Full Arch Implant Restoration Options

Raymond E La Vigne, DDS Palatine, IL

This article will describe the range of possible treatment options when all teeth within an arch (upper or lower) are missing already or need to be extracted.

• Full Denture
• Full Denture retained by 2 or more remaining teeth - over denture
• Full Denture retained by 2 or more Mini Implants
• Full Denture retained by 2 or more Standard Implants with Bars attached
• Full Denture screwed down to multiple Implants
• Long Span Fixed Bridge cemented or screwed onto multiple Implants

Full Denture

Supported entirely by resting upon the ridge bone and palate in the case of uppers
Retained by fitting into undercut areas
Least costly investment initially - do require relines recommended about every year at the start then about every three years on the average
Teeth wear, bone resorbs so that a new denture is typically needed after every 5 years
May require adhesive paste to provide additional retention initially for major chewing and later for all eating and speaking
Ridge bone continues to be lost due to two reasons:
Atrophy - lack of use since no more tooth roots embedded in bone
Resorption - forces upon bone as denture shifts during chewing causes stress
This is magnified and accelerated the longer the denture is worn without relining and the more unbalanced the bite is from the start (over bite, irregularities) or has become due to uneven wear of the teeth (especially a problem when various teeth oppose the denture - some natural enamel, some porcelain, various types of filling materials)
Dentures must be made and maintained in harmony with the surrounding muscles.
The tongue is an especially important factor in having success with lower dentures
Denture can be made to be attractive and natural looking
When initially fitted dentures allow about 25% of the chewing force possible with strong full set of natural teeth
Undercuts give dentures retention but also can be a source of sore spots

Over- denture

Two or more teeth with reasonably healthy bone and gum tissue can be saved so that a denture can be retained over them - The denture is still completely supported by resting on the gums and underlying bone The remaining teeth provide retention only.
Saving teeth also saves bone thus avoiding even more atrophy - the bone stays around the roots as long as forces are normal
The denture can be retained by a variety of options: silicone rubber, O- Rings or "snap "attachments, Clips on a bar.
Teeth saved must be in good condition and must be maintained by good home care and professional cleanings in order to make this feasible.

Attachments work well when there are poor existing undercut areas and / or very strong muscles wanting to dislodge the denture.
The forces used when chewing should still be within the 25 - 35% range. Care should be used in type of food and force used so that the attachments and remaining tooth roots are not overloaded. A night time retainer or second denture is often made to prevent clenching upon the attachments while sleeping.

Full Denture with Mini Implants

Denture is supported by the gums and bone Implants provide retention typically by silicone rubber or attachments like a snap.
The Mini Implants help prevent further atrophy of the ridge bone sine the implant acts similar to a tooth root
Mini Implants are great when teeth are not available, are in poor condition, or are poorly spaced for proper balance and stability.

Mini Implants are usually one piece - that is implant and abutment all in one Mini Implants are indicated in the lower front area due to their size and the type of bone density found in this area - which is typically the densest bone in the mouth In some cases the denture can be fit to be retained by the implants in the same appointment due to the dense bone allowing for immediate stability

Full Denture Supported and Retained by Standard Implants and Bars
Four or more standard size implants are strategically placed and joined by bars that are screwed down to the implants forming a frame. The denture has retention clips that fit over the bar usually in 2 - 4 places. In this case the denture rests upon the bar and is passive to the gum and bone tissues.

Dentures supported by bars can typically allow 50 - 60 % of maximum chewing force (based on natural teeth) Dentures are removed for cleaning. Implants and bars require cleaning with brush and floss with moderate effort needed. As with any Implant, professional exam and cleaning are recommended every 6 months and in some cases every 3-4.

Fixed Denture - Denture screwed down onto multiple Implants
Four or more standard size implants are placed and joined by bars similar to the above clip on but removable denture over bars. In this case, however, the denture is screwed onto the bar and not removable by the patient. These appliances allow 60 - 80% of maximum chewing ability. Since they can not be removed for cleaning after each meal, the denture borders are raised off the gum tissue enough to allow floss to pass under the base. Also frequent brisk rinsing and use of an irrigator such as a "Water-Pik" are highly recommended for cleaning several times each day.

