A 67-year-old requesting "all teeth out and fixed teeth in" with a limited budget and a wedding date
A 67-year-old woman attends requesting "all my teeth out and fixed teeth put in". She has lost 16, 17, 26, 27, 36, 37, 46 and 47. The remaining teeth show severe occlusal attrition and an apparently reduced occlusal vertical dimension; freeway space on the retruded arc of closure measures about 6 mm. She has no temporomandibular joint symptoms. Cone beam imaging taken for another purpose shows 4 to 5 mm of bone height below the maxillary sinuses posteriorly and 9 to 10 mm anteriorly, with a 6 mm wide mandibular posterior ridge. She takes alendronate 70 mg weekly (started nine years ago) and a thiazide for hypertension, smokes 10 cigarettes a day, and has not had a dental check-up for six years. She is retired, has savings of about GBP 6,000, and expects "teeth that don't come out" before her son's wedding in eight months.
1. Appraise the realistic treatment options against her anatomy, budget, medical history and deadline, and state what you would recommend.
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First, separate the request from the diagnosis. "All out and fixed" is driven by fear of a denture, but she has not been examined for six years: caries, periodontal disease and mucosal lesions must be diagnosed and treated first. The constraints are 4 to 5 mm of posterior maxillary bone, a narrow mandibular posterior ridge, nine years of alendronate, 10 cigarettes a day, eight months and GBP 6,000.
Options
- Bilateral removable partial dentures. Lowest cost, deliverable within the deadline, but with Kennedy Class I saddles in both arches there is no posterior tooth for indirect retention, the bases will move, and she has already rejected the idea.
- Implant-supported fixed prosthesis. Posterior maxilla needs sinus floor elevation or short/tilted implants; the mandible has adequate height but a 6 mm ridge requires care. A full-arch fixed reconstruction of both arches is well beyond GBP 6,000 in most markets. A realistic limited version is two implants in the posterior mandible to convert a Class I to a Class III (implant-assisted RPD) or a single-implant-retained mandibular overdenture.
- Shortened dental arch with occlusal reconstruction. Accept around 10 occluding pairs anteriorly, restore the worn teeth at a re-established vertical dimension with adhesive overlays, and defer or omit posterior replacement. Durable, affordable, no surgery.
- Do nothing about the missing posteriors while restoring the worn teeth. Not sensible with free-end saddles bilaterally and no vertical stop.
Recommendation. Option 3, possibly with option 2's mandibular component if she prioritises it, with a written statement that a fully implant-supported fixed replacement of all four posterior segments is not achievable with her budget. Offer a staged plan where she can stop at any point.
2. How would you assess and manage the occlusal vertical dimension in this patient?
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Assess rather than assume. A freeway space of about 6 mm is greater than the usual 2 to 4 mm and supports, but does not prove, the impression of a reduced vertical dimension; measurement error, neuromuscular posture and the retruded position all affect it. Record:
- freeway space at rest, retruded contact position and intercuspal position;
- lower facial height, facial profile and photographs;
- speech (sibilant sounds) and swallowing;
- the appearance and thickness of the worn teeth, and whether the loss is from attrition, erosion or both.
Test any change before committing to it. Build a removable overlay appliance or long-term provisionals at the proposed vertical dimension and leave them for 8 to 12 weeks. Review comfort, speech, appearance, masticatory function and any muscle symptoms. Small stepwise increases (2 to 3 mm at the incisors) are better tolerated than a single large opening.
Only then restore definitively with adhesive composite or ceramic overlays, onlays or crowns. Change the vertical dimension by the minimum needed for function and appearance; over-opening produces phonetic problems, clenching and a dissatisfied patient, and it is very hard to retreat from once the teeth are prepared. Also treat the bruxism/attrition risk with a night guard after reconstruction and warn her that the restorations will wear.
3. Set out a prioritised, phased plan and the consent discussion, including the implications of her alendronate and smoking.
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Priorities: disease control, then function, then the fixed prosthesis she is asking for.
Phase 1 (weeks 0 to 4). Full examination, radiographs, periodontal chart, caries control, mucosal check, and an honest discussion of cost. Any tooth needing extraction should be identified now, because extractions in a patient with nine years of oral bisphosphonate exposure carry a small but real risk of medication-related osteonecrosis of the jaw that is greater with longer duration; plan them deliberately, not as an afterthought, and record the discussion. Smoking cessation advice must be given and recorded.
Phase 2 (weeks 4 to 16). Restore at the trial vertical dimension with provisionals or an overlay; assess tolerance; then definitive adhesive reconstruction.
Phase 3. If she still wants implant support, place a limited number of mandibular implants at 3 months and convert to an implant-assisted prosthesis, keeping the maxilla removable.
Consent must cover: the diagnosis and the reasons her request cannot be met as stated; the cost of each stage and the option to stop; the number of visits; the provisional phase; that a removable prosthesis may be the final outcome; that implants are less predictable in smokers and that she should stop; the MRONJ risk for any extraction; and that the eight-month deadline may slip if healing is compromised. Document that she was given the option of a second opinion. The worst outcome here is not a partial denture, it is an unmanaged expectation.