Posterior Alveolar Ridges lacking in bone volume: recommendations?

This is a nice case for a mandibular subperiosteal implant with an overdenture. Since the majority of doctors do not know how to perform the subperiosteal procedures, then a fixed detachable (hybrid) overdenture is in order.

While there is little info to go on, This appears to be a great "all on four" case. Get a scan and evaluate the intra-foraminal bone, Get some mounted models of current situation and show your lab. Existing implant will likely have to go, and bone re-contoured in areas of previous implants. Do some homework, and I think you'll find this a great case for fixed hybrid as said above. The nice thing about all on four style technique is you can immediate load and immediate raise quality of life for patient.

Okay as usual I will choose to be the devil's advocate. I think that all the maxillary diseased teeth need to be removed due to perio and probable supra-eruption and more importantly to allow space for the mandibular prosthesis. My choice would be an all on four for the maxilla since the bond loss pattern is there anyway and the fixed mandibular prosthesis will be banging on it. That said the mandible could have either a sub, all on four with reservations since I would not like to remove more bone,or a fixed hybrid. Whatever the choice patient motivation and hygiene is very important. Just treating the mandible as demonstrated in the failed implants will lead to future problems. Prosthodontic planning needs to consider the space requirements for both arches and re-establishing the VDO. I would personally work with an experienced prosthodontist or generalist since this is an advanced case. Also whoever treats this case will need to be experienced in managing the maintenance of the prosthesis hygiene and will be married to the patient. Thanks for reading.

CRS, Yes the maxillary teeth are hopeless. The maxilla is the hardest of the two to treat. Several options are available for the maxilla.

May suggestions: 1. If the periodontal situation in the maxilla is under control leave as is. Might consider leveling the occlusal table by adjusting maxillary teeth. 2. No need to be concerned about the vertical which appears to be sufficient. 3. Stay away from subperiosteal for the mandible as the following are better options: a) if money is no consideration All On Four would be first choice, b) if cost is a concern place four mini implants to retain a new over denture. Consideration: Bone quality in the anterior mandible may be a concern; however, if mini insertion torque is greater than 30Ncm the case will be successful

all on four may not be enugh in my openion, but did you tought of laterization the ID nerve to get a longer implant in the molar area that will allow all on 4&6.

For the lower arch the only sensible implant solution is the four implants as suggested above The overlay denture does have a poor track record and I avoid them. I know oral hygiene is supposed to be an issue but I the initial implants that we did 20 to 30 years ago with a hybrid denture screw retained ,were in this area, and in elderly customers with along history of denture wear.They had no oral hygene whats -so- ever!The very long term success rate was remarkably good in this area of the mouth .Of course they had no maxillary teeth either to add to the micro flora. .

The upper teeth need to go they will compromise the lower prosthesis in regards to space and disease. The mouth needs to be healthy and there needs to be enough room for prosthesis in both arches. The use of implants may not even be an option due to the periodontal disease but I don't have the history dental or medical just a lot of very compromised teeth and two implants that are exfoliating.

As professionals, we must listen to the patient's request....but use our professional judgement as well.... your reputation is on the line....you be the boss! In the mandible, according to the xrays provided and without the benefit of a Conebeam CT scan, I would venture to say that with a vertical reduction of the thin anterior ridge, there would be sufficient bone to place 4 conventional size implants between the mental foramina. Healing collars could be placed, and the present lower denture relined with tissue conditioner to secure the denture to the collars to give some stability during the healing process. Ball attachments or an implant bar to secure a full lower denture could be the final prosthetic solution. As reviewed above, although the upper teeth are not great, they could be maintained, if meticulously scaled and the patient placed on daily Chlorhexidine rinses.....giving the patient time to get used to his lower prosthesis. If implants in the maxilla are desired, then extraction of all the teeth, and placement of an immediate denture would be the first step. With healing time and some grafting, and depending on the patient's finances, implants could be placed to either secure a palateless upper denture, or implant supported fixed bridges. This case must be done in phases, and time tested before the definitive final prosthesis is fabricated. Gerald Rudick dds Montreal AF AAID; F,D,P. ICOI

Please evaluate maxillary teeth clinically. Good perio treatment can keep them in good health for years to come. For lower All on four with two angulated implants , starting distal to mental foramen & implant apex mesio apically. Trans mucosal attachment with 30 degree or 17 degree can be used to change angle of prosthetic screw to favourable position, This will give better AP spread & will have minimum cantilever. Hybrid prosthesis with 3 mm gap between alveolar ridge & prosthesis . This takes care of cleaning .There should be minimum gap of 15-17 mm between upper incisal to lower crest of ridge. Prosthesis will have convex shape on soft tissue side. I can send you photographs , x rays of cases done by us , if you want. Shyam Mahajan

It is hard to diagnose hopelessness of periodontal disease on a panoramic radiograph. Clinical data should help determine that. Information such as furcation involvement, mobility, exudate, root caries, etc. There appears to be advanced bone loss for certain, but sometimes more diagnostic information is needed to form a final treatment plan. I am a periodontist and have been mistaken before when diagnosing from radiographs only.

CRS, you hit the nail on the head! The maxillary teeth are not just detrimental to the patients health. They are aesthetically and functionally compromised. The odds of long term survival are questionable at best. Not to mention the questionable use of the patients financial resources.

My opinion would be: 1)take CT mandible...if adequate width...plan for immediate load mandible All-4. 2)consider full upper extraction and full upper CD. Both arches would fall in "terminal dentition" category.

Uppers out, Complete upper. 4 implant hybrid or......... 7 pin Mandibular staple if it will fit, lol (anybody remember the staple ?) I keeping seeing references on here to subperiosteals but no one mentions the staple. You could build the world trade center on a staple !

I think after getting CBCT, reduce the thin crest (if its thin) and go for all on 4 technique in mandible. Maxillary teeth also need some treatment to keep the occlusal balance..

Great case for discussion. I agree with the suggestions regarding the upper teeth. You could leave a few upper teeth strategically to attach a temp bridge to telescopic crowns or go the all on 4/5/6 route. An additional option for the lower is a Ramus frame- I placed one of these with Tatum on my mother-in law 12 years ago and this has been a real success. Good luck and post the finals when you decide which route to go.

Subject to bone width i don't see a problem with the mandible and restoring it.Pretty much all options are given.Im not excited about staples any more and the Sub although some results look good...4 implants between foramina with All on 4 technique or 4 standard implants is a well tested and documented technique. However Maxilla is a disaster...I know there are some purists that would attempt to maintain those teeth...but I hardly think that this patient is suddenly going to become meticulously brilliant at personal oral hygiene....furcations et al! Too many variables in maxilla not to address at the outset.

From a prosthetic stand point ,if you attempt a lower implant supported prosthesis and it fails then you're in a lower denture and the upper teeth will need to go because the forces on the lower ridge with a denture will lead to further bone loss and the patient will not be comfortable. Natural teeth against a lower denture is a failure. Best to remove the upper teeth now for this reason and all of the above reasons cited in previous post,I.E. oclussal plane, perio etc. Figure out your occlusion and esthetics with a U/L denture first. Now do the implant supported prosthesis on the lower Then and only then ,if this works, you can proceed with an upper implant solution. The failure of this case was probably the prosthetic design in the first place but you are looking at a failure of lower implants that could be related to something not yet disclosed in the post or unknown