Abstract

In modern times, patients have a preference for fast treatment options and fixed restorations, particularly when compared to older patients. The field of fixed reconstructions on implants has witnessed significant advancements, providing a diverse array of treatment options for various situations. However, despite the numerous aesthetic and functional benefits, there is currently a lack of well-defined clinical guidelines regarding the ideal number of implants, loading type, and reconstruction methods.

Although there are some existing recommendations, it is crucial to consider the influence of micro/macroscopic factors when determining treatment plans and surgical approaches for each unique case. In this specific case report, we describe the rehabilitation of the upper jaw of a 36-year-old patient. The treatment plan was devised with the objective of not only addressing the patient's immediate needs but also considering potential future requirements in the lower jaw. Special attention was given to the patient's existing dentition and possible risk factors. Furthermore, the plan included the utilization of a 3Shape intraoral scanner (Trios 3) device to digitally capture the impression phase. Additionally, careful consideration was given to the patient's current dentition and possible risk factors.

Despite the widespread use of intraoral scanners in dental practice, their role remains somewhat limited due to insufficient significant results and the uncertainty that may arise when using them during surgical procedures. However, in this specific case report, the Trios 3Shape scanner showcased a high level of accuracy, resulting in streamlined workflow and reduced work time. Overall, the outcomes were satisfactory for both the patient and the dental team involved.

Keywords

Full-arch rehabilitation; Fixed- implant reconstruction; Intraoral scanner

Introduction

The rehabilitation of a completely edentulous maxilla is considered to be a crucial aspect of oral health care provided by implant prosthodontics in the field of implant dentistry. The impact of severe tooth loss is significant, affecting over 300 million individuals worldwide, with an increasing incidence rate of 3% per year carrying along psychological, nutritional and esthetic burdens [1-3].

Rapid developments in modern dentistry decreased the popularity of traditional removable treatment solutions. Patients nowadays are increasingly seeking not only fixed but also fast treatment options that cover functional and aesthetic aspects. Patients pursuing such results can benefit from the All-on-4 treatment concept, which requires shorter treatment time and costs, enhanced esthetics, and high patient satisfaction. However, this type of treatment remains challenging to many, as it requires solid experience and thorough planning [4-6]. Nevertheless, this All-on-Four treatment concept has been endorsed as a valuable treatment protocol for patients requiring complete-arch rehabilitation. Its application has consistently demonstrated excellent results in terms of short-term, medium-term, and long-term outcomes [5-8]. Despite these mentioned outcomes this this treatment option is unfortunately not always taken into account by many practitioners.

This treatment relies on a hybrid screw-retained prosthesis supported by 4 dental implants. In general, the implants are positioned in biomechanically appropriate positions which allows a balanced loading after designing the prostheses and during mastication. Till the time of this publication, these sites are only recommended in literature and not considered as guidelines [3,9,10].

This positioning process, along with the design of the prosthesis, is influenced by a variety of factors, including the type/quality of existing bone, inter-occlusal space, and the patient's preferences. Other clinical and anatomical difficulties can also vastly influence or even change the treatment plan. Such cases require a special individual multidisciplinary approach and most likely treatment-plan adaptations [9,11].

Intraoral scanners are also widely used in dental clinics, however, as seen in the literature, their role is still to be very limited due to insufficient significant results and the uncertainty that might accompany their usage during surgical treatments [12,13]. This article provides a comprehensive explanation of the treatment planning process, as well as the surgical and prosthetic steps involved in rehabilitating a patient's upper jaw using the All-on-4 treatment concept.

Case Report

A male patient 36 years of age, with a non-significant medical history presented with general aesthetic complaints, especially in the upper frontal region. Clinical and radiological examination revealed further details about other problems in the oral cavity with many compromised carious teeth in both jaws and also many destroyed teeth (Figure 1,2). However, bone volume in both jaws was considered adequate after the Cone beam computerized tomography examination (CBCT) as bone quality of type II and III were documented in the maxilla according to the Lekholm & Zarb classification.

Figure 1: Initial clinical situation.

Figure 2: Pre-operative panorama X-ray.

Several treatment options were discussed with the patient to treat both the upper and lower jaws and restore the vertical dimension. The patient was keen in the beginning to restore only the upper jaw first and as fast as possible, as the appearance of the lower jaw was not disturbing for him. Therefore, based on bone quality and quantity in the maxilla, an implant-supported fixed prosthesis was planned along with the extraction of all teeth in the upper jaw.

