Mandibular Rehabilitation: Treatment Options?

Show me the final bone level first.

P.S. It’s a pity that the dentist does not have his own treatment plan, because a classical approach is to start with transitional dentures to establish right vertical and cosmetic orientation.

Try to make an cbCT ....

I agree with Dr. Alex to see the final bone level first,and did you put any graft material after extractions ?

You could treat with fixed or removable. Dr Aex is correct, by grafting and waiting to determine the bone leve. Place the patient in a transitional denture. You could place three, two posted, single stage blades and place a provisional bridge. Two months later transition to a pfm bridge.

On initial examination this looks like a classic case for an 'all-on-4' type bridge ( e.g. Nobel or Bredent)There seems to be sufficient bone for immediate placement and restoration with cross-arch splinting. An initial complete lower denture to give the correct tooth position and OVD which could then be duplicated for an immediate screw retained fixed bridge or converted into the fixed bridge. This will avoid any concerns over the IDN and delayed treatment. With close examination of the OPG the position of the mental foramen will allow quite distal placement of the 2 angled distal implants which will avoid excessive cantilevers.

I agree with all the suggestions, but some of you behave like mothers, yet others behave like mother f....

AFTER TAKING A CBCT CONSIDER ALL ON 4 PROCEDURE FOR BOTH ARCHES

So many possibilities. What does the patient want?

I would do an "All on 4" with Bicon short implants...ha coated...probably 10 units...to match occlusion with the upper dentition. We might even be able to temporize with leaveing some lower teeth, but would need to see PA's to determine this.

Why this mad rush to give her a denture. Patients want implants because they abhor the idea of wearing a denture. Besides that it means the bone height drops, the gingival zone decreases, the jaw relationship is lost, as are all clues to the vertical dimension. The final design then has to be an implant retained denture or a full-arch hybrid design. It's simpler, easier and better with an "Immediate" or a "Staged" transition based on six implants: two posterior molars, two premolars and two canines. This allows the final design to be a "crown-and-bridge" case with two three-unit bridges in the posterior and one six-unit anterior section. More natural, quite simple and easily maintainable.

Perhaps the real important question is what does the patient want? A thorough discussion of fixed, implant-supported prosthesis vs. a removable implant-supported prosthesis vs a conventional denture should be had witht he patient. There is no ideal treatment plan from us. It comes from the patient after a thorough discussion of where she has been, where she is and where she wants to go, factoring in her general health and th local anatomy.

All on four case.

The panorex film is only two dimensional....we cannot see the width of the ridges in the posterior region. A CBCT would certainly be recommended, but I would agree with the above comments in that a temporary lower denture should be made to establish a plane of occlusion. There seems to be adequate space between the mental foramina to place several implants immediately, while extracting the teeth and grafting the damaged sockets. The immediate implant placement can help stabilize the lower denture from the start and give the patient some satisfaction while waiting for the bone to reach its repaired state. Depending on the financial situation of the patient, procedures to widen the posterior regions to accept short implants is possible, and this patient, if they can afford it could be nicely restored with multiple implants to have a fixed prosthesis. Gerald Rudick Montreal Canada Providing surgical and prosthodontic implant treatment

At first glance of the 2D x ray this is a straightforward case. Likely to be plenty of bone ....for almost anything! When you are a hammer everything looks like a nail..... There are at least a dozen implant solutions possible . I am interested to hear why several of you guys are so keen on the all-on-four for this particular case. I accept that it is an option. Personally in my mouth I would like to have more individual teeth rather than a ceramic block occluding against another ceramic block ..even if delivery time was quicker by a couple of months ...and I don't think all-on-4 is less expensive or more accesible.

Hmmmmm... is anybody worried about this patient's periodontal/hygiene/home care routine? Or am I paranoid in not placing implants in a mouth with active perio? Does anyone else think that this patient will have recurrent home care issues with implant-retained fixed porstheses? In which case, is she even a candidate for dental implants at the moment?