The bar under-structure is similar to the previous over denture however the denture is not removable by the patient since it is screwed down to the bars.

Fixed Bridge / Crowns Cemented or screwed onto 6 - 10 Implants
Multiple single crowns allow best appearance and easiest flossing.
Implants can also be abutments for several bridge sections or one long span bridge for the entire arch.
These restorations allow maximum cosmetic appearance since the crowns are made from porcelain which has natural translucency, many shades are available and shades can be custom blended.

These restorations are the strongest and can deliver 80 - 90% chewing force. Excellent daily home care is needed just like when a patient has many remaining natural teeth heavily restored by crowns or bridges. That means flossing between the implants.

Implants help maintain jaw bone since they give the bone a purpose - the bone in use with normal amount of force stays healthy - similar to exercising for muscles and joints.

In many cases a patient wears a partial or full denture as a temporary when they ultimately plan to have implants as their long term tooth replacement. Having good fitting and nice appearing partial or full dentures prevents further damage to remaining teeth and also protects implants as they heal within the bone. Having a good partial or full denture and also a dentist who knows how to customize and modify them, can be a great advantage when a patient desires implants but will need a year or even much longer before completion.

Not all removable appliances are created equal nor should they be called "plates".

On the contrary, removable partial or full dentures can be part of a complete "make-over". Any denture, even the most economical and temporary variety will provide a better look than multiple missing teeth or rampant decay and infected gums.

While temporary, first dentures placed immediately after extractions are certainly an improvement over the previously poor teeth and gum conditions, they are only average compared to what can be created when a second, customized appliance is made. Once the gum and bone tissues have adequately healed, new impressions are made which assure a better fit to the current conditions. When the second denture is made there are several benefits that were not feasible when the initial denture was made:
1. Impressions made with the "guess work" removed on how the fit will be after tooth extractions
2. Second denture can be made without rush and tried in before finish
3. Time is allowed for treatment of other remaining teeth and problems within the same arch as well as the opposing arch.
4. Some changes in the bite (occlusion) are possible (and highly desired for optimum stability) when the mouth is now considered as a whole and modifications are planned
5. Some changes in shade and size and arrangement of the teeth are possible

All of the above can be possible with standard dentures.
When even more customization and best possible fit and durability are desired, a Premium Full or Partial Denture is the right choice.

	Premium Denture includes higher quality tooth material and details in the pink gum area to look most natural.   Standard denture is nice but ordinary when compared
	Another view of a premium Full Upper Denture showing the nicely finished and detailed work in the base as well as the setting of teeth. Attention is paid to adequate thickness for strength while making optimum room for the tongue to feel comfortably at home. Speech as well as chewing and smiling are all considered.

The tooth size, shape, color and arrangement can be varied within a range.Custom made removables can create a nice natural look with a personal touch. This means that teeth match other existing teeth and the arrangement of the teeth is fairly straight and definitely assuring a balanced bite. However, there are minor imperfections making a realistic result. When there are no other teeth that need to be matched, then a nice clean but neutral shade is chosen. On the other hand, if desired by the patient they can be made very white and very straight (supernatural).

Here are the main features of Premium Denture Appliances:

Quality teeth with greater durability and natural variations in opacity and translucency Varied shade and contour of the artificial gums ( rather than very smooth and very pink)
High quality lab work
Minimum two step custom impression technique for optimum fit
Additional time and attention by Doctor in planning, tooth set up
Even greater ability to correct cosmetic problems, stabilize bite and correct alignment when entire mouth (both upper and lower arches) are being considered.

Additional time and steps are taken during the transition period from initial dental problems through final restoration. Temporaries are made and modified as needed in order to accommodate additional extractions, fillings, healing and cosmetic changes.

When there are cavities, gum problems, etc. with the anchor teeth or the opposing teeth then these problems are addressed prior to making the final restoration.
In order to create the best possible esthetic results and create long term stability, the bite is refined in all dimensions in order to obtain greatest chewing ability while assuring the least amount atrophy of ridge bone.

