Mandibular Rehabilitation: Treatment Options?
Last Updated: Feb 05, 2012
Dr. A. asks:
I have a 65 year old female who presents with extensive mandibular fixed partial dentures which are failing. I have already extracted several teeth. She will eventually have an edentulous mandible. It appears as though I will have adequate bone volume and bone height for a number of implant configurations and treatment options. What do you recommend as the ideal treatment option in this case? Where should I place the implants and how many implants? Please note that the patient requests a fixed bridge or overdenture.
55 Comments on Mandibular Rehabilitation: Treatment Options?
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DFCOMS
02/07/2012
No question that all on 4 is the best plan. You should be able to tell from a good examination if she has sufficient width without a CBCT saving some $$. No need for a transitional denture just get her vertical currently and duplicate it when you do the conversion of the denture to the hybrid bridge.
I would also do the lower only now unless she is having severe symptoms in the upper and let her know that more than likely she will need the same in the maxillae as her posteriors look pretty bad.
If the uppers are also symptomatic do both arches simultaneously. You may need a CBCT to evaluate the upper though.
Alexandre Junqueira Marqu
02/11/2012
All-on-4.
Dr. Alex Zavyalov
02/05/2012
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.
Dr sebastian
02/06/2012
Try to make an cbCT ....
celkupa
02/07/2012
I agree with Dr. Alex to see the final bone level first,and did you put any graft material after extractions ?
naser
02/07/2012
hi
i have extracted the lower ant.teeth and placed graft bone in the sockets and adviced the pt. to come back one month later because she had severe gingivitis .
Richard Hughes, DDS, FAAI
02/07/2012
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.
rsdds
02/08/2012
blades ???? omg !! i haven't heard about those in a while... read the literature they never fully osseiontegrate.. dr. norman cranin's book
barry tibbott
02/07/2012
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.
Dr Sanjay Jamdade
02/12/2012
Just for information, even Alpha Bio has "All on 4" abutments available. And I have no business interests in them.
Dr Zhann
02/07/2012
I agree with all the suggestions, but some of you behave like mothers, yet others behave like mother f....
Theodore Grossman DMD
02/07/2012
AFTER TAKING A CBCT CONSIDER ALL ON 4 PROCEDURE FOR BOTH ARCHES
rsdds
02/08/2012
why not all on 5 or 6 .. the more the better
Dr. Dan
02/07/2012
So many possibilities. What does the patient want?
Dr. Don Rothenberg
02/07/2012
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.
rsdds
02/08/2012
shortys??? why??
Peter Hunt
02/07/2012
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.
dr m s ray
02/10/2012
dear dr ,
i fully agree to your plan ,we should keep things simple .
DrS
02/07/2012
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.
Tomás Reynoso Bagües
02/07/2012
All on four case.
gerald rudick
02/07/2012
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
Dr S SenGupta
02/07/2012
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.
rsdds
02/08/2012
totally agree with DR.SENGUPTA
Dr. Vipul G Shukla DDS
02/07/2012
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?
Dr Sanjay Jamdade
02/12/2012
About the oral hygiene maintenance, Dr Shukla, couldn't that be said about most implant patients? If they were masters of oral hygiene they wouldn't need implants in the first place! Just a view point! Some how most patients do well, if not excellent, especially if it is drilled into them that if failure takes place they will have to spend a fortune to repair/repeat the implants. Just my experience.
carlos boudet
02/07/2012
"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.
Dr teeth
02/07/2012
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...
rsdds
02/08/2012
that is the rule of thumb !!!!
Dr L
02/07/2012
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.
Dr teeth
02/07/2012
I agree, the pronostic of any tx plan need to be evaluate each and every individual.
Mauro Carteri
02/08/2012
Are you sure that a 65 women is old?
naser
02/08/2012
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
ryoungoms
02/08/2012
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.
Dr. Don Rothenberg
02/08/2012
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.
Francois
02/08/2012
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
José Ferreira
02/08/2012
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!
Dr Samir Nayyar
02/09/2012
Go for all on 6 or all on 4
Baker vinci
02/09/2012
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
Dr Sanjay Jamdade
02/12/2012
Dr Baker Vinci most patients who end up with implants have a history of poor oral hygiene maintenance, or else they wouldn't have come this far. I have tried the removable trick for some time. Yea, it helps us dentist to convey to the patient "look you made me do implants" so that is an "insurance" for us. But Some just walk away to other dentists and get their implants done anyways.
Baker vinci
02/09/2012
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
Bill Cryderman
02/09/2012
2 things BV
I really appreciate what you have to offer on this blog and I am a total Led Zep fan. I look forward to future communiques!!
Dr. Don Rothenberg
02/09/2012
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.
Richard Hughes, DDS, FAAI
02/09/2012
A bar retained OD is a viable restoration with 4 to 6 implants.
K. F. Chow BDS., FDSRCS
02/09/2012
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.
SBoral surgeon
02/10/2012
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.
K. F. Chow BDS., FDSRCS
02/10/2012
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.
Baker vinci
02/10/2012
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
SBoral surgeon
02/10/2012
BV-
if I said "merger" on my above post when I meant "matter"
it's Nobody's Fault But Mine
Mario Marcone
02/11/2012
- 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?
Baker vinci
02/11/2012
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
K. F. Chow BDS., FDSRCS
02/13/2012
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....
Baker vinci
02/14/2012
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
Paolo Rossetti Milano
02/17/2012
all on four, nothing on three...
Baker vinci
02/18/2012
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
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