Prosthodontic Decision for a Patient with a Severely Resorbed Mandible
A 72-year-old edentulous woman presents with a severely resorbed mandible (less than 10 mm anterior height) and a moderately resorbed maxilla. She has worn complete dentures for 25 years and reports difficulty eating, denture instability, and sore spots. She has hypertension controlled with medication and type 2 diabetes with an HbA1c of 7.8%. She is not interested in extensive surgery but wants a stable lower denture. She has a limited budget and no dental insurance. She lives alone and has mild cognitive impairment but is able to make her own decisions.
1. Compare treatment options for the mandible, including conventional dentures, implant-retained overdentures, and implant-supported fixed prostheses, considering her medical and financial situation.
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Conventional dentures:
- Least invasive, lowest cost, but poor retention and stability in a severely resorbed mandible; may worsen sore spots and function.
- Not ideal for her chief complaint.
Implant-retained overdenture (two implants with locator or bar):
- Evidence-based minimum standard for edentulous mandibles; improves retention, stability, and satisfaction.
- Requires adequate bone volume; severely resorbed mandible may need short implants or bone grafting.
- Cost moderate; she has limited budget, so discuss phased approach.
- Medical: diabetes with HbA1c 7.8% is a relative contraindication; optimize glycemic control before surgery and consider antibiotic prophylaxis per protocol.
Implant-supported fixed prosthesis:
- Highest cost and surgical complexity; usually requires 4–6 implants and grafting.
- Not appropriate given her budget, medical status, and preference to avoid extensive surgery.
Recommendation: Discuss two-implant overdenture as the preferred option, with conventional denture as a fallback. Explore financing, community programs, or dental school clinics. If implants are not feasible, optimize conventional denture with a functional impression and consider a soft liner.
2. What informed consent and ethical considerations apply, given her mild cognitive impairment and limited budget?
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Capacity assessment:
- Mild cognitive impairment does not automatically mean incapacity. Assess her ability to understand options, appreciate consequences, and communicate a choice. Use teach-back and involve a trusted family member only with her consent.
Informed consent:
- Explain risks, benefits, alternatives, and costs in plain language.
- Discuss that implants require surgery, may fail, and need maintenance; diabetes increases infection and failure risk.
- Disclose that conventional dentures may not fully solve her complaint.
- Provide written estimates and a cooling-off period.
Financial ethics:
- Do not pressure her into treatment she cannot afford; present a range of options including low-cost clinics.
- Avoid overtreatment; recommend the least invasive option that meets her goals.
- Be transparent about hidden costs (grafting, repairs).
Autonomy and beneficence:
- Respect her preference to avoid extensive surgery.
- Document the discussion and her decision.
- If she lacks capacity for complex decisions, involve a legally authorized representative per local law.