"The patient requests a fixed bridge or overdenture" The most comfortable modality would be to treatment plan for implant supported fixed partial dentures(bridges) with implants placed in key implant positions. This treatment could also be a hybrid if the interarch space is too large, or even an immediate load case. Get a CBCT scan to treatment plan properly before you put a scalpel to the tissue. If cost is a problem, an implant supported overdenture on four implants should give the patient adequate comfort and function. Any active periodontitis should be controlled and the patient counseled before placing implants. I don't know if I would widen the posterior region, but I would try to retain bone levels posteriorly with implant placement if possible. This case allows you several treatment options. Take into account your patient's desires and give her the options and you recommendation.

All on 8 upper and all on 6 lower... Seriously, there is so many choices better than the basic all on 4 or nothing on 3...

All the recommendations for a fixed bridge are fine, and it would be something i would want in my mouth in a similar situation. The only hesitation i have, is that this patient has lost her teeth for a reason(s)- poor oral hygiene, perhaps difficult accessability under the pros work, attendance issues? and so on, but its mainly perio and you have made note about the 'severe gingivits'. If the patient is requesting a fixed bridge or overdenture, why not do an overdenture first to allow easier access for hygiene and for yourself to monitor perio condition around the implants. You can even place 4 implants in, use 2 or 4 and see how the patient responds. You can always convert this to a fixed bridge later on.

Are you sure that a 65 women is old?

hi every body,thank u all for your different and constructive discussions regarding this particular case. dr.Alex,its a pity that all the dentists have different opinions and treatment options and single treat. plan does not fit all the pts. Your classical approach to start with transitional denture to establish V.H.and cosmetic orientation seems to be incorrect in this case of swollen gum,periodontitis and fresh sockets .the ridge is decreasing in height day after day for days to come and what do you mean by cosmetic orientation of this 20 year old distorted acrylic bridge? i thank all colleagues for their thorough and constructive opinions particularly Dr.Peter hunt who hunted the most favorable idea: crown and bridge on 6 implants 2bridges on the post. and one on the ant.it will look more natural quite simple and easy. by the way i had some cases constructed on 6 implants with 2 bridges one left and one right on 3 each . thank u all

What is to be done on the upper? What is her financial situation? Medical condition? Motivation? Is she asking for "teeth in a day" -LOL.

It has been my observation that short implants...5-8mm ...produce a better quality of bone around the implant/bone interface (25years of watching this)...and will even regenerate new bone....esp. if one to use HA coating....check "Wolff' Law" of remodeling bone...the load is much more evenly placed in short implants...the crown to root ratio for teeth...1:1 (which we were taught back in dental school)....does not and should not apply to implants ...it is more like 4:1 or 5:1.

Should you extraxt the upper teeth? Keeping active perio in a mouth could raise the risks of problem with implants. This patient will most likely end up edentulous sooner or later. Clasical approch, 4-5 implants betwenn the foramens, fixed or bar overdenture sounds fine. CBCT will help confirm B-L width of bone. Altough thousands such cases were treated without CBCT. Good luck

I am sorry but this is an easy question. Maybe it is because I am Portuguese, as Paulo Maló, but the all-on-4 concept would make a perfect rehabilitation. No need for bone grafting... Just do it and sleep well!

Go for all on 6 or all on 4

I assume my comment got the DELETE, because I was under the impression that she was 85 and not 65, but I will stick to my same philosophy, with a twist. Why not explain the realistic limitations associated with what we do. This is one reason a lot of guys quit doing cosmetic surgery. Does anyone think this patient is a good candidate for all on anything? If you must, I agree, that transitioning first, to a removable option, that can be upgraded, is the most responsible plan. I must be a fool, because at least two times a week, I tell people just like this, that they are not even good candidates and the risk of failure is so high, I would only suggest a removable option. After that, if she were able to proove that she was capable of taking care of that, then she could move up to a more fixed restoration. Maybe I am trying to be " too perfect" as some have suggested. But I get disgusted at the thought of treating the failed surgery, regardless of who's it may be. Bv

Rsdds, you are going find out , that "more is always better", is not necessarily true, especially in this patient, unless she makes a biiiiiig change, in her ways. That 40,000$ is going straight in the toilet, if she "remains the same". Any led zep. fans? Bv

I agree that she needs to be informed about any and all limitations with any dentistry she has...that being said...I don't see many failures...and I have been placing Bicon impalnts since 1986...the only time hesitate is with any chronic smoking...that is a problem we have seen over the years. If she understands all the risks and advantages, and is a healthy 65 year old...she has to make the final decision...that is why we spend a lot of time in consultation.

