Module 1

Introduction to immediate full arch fixed implant treatment

Objectives

Identify the need and opportunity to treat edentulous patients and patients with failing dentition utilizing fixed detachable prostheses

Execute treatment in a simple, efficient, predictable and profitable manner from a team approach

Provide the tools to evaluate patients and to communicate treatment options and benefits

A reliable solution is essential to achieve predictable results

Images courtesy of Dr. Robert Levine

It’s about getting from here…

…to here!

How might edentulism affect your practice?

By 2020:

The adult population in need of 1 -2 dentures will approach 37.9 million

Adults aged 55-74 will increase by 86%

Seniors aged 75+ will increase by 61%

Retention rates for natural teeth will continue to increase

24% of people aged 55-65 will need 1-2 dentures

The decrease in edentulism will be offset by the growth of people aged 55+

Douglas CW, Shih A, Ostry L.

Will there be a need for complete dentures in the United States in 2020?.

J Prosthet Dent. 2002 Jan; 87 (1): 5-8.

Research

Visual Analog Scale Ratings 1 – 100

Variable Conventional group Implant group Post Mean Score Post Mean Score Overall satisfaction 64 89 Comfort 64 89 Stability 64 91 Overall ease of

chewing 61 91 carrot 54 89 apple 55 86 cheese 76 93 sausage 63 85 bread 78 94 lettuce 69 93 Ability to clean 89 91 Esthetics 89 91 Ability to Speak 85 92

Manal, A. Awad, BDS, MSc, PhD; James P. Lund, BDS, MSc, PhD; eric Dufresne, DDS, MSc; Jocelyne S. Feine, DDS, MSc, HDR Comparing the efficacy of mandibular implant-retained overdentures among middle-aged edentulous patients: Satisfaction and functional success The International Journal of Prosthodontics, Volume 16, Issue 2, 2003

Loading protocols for fixed prosthesis in edentulous jaws

From ITI 5th Consensus Statements and Clinical Recommendations for Implant Loading Protocols:

“The existing literature provides high evidence that immediate loading of

microtextured dental implants with one-piece fixed interim prostheses in both

the edentulous mandible and maxilla is as predictable as early and

conventional loading.”

“The number of implants used to support a fixed prosthesis varied from 2 to 10

implants in the mandible and 4 to 12 implants in the maxilla.”

“Immediate, early, or conventional loading with one-piece fixed interim

prostheses have demonstrated high implant and prosthesis survival rates and

can be recommended for the mandible and maxilla.”

“Patient-centered benefits of immediate loading include the immediate fixed

restoration of function, the reduction of postoperative discomfort caused by

removable interim prosthesis, as well as the reduction of overall treatment

time.”

Gallucci, German O. (2014). Consensus Statements and Clinical Recommendations for Implant Loading Protocols. The International Journal of Oral &

Maxillofacial Implants, 29(Supplement), 289. doi:10.11607/jomi.2013.g4

In order to achieve the desired final restoration, several aspects need to be considered

Image courtesy of Dr. William Runyon, Dr. William Ralstin, Lab work by Darrel Clark, CDT

Esthetics

Quality of Life

Money

Social Life

Time for Treatment

Bone Volume

General Health Conditions

Compliance

Anatomical Restrictions

Risk Factors Patient expectations Clinical Situation

Considerations for an immediate full arch fixed solution

Determining treatment factors:

Adequate bone (ridge height and width)

CBCT is recommended

Restorative clearance – enough space to accommodate the prostheses

Final ADA position of #8 & #9

Lip support

Gingival smile line

Vertical Maxillary Excess

Patient’s health, compliance, opposing dentition and finances

Treatment Advantages - Patient

Normal Function

Esthetics

Simplified treatment

Treatment Advantages - Clinician

Normal Function

Esthetics

Simplified treatment

The Surgeon, the Restorative Dentist and the Lab all must:

Believe in the team approach and believes in collaborative pre-surgical

planning

Understand how to evaluate the appropriate patients for fixed hybrid

prostheses

Have experience with Full Arch Cases, or a desire to learn how to treat full arch

cases with an understanding of their own clinical and technical limitations

Be an integral and valuable asset to the team and the preferred partner

Agree on a pricing structure that maximizes profitability for the group

Keys to Success –

Putting together the right team

The Team Contribution

Surgeon

Restorative Dentist

Implant Company Representative and Technical Support

Lab Technician

Who Owns What?

Who purchases components for immediate loading?

Who will order, deliver and charge for these components?

Warranty: Responsibilities for maintaining the prosthesis?

