[Surgery]  Mandibular tori removal for nSequence All on 4

Hi guys,

I'm going to be doing my first All on 4 case so I decided to use nSequence to give me a bone reduction guide as well as an implant placement guide.  Turns out, the case also has some tori that the technician believes that is not removed will either make the guide very difficult to place as it's thickness will be encroaching on the tongue space.  I've never removed tori and only watched it being done. 

Any suggestions for the proper way to go about it?  Should I remove teeth first and then raise the lingual full thickness flap for better access?  The first 4 images are of the left tori and the rest are of the right, slightly larger tori.

To add a little extra bit of complication, the patient wears a neuromuscular orthotic 24/7 and can only function at that VDO.  I've notified nsequence of this and we will be trying to keep here VDo unchanged with her provisional.

I'll post some of the pics from the techniciam as well that shows the bone removal requested.

Cheers, Sokhi

by Sokhi Sandhu at Mon, Sep 18, 2017 7:09 PM

1611 Views | 5 Replies | Avg Rating : 5.00

Attached Images


Likes : 1

Mark Kwon Replied at Tue, Sep 26, 2017 10:40 PM

This case worries me...

surgery is one thing but if the Patient  is on orthotic for tmj or parafunctions , i tend to get worried. 

1. Replicating exact VDO w immediate provisional bridge is difficult 

2. If pt has clenching or grinding habit, prosthtic breakage and  implsnt failure is possible

at the end, prosthetic maybe the real challenge.

it may be wise to go wirh locator and removable option at the beginning (due to ease of repair and other changes)

and once you are sure with VDO, go with fixed.  

Just my 2€!

- mark

Likes : 1

Bernard Jin Replied at Mon, Sep 25, 2017 3:58 PM

Can you please elaborate on what you mean by a neuromascular orthotic?  Which device are you referring to?  For which purpose to address the VDO?   What is the maximum intercuspation opening?  Range of movement?  TM conditions?  Please can you provide more information.  Thanks.

Likes : 1

Bernard Jin Replied at Mon, Sep 25, 2017 3:54 PM

Hi Sokhi

Thanks for the post.  My concerns is that undertaking a full mouth implant bridge in and of itself is complex (even with Nsequence involved).  If this is your first case, perhaps consider arranging for a surgical mentor to guide you through the case; that way - if anything unexpected happens - then you would have a safety net.  

As for tori removal - I completely agree with Dr. Chung.  This is a dangerous area (much vascularity, much innervation, much friable tissue) - especially if you are not familiar with what you're doing.  Perhaps consider referring out for the tori removal at first.  Or - again - consider hiring a surgical mentor to be present while it is being done.  Naturally if you're doing this as a separate treatment appointment at first, then you'd need to perform a re-scan.

Hope that helps.

Likes : 1

Ho-Young Chung Replied at Mon, Sep 25, 2017 2:48 PM

Hi Sokhi,

tori should be removed after removing teeth as it will make your flap manipulation and bone removal easier.  That is if you are removing teeth which you are planning to do for this patient.  

Tori removal is harder if teeth are present but it is still possible to do.  This I do when patient wants a PLD and has good remaining teeth.  

If you haven't removed tori in the past, this one may create some challenges for you.  They are moderately sized and flap manipulation will be challenging.  You need adequate access for bone removal and must respect the floor of the mouth.  One nick on FOM will be disastrous for your patient and you.  

Dr. Kwon and Dr. Jin will have more advice for you as well.

Ho-Young Chung

Likes : 0

Ho-Young Chung Replied at Tue, Sep 19, 2017 3:42 PM

Hi Sokhi,

Can you post a Panorex as well?  Thank you.