by Gilbert Tremblay, BSc, DMD; Scott D. Ganz, DMD
Dental implants, Concept, function, biomechanics, esthetics, mastication, full-arch restoration, financial investment, quality of life, “All-on-4” and patient satisfaction same day implants
The world is aging – epidemiological studies show that 11% of the world’s population is over 60 years of age, with a projected increase, by 2050 to 22% of the population.1 Metrics from the Center for Disease Control’s Morbidity and Mortality Weekly Report show a doubling of the population over 65 years of age in a 30-year time span.2 From 2000 to 2030, the percentage of the population who are 65 years of age and older will increase from 12.4% to 19.6% in the USA, from 12.6 to 20.3% in Europe, from 6% to 12% in Asia, from 5.5% to 11.6% in Latin America and the Caribbean and from 2.9% to 3.7% in Africa.3 Periodontal disease is among the most prevalent oral diseases worldwide with a tendency for the disease to increase in severity as people age.4
The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech and health, regardless of the atrophy, disease, or injury of the stomatognathic system.5 As described by Misch,6 there is a 25% decrease in width of bone during the first year after tooth loss and an overall decrease in height during this first year following extractions for an immediate denture. Hence, this bone loss is perpetual after tooth loss. The geometry of bone loss is unevenly spread out in the oral environment. In an advanced bone loss scenario, the maxilla can be a challenge to rehabilitate. Anatomical limitations can often times have a prosthesis exposed in the smile zone due to either vertical maxillary excess and/or high lip line.7 To aid in the process of rehabilitating patients who have lost function due to missing teeth and loss of bone, contemporary implant dentistry was introduced over six decades ago by the work of Brånemark.8 However, forty years ago, the mere mention of the word “implant” was controversial and organized dentistry was cautious in accepting the dental implant concept. Once long-term clinical data representing sound evidenced-based research and scientific principles were developed, implant dentistry rapidly became an accepted treatment alternative to traditional prostheses.
Dental implant manufacturers, clinical advocates, and ancillary biomaterials suppliers, introduced a variety of innovative components, protocols, and biologics developed to enhance both the surgical and restorative clinical applications as well as the overall patient experience. An important challenge of bone loss is the insufficient bone volume for primary implant fixation. Successful placement of dental implants requires sufficient alveolar bone dimensions, that is, at least 10 mm in height and 3 mm to 4 mm in diameter.9 For various reasons, including socket grafting, ridge preservation, and ridge augmentation, it has been estimated that up to 50% of all dental implant procedures currently performed will involve the use of bone grafts.10 Surgical protocol to correct this deficiency can involve a myriad of bone enhancement such autograft, allograph, synthetic bone substitute, composite bone substitute, xenograft1 and, more recently, mitotic molecules such as recombinant bone morphogenetic protein 212 and (rh-PDGF)13.
Bone density is also a crucial factor in implant-supported restorations. One can be misled by a bone volume mapped on a CT or CBCT scan as acceptable for a proper primary fixation, but the lack of sufficient trabecular bone density may compromise the primary fixation and/or the loading resistance. Cost is also an important factor in the patient’s decision for treatment acceptance. Multiple procedures will increase the professional fees and have a negative effect on the patient decision. Patient tolerance is challenged and can turn down their decision to go forward with the treatment in the following conditions; advanced bone graft, significant morbidity, multiple implants in large numbers, complex prosthetic restorations, time consuming procedures, long healing time between procedures, non-fix interim prosthesis, the ability of chewing properly during the treatment protocol can all influence the patient decision in enrolling into the treatment proposal regardless of the fees.
A study by Wang et Al.14 on the patient’s perceptions on dental implant reveals that patient expected dental implants to restore their appearance, functions, and quality of life to absolute normality. On the other hand, they were deterred from seeking dental implant treatment by the high price, invasive procedures, and risks. Another study by Yao et al.15 based on a database Pubmed, Cochrane, Web of Science and PsychINFO was conducted following PRISMA guidelines. The conclusion was that there is a growing interest in patients’ expectations of dental implants, with respect to aesthetics and function that are key attributes.
