The Quality of Life studies in the scientific literature highlighted the compromises with conventional removable prosthesis versus benefits of implant retained removable or fixed prosthesis. In addition, even a larger but unspecified number of patients present with terminal non-restorable dentition that will require full Arch/mouth rehabilitation in due time. When given a choice, most patients would request a fixed tooth replacement option to simulate the natural dentition. In addition, patient requested and driven protocol for same day fixed teeth with minimal intervention would be desirable. Advances in technology and understanding of immediate loading and occlusion concepts with dental implants may provide a viable fixed tooth replacement therapy within the same day. A Case presentation follows this article for a full maxillary arch using the All-In-1 Arch treatment concept. Appreciation and acknowledgement to Implant Direct and Shaw Dental Laboratories for their contributions and support for this case.
Consequences of Tooth Loss
The natural dentition may require extraction due to caries, periodontal disease, occlusal trauma, pathology or iatrogenic causes. Residual ridge resorption or bone disuse atrophy in the three dimensions of the alveolar bone is one of the irreversible consequences of tooth loss. When the patient has been completely edentulous over the years, the predicament becomes worse over time as the resorption pattern continues to change the intra oral morphology. Losing bone means losing the denture base surface area therefore making it difficult to treat a fully edentulous patient. Conventional complete dentures, especially in the mandibular arch, are compromised due to inadequate stability, retention and support. Other than bone loss, there are many other compromising factors that will negatively influence the final removable or fixed prosthesis (Table 1).
Clinicians and patients can choose from a comprehensive range of prosthesis from conventional removable or fixed prosthetics to implant-retained removable or fixed prosthetics.
The “traditional” fixed approach will require the invasive advance grafting procedures to heal four to six months minimally, before the dental implants can be surgically placed. After surgical implant placement, it is necessary to wait several more months for osseous integration to heal, after which time it is possible for the delivery of the final restoration with functional loading. The total treatment or healing time is at least twelve months and in most cases, the patients will utilize a removable provisional prosthesis aided by denture adhesives. A high percentage of the edentulous population are older and are medically compromised, rendering higher risks with each additional surgery, risks of complications and delayed treatment completion.
Full Arch Immediate Fixed Implant Rehabilitation Treatment Concept
The concept of treating the full arch edentulous patients utilizes the following parameters: minimum of four implants per arch in the anterior mandible or pre maxilla with posterior tilted posterior implants to avoid anatomic structures of the maxillary sinus or mandibular Inferior Alveolar Nerve, decreasing distal cantilever lengths, cross arch stabilization of the splinted implants, fixed provisional prosthesis, and when possible, immediate loading of the provisional on the day of surgery (Fig. 1).
Maxillary and Mandibular 4 Implants for All-In-1 Arch Protocol.
This concept was developed institutionalized and systematically analyzed in the scientific literature since the 1990s. The procedure has been well-documented success over 10 years. Bo Rangert, a PhD in Mechanical Engineering, developed the technique. The concept has been supported by successful clinical outcomes from studies using protocols on which four implants have been placed to support a full arch prosthesis. Overall published data on this treatment option shows cumulative survival rates between 92.2 and 100% which are comparable to the “traditional” approach.
Since the introduction of this new treatment concept, controversies and skepticism were raised among the profession and more studies were conducted to evaluate the success of such treatment option.
The utilization of posterior tilted implants were validated with several quality studies. A five-year retrospective longitudinal study (Koutouzis and Wennstrom 2007) failed to support the hypothesis that implant inclination has a negative effect on peri-implant bone loss (Clin Oral Implants Res. 2007 Oct;18(5):585-90. Epub 2007 Jun 30). Another five-year study on tilted implants in both jaws (Tilting Of Posterior Mandibular And Maxillary Implants For Improved Prosthesis Support, Krekmanov et al International Journal of Oral and Maxillofacial Implants 2000) found a 98% success rate for tilted implants in the maxilla and a 100% in the mandible. Stress patterns around distal angled abutments in the Teeth In A Day concept configuration (Begg et al International Journal of Oral and Maxillofacial Implants 2009) found that implants placed at 15 and 30-degree angles had very little difference in stress between the central straight and the distal angled implants.
Tilting of splinted posterior implants for improved prosthodontic support and diminished cantilever was evaluated using a two-dimensional finite element analysis (Zampelis et al J Prosthetic Dent. 2007; 97:s35-s43 and Effect of Cantilever Length And Inclined Implants On Axial Force And Bending Moment In Implant-Supported Fixed Prostheses, Geremia et al Rev Odonto Cienc. 2009;24(2):145-150).
Furthermore, a study published in 1999 (Implant Treatment Without Bone Grafting In Severely Resorbed Edentulous Maxillae; Mattson et al International Journal of Oral and Maxillofacial Surgery with a 10 year published follow-up: A Long-Term Follow-Up Study, Rosen and Gynther IJOMS 2007) showed a high success rate for tilted implants from surgeries that were done in the early nineties almost
20 years ago.
Increasing scientific documentation of this treatment modality revealed high cumulative success and survival rates. With predictable clinical outcomes and refined surgical techniques, controlled occlusion, biomechanics and laboratory expertise, this treatment option has gained acceptance and popularity. In particular, patient-driven request for immediate provisionalization also make this treatment concept a preferred choice for fully edentulous patients.
Table 2 provides a comparison of the “Traditional” versus “Full Arch Immediate Fixed Implant Rehabilitation” approach to full arch implant rehabilitation. OH
Pre-operative smile photo.
Pre-operative retracted photo.
CBCT evaluation of bone anatomy and treatment planning with All-In-1 Arch using Legacy 3 dental implants.
Use of clear surgical guide from diagnostic wax set up to evaluate implant positions, alveloplasty requirements, interocclusal restorative space requirement and proposed prosthetic teeth positions.
“Smart Pack” from Implant Direct to manage inventory re-quirements for All-In-1 Arch Treatment Protocol.
Open tray impression with polyether to fabricate model for conversion of immediate complete denture to screw retained fixed provisional.
Final implant placements with titanium temporary abutments to be picked up intra orally with immediate complete denture to be converted to screw
retained fixed provisional.
Intra oral pick up of anterior titanium abutments with prosthesis in correct midline, vertical dimension of occlusion indexed to the palate.
Inserted immediate implant screw retained fixed provisional on the same day of implant surgery.
Post-operative panorex with All-In-1 Arch using Legacy 3 Treatment Concept.
Full Contour Zirconia with anterior porcelain layering final screw retained fixed implant prosthesis (Shaw Laboratories).
Oral Health welcomes this original article.
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Dr. Mark H. E. Lin graduated from the University of Detroit Mercy for his dental program. He then completed a one-year General Practice Residency program at the Miami Valley Hospital in Dayton, Ohio. He practiced general dentistry for 13 years and then returned to complete his post-graduate training in the specialty of prosthodontics at the University of Toronto. He maintains a full-time practice as a prosthodontist at Dr. Mark Lin Prosthodontic Centre.