Providing a full arch fixed prosthesis in one day

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Posted by: Dental Design 21st November 2022

Dr Jonathan Dougherty has recently used the GM Neodent® Aqua Implant to perform a fixed full arch implant-retained prosthesis on four dental implants. Here he shares his case:

A 58-year-old female patient presented. She was generally fit and well, and had no medical conditions. She was a non-smoker and a non-drinker. She presented with failing upper dentition, and wished to explore some options to address the aesthetics and the function, because she was finding it difficult to eat. An intra- and extra-oral examination was undertaken which revealed that she had good oral hygiene.

All remaining teeth were failing with a hopeless prognosis, which included the UR1-3, and UL1-4. UR1, UL3 and UL4 had existing amalgam and composite restorations. All other upper dentition was missing.

The patient was hoping for a fixed solution. So, the various treatment options were discussed with her. These were to either; do nothing, provide a removable partial denture, a removable full denture, or a full arch implant-retained fixed prosthesis. The two latter options would require the extraction of the existing teeth. All benefits and risks were discussed with her for each of the treatment options – she wished to proceed with a permanent fixed solution, so the full arch dental treatment was explored.

Treatment planning

Having made her choice, we proceeded on that basis, and we completed a comprehensive assessment to inform our treatment plan. Firstly, we undertook a CT scan to assess her bone volume and bone quality. In this case, the patient had high-quality, volume and density and was therefore suitable for full arch treatment without the need for bone augmentation.

From here, intraoral scans were taken using the 3Shape Trios scanner, alongside some clinical photographs. Extraoral photos are important, as they are used to assess how high the patient’s smile line is. This tells us how much alveoloplasty we have to undertake to allow sufficient restorative thickness for our final prosthesis, and to ensure we are able to hide the transition line behind the patient’s upper lip. This is important for aesthetics as, when she smiles, we won’t be able to see the transition line of the final restoration.

My dental technician and I always have a planning meeting for each case. In this meeting, I looked at the CT scan and the dental technician looked at the extraoral photos and the intraoral scans. We always base our treatment plans on a restoratively driven approach, prioritising the aesthetics and functionality of the prosthesis, and accommodating treatment to provide an ideal outcome in these areas. We then create a digital wax up of the final prosthesis, and plan backwards accordingly.

Once the dental technician and myself agreed on the treatment plan, I set up a consultation with the patient. We discussed the digital wax up, and what the treatment would involve. The patient was also advised on the role she would play in a successful outcome. Oral hygiene instruction was provided to help the patient protect her investment and maximise the longevity of the results. After this consultation, the patient consented to the treatment plan and surgery was scheduled.

Treatment process

Our aims for this treatment were to provide the patient with a fixed full arch implant retained prosthesis, in one session. Where possible, immediate loading provides the patient with a range of benefits. They receive a functional and aesthetic restoration within a matter of hours, and are able to resume normal activity fairly quickly.

To begin, we atraumatically extracted her remaining upper teeth. A full thickness flap was then raised to expose the alveolar ridge. An alveoloplasty was then performed in order to allow sufficient space for the final prosthesis. This step was executed based on the desired final restorative outcome, which again, aims to hide the transition line of the final prosthesis.

On completion of the alveoloplasty, progress was checked against the restorative guide to ensure that the bone had been sufficiently reduced. Once this was confirmed, the GM Implant System was used to place the Neodent^® Aqua implants. I always use GM Neodent^®Aqua for immediate placement as the surface chemistry and wettability of Aqua implants promote osseointegration. Four dental implants were placed – two 3.75 x13mm and two 3,75 x 11.5mm – this gained a sufficient anterior-posterior spread which is important for reducing stress on both the implants and the prosthesis. This was also checked against the restorative guide to ensure that all placements were within the restorative envelope.

From here, we proceeded to place multi-unit abutments, then healing caps. The flap was sutured closed around the healing caps maintaining no tension in the soft tissue. Following this, temporary cylinders were placed, and a denture conversion was undertaken chairside using an intraoral pick-up technique and the Ufi Gel hard pick up (Voco). This allowed us to provide the patient with a temporary full arch prosthesis on the day. The patient was happy with her results.

Discussion

This demonstrates a freehand surgical case that utilised the GM Neodent Surgical Kit. A great result was achieved thanks to the thorough planning and precision of products and technologies used.

For anyone approaching full arch reconstruction, I would highly recommend finding a suitable mentor while learning the skills and gaining experience. It may also be helpful to seek a second opinion from a specialist regarding the prognosis of any existing teeth, and compare this to the likely success rates of other treatment options. Presenting all this to the patient will ensure fully informed consent.