Prosthodontic Decision for a Partially Edentulous Arch
A 67-year-old female presents with missing teeth #14, #15, #24, #25, and #36. She has a history of periodontitis with generalized 4–5 mm pockets and 20% bone loss. Teeth #16, #26, #35, #37 have fair prognosis. She is edentulous in the maxillary anterior region from #13 to #23, with a well-healed ridge. She is unhappy with her existing maxillary removable partial denture (RPD) due to instability and wants a fixed solution. She has adequate bone volume in the anterior maxilla (CBCT shows ≥10 mm height and width). Her medical history includes osteoporosis treated with alendronate for 5 years. She is a non-smoker. Her oral hygiene is fair.
1. What are the key considerations in choosing between a fixed implant-supported prosthesis and a removable partial denture for the maxillary arch?
Read the worked answer
Key considerations:
- Bone volume: Adequate bone in anterior maxilla allows implant placement without grafting.
- Medical history: Long-term bisphosphonate use (5 years) increases risk of medication-related osteonecrosis of the jaw (MRONJ) after invasive procedures. Need to assess risk: consider drug holiday? Actually, for oral surgery, risk is low for oral bisphosphonates <4 years, but >4 years may warrant consultation with physician. However, implant placement is generally safe with proper consent and atraumatic technique.
- Periodontal status: Remaining teeth have moderate periodontitis; a fixed implant prosthesis may help splint and reduce load on abutment teeth, but oral hygiene must be excellent.
- Patient preference: She wants a fixed solution and is dissatisfied with RPD.
- Cost and maintenance: Implant-supported fixed prosthesis (e.g., full-arch) requires higher cost and maintenance but offers better stability and function.
- Alternative: RPD may be less invasive but does not meet her desire for fixed.
Decision: Given adequate bone, patient preference, and ability to maintain hygiene, a fixed implant-supported prosthesis (e.g., implant-supported bridge or full-arch) is reasonable, but must discuss MRONJ risk and obtain informed consent. Consider referral for implant placement with careful surgical protocol.
2. How would you address the bisphosphonate therapy in your treatment planning?
Read the worked answer
Addressing bisphosphonate therapy:
- Risk assessment: Alendronate use for 5 years places patient at moderate risk for MRONJ (risk increases after 4 years). However, the risk for implant placement is low (<1%).
- Consultation: Coordinate with her physician to assess need for continued therapy and consider a drug holiday (typically 3 months before and after surgery) if systemic condition allows.
- Informed consent: Discuss the small but real risk of MRONJ, emphasizing that atraumatic surgery and good oral hygiene reduce risk.
- Surgical protocol: Minimize trauma, achieve primary closure, prescribe antibiotics post-op, and monitor healing.
- Alternative: If risk is deemed unacceptable, consider a removable prosthesis with implant support (overdenture) which requires less invasive surgery? Actually, overdenture still requires implants. Or consider conventional RPD.
Rationale: Shared decision-making with the patient and physician is essential. The benefit of improved quality of life may outweigh the low risk.