What steps do dentists take when planning full mouth reconstructions?

Full Mouth Reconstruction Planning

Comprehensive Diagnostic Assessment

Dentists planning full mouth reconstructions must begin with a meticulous clinical and radiographic examination using advanced three-dimensional imaging (cone-beam computed tomography) to rigorously evaluate treatment options and develop a hierarchical, evidence-based treatment plan. 1

Initial Patient Evaluation

• Medical and dental history assessment should identify systemic conditions that impact treatment decisions, including diabetes mellitus, osteoporosis, cancer history, and medications (particularly bone-modifying agents) 1
• Cognitive status evaluation is critical in elderly patients, as complex reconstructions may be contraindicated in those with cognitive impairment who cannot maintain oral hygiene or may experience declining decision-making capacity during lengthy treatment 1
• Oral examination must document periodontal status, restorative condition of remaining dentition, occlusal relationships, and soft tissue health 2
• Radiographic evaluation requires panoramic radiographs and periapical films at minimum, with cone-beam CT imaging essential for complex cases to identify anatomical variations (present in approximately 30% of patients), bone volume, and sinus anatomy 3, 2, 4

Study Models and Diagnostic Setup

• Mounted study casts are mandatory for complex reconstructions to analyze occlusal relationships, vertical dimension, and esthetic parameters 2
• Diagnostic wax-up should be fabricated to visualize the final restoration and can be converted into provisional restorations and surgical templates 2
• Digital workflow integration using intraoral scanning accelerates diagnosis and treatment planning while improving accuracy 5

Risk Factor Assessment and Modification

Medical Risk Stratification

• Bone-modifying agent users (bisphosphonates, denosumab, angiogenesis inhibitors) require comprehensive dental assessment before initiating reconstruction, with elective implant placement contraindicated during active oncologic-dose therapy 1
• Modifiable risk factors must be addressed before treatment: poor oral health, tobacco use, uncontrolled diabetes, and ill-fitting existing prostheses 1
• Radiation history to the jaws is an absolute contraindication to certain procedures and requires specialized management protocols 1

Patient-Specific Considerations

• Manual dexterity limitations in elderly patients may preclude complex implant-supported reconstructions requiring meticulous hygiene maintenance 1
• Access to ongoing dental care must be confirmed, as complex reconstructions demand regular professional maintenance 1
• Treatment timeline considerations are critical since implant reconstructions require months to complete, during which cognitive decline may occur in vulnerable patients 1

Treatment Planning Algorithm

Residual Bone Assessment

The height of subantral bone (residual bone height) is the primary driver for treatment selection in posterior maxillary reconstruction. 1

Available therapeutic options include:

• Standard-length implants (when adequate bone exists)
• Transalveolar sinus floor augmentation with simultaneous implant placement
• Lateral window sinus augmentation with simultaneous or delayed implant placement
• Short implants
• Tilted implants
• Distal cantilever restorations 1

Implant vs. Natural Tooth Decision-Making

• Tooth preservation is preferred when the tooth is not extensively diseased, has high strategic value, is located in an intact arch, or when gingival structure preservation is paramount 6
• Strategic implant placement with smaller restoration units (short-span fixed prostheses) minimizes catastrophic failure risk compared to long-span reconstructions 6
• Complete-mouth restorations should utilize a combination of implants and natural teeth with good prognoses to distribute risk 6

Prosthetic Design Considerations

Material Selection

• High-strength zirconia in monolithic or micro-veneered designs is preferred for implant-supported reconstructions 1
• Titanium frameworks are recommended over ceramic for cantilever restorations to prevent fracture 1
• Titanium base abutment systems require sandblasting with 50-μm Al₂O₃ and appropriate resin cement selection for durable bonding 1

Occlusal Planning

• Cantilever units should contact only in maximum intercuspal position on flat surfaces, remaining out of contact in all excursive movements 1
• Opposing implant restorations require cantilevers to be slightly out of occlusion, while cantilevers opposing natural teeth should be in contact at maximum intercuspation 1
• Connector areas must be maximized by reducing embrasure size, with unveneered shoulders employed in ceramic frameworks 1

Coordination of Care

Multidisciplinary Communication

• Dental-medical coordination is mandatory for patients on bone-modifying agents, requiring communication between dentist and oncologist before initiating treatment 1
• Specialist consultation with periodontists, oral surgeons, or prosthodontists experienced in complex reconstruction improves outcomes 1
• Otorhinolaryngology referral is indicated for patients with sinusitis history before sinus augmentation procedures 3

Surgical Template Fabrication

• Radiographic and surgical guides transfer the diagnostic wax-up to the surgical field, ensuring accurate implant positioning 2, 4
• 3D-printed guides from CT data with reformatting software (Dentascan, SimPlant) enhance precision 4

Critical Pitfalls to Avoid

• Avoid complex reconstructions in cognitively impaired elderly patients who cannot maintain oral hygiene or may experience declining capacity during treatment, as failures are catastrophic in this population 1
• Never perform elective implant placement during active bone-modifying agent therapy at oncologic doses without specialist consultation 1
• Do not proceed without addressing modifiable risk factors including tobacco cessation, diabetes control, and elimination of active periodontal disease 1
• Avoid long-span reconstructions when strategic use of multiple shorter units can distribute failure risk 6