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.

Comments

Commenter's Profile Image Mark Gray
February 19th, 2012
**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.** With her gummy smile an issue, the bone height could be reduced considerably. My question is, what advantage does she get from an immediate denture compared to an immediate loaded full arch implant supported hybrid denture? I would be thinking reduced surgical appointments, reduced healing time, and a fixed prosthesis would override the pull the teeth and decide later approach. Thanks again for another great case. Mark
Commenter's Profile Image Steve
February 20th, 2012
Hey Mark You are correct on many counts and perhaps it is just the pain of past experiences that make me cautious on this case. She has significant periodontal disease that likely will compromise preferred implant sites on her left side and I want the comfort of being able to evaluate her lip mobility before we finalize the position of the hybrid. All the advantages you list are always compelling, until you have a prosthesis in the mouth with compromised esthetics and the implants already in place. I trust computer design, I use it regularly, I am just gun shy in this particular set of circumstances. Thanks for the comments, I love the dialogue! Steve