How can most of these clinical obstacles be challenged with a treatment protocol that will give a predictable outcome, shorter healing period, less surgical and prosthetic interventions at lower cost?
One novel protocol introduced more than two decades ago by Malo et Al16 provided new solutions for the terminal dentition with full-arch implant-supported reconstruction based on placing four implants in the maxilla or mandible using a graft-less solution for patients looking for an alternative to orthognathic surgery.
Despite ample positive evidence after many thousands of documented cases, organized dentistry was again skeptical and was cautious in accepting the concept.
The “All-on-4” protocol is an option that can answer that challenge.17 This treatment concept provides edentulous patients, terminal dentitions, and post extraction subjects to benefit of an immediately loaded, fixed prosthesis on 4 implants per arch: 2 of them that are axially loaded in the anterior of the arch and 2 tilted posterior implants18,19 to avoid grafting procedures and reducing the length of the cantilever arm.20 Furthermore, the marginal bone level around tilted implants does not significantly differ from that around axial implants.21 The prosthetic principle involves the use of 4 multiunit abutments that are straight in anterior and angled in posterior.22 An immediately loaded, full arch prosthetic prosthesis is fixated on the same surgical day. The All-on-4 treatment protocol has been developed to avoid bone graft and achieve immediate function. Long term study reveals a 94.8% implant survival rate and a 99.2% prosthesis survival after 10 years.23
The descriptor “All-On-X” refers to a full-arch implant-supported prosthesis where the number of implants is greater than 4. Clinician may vary that number accordingly to clinical judgment.24 Several factors may contribute to the decision of the required implant numbers: poor bone density, deficient bone height, large maxillary perimeter, bruxers, brachycephalic patients, and muscular activity in relation to patient facial anatomy. The maxillary bony anatomy on 3-D imaging examination exhibits less bone density and thinner cortical plates than the lower arch, and, therefore, many clinicians prefer 5 – 6 implants in the maxilla to help enhance distribution of forces when prosthetically loaded.
Dental clinicians should be aware that there are risk factors associated to dental implant therapy25 based on the patient’s medical history. Patients with an American Society of Anesthesiology (ASA) Patient Status of IV or higher describes a medical condition that may jeopardize the life or lifespan of the patient treatment. Patient behavior and medical factors, a past history of periodontal disease, bruxism, smoking, vaping, high blood pressure, uncontrolled diabetes / high A1c levels, cancer, and radiation therapy just to list a few, are to be taken into account when planning a rehabilitation scenario. The present paper describes several case presentations with various treatment protocols to provide patient’s with improvements in aesthetics, masticatory function, and quality of life. It is postulated that rehabilitation of oral deficiencies can have a positive impact on long-term health with the potentials of reducing future global health care costs.
This first case study, completed in 2004, is an example of a conventional double-arch implant-supported fixated prosthesis treatment protocol that was completed prior to the “All-on-4” protocol implementation. The goal of this case description is to understand and compare the advantages and value to both the patient and clinician of the “All-On-X” protocol that will be described with clinical case study. The author selected this case to introduce the complexity and challenges that a clinician and patient had to encounter to achieve a successful complete double-arch rehabilitation.
A 48-year-old female fully edentulous patient presented wearing maxillary and mandibular complete dentures. The patient desired to move from removal to fixed-type restoration supported by implants. Her ASA rank was 1 with no reported allergies. Clinical evaluation reveals poorly retentive complete dentures with worn- down acrylic teeth. Her dentures were fabricated more than 20 years ago resulting in a compromised occlusion pattern affecting her chewing ability. The patient had complained that her teeth were too short as evaluated aesthetically in the smile zone (Fig. 1). The remaining alveolar crestal bone for both arches was severely resorbed (Misch Division C bone classification). The patient also exhibited a slightly prognathic profile which is likely attributed to her resorbed pre-maxilla. The zone of keratinized tissue was extremely thin in the mandible and acceptable for the maxillary arch.
