A Case Series: Full mouth rehabilitation in the terminal dentition with All on X
- Brandon Saxe
- Jul 15
- 8 min read
Article from USA
Brandon Sake
Resident
Nassau University Medical Center
Abstract
This is a report of the rehabilitation of terminal maxillary and mandibular dentition with placement of a hybrid dental prosthesis immediately loaded on implants with “All on X”. The concept of “All on X” allows patients to have full dental rehabilitation with a temporary prosthesis and new teeth within 24 hours of having the conventional implants placed. Using the digital workflow and grammetry we are able to index the positions of the dental implants to be placed free hand and provide our patients a usable prosthesis to restore their smiles in a timely fashion. The technique described is a fast and effective option for patients with terminal remaining dentition with a desire for a quick and esthetic solution.
Introduction
In patients with terminal dentition or atrophic maxilla or mandible different treatment options include: complete upper and lower dentures, implant supported overdenture and fixed hybrid implant supported prosthetics. Initially in the 1990s Dr. Paulo Malo developed the All-on-4®,which allowed patients to have 4 dental implants placed in maxilla or mandible and allow for full arch dental rehabilitation within 24 hours of implant placement. This concept is beneficial in that a surgeon can avoid the need for regenerative procedures such as maxillary sinus augmentation, delayed prosthesis fabrication, injury to the inferior alveolar nerve and a more favorable anterior -posterior (AP) implant spread with a minimal cantilever in the edentulous patient. This concept when used for mandibular or maxillary rehabilitation places 2 anterior implants placed axially and 2 posterior implants placed at an angle for a favorable AP spread (30-45 degrees). AP spread is the distance from the center of the most anterior implant to a line joining the distal aspect of the 2 most distal implants on both sides. For example placing the 4 implants between the mental foramen and anterior loops for a favorable AP spread. Multiunit abutments are placed for restoration at 0, 17 and 30 degrees. The all on X concept is a similar concept except the implants are placed where deemed necessary to allow for favorable AP spread, to eliminate cantilever, and provide a stronger prosthesis. There are several requirements for All-on-4® technique: 1. At least 35 Ncm insertion torque, patients without parafunctional habits, bone dimensions: >5 mm width in maxilla and mandible; at least 8 mm of height in mandible, and 10 mm height in maxilla, and favorable bone density. All on X is different in that with a combined 120 Ncm across immediately loaded implants the prosthesis can be placed. Additionally the implants can be placed wherever there is available bone.
Advantages of the all on X with digital workflow solution include: immediate fixed temporary prosthesis fabrication <24 hours, fewer implants with less cost to patient, less operating time, more esthetic prosthesis, and preservation of existing bone density. Disadvantages include: surgery can be technically difficult, complications can be difficult to treat, if severely atrophic bone in maxilla may need to resort to remote anchorage solutions such as transnasal, transsinus, pterygoid, or zygomatic implants. Additionally, hygiene around the prosthetic is also a disadvantage as the entire prosthesis must be removed with hygiene visits every 3-6 months. Patients also must be on a soft diet while allowing the implants to osseointegrate for around 3 months depending on the patient.
Technique
The patient has their upper and lower arches including occlusion scanned by an intraoral scanner with fiducial markers placed as a reference point to guide the digital workflow: 2 in hard palate for maxilla or 1 on each retromolar pad/ posterior mandible for mandibular surgery. Following the placement of fiducial markers (such as Arch tracersTM by Digital Arches LLC) and scanning of the arches the dentition is removed and alveoloplasty is completed where needed. Multiunit abutments then can be placed followed by soft tissue closure with healing caps. The soft tissue is then scanned with scan bodies placed on the multiunit abutments and finally the implants themselves must be indexed for lab fabrication digitally. The digital workflow allows for 2 measurement verifications for implant placement. This includes grammetry and photogrammetry. Our digital workflow uses grammetry or taking measurements using scan bodies such as OptisplintTM by Digital Arches LLC. Using an intraoral scanner the surgeon can scan the position of the placed implants with their corresponding scan bodies. This information is digitally sent to the lab for fabrication of a PMMA temporary denture that can be immediately loaded within 24 hours of surgery.
Digital Workflow Chart
Case Examples:
Patient #1: The first case example is a 66 year old female who presented with concerns for getting new mandibular teeth to replace her existing failing ones. Patient has a past medical history of well controlled lupus taking ASA 81 mg, hydroxychloroquine, mycophenolate. She denied past surgical history, denied allergies, and had a non contributory social history. Patients exam was pertinent for carious non restorable tooth #31, and roots remaining #21, 22, 23, 26, 27. Patients panoramic and CBCT radiographs revealed similar findings as above, with additional root remaining #16.
The assessment for the patient is carious non restorable remaining mandibular dentition with exception of implant site #30 which was stable and without problems. The plan for this patient was placement of x5 mandibular implants in preparation for All on X treatment. These treatments have been completed under intravenous sedation in our clinic with patient receiving fentanyl, versed and a propofol infusion pump. The intraoperative pictures are shown below. In this case we utilized TruAbutmentTM digital scan bodies which allowed us to not have to connect the scan bodies with material such as Stonebite ® which is used to connect the multiunit abutments together to be indexed by the lab and scanned with an intraoral scanner. This digital solution helped us save time in the case. The post operative radiograph is shown below which 5 implants placed and immediate temporary provisional placed the following day after receiving from lab. The temporary prosthesis is shown to be very esthetically pleasing to patient and pending 3 months of healing patient to receive a final porcelain prosthetic.