Taking into account the anatomical topography of the upper jaw and the sufficient lip coverage that the patient possesses the All-on-5 implant-supported and CAD/CAM-designed prosthesis was planned. Plans were conducted after thorough CBCT measurements, and implant sizes were selected. Such a design would help in achieving equal force distribution on all 4 implants and eliminate any possible cantilever effects. The remaining dentition in the lower jaw is a clear sign that the patient will use mainly the frontal region during the primary mastication phase. However, the slight occlusal contact between teeth 27 and 37 was essential in the planning, as it can indicate a suitable vertical dimension for future prostheses.

All possible complications were discussed with the patient. The surgical and prosthetic approaches were explained, and consent forms were signed. The operation was performed under general anesthesia. The first step included atraumatic teeth and root extractions, followed by mucoperiosteal full-thickness flap elevation. The second step started with an osteotomy procedure as planned to insert the implants in an optimal functional and aesthetic position. Selected implants were placed at osteotomy sites.

One implant each in the 14/24 regions was planned to be angled at 30º, while the remaining two implants were inserted in regions 12, and 22 respectively, at a 0º angle. All implants were cylindrical-shaped Nobel Biocare^® implants and achieved an initial primary stability of more than 35N cm at all sites and were all placed below the bone level. Figure 3 is a control panorama after the insertion of the implants and the installation of provisional abutments.

Figure 3: A post-operative X-ray.

Afterwards, the operated area was controlled. Removal of all bony sharp edges was performed. All extraction sites and bony irregular formations were managed by what is known as the sticky bone technique using a mix of auto-grafted bone and allograft bone substitutes Puros^® and plated rich fibrin (PRF). The grafted region was afterward covered by a PRF membrane. The flap was adequately re-positioned and sutured. Figure 4 shows the initial situation after suturing the operated area.

Figure 4: Initial situation after suturing.

To begin the prosthetic process, multi-unit abutments for Nobel Biocare^® were installed on all implants, and two intraoral scans for the upper and lower jaws were performed using a 3 Shape Trios 3. Subsequently, healing abutments were installed, and the recovery process was performed by the anesthetist. After the scan, it's worth mentioning that instead of using 4 regular gingival formers, we opted for 4 closed impression posts deliberately attached to the multiunit abutments. This decision was made to facilitate the insertion process the following day Instructions were provided to the patients, and 24 hours later the general situation was controlled again and multi-unit abutments were inserted with a torque of 15 N cm on all implants. Then a Polymethyl methacrylate (PMMA) screw-retained prosthesis was installed. The color and shape of the teeth were agreed upon prior to the treatment with the patient. In this case, thorough planning and a digitized approach minimized the margin of errors and reduced patient waiting times. This can be easily implemented in daily routine and further developed according to each case separately.

Figures 5 and 6 show the scans of both jaws. The patient was instructed to follow a soft food diet for the first two weeks, and regular follow-up appointments were scheduled, including an appointment after 10 days to remove the sutures. Intra-oral pictures (Figures 7,8) taken four months after the operation show complete healing of the soft tissues. Figure 8 shows an overall frontal view reflecting satisfactory aesthetic results.

Figure 5: Intraoral scan of the maxilla.

Figure 6: Intraoral scan of the mandible.

Figure 7: 24 hours after the operation.

Figure 8: The installed prostheses 24 hours after the operation.

Discussion

Various systematic reviews recommend a minimum of four implants for implant-supported overdentures. As a result, the Allon-Four treatment concept is gradually gaining popularity among both practitioners and patients. However, it is crucial to consider the influence of a surgeon's clinical experience, as factors such as clinical and anatomical variations can significantly impact the surgical approach. In general, the total rehabilitation of the maxillary arch is typically recommended to involve a range of four to six implants. However, it is important to note that there are no definitive guidelines in the literature regarding the ideal number or preferred positions of implants for this purpose [10,14,15].

On the other hand, the widespread integration and accessibility of digital technology in clinical practice have greatly facilitated both clinical and laboratory procedures in implant dentistry. However, these rapid advancements require the remodeling and adaptation of various clinical procedures. While incorporating digital techniques can enhance the rehabilitation of the full arch with fixed solutions by improving diagnostic and treatment procedures, many practitioners may still feel apprehensive about relying on such techniques [16-20].

