in VDO would be tolerated by the patient. You will probably find your abutments/ screw access holes will lay in the i nterproximal spaces if you planned your implants at the current VDO then changed it, Good luck

I think that you are a very talented dentist.... as a beginner in this field you did very well. The methodology these days is to have in mind the final prosthetic outcome before you start a case......... If you have some doubts how to handle the situation, my advice would be to restore all four posterior quadrants with temporary crowns......this way you can determine the proper vertical dimension, decide whether the upper anterior teeth that have been worn down need to have crowns on them; as well as being able to test for a period of time if all the implants are successful under loading. The patient will be happy to have these temporary crowns, and will able to function well ...and this gives you the information for the design of the final prosthetics. Gerald Rudick dds Montreal

Did your original plan include fees for the (minimum) upper 6 anterior crowns and also provisional crowns on the implant restorations, if not then you would need to absorb those costs yourself as handing them on to the patient at this point would be difficlut to justify (legally)

I think the left sided implants are lined up very well. Are you right handed and placing from the right side? Sometimes you can be thrown off a little next time have an assistant stand at the patient's feet and look from that view to help line up. Also I ask my assistant on the left side to help line up the implants. I also think that when the implants are placed by the restoring doctor sometimes corners are cut by trying to eyeball the case without a stent to determine mesial distal spacing. CT guided cases are used when trying to avoid anatomical structures and to determine width the surgical stent is the most important thing.A lot of questions will be answered in the provisionals for the lab work as Dr Rudnick wisely suggests.Also what does " ad hominem mean?

Okay I looked it up! Anyway I feel that the confusion may be when a CT guide is needed. This case would be just fine with a simple vacuform lab splint since there appears to be enough bone. That's how I did them and still do, prior to ct guides. Implants are tough to line up and space without them. This case is a pretty good first effort most likely restorable. I could not get away with this as a specialist since a few headaches were created in the placement, look at the feedback posted!

Personally, I would restore the vertical dimension (crown caninie to canine upper) use upper and lower removable partial dentures to provisionall hold the new vertical and protect the crowns from parafunction (occlusal splint at night). Use the denture set up to fabricate surgcial guides as per CRS plan then plan the implant placement and restore. I would not start with the implants and try to engineer accordingly.

I think that implants look good. In cases like this we don't use guided surgery too. The simple lab splint is just ok like CRS says. The main problem I see is distance from tooth to implant in UL, LL and LR segments. The implants are a little bit distal. It will be tricky to put crowns with normal dimensions. I would restore vertical dimension according to patient TMJ and other rules, then prepare front teeth and put e.max crowns to get them in contact. I must agree with poster and with OsseoNews post that sometimes editor corrects postings in wrong way. Then it starts to be confusing and we misunderstand. I know this from my own experience. People outside US and other English speaking contries read this web pages, also.