[Diagnostic / Planning]  options


I know this is an outdated PANX, as implant #22 has been removed, but I am looking for some treatment options here for this pt before I move further. He has not had posterior teeth in 15 years and functions well. He is a severe gagger and can not tolerate impressions/materials in the posterior at all. He would like to restore the max anterior. He eats like a rabbit and it works for him.

I have discussed need for posterior replacement, either sinus lifts and implants or at least a denture. I dont think he will be able to tolerate a denture.

I have been thinking on placing implants #13, 23 (as distal as possible) and #21 and use the #12 (Nobel Active) implant that remains.

I was thinking of fixed bridge but do not think the mand anteriors will be able to last.

I was thinking 4 locators and a denture trying to extend back to get a posterior, or at least the 5's.

an All-0n-4 option may work but the pt is not interested in that type of expense. I was thinking of making an all-on-4 but leaving it with just the temp cylinders and leaving it in the temp phase to bring cost down.

 I will likely need 2 mand implants with a locator denture to correspond or a conventional RPD.

I like locator dentures and think this might be the best for him. Mike from EvoCad recommended I post and also mentioned Ho-Young Chung as a great locator specialist.

Any suggestions/advice would be appreciated? 

by Mike Budrewicz at Wed, May 31, 2017 7:06 AM

1244 Views | 4 Replies | Avg Rating : 4.50

Attached Images


Likes : 0

Mark Kwon Replied at Sat, Jun 3, 2017 7:08 AM

Thanks for the upload:

This may turn into a FMR.   

We have done ton of full mouth rehabs. 

We had many fantastic  sucess stories to go with them.  However, the reality is , we also learned ton due to failures.


I agree w all the above suggestion and i would add one more if i may.

Phase 1:  orthotic tx! This pt has been chewing like a rabbit

Likes : 2

Ho-Young Chung Replied at Wed, May 31, 2017 1:13 PM

Hi Mike,

I posted my first comment before seeing Dr. Jin's response (as I was typing my response in between surgeries).  I agree with everything Dr. Jin said and he said it in better words as well.  

Bilateral sinus lifts/augmentation needs to completed for any implant procedures for the maxilla in this case.  The lift will be quite significant anterior to posterior as patient has advanced pneumatization of the maxillary sinuses.  I would be waiting at least 9 months before placing implants in those grafted sites.

Ho-Young Chung

Likes : 2

Ho-Young Chung Replied at Wed, May 31, 2017 1:08 PM

Hello Dr. Mike Budrewicz,

That's nice of Mike from EvoCad to recommend me.  

This is a tough case especially for the maxilla but also as a patient as a whole.  Would be inaccurate of me to recommend me any specific treatment plan based on a Panorex but I'll give my two cents.  

For the mandible (the easier of the two arches), assuming there is sufficient bone width, you have the option of doing implant-supported crown and bridge or RPD or even a complete lower implant-retained overdenture or even going fixed.  Two things to keep in mind is that 43 and 44 are heavily restored (with limited lifespan remaining) and all lower remaining teeth have supra-erupted (due to combination syndrome).  

I understand that patient's have limitations and wishes based on cost.  In this case, full mouth rehab w/ sinus grafting is warranted in my opinion.  At the same time, I would approach this case with caution or perhaps even pass on it.  To be frank, this looks like a case that you are best off in sending to your best friend (or worst enemy)...what I mean is that there are too many unpredictable factors involved and a high chance of things going sideways.  I personally would not treat this patient unless the patient took my recommendations for treatment plan and had realistic expectations as well.

Patients expect implants to last forever.  I get a feeling that this patient likes to dictate treatment planning and that never goes well.  

I hope my advice is of some use to you.  

Ho-Young Chung

Likes : 3

Bernard Jin Replied at Wed, May 31, 2017 11:04 AM

Hi Mike

You brought up a few really good concerns.  Yes - a patient with no posterior occlusion and having anterior dentition that appears to be failing.

Naturally without photographs, models or even a CBCT scan, we are very limited in information - for the purpose of treatment planning.

However, for the purpose of discussion... let's discuss this.

I concur with you that most patients with removable partial dentures addressing edentulous free-end in the maxillary are likely to be very frustrated with any delivered prosthesis.

Finance aside, if you wish to assist him with any level of restoration - a few concepts must be considered.

- he has extensive restorations (including previous endo treatment) in his premaxilla;
- he functions like a rabbit (using his incisors and canines to masticate his food);
- force is most certainly a big player here;
- even with full coverage restorations (ie: crowns), his dentition is most likely to fail when we incorporate the force he places on them;
- if/when we consider alternative extensive rehabilitation - we should also consider this force he will inflict on the implants & implant supported prosthesis;
- by the time you perform the maxillary extractions and debride the infections, you will be left with very poor remaining bone.

Yes - you can certainly using the All-on-4 option - but even with tilted implants, I anticipate at most you will only give him at most 1st bicuspid occlusion in the max. posterior.  I would consider having him undergo a sinus lift, which would allow him to have more of a posterior support (with implants, of course).  I would be recommending he receive the sinus lifts & posterior fixtures - even if he were to elect the locator retained prosthesis route in the maxilla, for the purpose of better A-P spread.

The finding that the patient is a gagger and non-tolerant of anything in his posterior can be easily remedied.  This can be addressed by rendering his treatment under sedation (IV or otherwise).

My thoughts are that you prepare him to consider staging out the treatment.  Extractions, followed by osseous grafting, and complete denture wearing for the interim (which allows you to determine better functional VDO, if needed).  Bilateral Sinus Lifts.  Implant placements.  Establishment of posterior support with fixture & type (removable?/fixed?) prosthesis.

In terms of the mandible - it looks promising for whatever treatment you/your patient may desire.  However, only a CBCT can determine whether he has available bone.  Also, photographs would help us determine the level of VDO collapse he has, not to mention soft tissue biotype, etc....

Hope that helps.