Severe bone resorption in the mandible had the consequence of leaving a reduced vertical bone height that only allowed for short implants to be placed. After a thorough assessment of the CT (computed tomography) scan provided the three-dimensional information necessary to diagnose and plan for a free-hand surgery protocol consisted of placing 5 implants implemented with a particulate xenograft (Bio-os, Geistlich Pharma) to support the soft tissue profile (Figs. 2-4). Cone Beam Computed Tomography (CBCT) devices were not yet commercially available. The implants placed in the mandible were planned to be short due to poor bone availability for which a fifth implant is added to increase the loading resistance.
After healing, conventional fixture-level impressions were completed to design and fabricate a hybrid Montreal screwed-bar restoration. Once the bite was confirmed, a tooth set-up was evaluated for aesthetics and function. The lab then fabricated a milled titanium bar which was verified for accuracy and passivity. Then, using a pre-defined matrix the denture tooth set-up is transferred to the metal bar and processed with wrap-around acrylic.
Planning for the maxilla was a challenge. Utilizing the CT scan data imported into an interactive treatment planning software (SimPlant Dentsply, Sirona, USA), was used to plan the case. Bone volume was scarce at the alveolar crest and perimeter of maxillary arch (Figs. 5-8). To provide an adequate foundation for later implants, it was determined that a large volume of grafted bone was required and intra-oral donor sites would not sufficient for this procedure. It was elected to harvest autologous bone from the hip. An Iliac crest graft was then planned for a donor site under a hospital setting (Figs. 9, 10). Virtual planning revealed that an atypical resorption pattern in the maxillary posterior segment had resulted in palatal bone loss rather than the typical buccal bone loss. That later condition increased the bone enhancement challenge, and therefore a separate bone graft was required to be fixated on the palatal surface of the posterior maxilla along with bilateral sinus lift grafts. To facilitate the planning process, a stereolithographic (STL) maxillary arch resin model was 3-D printed and utilized to adapt the segmented bone blocks that were sectioned and sized with a Piezosurgery device (Mectron Piezosurgery Carasco, Italy) to reduce heating from the bone cutting procedure (Fig. 11).
Adapting the bone segments using the stereolithographic model increased the precision of the bone block adaptation to the host bone and reduced surgical time (Fig. 12). Autologous iliac graft has a bone structure with a low density that can resorb quickly and unpredictability. The patient had to undergo a minimum of 3 months of healing time with conventional dentures and a mandated soft diet. After the healing time, a clinical evaluation revealed that the bone volume at the pre-maxilla was short of the predicted outcome (Figs. 15,16). An anterior-posterior discrepancy would compromise the prosthetic outcome. Fortunately, the mandible restoration was slightly protrusive and a revision of her mandible teeth set up was undertaken to move more posteriorly the entire restorative arch in order to achieve an acceptable anterior-posterior relationship (Fig. 17,18). 3-D software planning for implant surgery was completed with the revised dental set-up (Fig. 19). It was determined that the implant surgical procedure could be completed with a flapless protocol undertaken with a Navigator soft tissue supported surgical guide (Zimmer Biomet USA) (Figs. 20-22). Due to the soft nature of the grafted bone, it was elected to place a large number of implants, (10 units), fixated utilizing a guided flapless surgery protocol. Finally the maxillary arch was restored with a fixed FP-3 designed restoration separated into three segments. The prosthesis was then cemented on CAD CAM custom abutments (Fig. 23). At completion of this treatment, this patient was satisfied and did refer other patients to our facility.
