This is one of the more complex cases I've jumped into in my short career.

Three months ago, as my GPR at a nursing home was wrapping up, I saw this 48yo pt. with h/o CVA 7 years ago, now with aphemia, R side hemiparesis, and mild cognitive deficits.

At the time, he presented with his 1 yo PFM bridge #6-11 in his hand. It was clear it had been destined to fail due to collapsed VDO necessitating incisal proclination of the prosthesis and insufficient clinical crown lengths rom jump street. His lower posterior bridges were carious, and had been restored inappropriately at the collapsed vertical, sacrificing a lot of tooth structure. Because I would be leaving the residency soon and couldn't undertake much, I sealed the exposed abutments with cavit and made him an interim partial denture myself in the lab. It had the same space limitations as the bridge, but at least it was more esthetic than nothing. His guardian and aide were most appreciative, and we made a great connection. I scheduled him with the RDH and trusted that this year's residency class would pick up with comprehensive tx.

Three months and a lot of budget cuts later, there is no residency, and there is now one dentist per day to treat a few thousand high-need patients. I got a call from his legal guardian a few weeks back saying she wants him to be seen by a private dentist, in part because the interim prosthesis was lost just a few weeks after I saw him. So I scheduled him in the practice where I now work. The guardian repeatedly said “cost is not an issue.” Her only caveat was that she wants to “minimize surgery,” and get this done soon” which I’m guessing means implants are off the table.

This is how he presented:

[image:VCFMS.jpg]

Between when I last saw him and now, the bridges were taken off the lower and #17 and 28 were excavated and RCT #28 completed. So now caries is not a huge problem for him, but the periodontal condition, particularly of the posteriors, is very worrying, doubly so given that the only lowers occluding are #20 and 21 which have caused serious 2ndary occlusal trauma on #13 and 14. On top of all that, the pt is incapable of performing basic hygiene, and the pt.’s aide says “He won’t always let me clean his teeth.”

Because the past removable was quickly lost, the guardian wants “nothing removable,” but hygiene is obviously a huge concern. I’ve warned her and the aide of this repeatedly, but both are confident that proper hygiene will be achievable, though frankly, I’m not sure why. I did a quick debridement to try to minimize the inflammation before I start temping, but given how much schmutz I removed from his mouth, I’m now wondering if there’s a recall period short enough to make this work, even after osseous recontouring, open flap debridement, and grafting the furcations and vertical defects.

These are my broad-strokes proposals for his treatment, understanding that the maxillary posteriors are likely not long for this world, and the anterior teeth may be kept for now mostly so they can be used as root anchors for an overdenture in the not-too-distant future.

Mandible:

Option 1

Ext #17
Cast P/C #28
ERA crown #20
FCZ #21, PFM# 27-28-x-30-31
Kennedy Class 2 ERA RPD

Option 2

Ext #17
Cast P/C #28
ERA crown #20
Surveyed #21,22,27, 30,31
Kennedy Class 2 mod 1 ERA RPD

Maxilla:

Option 1

Osseous surgery/ debridement/GBR
CL #6-11
Endo, Cast P/C #6-11
PFM bridge #6-11

Option 2

Osseous surgery/ debridement/GBR
CL #6-11
Endo, Fiber P/C #6-11
composite/ribbond bridge #5-13

My main concern for now is the advisability of restoring #6-11, even after crown lengthening, RCT and cast P&Cs. I feel like they’ll need cast posts to be at all stable, but I’m concerned about the possibility of catastrophic failure that precludes their later use as overdenture attachments, especially with the increased VDO. Extending the bridge to #5 is a possibility, but #13 is hardly reliable between its angulation and vertical defect. It is definitely a candidate for GBR, but I’m not confident in how it will turn out afterward with off-axial forces, etc. That’s why I’m starting to lean toward composite splinting incorporating #5-13, but with basic hygiene a major concern, it’s hard to justify incorporating all those teeth.

Any feedback or ideas are appreciated.