“Teeth in a Day” Immediate Full Arch Fixed Implant Rehabilitation
According to the World Health Organization in 2008, six to 10 percent of the world’s population is estimated to be edentulous.1 Close to 40 million people in the Western world, and 250 million people in Asia, are estimated to be fully edentulous. 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 will require full mouth rehabilitation in due time.
CONSEQUENCES OF TOOTH LOSS:
Residual ridge resorption 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 intraoral 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 prostheseis; from conventional, removable or fixed prosthetics to implant-retained removable or fixed prosthetics. In order to place dental implants in the correct prosthetic teeth positions, it may require bone augmentation from either intra or extra-oral donor sites. For example, bone can be harvested from the mandibular ramus, symphysis or iliac crest donor sites.
Procedures may be required to augment various future implant recipient sites. The maxillary sinus may often require either an indirect or direct sinus grafting prior to implant placements.
The “traditional” approach will require the 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 medically compromised, rendering higher risks with each additional surgery.
TEETH IN A DAY TREATMENT COMCEPT:
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).
TEETH IN A DAY TREATMENT WITH HIOSSEN DENTAL IMPLANTS – CASE 1
FIGURE 2. 46-year-old Chinese female. ASA 1 medical status, non-smoker with social alcohol consumption. Extreme dental phobic due to past childhood dental experiences. Past dental treatment consists only to address dental emergencies.
FIGURE 3. Patient with desired nal treatment goal to be rehabilitated and restored with implant retained xed nal prosthesis. Treatment goals to restore masticatory function, optimize aesthetics, soft tissue support, contour, phonetics and comfort. If possible, patient preferred for immediate extractions, implant placements and immediate loading with xed provisional.
• Partial edentulism
• Generalized advance periodontitis
• Advance composite residual ridge resorption
• Unstable functional occlusion
• Compromised aesthetics
• Extreme dental phobia
FIGURE 5. Under I.V. sedation, mandibular full arch extractions, removal of radicular pathology and alveloplasty of residual bone level in preparation for implant recipient sites.
Lingual soft tissue tie back to inspect and visualize contours and undercuts. Identied and visualized bilateral mental formens.
FIGURE 6. Initial pilot osteotomies for four Hiossen ET III implants. Direction guide pins to conrm positions prior to nal osteotomy preparations for 4 mandibular implants.
Posterior angled implants to minimize distal cantilever and to avoid violation of Inferior Alveolar Canal and mental foramen.
FIGURE 7. 4 Mandibular Hiossen ET III implants placed for Teeth In A Day concept. Primary stability of >35 Ncm achieved for all four implants.
Conversion of complete denture to implant screw retained immediate provisional.
FIGURE 8. 30 degrees multi-unit abutments selected for posterior implants to conrm screw access holes through occlusal surface of prosthesis.
Straight multi-unit abutments selected to anterior implants to conrm screw access holes through lingual surface of prosthesis.
FIGURE 10. Titanium temporary abutments placed over the multiunit abutments in preparation for intra oral pick up of the complete denture.
FIGURE 11. Interocclusal records in centric relation position maintained in position referenced to nal vertical dimension of occlusion, midline and occlusion.
FIGURE 12. Triad light cure resin material to index adjusted titanium temporary abutments to provisional prosthesis.
FIGURE 13. Occlusal triad index further secured titanium temporary abutment to provisional prosthesis.
FIGURE 14. Laboratory alteration and conversion of removable complete mandibular denture to implant screw retained provisional.
FIGURE 15. Four months after conrmation of osseous integration, fabrication of new maxillary complete denture and new implant screw retained prosthesis with metal substructure.
Dr. Mark H. E. Lin graduated from University of Detroit Mercy for his dental program. He then completed a 1-year General Practice Residency program at the Miami Valley Hospital in Dayton Ohio. He practiced general dentistry for 13 years then return to complete his postgraduate training in the specialty of Prosthodontics at the University Of Toronto. He maintains
a full time specialty practice as a Prosthodontist at Dr. Mark Lin Prosthodontic Centre.
Oral Health welcomes this original article.
1. Piper Jafray Investment Research (Oct 2008)
2. Agliardi E, Panigatti S, Clericò M, Villa C, Malò P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants. Interim results of a 5-year single cohort prospective study. Accepted for publication in Clin Oral Implants Res.
3. Clin Implant Dent Relat Res. 2008 Dec;10(4):255-63. Epub 2008 Apr 1.
4. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study.
5. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Fabbro MD. Int J Oral Maxillofac Implants. 2012 May;27(3):628-33.
6. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Fabbro MD. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res 2008; 10(4):255-263.
7. All-on-Four” immediate function concept and clinical report of treatment of an edentulous mandible with a fixed complete denture and milled titanium framework. J Prosthodontics 2008;17(1):47-51.
8. Maló P, de Araujo Nobre M, Rangert B. Implants placed in immediate function in periodontally compromised sites: a five-year and one-year prospective study. J Prosthet Dent 2007; 97:86-95.
9. Pomares C. A retrospective clinical study of edentulous patient rehabilitated according to the all-on-four or the all-on-six immediate function concept Eur J Oral Implantol 2009; 2 (1):55-60.
10. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL. Immediate occlusal loading of tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res 2008 Mar; 19 (3):227-32
11. Clin Oral Implants Res. 2007 Oct;18(5):585-90. Epub 2007 Jun 30.
12. Begg et al International Journal of Oral and Maxillofacial Implants 2009.
13. Zampelis et al J Prosthetic Dent. 2007; 97:s35-s43 and 3. 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.
14. 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.
15. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Krekmanov et al International Journal of Oral and Maxillofacial Implants 2000.