Resorbed Anterior Mandible: Possible Treatment Plan?

Challenging case. Your patient looks like they have had a resection- a tremendous amount of bone missing. You can't even begin to answer this question without a CT scan. Two things that I can tell you from this x-ray: 1. Vertical bone grafting is the most difficult and unpredictable procedure in all of GBR. 2. If you aren't comfortable with identifying and manipulating the mandibular nerve, don't even think about this one. Your mental foramen is probably crestal or just slightly inferior to it. Get a scan, and get a 3D model for yourself. They aren't expensive, and you can bill the patient for it as part of a necessary work up to this challenging case.

Agree with getting a CT scan. Treatment plan wise, if the pt is open to the option of implant-supported removable denture which is also the most cost-effective way, I would definitely recommend it. Tooth#18 can be restored only if there is enough healthy tooth structure left for ferrule rule (can't tell for sure from the PAN). Also, need to see PA of #20, #21. If implant supported removable denture is chosen, I would do an overdenture with O-ring retention. The rubber o-ring is more durable than the plastic Locator female.

How about precision attachment cast partial denture. I think this is a good non surgical option .

It's sad to see such an intact maxillary arch but a mandibular arch which is so compromised. Your commentators are correct in seeing the problems with grafting the severely resorbed mandibular right. However, it might be worth considering parking an implant or two in the mandibular anterior region and then it should be easy enough to find room for another in the distal region. Obviously, it would be critical to have a CBCT analysis to see if such a plan might be feasible. This would open up a whole additional range of restorative options.

Wow this is a great case for a PG grand rounds. Sometimes we all miss the forest for the trees and this is definitely one of those times. First I agree CT is paramount. Secondly this patient has an overall type III adult chronic Perio issue that needs to be addressed. As far as treatment plan forget the block graft and Ti mesh route. There are 20 maybe 50 surgeons in the world that can handle what needs to be done and unless you have experience with that this is not the case to begin with. May I propose a different route? Take out all the mandibular teeth. Place 5 implants splinted with a Bar and create a denture that attaches to it. Avoid the resorbed area completely when you place the implants. Think like the patient has had a jaw resection. (Which it actually looks like he or she has had done)

Not intending to be rude here, but I'm a bit shocked that you're considering a bridge on the lower left. You're going to bridge a hopeless molar with no retentive structure to what? Two root canalled bicuspuds with no biologic width? Opposing a supererupted UL first molar? How long do you really expect that to last? Again, I'm not trying to be rude. I want to understand your rationale so that we can come up with a solution. i.e. Maybe clinically things aren't as bad as they look radiographically? Better option was described above. Extract all, place five implants with a bar and a removable full lower denture.

I agree with removing the teeth but a bar and clip overdenture? Why? Give this patient a fixed hybrid restoration on 5 implants ( or 6 or 4) That's the most functional prosthesis. This is a classic case of not wanting to sacrifice reasonable teeth (left anteriors) for the better good of the full arch. It is so easy to want to try and save teeth but sometimes it's false conservation. 1) remove the teeth, trim alveolus to create a smooth transition from defect to left posterior. 2) The IA nerve runs so low you can get implants in the first molar areas to eliminate cantilevers on your hybrid prosthesis. Place implants 19, 22, 24, 27 and 30 sites taking into consideration you need at least 15mm between the implants and opposing arch. 3) simple implant supported hybrid without cantilevers. See? Easy when you eliminate thinking about including teeth.

I wouldn't recommend any fixed prosthesis option as I'm concerned about oral hygiene. Removable prosthesis is better for this. Pt is the ultimate decision maker after being presented with all options and their pros&cons as well as costs. Not all pts are open to extractions of functional natural teeth, regardless of any possible benefits.

I agree with Dr.Johnson^^ Remove all teeth and placed a fixed prosthesis. However, I would recommend more implants on the patients left side. 7-8 implants for the total arch. Very challenging case. Keep us all posted on the outcome. Good luck.