Laboratory

GP Surgeon

Implant-Retained Restorative Options

Overdenture

w/

LOCATORS®

Bar

Supported

Overdenture

Immediate

Fixed Hybrid

Directly

Veneered

Fixed

Prosthesis

Immediate Fixed Hybrid Solution (Doctor Removable Bridge)

4-6 implants (on average)

Implant retained & supported (prosthesis typically not in contact with tissue)

Though fixed, still made of same material as a conventional denture (acrylic base, plastic teeth)

Bar is processed/embedded within the denture

More esthetically pleasing – vestibular flanges removed

Not removable by patient

Photo courtesy of Dr. William Runyon

Immediate Fixed Hybrid Solutions- Maintenance and other considerations

Maintenance: routine, thorough cleaning by patient necessary

A water irrigation device is recommended for hygiene and maintenance

The need for removal is patient dependent

Based on lip support and final position of central incisors, patient may not be a candidate for a hybrid

Photo courtesy of Dr. William Runyon

Practice Impact

Clinician Patient

Reduced patient discomfort

Reliable restoration

Time saving treatment with the

option for immediate

provisionalization*

Individualized patient solution

Enhanced quality of life

Enables patient to get off the dental

treadmill

Comprehensive treatment options

Reduced complexity by addressing

the individual anatomical situation

and leveraging innovative surfaces

and materials

Evidence-based, predictable

success rates for all loading

protocols

Confidence in all indications

Enhance and grow clinical practice

Review of clinician and patient benefits of immediate full arch fixed solutions

* when good primary stability is achieved.

Patient evaluation

Determining treatment factors:

Patient expectations- already covered

Current oral health status

Smile line and final position of the central incisors

Opposing dentition

Anatomy of ridge

Vertical dimension / restorative clearance

Patient evaluation

Determining treatment factors:

Patient expectations

Current oral health status

Smile line and final position of the central incisors

Opposing dentition

Anatomy of ridge

Vertical dimension / restorative clearance

Presenting Case Types

1. Presenting case types:

a. Non-restorable teeth due to root fractures and/or caries

b. Medication related dry mouth haven’t been to the dentist in a while, have dry

mouth, side effects

c. Medically compromised patients

d. Enhanced periodontal disease

e. Failing or poorly placed dental implants

f. Conversion to a fixed-implant case desired

g. Desire to get off the dental treadmill

h. Esthetic concerns

i. Combination of some of the above

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Available treatment planning tools

ITI® SAC Tool

www.iti.org

Assessment Tools

Patient evaluation

Determining treatment factors:

Patient expectations

Current oral health status

Smile line and final position of the central incisors

Opposing dentition

Anatomy of ridge

Vertical dimension / restorative clearance

Smile line

Images courtesy Dr. Alfonso Pineyro DDS

Patient evaluation

Determining treatment factors:

Patient expectations

Current oral health status

Smile line and final position of the central incisors

Opposing dentition

Anatomy of ridge

Vertical dimension / restorative clearance

Opposing dentition

Patient evaluation

Determining treatment factors:

Patient expectations

Current oral health status

Smile line and final position of the central incisors

Opposing dentition

Anatomy of ridge

Vertical dimension / restorative clearance

Anatomy of ridge

Models courtesy of Salvin Dental

Class 1 – Absence of significant atrophy

All treatment options are available (fixed & removable)

Selection based on patient’s expectations & cost

Models courtesy of Salvin Dental

Class 2 – Moderate vertical or horizontal atrophy

Implant-supported overdenture

Hybrid: fixed-detachable w/acrylic to compensate for atrophy

Fixed PFM or all-ceramic restoration w/pink porcelain or longer teeth to compensate for atrophy

Grafting and/or sinus elevation to re-create the ideal ridge (optional)

Models courtesy of Salvin Dental

Class 3 – Advanced atrophy

Implant placement can be possible in the mandible without ridge augmentation in the right situation, whereas advanced bone grafting may be necessary in the maxilla

Final rehabilitation is determined by degree of success of bone augmentation

Model courtesy of Salvin Dental

Patient evaluation

Determining treatment factors:

Patient expectations

Current oral health status

Smile line and final position of the central incisors

Opposing dentition

Anatomy of ridge

Vertical dimension / restorative clearance

Restorative clearance

Image courtesy Dr. Alphonso Pineyro

Minimum distance from crest of ridge to incisal edge of planned prosthesis: 15 mm for a hybrid restoration

Vertical clearance

Depending on the treatment modality, different heights of vertical clearance will be required.

Refer to the following literature to determine the vertical height necessary for treatment:

Compend Contin Educ Dent 2012 May;33(5):328-34;“Rules of 10”—guidelines for successful planning and treatment of mandibular edentulism using dental implants. Cooper LF, Limmer BM, Gates WD.

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Join us for Module 2- Surgical Treatment Options

Questions?