It is crucial to have scientific validation and evidence regarding the clinical and technical feasibility, long-term biological outcomes, and economic analyses of complete digital workflows. This understanding is essential to assess the impact of the ongoing digitalization trend on modifying traditional protocols in prosthodontics. However, the lack of valid long-term clinical results creates uncertainty for many practitioners, leading them to avoid even the most basic steps, such as utilizing intraoral scanners [19,20].

Researchers are constantly studying the accuracy of various intraoral scanners. However, most of these studies are conducted in controlled laboratory settings and do not fully replicate the complexities of the clinical environment or provide long-term results. Despite the potential for high accuracy with intraoral scanning, it is currently not recommended to rely solely on digital intraoral impressions for fabricating full-mouth implant-supported prostheses (Figure 9) [18,21- 23]. This does not only apply to intraoral scanners but also includes different steps of digitalization in modern dentistry. The precision of implant positioning due to 3D planning and imaging in both intra/ extra oral scanners must be further investigated16. What makes it even harder is the fluctuating research results concerning full-mouth fixedimplant rehabilitation [24]. However, this should not discourage us from incorporating digital tools that can genuinely streamline various procedures into our daily routines. As more practitioners embrace these methods, it becomes increasingly feasible to gather reliable data efficiently and prevent errors through the sharing of expertise.

In this case report, we presented a routine All-on-4 procedure conducted in our office, where we utilized a 3Shape intraoral scanner (Trios 3) device. The scanner demonstrated a high level of accuracy, greatly streamlining the workflow and reducing work time. The positive experience with digitalization has encouraged us to explore further integration of digital tools in the near future. We are gradually moving towards embracing more digital solutions, with the goal of enhancing our practice. It is essential to have long-term documentation in order to accurately assess and monitor the success of the procedure. Continuous follow-up will be conducted to ensure comprehensive tracking of the treatment outcomes.

Conclusion

Implant-supported fixed restorations provide an excellent solution for young patients seeking both aesthetic and functional outcomes. Utilizing a digital workflow is highly recommended not only during the planning stage but also throughout the operative phase. By incorporating this reliance on digital tools in a step-by-step approach, unnecessary errors and complications can be minimized. Furthermore, both short-term and long-term documentation plays a crucial role in preventing potential post-operative complications.