In conclusion, the treatment protocols described for this case required necessary staging, several surgical and restorative appointments, several surgeries, significant morbidity following the iliac crest graft, diet control post graft surgery requiring a compliant patient, initially having a healthy patient as a pre-requisite to sustain this invasive surgical protocol, the long and lengthy time requirement for the completion of this protocol required a motivated patient and a tight follow-up of the patient. Additionally, the nature of the successful maxillary and mandibular reconstruction relied on an unpredictable bone graft outcome, complex restorations, multiple visits and costly laboratory fees which required a patient with sufficient financial resources. These listed factors may limit the number of patients that can benefit from a complete oral rehabilitation with implant-supported prostheses. Also, with all the energy and substantial resources, patients will expect a long-term return on their investment (Fig. 24).
A 50-year-old patient with advanced periodontal disease, malocclusion, skeletal Class 2 division 1 retrognathic mandible, excessive overjet, 100% deep bite with a palatal soft tissue marked by repetitive trauma from biting the anterior surface of her palate. The patient’s healthy medical evaluation ranked as ASA 1 (Figs. 1-6). Her profession is a pastry chef. The patient brings her hand forward to cover her mouth when smiling in order to hide her unattractive teeth. This patient’s chief complaint was; “my unappealing smile.”
Clinical evaluation revealed a Stage 2 and Stage 3 periodontitis in both the maxilla and mandible. The missing teeth and crowding resulted in a constricted anterior envelope, steep Spee curve, closed vertical dimension of occlusion and lack of posterior support. Biomechanically, the patient exhibited defective restorations and active decay. Aesthetically, her upper midline was shifted to her right, the upper lip-drape within her smile presented as less than one-third of her maxillary incisor teeth. CBCT scan imaging revealed sufficient bone volume and soft tissue to proceed with an “All-on- 4” treatment protocol. Bone density can be assessed with CT scan imaging using Hounsfield Units (HU) in contrast to CBCT devices which only provide “relative-density” measurements. Therefore, to achieve a precise reading a medical Computer Tomography (CT scan) would be necessary.26 In this case study, CBCT bone density readings were lower than 300 HU. Fuster-Torres et al.27 revealed that a 623 HU measurement can provide for an average insertion torque value of 42.4 Ncm units. With these torque values it is predictive for planning primary implant fixation with immediate loading protocols.
For this case presentation, the low-density CBCT readings subjectively provides for a good appreciation and predictability of the quality of this patient’s bone density. When presented with low bone density readings, the number of implants, positioning of the implants, osteotomy drilling protocol, and implant design are all clinical factors that need to be assessed. Additionally, low bone density readings can predict low insertion torque values. Planning an implant receptor site with low bone density may end up differently from the original plan during surgery. Therefore, flexibility in the surgical execution for the implant positions will be required if a low bone density area is encountered. Hence, deviating from the original planed position to manage a low bone density area, would require modifying the osteotomy protocol, implant position or/and implant design selection. A complete guided surgery in low bone density regions would not be recommended since the implant may end up in a different position than the original plan.
Three-dimensional imaging DICOM data was imported into another interactive treatment planning software DTX studio (Nobel, Envista Holdings California), was completed for a tooth supported pilot-drill surgical guide protocol (Figs. 7,8). The surgical plan was to extract most of the maxillary dentition while maintaining 3 strategic teeth to support the computer-generated surgical guide (Fig. 9). After osteotomy completion with a pilot drill, the remaining 3 teeth were extracted (Fig. 10). In the low bone density protocol, this minimalist surgical guide gives the surgeon the freedom of fixating the implant in a different position from the originally planned site. Having a pilot guide also expedites the surgical process. Each osteotomy was under-prepared (soft-bone protocol) to help achieve an optimal primary implant fixation. The maxillary implants were fixated at an average of 38 N/cm and the mandible 45 N/cm. Resonance frequency analysis (RFA) was utilized to record and document the implant stability quotient (ISQ) of all implants for both arches. A minimum of 65 ISQ values was deemed necessary to confirm an immediate load scenario. Both maxilla and mandibular alveolar bone crest were reduced (alveolectomy) to achieve a flat crestal bone topography which provided a favorable surface for designing and fabricating a prosthetic device with optimal hygiene and function* (Figs. 11, 12). Autologous bone collected from the alveolectomy was mixed with an allograph Creos (Nobel Biocare USA) and a-PRF ( Platelet Rich Plasma) (Fig. 14). This bone mixture was incorporated into the extraction bone sockets. At completion of the surgery, both removable prostheses were converted into a fixed transitional prosthetic design with the flanges modified to fit the resultant ridge topography. Occlusion was equilibrated in static and dynamic movement with a pressure mapping and force measurement device, Tekscan (Tekscan, Norwood, USA). Four months after healing time, a protocol to fabricate a definitive milled Titanium bar-supported hybrid prosthesis was completed.
