Immediate implants and retained over-denture: advice?

At the end, amount = out. Thanks again.

This is an often seen condition. The decisions for extractions, immediate or delayed implant loading, and overall treatment planning is changing in our current environment. There are many options available to provide what the patient wants and needs, what they can afford, and how convenience for the patient (and doctor) are important factors. In the current state of dentistry, when it reopens, cash flow will be a real factor and can be addressed directly. With overdenture implant cases cost can be a real factor in treatment decisions. I am presenting webinars with Zest Corporation this week to demonstrate how dentures and implant overdentures are gaining acceptance due to affordability, convenience and meeting expectations. The link to the webinar is below for this Thursday, on the Zest Dental website, link below. https://register.gotowebinar.com/register/3876219798625483277

Nice Case. I would suggest doing an immediate as area can be grafted properly. would also suggest you consider gingival height and position implants accordingly. I also would suggest keeping implants as level as possible and recommend angling the distal last implants back to get better A-P spread for first molar function. As to grafting, i would graft and I would also use the bone from the possible Bone reduction you may have to perform. Good luck!

Some input from another denture guy like yourself. ? Based on the very limited info you provided Without lower treatment plan you are asking for problems if you are planning implants You need to know how you are going to get posterior support. If you do an anterior implant bridge then you will have the same forces that destroyed the previous anterior bridge and that will be trouble If this is your locator design then that is a failure-In the max you will need to splint to protect the implants and while you may have great experience with maxillary locator retained OD this placement is dangerous. without a clear image of the lower I can't tell you much but lets say you get the implants in the upper and you then realize that you need to take the lowers out and he wants lower fixed because that is the only way to get him posterior support but he has spent all his money in the max. do you think that an upper supported prosthesis will be kind to a lower denture? If he's in a hurry then do the upper denture Get the lower treatment planned then decide where to go with the upper based on your lower (total) treatment plan That is the safe way to proceedJMHO Bill McFatter

My first comment is that it seems to me from the radiographs that most existing teeth are salvageable and could be restored. However I understand that a clinical exam is required before a definitive conclusion can be made. Secondly is that the case does not seem too hard if you (or the patient) insist on full clearance. The ridge height and width seem good. I think your comment of extract and delay implants is good. If you want to graft at extraction then fine but probably it is not required especially if you intend to implant within 2 months of extraction. My suggestion is to look into Ethoss bone graft information. It is ideal for this situation and Peter Fairbairn has a lot of tutorial information on the internet about how to use the material and he has published his results over 15 years. The graft material is minimalistic (ie no membrane required), quick and easy to use and the results are very good. Having said this, I suggest you consider extractions (no graft), then leave the site for 4-5 weeks, then raise flaps and implant and graft if required. You could decide whether to 1 or 2 stage placement at the time of surgery but I would expect 1 stage should be fine. I would use a surgical guide and aim to place parallel implants using CADCAM design. However from a prosthetic aspect, I would suggest you consider only 4 implants if you are to do a locator retained denture. 5 implants would be over kill I think. I generally only place 4 implants and activate 3 locator denture inserts. I find if 4 locator denture inserts are used then the denture is far too retentive and the patient gets quite upset when the denture is initially inserted (because it is too hard to remove). After a “wearing in” period, I sometimes activate the fourth locator denture insert but in the majority of cases the patients do not want me to do this. The reason I still have 4 implants is to have a “spare” in case one fails or if a locator wears or breaks. You will already know that locators have a habit of wearing in some cases. As an extra suggestion for you to consider (either now or in the future) is a vertical bar/ shoe/ overdenture. The bar and shoe are: CADCAM designed, milled metal frames with “dolder” type clips milled into the bar and a plastic retainer system milled into the shoe. These are amazingly retentive and the resistance is brilliant. The cost is higher but the value is greater. The only drawback (as with all bar systems) is that the gingiva sometimes becomes hyperplastic and fills in the “gingival-bar” gap which can make cleaning of the implants difficult. If a bar is a possible option (either now if in the future) then 5 implants would be fine. It looks like a good case – but lastly, could I suggest that you discuss this with your usual oral surgeon and ask for his/her thoughts. I am sure the surgeon would be willing to make some relevant comments. It certainly would do no harm to ask.