Patient #2: The second case example is a 35 year old female who presented with concerns for wanting to improve her smile and have more teeth. Patient has a past medical history of exercise induced
asthma and GERD. Patient previously had bilateral maxillary sinus lifts with xenograft bone graft placement 5/22/24 to sites #4, 14. Patient with allergies to penicillin. Patient takes omeprazole, and albuterol. She uses alcohol socially. Patients exam is pertinent for remaining teeth #6, 7, 8, 9, 11 for maxilla and missing teeth #1-5, 10, 12-20, 31. Patient with stained teeth #7, 8 that do noit match color of adjacent crowned teeth #6, 9-11 bridge. Periapical radiolucent noted on #8, #9, decay down to mid root #11, possible mid root fracture #8.
The assessment for this patient is carious non restorable remaining maxillary dentition. Initially the surgical treatment plan for patient was to extract all remaining maxillary teeth and completed bilateral maxillary sinus lifts with placement of 8 dental implants with several implant bridges: #3-5, #6-8, #9-11, and #12-14. Patient wanted to have teeth as soon as possible and did not want to wait several months for the implants to heal without new teeth. The revised plan was for All on X implant placement with immediate temporary hybrid prosthesis to be placed within 24 hours of implant placement. Surgery pictures are shown below. 7 implants were placed into maxilla including angled implants towards pre molar sites. The graft from sinus lifts allowed for accomadation of posterior maxillary implants eliminating distal cantilever and improving AP spread. This case utilized Optisplint™ by Digital Arches LLC placed over multiunit abutments to help the lab index position of implants and all were luted together using Stonebite® scan material. Which was then scanned digitally and removed for lab to use.
The patient was very happy with the results and felt like she had a brand new smile faster then she though previously possible. The post operative plan for patient is for softer diet x 3 months while implants osseointegrate followed by final porcelain prosthesis to be fabricated by lab.
Patient#3: The final case to be discussed is a 53 year old male patient who presented with referral from dental clinic for full mouth extractions and possible dental implant placement. Patient has a non contributory past medical history, past surgical history, denied allergies, medications and contributory social history. Exam was pertinent for grossly mobile periodontally involved remaining dentition. Radiographically patient had severe generalized periodontal bone loss of remaining dentition although had good height and width of remaining mandibular and maxillary alveolus. Implants were treatment planned 6 in maxilla and 6 in mandible.
Discussion
The All on X workflow has allowed our patients to be able to have new teeth and restore their smiles and confidence in a rate unheard of prior. The digital workflow and accuracy of intraoral scanning and use of technology have allowed our patients to receive esthetic, and quick solutions to address their failing dentition. Procedures such as multiple dental implant bridges, ill fitting upper and or lower dentures, grafting procedures with delayed surgical results, and impressions intraorally can now be avoided with the use of the digital workflow. The prosthesis made eventually meets full function with esthetics while avoiding full palatal coverage, delayed results from bone grafting and procedures like sinus lifts.
Some challenges with digital intraoral scanning include: blood in the surgical field, limited keratinized and mobile soft tissues, saliva, limited maximum incisal opening and patients with severe alveolar resorption. To mitigate these issues high resolution scanners with small scanning tips are utilized. The use of soft tissue scan bodies and properly placed multiunit abutments can also help with these issues. Additionally with the use of grammetry the implant positions can be poured up in stone and verified by the lab to make a well fitting prosthesis. Temporary prosthetics made from polymethylmethacrylate can be 3D printed.
When comparing the digital workflow to previous methods a patient can have a much faster turn around time to functional esthetic solutions in a much shorter time frame than previously thought possible. The use of all on X implants also allows the surgeon to place additional implants where there is sufficient bone that can allow for a functional prosthesis even if an implant fails or cannot be used. Implants immediately loaded with an insertion torque of 30 Ncm yielded a high rate of implant survival at 96.8% via Wilya Douglas de Oliviera et al 2016. The total combined torque across placed implants in a fully loaded all on X case should be at least 120 Ncm meaning that not every implant has to be loaded at an insertion torque of 35 Ncm.
Conclusion
In conclusion the All on X concept has allowed us to change our patients lives and restore their smiles and self confidence. Previously patients would have to wait several months or even years to be able to rehabilitate their smiles which can now be done in less than 24 hours. The digital workflow has allowed our team to communicate faster with our associated laboratory, and dental colleagues. The all on X helps provide a long lasting prosthetic, preserves alveolar bone height, does not need as many implants as single unit/ implant bridges, improved speech and improved esthetics than previous methods could. In the future likely the process will continue to improve in accuracy, speed and esthetics.
Bibliography
Misch Contemporary Implant Dentistry by Randoph R. Resnik Copyright 2021
Minase DA, Sathe S, Borle A, Pathak A, Jaiswal T. Less Is More: A Case Report on All-on-4 Prosthesis. Cureus. 2024 Feb 25;16(2):e54873. doi: 10.7759/cureus.54873. PMID: 38533146; PMCID: PMC10964220.
Use of a dual-purpose implant scan body to obtain both digital and analog records for complete arch fixed implant restorations. Crockett, Russell J. et al. Journal of Prosthetic Dentistry, Volume 133, Issue 1, 36 - 42
Douglas de Oliveira DW, Lages FS, Lanza LA, Gomes AM, Queiroz TP, Costa Fde O. Dental Implants With Immediate Loading Using Insertion Torque of 30 Ncm: A Systematic Review. Implant Dent. 2016 Oct;25(5):675-83. doi: 10.1097/ID.0000000000000444. PMID: 27540837.
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