In conclusion, several treatment plans were suggested to this patient. An option of a complete teeth extraction with immediate dentures had been presented to the patient; which she declined based on a potential food tasting interference since she is a pastry chef. A second treatment plan of a periodontal – orthodontic – orthognathic surgical protocol was presented to her. She declined the treatment plan based on lengthily time consumption. Hence, the All on X treatment protocol reaches this patient time goal requirement and even more since she has to function with a mouth that can taste food during the interim of her treatment; being a chef, tasting is mandatory for her occupation otherwise with a complete interim denture this will significantly alter her working skills. Due to advanced planning afforded by three dimensional imaging and software applications, the surgery and delivery of maxillary and mandibular conversion prostheses was able to be completed in a single combination surgical/restorative visit. No graft surgeries were necessary prior to implant fixation. If needed, bone grafting were to be done within the implant fixation surgery. The treatment protocols also have the benefit of not requiring advanced surgical procedures (orthognathic surgery), which requires healthy and motivated patients. Lowering the requirement for patients’ health, time requirement and financial resources in an “All-on-X” treatment plan, increases the potential pool of patients that may be eligible for an oral rehabilitation treatment.
The patient’s satisfaction at the conclusion of the reconstruction was higher than expected. This patient now happily smiles spontaneously without having to cover her mouth with her hand.
A 63-year-old male patient presented with several missing teeth and a skeletal Class 3 occlusion was seeking a fixed implant restoration for his maxillary arch (Figs. 1,2). This patient exhibited teeth only in the pre-maxilla, malocclusion, no posterior support, and severe tooth attrition (Fig. 3). A diagnosis of a terminal dentition for the maxilla was established. The patient’s main concern was to correct his maxillary dentition and eventually move on to treat the mandible dentition. The patient’s general dentist accompanied him to the consultation appointment. His primary dentist presented a historical review of treatments and maintenance. Treatment options were presented for a complete denture or orthognathic surgery. The patient was determined to replace all remaining maxillary teeth with an implant-supported prosthesis. Clinical evaluation and CBCT imaging revealed sufficient bone volume and acceptable bone density for immediate implant placement for an “All-on-X” protocol.
A cotton roll was introduced under the upper lip to mimic the protrusion of a prosthesis that would correct the anterior Class III complete cross-bite. Patient was advised that there would be significant change in comfort, aesthetics, and function. The proposed treatment was accepted by the patient. Final planning was completed virtually based on the DICOM data supplied by three-dimensional CBCT imaging and desired aesthetics. To resist the anterior cantilever loading of a Class 3 correction, 6 implants where planned (Figs. 4,5). Free-hand surgery was completed for an “All-on-X” protocol. An immediate fixed transitional prosthesis was delivered at the day of surgery, hence, the patient received an aesthetic and functional dentition during the interim healing time. The patient was advised to maintain a soft diet during the healing phase. 4 months post-surgery, a fixed- hybrid prosthesis was fabricated and completed (Figs. 6-10).
