You’re right, the bite collapse and the uneven ridge in the upper anterior make things tricky. It’s understandable the patient struggled with the partial denture, especially with the adjustments.

Absolutely, orthodontics is something you should be considering, but it’s not the first step. We need to really figure out where we’re going before we start moving teeth.

Here’s my approach with cases like this:

First, we need a diagnostic wax-up. This is crucial. We need to visualize the ideal tooth position and arch form before we commit to any treatment. This wax-up will help us assess:

1. Maxillary anterior tooth position: Where do we want those upper front teeth to be for ideal esthetics and function?
2. Mandibular anterior tooth position: Same goes for the lower front teeth. How do they relate to the uppers?
3. Occlusal plane: Is it level? Does it need to be corrected?
4. Vertical dimension of occlusion (VDO): How much do we need to open the bite? This is key to restoring function and esthetics.
5. Occlusal scheme: What kind of bite are we aiming for? Centric relation? Mutually protected occlusion?

Once we have the wax-up, we can then evaluate:

What teeth need to be kept versus extracted.
Where bone needs to be reduced or can be preserved.
How much VDO needs to be opened.
If and how orthodontics will play a role in achieving our ideal outcome.

For complex cases like this, I always use Dr. Jack Piermatti’s framework for assessment (the one I mentioned above). It really helps to break things down and get a clear picture.

Basically, we need to design the final restoration first (with the wax-up), and then work backwards to figure out the best way to get there.

And just to add, the wax-up can be done either digitally or analog (traditional). Digital wax-ups can be great for visualization and communication, while analog wax-ups are still a very reliable method.

I say remove the upper remaining teeth and now the sky is the limit you can do upper denture snap on or all on X ! and that’s it cz if the pt is unreliable and had this much gim disease i don’t know about compliance and orthos ?