You saw this 55-year-old patient in my last blog, “Sigh...Where Are The Easy Ones? Part 1”, so you know that she has a deteriorating joint on the left side as well as severely periodontally involved teeth under the existing bridge. We know that the joint may not be stable and that we need to make sure the patient knows this before we do any treatment and that she is aware that some bite changes will most likely occur. Now to the questions in this blog. All of the abutments under the bridge will be lost as well as the upper right third molar. The only salvageable teeth are the upper right premolars, canine and lateral. Structurally, the lower arch is intact; she may lose the lower left second molar, and the implant in the right lateral position may need to be replaced. So the question is, what is your best solution for this patient? Do we keep every tooth we can or find an alternative? How would you guide her? If you keep the remaining upper teeth what are the considerations? This patient wants the best esthetic result possible. She says she has had “patchwork, I don't want that anymore!” Throw out your ideas and let's see where it takes us.

Close-up of smile from the front.
Close-up of smile from the left side.
Close-up of smile from the right side.
Close-up of teeth from the front with lips retracted.
Front panaramic x-ray.

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Comments

Commenter's Profile Image Paul Ganucheau
January 10th, 2012
I think I would lean more towards a complete upper denture, or an implant supported hybrid prosthesis if the patient's finances allow for it. But first I would place her in a full arch flat plane splint to see if the muscle and joint pains subside before initiating any irreversible treatment. Also, it would allow you to evaluate how much her bite is going to change. This should give you a good idea on how and where to build her occlusion when you rebuild her into a good treatment position or hopefully, a stable adaptive CR position if the condyle stops remodelling.
Commenter's Profile Image Mike Weisbrod
January 11th, 2012
Is there any possibility of: 1)Root banking #9 and #13? 2)Sectioning the bridge and orthodontically extruding the incisors? In hopes of regaining some bone without relying solely on ridge grafting. They might be completely ridiculous ideas, but answers to these two questions would help me to help the patient understand the options available to guide the patient to the best outcome available. If my surgeon told me ridge grafting and soft tissue grafting were going to provide us with stable tissue and bone right where I wanted it- great! Slam dunk. But I need to know where the underlying bone will be to provide the papilla height and gingival margins! I think she is lucky she displays so much tissue, that means we have some room to move things apically and hopefully recreate some papilla. I would start with an equilibration to get all the teeth to touch, make a splint to get the joints and muscles comfortable, then monitor things for awhile. I would also prefer to keep the upper premolars, canine, and lateral incisor for functional occlusion and for stability of tissue and bone- so not everything is relying on the stability of implants. What should I be worried about keeping the natural teeth? Will they compromise the outcome of the final treatment (EFSB) or compromise the future stability of future treatment? A full denture supported by implants is definitely a strong consideration for efficiency, expectations, and outcomes. This one is definitely above and beyond my comfort level, but an awesome brain teaser. Thanks!