October 31, 2015
A recent dental graduate recently posted a complex case on dental Product Review. He faced a dilemma of how to plan a young 35 years old woman, who had numerous missing teeth and a Class III skeletal discrepancy. Here is an image of this dentist’s post, and me reply below:
To make proper assessment need to see lat ceph, photos at wide smiling, CR position record on mounted models at the correct physiological/phonetic OVD. In order to consider unitary implants need cross sectionals x-rays.
From the limited information it appears that the maxilla is highly underdeveloped and the mandible overdeveloped. Its a skeletal problem, and the aesthetics, function and stomathognathic health would all highly depend on how the skeletal discrepancy is dealt with.
From the limited information, it appears to be highly unlikely for it to be possible to fix this functionally and aesthetically with ortho and crowns/implants alone.
The ortho itself is complex because of lack of anchorage. Even if ortho was possible, this case will need orthognathic surgery.
If the orthodontist and surgeon approve this for ortho tx and surgery, then you have the issue of what appear to be narrow ridges, and lack of papilla in the edentulous spaces. So even if all this was possible, the end result is highly likely to be compromised by recession and lack of papilla/ black triangles.
Provided all the above was possible, the cost would be very high, with many appointments and need to also account for the morbidity associated with Bimax surgery and attempts at orthodontic anchorage.
If the patient does not show teeth or gums on wide smiling, the above might be an option to consider, but it would all still be very optimistic, and the patient will need to accept all the above.
However, if the patient has higher aesthetic expectations and wants a less complicated process, she can be fixed skeletally, functionally and aesthetically with “All-On-4 Plus“, which has the required contingencies for a young patient.
Even with All-On-4 Plus, this would need to be done by clinicians with a high level of experience in this area. It is a highly complex case for the dentist, but for the patient it would come across as seemingly simple, and quick. Click to see an example of a case with severe skeletal discrepancy and missing teeth that I treated with All-On-4-Plus Dental Implants.
There is a big difference between a “cosmetic procedure” and an “aesthetic procedure”. Patients are expecting us to provide them with a solution, not merely dental treatment. What the patient considers a solution might be different from person to person.
So, checking and ticking all the clinical and mechanical parameters is one thing, but like PI Branemark famously said,
‘LISTEN to your patient instead of just looking into the computer’
Implants and orthognatic surgery are not easy to undo. So make sure you talk to your patient and counsel her as to the differences between the various options.