In conclusion, orthognathic surgery was a treatment option to correct the Class 3 occlusal relationship. However, this invasive surgical intervention was declined by the patient. Avoiding the extensive orthognathic surgical procedure influenced this patient in accepting an “All-on-X” oral rehabilitation treatment plan. Subjectively, the patient’s occupation as a business owner left him with little personal time and low dental motivation. His personal schedule limited his treatment acceptance to only short-term treatment scenarios. The “All-on-X” treatment protocol provided a viable and successful treatment option for the patient presentation, meeting his expectations.
A young 42-year-old male patient with severe teeth destruction was subsequently diagnosed with a terminal dentition. A CBCT scan, intra-oral optical scan (IOS) and photographic images were collected to establish treatment options for the patient. Clinically, advanced dental caries and biomechanical failure were diagnosed on all remaining teeth for both maxillary and mandibular arches. Malocclusion, loss of vertical dimension of occlusion and forward rotation of his mandible were concerns that needed to be addressed (Fig. 1). An “All-on-X” protocol was proposed to the patient utilizing virtual aesthetic planning images. The patient accepted the treatment proposal and was determined to go forward with the plan. To fulfill the financial obligation, he arranged for a bank loan.
Traditional concepts have advocated first extracting the remaining teeth in a phased approach with socket bone grafting to allow the residual ridge proper time to heal prior to placement of implants in strategic positions months later. During the interim, the patient would receive an immediate complete maxillary denture. It had been postulated that by allowing the ridge to heal after tooth extraction a certain percentage of bone resorption would occur, especially under the forces of mastication transmitted from the immediate denture. Ideally, the vertical dimension of occlusion would be maintained, as well as an acceptable esthetic appearance based on sound prosthodontic conventions. The healing phase usually required three to six months to allow the underlying bone to mature depending on the graft material utilized. If either a fixed or removable implant-supported restoration was desired, a CBCT scan would help determine ideal receptor sites based upon the volume and quality of the maxillary alveolar bone. Once the implants were placed, a subsequent three-to-four month healing phase has been required to allow for adequate osseointegration prior to fabrication and loading of a provisional prosthesis followed by the definitive prosthesis.
Technology has evolved for both clinicians and dental laboratory technicians. Software and CAD-CAM technology assists the dental surgeon in treatment planning a virtual diagnostic wax-up, opening the vertical dimension of occlusion, and restore the teeth to a normal contour and functionality. Aesthetic parameters are set to achieve proportional teeth size and position according facial landmarks. The virtual set-up was then converted to a 3-D STL file and merged with the CBCT DICOM data file (Fig. 2). The merging of these files provided vital information that allowed the simulated implants to be virtually positioned accordingly to the prosthetic wax-up. This process can be called true restoratively-driven planning.
The existing bone topography at the alveolar crestal surface was found to be unevenly distributed resulting in irregular contours that needed correction for optimal implant positioning and ideal aesthetic outcomes (Fig. 11). The bone correction was achieved by leveling the alveolar bone crest (alveolectomy) with the guidance of a computerized bone generated leveling guide, or bone reduction guide.28,29,30 Once the bone has been reduced to provide a flattened and widened topography, a second drill guide would be stabilized to allow for precise guided-osteotomies following the CBCT scan plan for implant placement (Fig. 13). Once the implants have been delivered through the guide, pre-chosen multi-unit screw-receiving abutments (MUAs) were secured to each implant. Titanium cylinders were then secured to the MUAs. A transitional polymethyl methacrylate (PMMA) prosthesis was then fixated to titanium cylinders utilizing polymerizing liquid composite (NobelBiocare, Kloten Switzerland) (Fig. 16). Occlusion was equilibrated in static and dynamic movement with a Tekscan device (Norwood, USA). Current digital workflows allowed the patient to have his teeth removed, guided alveolectomy, guided placement of dental implants, positioning and securing of an interim fixed prosthesis in a single visit which provided both aesthetics and limited function during the healing phase.
