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Didn’t expect this case to walk in the door today..
New patient exam. 82 yo Male who was recently diagnosed with stage IV prostate cancer. His oncologist told him he needed a dental exam prior to beginning his cancer treatment.
Patient’s CC: “My denture has gotten a little loose over time, can you reline it?”
Maxillary arch: 4 implants with fixed bar and removable overdenture
Mandibular arch: Edentulous (just never got around to getting a lower denture he said – functioning fine)
Implants were placed in 1990s and the patient has not seen a dentist since the implants were placed. He reports not taking his dentures out at night.
First, we took a pano which was useless due to the patient moving during exposure.
So I sat down and took a look prior to getting periapical radiographs.
The denture was rocking front to back. I removed it and noted that one of its bar attachments was missing.
Further investigation revealed the two most posterior implants had deep probing depths. The back left implant’s prosthetic screw was loose as was what I thought was the abutment – but which I now know is the implant body. So I grabbed a hex driver and tightened the screw and pus exuded from the implant site…. oh sh*t I said internally…
Time to get some PAs.
I should have just waited to look until those radiographs were taken… what a mess!
Where to go from here?
I spoke with the patient’s nurse practitioner and found out that they want to start him on Reclast at some point but she isn’t sure when.
Obviously those two implants need to go…
My thoughts are to remove the bar, explant those two and graft the defects. Then put the bar back on as a cantilever situation and let this guy live his life the best he can going forward..
What are your thoughts?? Should grafting be avoided with Reclast being in the near future plan?? Would you proceed in a different manner altogether? @ivan-chicchon @restoredsmiles
Erick and Jedediah11 Comments-
Definitely a can of worms. Given his situation it sounds like we want to make the best with what we can it get him healthier and ready for larger more important treatment. I would most likely do something similar. I would cut the bar and try to use the two anterior implants and get what function out of them I can and reline and/or do a new. Denture with just two connections in their specific case and it some good suction with the palate as well and bone the two distal sites after implant removal and thoroughly cleaning out those sites, and yes I would definitely bone graft those infected areas after I cleaned them. Good luck!
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Super interesting case Ryan. Do you have any additional pictures?
Helping patients in this situation can be tough.
The back two implants are obviously goners. Your plan to remove them is sound.
You might consider removing the bar and sectioning it to remove the back two implants.
The anterior portion can stay intact. You can re-insert the anterior portion and just let the implants grab onto that.
Definitely worthwhile to evaluate the patients existing denture to make sure it is fitting optimally at this point.
The goal is to make it so that the denture does not put too many off angle stresses on the implants. How? Make it an excellent denture with strong palatal and ridge support. It can grab on to the implants as a bonus—not the main retentive feature.
And make sure the patient takes it out at night! Might be good to make a night guard for him to wear over the bar.
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Hi @javohiros i would love your input on this! 🙂
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@ivan-chicchon hey boss what’s up? Sorry been a little too busy lately.
About the case : so I’m thinking we all agree on posteriors needing to be removed asap, I’m also hopeful that we all agree that during the removal of those posteriors a very good and clean currettage should be done because that infected tissue around the posteriors is 100% already affecting the anteriors (just unknown to what extent)
Furthermore I’d just clear it all out very very extremely well, place some hemostatic sponges with collagen into the sockets and stitch them up completely with no further bone graft or anything else.
I would use the anteriors and install ball head abutments on them and get a great impression and a scan to then make a removable full-jaw denture with ball and socket connections that will be anchored on the anteriors and let the patient be.
Basically minimalising surgery as much as possible and restoring function as much as possible without making the patient suffer even more given he already has a bad diagnosis elsewhere in his body.
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@javohiros really good thoughts! Thanks for chiming in
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@ivan-chicchon @restoredsmiles
Thanks so much for the input! Unfortunately I didn’t take any photos.
It makes sense to section the bar and then work to get really good tissue support for the denture afterwards.
Love the idea to make him an occlusal guard for the bar!
With the patient going onto reclast soon, would you expect any issues with the grafts taking?1-
@RYAN it depends how immune compromised the patient is, some type of healing of bone would be better than none so I would graft regardless and see how the patient responds especially to help the UR implant and the infection is already compromising that one.
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@RYAN Removing the posterior implants and grafting would presumably done very soon right? Like in the next month? Healing from the graft shouldn’t take longer than 1 month or less. I’m guessing this won’t be near the time he starts Reclast.
Once he starts Reclast, any kind of surgical intervention would not be recommended. So best to get those posterior implants out as soon as possible for him IMO 🙂
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He’s already been an all on 2 for years now. Against nothing on the bottom, it’s going to be fine, especially since he probably doesn’t have a lot of time left. I would take the bar off, remove the 2 posterior implants (prob can do with your fingers) then screw the bar back on the front two. Fix the missing attachment and let him live whatever he has left in peace.
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@bryanabauer I don’t disagree with any of that!
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@bryanabauer There is a lot of wisdom in this advice. Sometimes less intervention is best. Thanks @bryanabauer !
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