Teeth are best able to withstand normal chewing forces (and abnormal clenching forces) when there are many teeth with long roots firmly embedded in bone and with no spaces between them. Having roots in vertical alignment is also a key factor.
Bone can be lost from too much force as well as from lack of use. Ridge bone also lost due to the same two reasons. Atrophy is loss of bone due to lack of use - since there are no longer teeth with roots supported within bone, the bone weakens and "melts away" from disuse. Resorption of jaw bone happens due to too much force such as when dentures are rocking and rubbing causing irritation. In order to maintain healthy bone for as long as possible the following are needed:
1. Optimum fit from the start
2. Refitting via relining as needed and as early as needed
3. Establishing an optimum occlusion (bite) Dentures must have balanced forces to prevent tipping. Denture teeth must be aligned over the bony ridge to reduce adverse leverage.

4. The bite must be maintained and checked for uneven wear periodically. This is extremely important when there are a variety of tooth materials - natural enamel, porcelain, metal or plastic.

Dentures work best when the bite is well balanced. Missing teeth in one area causes overload and tipping forces. Teeth that are irregular like "mountains and valleys" will also cause very unstable conditions.

Bone is lost around teeth due to periodontal infection. Habitual clenching due to stress especially happening during sleep also contributes to recession of gum and bone. When some teeth are already missing the amount of force upon the remaining teeth is increased.

Sometimes it is recommended to have a Night Guard Retainer when a patient has a Full or Partial Denture. The Denture is worn during the day for normal eating and speaking. The Retainer worn while sleeping protects from damage due to night clenching. This is especially beneficial when a patient has only a few remaining teeth. Without a Night Retainer, they are highly likely to grind the remaining teeth loosening more bone and also frequently bite their tongues and cheeks while asleep.

More time and quality materials Are used in every step. The denture on the Left is average While the Right one shows excellent Fit that can only be possible with Custom impressions.
	Lower Dentures are notorious for Being loose and easily dislodged By the tongue. Note how the borders Are established to avoid interference With muscles and how the denture is Fashioned with a "cavern" to Accommodate the tongue. Rather than crowd the tongue, the tongue actually helps to weight down the denture instead of constantly lifting the denture upward.

Examples of customized Partial dentures.

Use of flexible nylon denture bases and silicone retention surrounding natural teeth have many benefits including: Easy to place by first time denture patients and patients who have limited strength and dexterity in their hands. Effective but gentle retention on the anchor teeth. Little or no preparation of anchor teeth required compared to traditional metal frames and clasps. They are light weight and easily modified. The disadvantage is being less strong than a partial with a metal framework.

CuSil Silicone retention

Flexi Nylon base and clasps

Nylon Tooth Shade Clasps on standard frame Partial denture

When there are only a limited number of remaining teeth that are strong enough to serve as anchor teeth, traditionally a partial denture is made that has visible metal clasps. As an alternative, tooth shade nylon clasps can be placed in areas that would otherwise show metal. Nylon clasps have the additional benefit of being gentle to the anchor tooth. Flexible partial dentures can be made that are held in place by the necks of the teeth so that there is virtually no artificial material above the gum line. Another method of saving worthwhile teeth, few in number and giving more support to a denture than resting solely upon the gum tissue is to make an over denture. In this case the anchor teeth and anchors are completely invisible under the denture base.

In many cases a patient wears a partial or full denture as a temporary when they ultimately plan to have implants as their long term tooth replacement. Having good fitting and nice appearing partial or full dentures prevents further damage to remaining teeth and also protects implants as they heal within the bone. Having a good partial or full denture and also a dentist who knows how to customize and modify them, can be a great advantage when a patient desires implants but will need a year or even much longer before completion.

We will be happy to show further examples and give you further information.

We can provide you with an estimate for comparison when you have the ability to choose between Economy, Standard and Premium restorations for your individual situation.

