Treatment of resorbed anterior mandible with implants: What’s Safer?

You can fabricate surgical guide and place implants flapless. You will not damage lingual artery, I hope you placing them in anterior region between mental foramens. In case you develo bleeding during preparation of osteotomy, when you place implants it stop all the bleeding. You can place 3 implants and place a bar with distal extension, that will provide better retention at posterior. Or you can do locators but that will posterior of the denture to move.

Bleeding will be if you perforate lingual plate in the posterior area, that way you may damage lingual artery.

This is a person. Can you give some information about health history, age of the patient, etc... I am not a proponent of mini-implants, but by the appearance of the atrophic mandible, this could be a person of advanced age with debilitating systemic conditions. Dont rule out four minis and an immediately placed well adapted complete overdenture.

The patient with the resorbed mandible is a 70 y.o. female with type 2 diabetes.

There is nowhere near enough information to provide a proper or adequate reply. For example: What is the bone width? What length implants do you propose? Are you grafting or not? What is the patient’s age and health status? Have you placed implants before? What are you trying to achieve (bar retained over denture, locator or ball retained denture, hybrid bridge)? What is in the opposing arch? Is there para-function? This is not an easy case and has the potential to be a disaster if not properly assessed and planned and then finally completed with competent surgical technique. It is definitely not a case for a beginner (at least not without guidance or the help of an experienced practitioner - preferably a specialist). I would urge you to think carefully about this and consult locally with someone willing to give you hands on advice. Apologies for asking basic questions if you are an experienced practitioner, but your post implies you are not.

We need more information regarding the patient's health to know if she is a good candidate, and not taking medication that would do harm...i.e. if she has Osteoporosis and is taking injectible Prolia, this may cause osteoradionecrosis.. The 9mm height that you speak of is in the regions of the mental foramena, her chin seems to be a good size, and it would be easy to implant three or four normal sized implants, and not necessary to use mini implants.

To be more specific about this very resorbed anterior mandible: the bone on tge buccal between 22 and 27 is resorbed inferior to the attachments of the genio glossus so branches of the sub lingual and submental a. will be on the ridge crest. The patient is healthy. I am not asking for help treatment planning the case. Yes I am a very experienced specialist. My question is: how would you manage this case surgically to avoid potentially serious bleeding. Would you use a small flap with gentle blunt disection? Yes I will use a cadcam surgical guide, etc and place 3 implants for a bar overdenture. I'm curious about how you, given that you have done cases like this, would design a flap, dissect etc. Thanks

Dear colleagues, have you all read the question he is asking? Looks like not. Please read again and provide your answers. He is not asking you if he should do it or not, he is not asking you to check patient medical history, etc. if you have no answer then don’t answer it. Please don’t try to show someone that you smarter than another person.

If a person has type 2 diabetes and is well controlled, then placing implants should not be discouraged...but the patient must promise to always be in control of the situation. I have had several patients with type 2 diabetes, and they did very well with their implants.

Flap the tissue so you know where you are with the bone. Buccal lingual width is an issue since you will weaken the bone via implant height. The wider the ridge the less bleeding you'll fight too. Are you comfortable with all methods of managing bleeders? I would wonder why place 3 implants. The middle one is the most risky: 2 or 4 will achieve different goals and are used more commonly for a reason. The midline implant puts the anterior implant at significant risk and the patient at a great risk of bleeding that raises the tongue and blocks the airway. No surgical guide will promise that you'll avoid the lingual artery.

A question was posed " where do you see the lingual artery?" So in a mandible that is resorbed to the superior aspect of the genital tubercles, the branch of the sublingual A. will lie above the mylo hyoid and with in the fibers of the genio glossus muscle. The submental A. is also found there as well. Flapless surgery could be dangerous but blunt elevation of a small flap, careful not to tear the peri ostium, will expose the vessels. Bleeding can be stopped with a,fine hemo stat and the vessels tied with 5 0 chromic and a fine end cutting thin needle. The suture will also help retract the soft to allow seating of the guide.

I have a similar case in planning , but resorbed to 9 mm . I planned to place 4 implants using a surgical guide which only requires to flap on buccal only. The guide will be secured with anchor pins and don’t have to extend the lingual flap to seat the guide.

Could we have a 3d image picture of the lingual side of the mandible

expect strong bone. use new drills . go slow. plenty of irrigation. do not expect much bleeding . i generally try to avoid mid line as sublingual glands cause more calculus accumulation there leading to more implant failure

Oleg, most dentists here do not try to show off to be smarter. If the posting doctor had given more information in the beginning, hi question probably would have been addressed more appropriately. Thanks for the remark.

Go with mini implants, I have done multiple of these case with no complications. Make sure you use brand new drills due to dense cortical chin bone. Make sure patient does not have osteoporosis. Good luck

I don't think the lingual artery is an issue unless you perforate the lingual There is an artery that can insert near the midline that can be a bleeder if it is large. Your pictures don't show this as having been assessed My question is why 3 implants ? Are you are planning a bar? If this is a OD with locators or ball abutments you only need 2 at the B/D region Same results and avoid any artery issues Flap it so you can see and remove that boney projection so you have a flat ridge. Keep parallel to the lingual plate let it guide your osteotomy. Don't do this flapless unless you are really skilled. Dentist often underestimate the trouble you can get into in the anterior mandible