This 50-year-old woman presented with hopeless teeth from the upper right central through the upper left second molar. Her one remaining molar on the right is also hopeless. The upper right premolars, canine and lateral are untouched by periodontal disease. She wants a “pretty, even smile” We can either save the four solid teeth and do implants or an RPD around those teeth, or we can remove them with the other teeth to better manage the esthetics. Here are the mitigating factors: She also carries a diagnosis of vertical maxillary excess, hence the gummy smile all the way to her molars. That means that if we keep teeth we have to manage the gummy smile. Consider also that by keeping those four teeth we will have significantly different bone levels between the four good teeth and the area where the periodontal disease has destroyed bone. Yet again, a very difficult esthetic challenge, one that will involve using pink restorative materials. There will be resorption secondary to extraction of the teeth and if the choice is to remove all the teeth, then the bone around the healthy teeth will need to be reduced significantly to accommodate a new prosthesis. Ultimately, she decided to have all of the upper teeth removed, a temporary denture inserted day of surgery and then decide on the final treatment plan. Although the case could be planned for immediate implants, with the bone height differential it is safer to let the bone remodel prior to deciding where and how many implants are needed to meet her goals. Stay tuned, I will post updates of the case as it progresses.