A night guard appliance was given to the patient to protect the interim prosthesis and newly placed implants from clenching forces and bruxism parafunction. Four months after surgery, a double-arch zirconia fixed screw-retained prosthesis was delivered with a night guard appliance.
Conclusion: It is evident that evolving technologies has merits and benefits for the surgeon, the restorative dentist, and the patient by; expediting treatment, reduction in the potential for complications, reduction of treatment procedures for bone enhancement and prosthetic interventions and increased accuracy when a guided protocol is used and for the restorative phase. At completion of this surgical protocol, the patient illustrated in this case presentation was pleased by the final outcome which surpassed expectations. Two week after surgery upon removal of his sutures, the patient presented himself with a new hairstyle, confidence in his vocal expression; his non-verbal behavior changed in that short period of time. Definitely, a positive outcome and change of quality of life from his dental intervention.
A 50-year-old female patient presented wearing a complete maxilla removable prosthesis since her teen years and desired a fixed solution for her missing teeth. Her chief complaint was poor retention of her existing removable prosthesis which she found to be deficient and socially embarrassing. She expressed the desire for a non-removable treatment option supported by dental implants. Her overall health is good with an ASA 1 rating. Clinically she has advanced bone resorption of her maxillary arch. Advanced bone resorption led to the lost of her vault architecture at her maxilla. The CBCT scan data confirmed that there was no bone left in the pre-maxilla zone (Figs. 1,2). In order to accommodate such a reconstruction of her maxilla bone loss, one treatment option was to regenerate bone from an autologous iliac crest graft. The prognosis of a vertical graft is relatively low due to the significant volumetric gain necessary to stabilize dental implants. Taking bone from a distant site like the hip can lead to complications such as insufficient bone volume, further bone loss, lack of adequate bone density to achieve primary stability of the implants leading to potential failures.
The “All on X” treatment options as currently available when compared to the traditional iliac crest graft protocol, provided a successful outcome that did not require the more invasive advanced bone grafting, no donor surgical site, reduced the healing time, lower surgical risk and morbidity, and increased prognosis. At the conclusion of the treatment, the patient was so pleased by her treatment that she elected to replace her falling lower dentition by implant-supported fixed prosthesis (Fig. 9).
Implant dentistry has evolved significantly over the past decades to provide a wider variety of treatment modalities to address the needs of the partially and fully edentulous patients around the globe. Improved implant designs, innovative surgical and restorative protocols, advanced 3-D imaging and software planning applications, biologics, CAD CAM, guided surgery, 3-D printing, increased abutment options, and new digital workflows have enhanced the ability of clinicians to deliver predictable treatment outcomes for their patients. Having access to advanced technology and ever-changing digital workflows provides a diagnostic foundation where various software files from CBCT devices (DICOM), intra-oral scanners (STL) and digital photography, to aid clinicians, lab technicians, and patients to visualize desired treatment outcomes from the first day of consultation. Advanced planning and simulation of implant positions to support virtual prosthetic designs becomes a more accurate methodology to present the proposed treatment plan for the patients’ aesthetic and functional goals.
Patients now have more choices regarding their dental implant treatment which can be confusing. Patients want teeth, not implants, and therefore it is the goal of the clinicians to properly diagnose and treatment plan to the desired outcome of the patient. Most patients would choose to save time, avoid the increased morbidity of several regenerative bone grafting surgeries along with their unpredictable results, and favor proven, effective, and predictable surgical and prosthetic protocols. These are all important factors in a patient’s decision. The “All-on-4” protocol has the benefit of avoiding invasive bone grafting, reducing the anterior-posterior prosthesis cantilever that will improve long-term prosthetic prognosis, saving time by delivering an immediate fixed interim prosthesis that is aesthetic and functional. These are all factors that have an impressive impact on overall patient satisfaction.
