A request for "fixed teeth" in a fibrous maxillary ridge
A 71-year-old woman attends asking for "fixed teeth". She has been edentulous for eight years and has worn an unstable upper denture for five. The anterior maxillary ridge carries a mobile, displaceable fibrous mass about 2 cm by 1.5 cm extending from the crest to the labial sulcus. There is a broad-based, non-ulcerated torus palatinus 2.5 cm wide. The mandibular ridge is resorbed to about 3 mm above the mental foramina, and the interarch distance in the first molar region is 12 mm. She has taken alendronate 70 mg weekly continuously for six years for osteoporosis and also takes amlodipine; she reports a dry mouth. There is no history of radiotherapy, corticosteroid use or malignancy. She is medically stable, has good manual dexterity and is strongly motivated.
1. How would you record the fibrous anterior ridge and the torus in your impression, and why is a single-stage alginate impression unacceptable here?
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The problem. A single-stage alginate impression in a stock tray compresses the mobile fibrous tissue and records it in a displaced state. The denture is then processed on that distorted cast, and when the tissue recoils the denture rocks - which is exactly why her current upper denture is unstable.
Technique. The principle is to record the stable dentritic-bearing tissue under functional pressure and the fibrous tissue with as little pressure as possible:
- Take a preliminary impression in alginate and pour a cast; construct a spaced custom tray.
- Create a window in the tray over the fibrous area so the tray does not contact it.
- Border-mould and record the rest of the ridge with a medium-body material (zinc oxide–eugenol or a polyvinyl siloxane of appropriate viscosity).
- Through the window, record the flabby tissue with light-body polyvinyl siloxane or impression plaster, using only the weight of the material and no tray pressure.
- Alternatively, use a two-phase technique with impression plaster over the mobile tissue and a wash of light-body material elsewhere.
The torus. A broad-based palatal torus is usually left alone and relieved in the denture base; it only needs surgical removal if it prevents the posterior palatal seal, creates an unmanageable undercut, or is traumatised. I would relieve it, keep the denture base border moulded over it, and review the area at the fitting appointment.
2. She wants "fixed teeth". What would you actually offer her, and how do you handle the bisphosphonate?
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What "fixed" would demand. A fixed maxillary prosthesis in a severely resorbed maxilla typically needs four or more implants, often sinus floor elevation and grafting, and a ridge that can accept them. She has a fibrous anterior ridge, a torus, reduced interarch space and dryness - a combination with a high complication rate. It is also expensive and irreversible.
What I would offer instead:
- A well-made conventional maxillary complete denture using the technique above;
- a two-implant mandibular overdenture, which gives the single largest improvement in function and satisfaction for an edentulous patient, and requires far less bone than a fixed prosthesis;
- alternatively, an implant-retained maxillary overdenture on four implants if CBCT confirms adequate bone and she accepts the cost and maintenance.
The bisphosphonate. Six years of oral alendronate is long-term. The risk of medication-related osteonecrosis after implant placement is low but not zero, and it rises with duration. There is no evidence that a drug holiday prevents it, so I would not request one routinely; instead I would explain the risk, record the discussion, obtain informed consent, use minimally traumatic surgery with primary closure, and coordinate with her physician. If she is unwilling to accept any osteonecrosis risk, the conventional denture plus a mandibular overdenture discussion is the honest alternative.
3. She insists on a fixed maxillary prosthesis. What must you establish before agreeing, and what are the specific risks you would put in writing?
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Before agreeing:
- CBCT to measure bone height and width, the position of the nasopalatine canal, sinus floor and any undercuts, and to decide whether grafting or sinus elevation is needed.
- A validated risk assessment - plaque control, dry mouth (polypharmacy), smoking, glycaemic status, and her ability to maintain a fixed prosthesis with special interdental aids; a fixed prosthesis in a dry mouth with poor cleaning is a recipe for peri-implantitis.
- Interarch and occlusal space confirmation - 12 mm is workable for an overdenture but constrains a fixed prosthesis with a metal framework and acrylic teeth.
- A written, itemised treatment plan and fee estimate, with the alternative (conventional denture ± mandibular overdenture) set beside it.
- Medical liaison with her physician regarding the bisphosphonate and a documented consent discussion.
Risks to document:
- Implant failure and the possibility of being left with a worse denture ridge than she started with;
- medication-related osteonecrosis of the jaw related to alendronate, including the possibility that it occurs after apparently successful surgery;
- peri-implant mucositis and peri-implantitis, with a realistic maintenance burden and a need for regular professional review;
- sinus complications and graft resorption if sinus elevation is required;
- the possibility that the fibrous anterior ridge yields less aesthetic support than she expects.
If, after all that, she still wants the fixed option, I would refer her to a prosthodontist working with a surgeon for a joint assessment rather than begin solo.