Patient with Lower RPD considering implants: opinions on treatment options?

This 55 year old female patient is in good health without any contraindications to treatment and is currently wearing a lower RPD. She wants something more permanent and more stable. She is interested in implants as an option. Her upper arch is natural dentition and her remaining lower anterior teeth are stable.

Please note CT scan:
-Ridge width is marginal, I believe.
-Note thick cortical bone on superior aspect of ridge on lower left side.
-Patient is resistant to bone augmentation due to cost and previous experience on lower left side.

Thoughts on treatment options:
-No treatment
-Conventional implants, splint and/or cantlievers
-MDI locator over denture
-RPD with mini implants

What do you think?

25 thoughts on: Patient with Lower RPD considering implants: opinions on treatment options?

  1. Timothy Carter says:

    2 conventional implants with Locator attachments in the 1st molar regions to eliminate the distal extension. If this does not satisfy her you can build from there. I inherit this similar case frequently and this almost always solves the problem. Having done 20+ (All on 4, Diem, Revitilize, etc…. whatever you want to call it) I will say from experience that it would be my last resort.

  2. implant guy says:

    implant direct, besides conventional 2 piece implants with locator abutments, also make a one piece 3.0 mini implant with locator abutment on the top. Very cost effective and work very well. They are called go direct mini. Check them out

  3. Ed Dergosits says:

    There appears to be plenty of room for 3.5 or even 4.0 implants. I would restore both posterior quadrants with implant supported fixed bridges. I see little benefit to placing implants and using locator attachments to support an RPD.

  4. Timothy Hacker says:

    Why commit your patient to a removable prosthesis which they want out of when you can provide a fixed prosthesis very affordably with ramus blades and root forms as abutments for posterior bridges? Even if you do these one at a time separated by a year or so to extend the expense for the patient it is infinitely better than a removable solution and will help preserve the anterior teeth.

  5. Robert Moxom says:

    Agree that conventional 3.3mm tissue level implant,Straumann in my case,supporting screw retained fixed bridgework.These days I’d probably have a computer guided template but would raise flaps for extra reassurance.

    • Ed Dergosits says:

      Richard I think this case is very straight forward and can easily be treated with 4 root form implants and two 3 unit fixed bridges. Why use a ramus implant when there is so much available bone? The surgery is more invasive and the abutment “what it is” at the time of placement.

    • Matt Helm DDS says:

      Richard, your argument is simply not supported for this case. The surgery for ramus blades is much more invasive than it is for regular implants, and the patient does have all the available bone in the world. Just how is the treatment superior, and how will it yield a superior prosthetic outcome as opposed to standard (or root form) implants and fixed bridgework? Please do humor me.

    • Matt Helm DDS says:

      Richard, since this is an open-discussion forum, I wasn’t kidding when I said to humor me. I really, really, would like to hear your arguments for ramus blades in this case. So please do take the time and briefly argue your case, like Ed and I did. We might all learn something from the opposing viewpoints, right?

  6. Matt Helm DDS says:

    Ed Dergositis is absolutely correct! There is plenty of bone available for 2 or 3 standard implants on each side and screw-retained or cemented fixed bridgework. This approach is also all-the-more supported by the fact that she has her natural dentition on the maxilla.
    The all-on-4 or the ramus blades would unnecessarily complicate what is a simple, very straightforward case, while a locator RPD simply defeats the purpose. I feel the all-on-4 particularly would be too radical and unnecessary overkill. Why extract her remaining good anterior teeth?? I would not want to even imagine this patient’s reaction at that suggestion.
    I always like to ask a patient precisely why they want implants. Presumably this patient is considering implants for an improved “quality of life”, and that clearly means fixed bridgework in this case, not another RPD.
    One question is what poor previous experience did the patient have with bone augmentation? Were implants attempted before? Important to know, in case you do have to do a little local augmentation. (One never actually knows what bone one is dealing with until we actually go in.)
    Lastly, another question is what exactly is the oval osteocondensation lesion with the radiolucency in the middle apical to the lower right lateral incisor. You might want to get an OMS’s opinion on that.

  7. mike says:

    Thanks for your comment. The patient had ridge augmentation on LL posterior ridge…it went well but she said it was costly and painful. But it healed very well. As far as previous implants, I did implants on this patient at 4 and 5 area with no issues. Good stability.
    Regarding the radiolucency , that is burnthrough from the scan. If you note, the archline on the scan is a little more lingual in that area so you are seeing the cortical plate margin. I have PA’s of that area…normal. Thanks

    • Matt Helm DDS says:

      Mike, everything you just said supports Ed Dergositis’s and my opinion that standard (or root form) implants with fixed bridge-work is the only reasonable and sane solution to this case. First, why let a good augmentation go to waste? Second, if the patient went through the expense and the trouble that means that she is much more desirous of fixed bridgework. Third, you already have a positive outcome on the implants in the 4 and 5, so you know the patient heals well and, you already have a patient who is educated on the subject. And since that radio-opaque area is only burnout you’re good to go! (I thought it might be burnout, but without the whole actual scan it was hard to tell, so I played it safe.)
      Richard Hughes argument that “Ramus blades simplify the case and render a superior treatment” is simply not supported in a straightforward case like this. It’s quite the contrary: the surgery is much more invasive. Generally ramus blades are reserved for the more desperate cases where there isn’t enough bone, and augmentation would be too extensive and expensive.
      In my 32 years I learned to remember the KISS rule — keep it simple. Do standard (or root form) implants with fixed bridgework — your patient will be happy and so will you.

    • Matt Helm DDS says:

      mike, by the way, I had also meant to add that, in my view — and I think in any reasonable view — the all-on-4 that was suggested would constitute downright mutilation of this patient, because it implies extracting her remaining anteriors which are sound.

  8. Chris Bugg says:

    Another option would be extract all remaining teeth and do 4-6 conventional implants with a full denture with locators! Just a thought…

    • Ed Dergosits says:

      Because one can does not mean one should. Removing the remaining teeth and restoring the patient with a locator retained complete denture would be a great compromise. This patient apparently has healthy anterior mandibular teeth. Removing them would be borderline criminal in my view for many reasons.

  9. Chris Bugg says:

    I didn’t know the state of the remaining teeth, if heathy then the 4 implants and two 3-unit fixed bridges would be my choice…most people that come to my office need all their teeth out!

  10. Bill McFatter says:

    The only reason to go to extraction and All on 4/5 would be if you were unable to get posterior support due to the severe posterior atrophy of the mandible making it impossible to get implants distal to the mental nerve That doesn’t seem like the case here.

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