In a study by Mumcu31 and al., the All on 4 concept comparing an implant retained overdenture to an implant supported fixed prostheses for patient satisfaction, oral health-related quality of life, and marginal bone loss. They concluded that similar marginal bone loss and quality of life scores were exhibited after 2 years of function. However, patients found overdentures easier to clean but more painful in comparison with the fixed prosthesis. Another study32 assessed the quality of life with immediate loaded full arch implants on 20 consecutives patients found that the greatest improvements were seen in psychological discomfort and disability, and pain. Wang et evaluated 95 patients ten years after implant placement assessed patients’ satisfaction regarding function, phonetics, chewing comfort, stability, cleanability. Oral health-related quality of life (OHRQoL).33 High satisfaction with implant-supported restorations was seen in all 95 patients ten years after implant placement.
A search was performed in the PubMed/MEDLINE, Web of Science, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria (PRISMA). In Yaguinuma et al,. the PICO question was used to address the following specific question: “What is the level of oral health-related quality of life and satisfaction in edentulous patients and with atrophic jaws who received dental implants for full-arch implant-supported restorations following the all-on-four in the mandible or maxilla?”34 Eleven studies including 693 patients aged 55 to 71 years were selected. The shortest follow-up period was 3 months and the longest, 7 years. Regarding the OHRQoL assessment method and patient satisfaction, the oral health impact profile (OHIP) and the visual analog scale (VAS) were the most used. The conclusion was OHRQoL and satisfaction in patients whose rehabilitation was based on the all-on-four concept were high.Also, clinical relevance reveals that satisfaction and oral health-related quality of life of rehabilitated patients with implant-supported total prostheses fabricated according to the “All-on-Four” concept, aiming to achieve success through procedures with greater predictability and less complexity, as these are directly associated with recovery oral health of edentulous individuals with less morbidity and minimized costs.
Post-operative subjective observation such as; patient satisfaction beyond their expectations, regaining self-confidence and self-esteem, improving their health habits such as stopping smoking, improved self-awareness leading to being conscious of their health, dietary changes resulting from better mastication and function with their new dentition, overall improved quality of life which can benefit social interactions as patients become more confident in their physical presentation. It has been observed that patients’ behavior can change as a result of a full-arch restoration and especially the willingness to smile, not hiding or being embarrassed by their previous oral condition.35,36 For some completed cases that are followed at a long term, corporal weight subjectively seems to increase. It can be postulated that if the “All-On-4” treatment protocol has a positive impact on the patient’s health with an improved outcome; long-term benefit maybe to reduce health care expenses and increase quality of life. It is postulated that rehabilitation of masticatory function, patient comfort, improved aesthetics, removal of pathology, enhanced lip support, elevated nutrition, toning of facial musculature, can lead to benefits of quality of life and reduced global medical complications.Future study should focus on the relationship of the “All-on–X” treatment and the universal health impact and potential reduction of the financial burden of health care expense on the patient.
Oral Health welcomes this original article.
Gilbert Tremblay, B.Sc., D.M.D., Diplomate of the American Board in Oral Implantology/ID and Fellow of Pierre Fauchard Academy. His practice is in Montreal and awarded Center of Excellence for All on 4. He worked in the private sector on computer surgical guide design and published extensively on digital dentistry. He is president and founder of the Quebec Dental Implantology Institute, member of the exam construction committee for the American Board of Oral Implantology and examiner for the oral exam of the American Board of Implantology.
Scott D. Ganz, DMD, has published over 135 articles and contributed to 22 professional textbooks. He presents globally as a featured speaker and is considered one of the world’s leading experts in the field of Computer Utilization for Diagnostic, Interactive Treatment Planning, Digital Workflows, CBCT 3-D imaging, and CAD CAM Applications. Dr. Ganz maintains a private practice in Fort Lee, N.J. USA, and is the Director of Oral Restoration dedicated to full-arch dental implant reconstruction in New York City.
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