It seems clear to me from your question that, even though you have done a lot of implants, your level of fully edentulous implant restorative experience is extremely low. The patient wants a denture. Why graft the sockets and add unwarranted cost to the procedure? Remove the teeth, make a temporary denture, follow healing for 6-8 months then make a final denture. Easy. Now, if the patient wants implants that's a different story. What implant restoration are you proposing? Fixed ceramometal or ceramozirconia restorations? Then graft the sites, plan your implant restoration, decide how many and where the implants should go then make a surgical guide and place the implants. A hybrid? Then no grafting needed because you'll be reducing the ridge anyway. Possibly extract, level alveolus and place implants at the same time. Maxillary bar retained overdenture? Again, grafting is not needed since there needs to be bone reduction to create space for the bar and overstructures. I rarely, if every, use locators in the maxilla. Only if you can get them spaced out to fully support the denture and make sure they are reasonably parallel. Otherwise, it's a bar/clip overdenture. If your locators are anterior then any function posteriorly will cause the locators to pop loose over time. Very frustrating for the patient and you. Figure out what the patients needs and wants are, then guide the patient to the best treatment for him or her. You need to have the skills to perform any of the above treatments for the fully edentulous otherwise refer to a specialist that can do the more complex care. Only presenting your limited knowledge of a locator overdenture is a disservice to the patient.

you seem to take constructive criticism as trolling. You may want to read your post. It says your practice is 90% dentures and implants and you've done over 200 overdentures. I appreciate your skill set. My only comment is that, if you're holding yourself to a specialist standard then you should be treatment planning like a specialist. You are asking for advice, which is good, but have you thought about your plan if implants are to be used? No where in your question did you once discuss a treatment plan other than an overdenture and this seems to be your only answer to an implant restoration. As a specialist, any surgeon or prosthodontist will tell you there's multiple ways to treat the edentulous patient and each treatment requires different bone levels, different numbers of implants, different positions of implants and the restorative plan will dictate the surgical plan. You are doing it backwards by asking about surgical questions when you haven't determined a restorative treatment plan. My favorite line is "you don't know what you don't know". I am not trolling you, I only want you to understand that if you want to do specialty work (surgery and prosthodontics) then you will be held to the level of a specialist. This includes fully informing the patient of all the different treatment options first then determining surgical needs secondarily. Not everyone wants a locator overdenture. I wish you all the luck as you continue on your education to be a fully rounded surgeon and restorative dentist.

See that wasn’t so hard. Ok. So for this case we did discuss fixed options with implant placement by a specialist but cost obviously wasn’t a factor which it is with every patient and I’m not going to propose treatment I know they can’t afford and that I’m not familiar with. We can’t simply blanket the best most expensive treatment plan out there. Cost is a real factor as well as future cost of replacement of the fixed prosth. You can’t buy a Ferrari and expect to get your oil changes at jiffy lube. The other thing I wanted to point out is that If you go back you can see that my denture treatment plans included immediate denture with/without implants as a treatment plan. Why would I plan what you suggested when I know the patient cannot afford it. Discussing it with the patient is still considered informing the patient of his options. While I do invite constructive criticism, which is more personal commentary on your part, not answering my question and pontificating on a topic I did not ask isn’t what I’m looking for. Once again this large discussion and you still never answered my question. When you extract teeth and place immediate adjacent implants to extraction sockets, even after reduction, to create space for whatever prosthetic you are planning, will grafting w/ barrier membrane prevent the resorption of the ridge Or do we still see possible thread exposures. It seems like many articles that I have read do not touch upon this. I would assume that it would resorb but not to the level as not grafting. Is this a worry OS has when deciding to perform immediate consecutive implants next to extraction sockets? Should one assume to always graft adjacent sockets?

holy cow! First, I'm assuming you meant that cost IS a factor, and yes, it always is. And you just admitted that you don't recommend treatment you're not familiar with. You've done 200 or more overdentures. But you only have one treatment plan. so everyone gets the same treatment. That is wrong. I can't tell you how many patients I've seen for opinions after the fact that don't like their locator overdentures. When I propose other treatment options they say "why wasn't I told about those choices?" It's because you don't know what you don't know. So.... you need to inform them even if you don't have the skill set. It's your responsibility. You don't have the skills ? Refer. Why did I get off topic about your bone graft? You discussed simply a denture so I told you no bone graft is needed. You then asked, bone graft adjacent to implants and I asked, what is your plan? May or may not need to graft. The surgeons on this thread can answer your surgical questions but I want you to think about what your final result is and do you really need to bone graft. that's the beauty of osseonews. You get info from all specialties. So, as a general dentist, take the specialists advice and learn. you are lucky enough to get both surgical and prosthetic questions and answers. Now was that so hard?

Thanks for posting. From what I can see on the pictures,I would remove the compromised teeth. I would wait around 3 months. Do splinted crowns 5 and 6, 12 and 13? Do a precision attachment PD. I practice in a rural, economically challenged area. I do many MICD over implant retained lower dentures (usually two locators). My greatest headaches have come from maxillary implant retained dentures. In my experience that's a complex restoration. I think anything less than splinted implants is asking for trouble. I know this doesn't answer your question. Just another opinion on your case. Much luck to you. 42 yrs and still learning.