A bar retained OD is a viable restoration with 4 to 6 implants.

Total clearance for the lower and the upper two molars should be extracted due to severe bone loss. The upper central incisors and first premolars can be saved and a temporary bridge placed from first molar to first molar using the 4 saved teeth as abutments. Two implants can be placed in the second premolar areas... plenty of bone. A full lower removable acrylic denture can be constructed simultaneously and stabilized using 4 minis. The upper can be completed later with a roundhouse bridge from first molar to first molar cantilevered. The patient will then have a fixed bridge on the upper and a removable overdenture for the lower.

Thanks BV As I tell people eveyday- If your patient lost all there teeth due to periodontal disease, They will face the same issues with peri- implantitis, it's just a merger of time. Just because you can immediately deliver a prosthesis on four implants doesn't mean that your patient will actually pick up a toothbrush. And I do like the all on four concept, but 6-8 is better when bone is available. This will give you options if your patient loses an implant. Looks like I agree with you on this one BV.

The patient's current dire situation may not be entirely her fault. She may not have been properly perio treated before all the bridges. The lower right bridge is a bridge too far. The upper anterior bridge design usually ends in at least one of the abutments loosening from the bridge and decaying. As they say, when we point one finger, three points back.

Dr. Chow, I give you " no quarter", on that statement. With the exception of the severe trauma case or pathologic ablation procedure, people get into this predicament , one way. NEGLECT ! You are a "soft hearted " man and thank God , for people like you, but the poor dentistry is not the cause. The patient still has to be responsible for cleaning themselves. Bv

BV- if I said "merger" on my above post when I meant "matter" it's Nobody's Fault But Mine

- Is it not true that implant therapy will be plagued with a possible compromised prognosis in a patient with a history of non-compliance to oral hygiene recommendations? - Is it also not an observable clinical fact that most patients never abide by the oral hygiene recommendations they are provided? - Is it possible that our implant therapy treatment planning should consider first and foremost the cause of tooth loss in a particular patient?

Yes Mario, sometimes , I will go so far as, tying my patient up " to the gallows' pole", by either holding their denture hostage, placing a feeding tube or seeing them everyday post op.. The investment, that we all make(ie. patient and doctor), is a big one and sometimes forcing compliance is the "only way ". A lot of patients ultimately relent, simply from social attrition. Bv

BV. The word is not "soft hearted", but "equitable" , which means to deal fairly and equally with all concerned. The dentist, like any other professional cannot deliver a solution to a problem and then carry no more responsiblitiy whatsover for it. I am sure you do not mean that, though the response seem to imply that. In this particular case, I stand firmly that the treatment given is a built-in timebomb. No matter how meticulous the patient may keep her mouth clean and hygienic, the bridges will fail not because of poor oral hygiene but because of poor engineering by the dentist. Actually, I am just being totally selfish in that I am just looking out for my ultimate self interest which is tied to the satisfaction of my client. BTW, "no quarter" means to have no mercy at all....

Yes, dr. Chow, I understand the meaning of "no quarter". I apologize for continuing on , with the "musical puns ", but couldn't help myself. I agree that the dental treatment is borderline, malpractice, but again, the patient got here just as most partially edentulous patients do. I will try to be more professional, but "where Is that confounded bridge"? Bv

all on four, nothing on three...

Dr. Jamdade, why has implant dentistry caused many of us to abort, the hard nosed" tenet" of the good restorative dentistry and oh model. I know plenty of CVT surgeons, transplant surgeons and even endocrinogist, that refuse to proceed with optimal treatment, until the patient prooves that they are willing to quit smoking, clean themselves up, or even get the appropriate clearances. Yes , a lot of these patients end up going elsewhere, only to get care, that is inevitable to fail. Do you not feel some responsibilty, in this scenario, or do you just proceed under the premise, that if they don't do it here, someone else is going to get "the money". This mentality, has no place in Medicine and while I refuse to proceed with more complex tx, in these patients, when my head hits the pillow, at night, I'm sleeping in about 40 seconds. No I'm not perfect, but I'm trying my best. Bv