Planning Implant Treatment for Excessively Resorbed Maxilla?

What concerns me is that the maxillary denture is fracturing. This is a very atrophic maxilla for anyone especially a 52 year old. There is not a lot of margin for error. There is significant sinus pathology which need be addressed if zygomatic implants are placed. I don't think those four little anterior implants will do the trick.

If you place a trans sinus zygomatic implant or do a sinus lift the membrane could be an issue and become symptomatic or the tissue may block the OMC when lifted. It would be beneficial to have an optimum A/P spread. It would be nice to see what's on the mandible and if it will be balanced with the maxillary restoration. There is a concern with bone loss during osteointegration from pressure caused by the temporary prosthesis combined with the trauma from the mandibular prosthesis. I am starting a similar case with my prosthodontist, not sure what we are going to do yet.

Midline fracture is due to ridge resorption. IF - Surgically compromised Give metal palate with softliner (molloplast ) on the ridge area - very comfortable and increases retention. Balanced occlusion Prostho

Are you planning overdenture or Fixed restoration on implants?

This case...while challenging... can be treated effectively with fixed restoration using All-on-4 technique. I would refer you to an article by Babbush& Brokloff from 2013 using 3.5MM nobel active type implants. Key to case is to not perforate buccal plate and obtain good A/P spread of implants and angled abutments. This will avoid any sinus issues.

If cost is an issue don't even think about implants. He's busting his denture now, what's he going to do when you fix the restoration on implants? He'll just be breaking a more expensive prosthesis and it'll be your fault. I've had several patients break their CD. Simply remake the denture with a cast metal palate for added strength and save the time, effort and expense of implants

Consider adding Pterygoid implants area of 18 and 28, I can send you an article, or Nevins textbook has a chapter. Also angle the two distal implants 30 to 45 degrees.

P.S. I'd definitly get an ENT consult

A plan for four anterior implants as put forth here with any restoration--whether a locator or fixed hybrid--will result in failed implants for sure. With this amount of bone loss in the maxilla, any prosthesis will require a great amount of bulk of plastic or metal to restore vertical. This will stress any array of four implants anteriorly beyond their ability to withstand it. THat said, any prosthesis, conventional denture, locator, or hybrid (unless stabilized with some metal base or framework), will fracture. So sinus lifts despite the mucocele and maybe even some vertical anterior augmentation are one way to gain posterior bone and more anterior bone. If cost is an issue for all this, then so be it. If it comes down to a "conventional" denture, than that's the patient's decision. But all structural materials have potential for failure--and here is where patients need to be reminded--it is THEIR bone loss, not YOURS. Good luck, but forget the four anterior implants alone.

There are several ways to treat this patient. Given the past history of breaking the maxillary complete denture, one has parafunction. A metal palate denture will be the most conservative and the patient may require repairs on a frequent basis. One can address the sinus pathology and proceed with sinus grafting and a fixed or over denture prosthesis. This is dependent upon the inter occlusal clearance and the patients resources. Again the occlusal parafunction needs to be addressed. I have a patient that has fractured upper and lower over dentures several times and the maxillary bar three times in the same place. Botox injections worked to reduce the forces of occlusion. Occlusal parafunction can be a real SOB.

From my extensive experience of 28 years of treating such cases I feel one has to accept reality. what Dr.Richards Hughes has advised is the ideal way to treat such cases.

Fractured maxillary denture is because you have a rigid lower hybrid banging on an upper denture with little bone and lots of tissue. Not stable foundation so the denture cannot withstand the force. I would encourage you to take another CBCT with a radiographic guide that is a duplicate of the ideal denture setup. Then you will be able to properly plan the position of the implants. Some of your implants will need to be repositioned so that you maximize bone surface area and to get the apex of the implants into the better bone near the floor of the sinus. For all on four pay particular attention to making sure the access holes for the implants are lingual to the anterior teeth and on the lingual side between the premolars if possible or occlusal of first molar if angled. Another treatment consideration should be CONUS Bridge over 4 implants using a chrome cobalt reinforced overdenture without palate.

You have to look at the function of an implant supported prosthesis as if it were a denture. The movement of the denture will replicate the subtle issue of forces on the implants. It will just take longer to fail. There is the possibility that your denture broke because the occlusion that was built created some type or degree of overlap of the teeth vertically. There is also the possibility that this situation was created due to wear but that would be very quick if the denture was only 1 year old. This occlusion would capture the lower teeth within the upper denture and the forces would create a spreading effect on the denture hence the crack. The occlusion needs to be like a niteguard -flat and smooth in all directions. He may or may not have parafunction but either way the occlusion need to be flat and metal frame will help You have to have occlusion on the back teeth to protect the anterior ridge The idea of 4 implants in the area you have treatment planned will not support the occlusal forces in the vertical axis and you will eventually damage the prosthetic system. You have an anterior cantilever with your upper prosthesis so you need posterior implants to give you the protection you need You will need one implant in the anterior segment and move the 2 distal ones back or do an All on x type of restoration Please don't do locators on independent implants in the maxilla There are also some advanced techniques that are mostly in Europe using vertical implants along the palatal wall with 'sticky bone'/ PRF to rebuild bone These will be presented at the ADIS Summit in Atlanta in August