References

1. Grandi T, Signorini L (2021) Rehabilitation of the Completely Edentulous Mandible by All-on-Four Treatment Concept: A Retrospective Cohort Study with Up to 10 Years Follow-Up. Medicina (Kaunas) 58: 10. [Ref.]
2. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388: 1545-1602. [Ref.]
3. Di Francesco F, De Marco G, Capcha EB, Lanza A, Cristache CM, et al. (2021) Patient satisfaction and survival of maxillary overdentures supported by four or six splinted implants: a systematic review with meta-analysis. BMC Oral Health. 21: 247.[Ref.]
4. Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M (2012) “All-on-4” Immediate-Function Concept for Completely Edentulous Maxillae: A Clinical Report on the Medium (3 Years) and Long-Term (5 Years) Outcomes. Clin Implant Dent Relat Res14: 139- 150. [Ref.]
5. Maló P, Rangert B, Nobre M (2003) “All-on-four” immediatefunction concept with brånemark system^® implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent Relat Res 5: 2-9. [Ref.]
6. Luthra R, Pathania P (2018) Rehabilitation With Implant Supported Fixed Prosthesis- A Case Report. Eur J Exp Biol 8: 1-4. [Ref.]
7. Malo P, De Araújo Nobre M, Lopes A, Moss SM, Molina GJ (2011) A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 142: 310-320. [Ref.]
8. Figliuzzi MM, Giudice A, Pileggi S, Pacifico D, Marrelli M, et al. (2016) Implant-Prosthetic Rehabilitation in Bilateral Agenesis of Maxillary Lateral Incisors with a Mini Split Crest. Case Rep Dent.[Ref.]
9. Soto-Peñaloza D, Zaragozí-Alonso R, Peñarrocha-Diago M, Peñarrocha-Diago M (2017) The all-on-four treatment concept: Systematic review. J Clin Exp Dent 9: e474-e488. [Ref.]
10. Roccuzzo M, Bonino F, Gaudioso L, Zwahlen M, Meijer HJA (2012) What is the optimal number of implants for removable reconstructions? A systematic review on implant-supported overdentures. Clin Oral Implant Res 23: 229-237. [Ref.]
11. Penarrocha-Diago M, Penarrocha-Diago M, Zaragozí-Alonso R, Soto- Penaloza D, On Behalf Of The Ticare Consensus M (2017) Consensus statements and clinical recommendations on treatment indications, surgical procedures, prosthetic protocols and complications following All-On-4 standard treatment. 9th Mozo-Grau Ticare Conference in Quintanilla, Spain. J Clin Exp Dent 9: e712-e715. [Ref.]
12. Ashraf Y, Abo El Fadl A, Hamdy A, Ebeid K (2023) Effect of different intraoral scanners and scanbody splinting on accuracy of scanning implant-supported full arch fixed prosthesis. J Esthet Restor Dent 35: 1257-1263. [Ref.]
13. Marshaha Nour NJ, Azhari AA, Assery MK, Ahmed WM (2023) Evaluation of the trueness and precision of conventional impressions versus digital scans for the all-on-four treatment in the maxillary arch: An in vitro study. J Prosthodont 33: 171-179.[Ref.]
14. Durrani F, Painuly H, Shukla A, Nahid R, Pandey S (2021) Terminal dentition to functional esthetic full-mouth implant reconstruction: Evidence-based approach. J Indian Soc Periodontol 25: 176-180. [Ref.]
15. Bencharit S, Schardt-Sacco D, Border MB, Barbaro CP (2010) Full mouth rehabilitation with implant-supported prostheses for severe periodontitis: a case report. Open Dent J 4: 165-171. [Ref.]
16. Ntovas P, Spanopoulou M, Martin W, Sykaras N (2022) Superimposition of intraoral scans of an edentulous arch with implants and implant-supported provisional restoration, implementing a novel implant prosthetic scan body. J Prosthodont Res 67: 475-480. [Ref.]
17. Revilla-León M, Gómez-Polo M, Vyas S, Barmak AB, Gallucci GO, et al. (2023) Artificial intelligence models for tooth-supported fixed and removable prosthodontics: A systematic review. J Prosthet Dent 129: 276-292.[Ref.]
18. Katsoulis J, Müller P, Mericske-Stern R, Blatz MB (2015) CAD/CAM fabrication accuracy of long-vs. short-span implant-supported FDPs. Clin Oral Implants Res 26: 245-249. [Ref.]
19. Joda T, Gintaute A, Brägger U, Ferrari M, Weber K, et al. (2021) Timeefficiency and cost-analysis comparing three digital workflows for treatment with monolithic zirconia implant fixed dental prostheses: A double-blinded RCT. J Dent. [Ref.]
20. Joda T, Zarone F, Ferrari M (2017) The complete digital workflow in fixed prosthodontics: A systematic review. BMC Oral Health 17: 1-9. [Ref.]
21. Lo Russo L, Caradonna G, Biancardino M, De Lillo A, Troiano G, et al. (2019) Digital versus conventional workflow for the fabrication of multiunit fixed prostheses: A systematic review and meta-analysis of vertical marginal fit in controlled in vitro studies. J Prosthet Dent 122: 435-440. [Ref.]
22. Zhang YJ, Shi JY, Qian SJ, Qiao SC, Lai HC (2021) Accuracy of fullarch digital implant impressions taken using intraoral scanners and related variables: A systematic review. Int J Oral Implantol (Berl)14: 157-179. [Ref.]
23. Lepidi L, Suriano C, Wang HL, Granata S, Joda T, et al. (2022) Digital fixed complete-arch rehabilitation: From virtual articulator mounting to clinical delivery. J Prosthet Dent 127: 398-403. [Ref.]
24. Shemtov-Yona K (2021) Quantitative assessment of the jawbone quality classification: A meta-analysis study. PLoS One. [Ref.]

Download Provisional PDF Here

 

Article Information

Article Type: CASE REPORT

Citation: Al Ibraheem A, Holzinger P, Jahl G (2024) All-on-4 Implants Supported Prosthesis with a Digitalized Approach: A Case Report of Maxillary Jaw Rehabilitation with a Temporary Prosthesis Int J Dent Oral Health 10(2): dx.doi.org/10.16966/2378-7090.422

Copyright: © 2024 Al Ibraheem A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication history: 

Received date: 13 May, 2024

Accepted date: 30 Jul, 2024

Published date: 05 Aug, 2024