New technology impresses people in different ways. Some people have got to have all the latest gadgets in their life and expect that from those who they make any major purchases for products or service. On the opposite extreme are those who are highly skeptical of "new fangled ideas" or do not see the benefit for themselves.

In between are those of us who carefully learn and try out new ideas. We do test trials and compare the results obtained with the new versus the old way. We also cautiously weigh the cost versus the benefits. When we do decide to make any change or transition we are confident that we can justify our investment as well as our effort and time. Taking the "sensible approach" one step further is reflected in our decision to maintain those older products and techniques that still have validity. Rather than an abrupt revolution, we evolve by offering and utilizing both some new and some of the old materials and methods.

We get a fair amount of new patients in our office that have not been regular dental patients. Those who have not been in our office before are often impressed by several of the steps that we take and the equipment we use. The number one thing that they comment about is how we use the intraoral camera. We use it frequently for exams and also for procedures allowing before / during/ after treatment to be seen by the patient. In addition to the visual image, they are always impressed with our style of presentation. We aim to be informative and clear to understand. We will only share "the gory details" on request! By the way, our television monitors are not large flat screens. The classic ones are still working fine.

There are many other examples of new equipment, instrumentation and materials in use in our office. Dr. La Vigne does a tremendous amount of continuing education. He attends classes, reads journals and text books. He sees many classes on videos. In addition to researching and learning new techniques and skills, Dr. La Vigne has also tested quite a few ideas in his own mouth. With the help from other Dentists and also from his team, he has tested many types of dental materials including tooth shade restorations and various adhesive cements. He has also tried numerous home care products and had several methods of tooth whitening.

Another group of new patients that we impress are those that see the value of our sensible approach. We do not hype nor do we over sell. We always try to be helpful and fair in explaining both advantages and disadvantages. Whether we are purchasing some major new equipment or redecorating our office, we consider carefully every aspect of the decision.

The procedure of placing 6 implants, allowing 4-6 months for healing and later delivering a full denture that is screwed down over the implants has been a successful treatment option for over 10 years.

Recently, the concept has been advanced to placement of the implants immediately after extracting remaining teeth and also placement of the denture attached to those implants in the same visit. In addition, reducing the number of implants to 4 has been used.

This works wonders for some patients who qualify for this major treatment. However. there are many who cannot have this same treatment regimen. In order for the "All on Four" "Teeth in one Day" to be realized, there are indications and prohibited conditions. In order for implants to be placed immediately following extractions in general:

The teeth being extracted must either be distant enough from the implant sites or the bone must be adequate to allow an implant wider and f or longer than the extraction site. There should be no active infection.

Although prosthetic teeth are placed immediately, there must be absolute compliance by the patient with regard to eating extremely softly for the recommended time frame. There must also be provision made to prevent the effect of bruxism (night grinding during sleep) from damage to and failure of the implants healing within the bone.

The total surgical and restorative procedure is at a fairly high cost in a short period of time. Even with zero % financing, some patients find this difficult to fit into their overall budget.

The good news is that there are other options for patients to consider. Rather than make a quantum leap to a denture loaded upon 4 implants in one appointment, patients can elect to go much more gradually. As an example, teeth can be extracted one or a few at a time. Implants can be placed one or two at a time. Extraction sites can be allowed to heal and Implants can be left unloaded in the traditional fashion for at least 3 months. The patient is fitted with a temporary partial denture or temporary plastic fixed bridges. These can be modified as the treatment progresses. Implants that have been confirmed as integrated into bone can then be used as' anchors while additional teeth are extracted and more implants placed.

The above approach allows for treatment to be phased in over a much longer time frame. While the concept of everything done quickly is appealing to some, it is not for everyone.

The advantages of the gradual~ phase in method are as follows:
1) Conservatively allowing time for healing of extraction wounds, bone grafts, implants
and confirming this stability before relying on their support for chewing.

2) Extend financing even further by doing the treatment in smaller phases still possibly using zero % financing.
3) Avoiding complications from infection, night clenching.
4) Give patient opportunity to gradually become acclimated to having implants and doing the necessary daily care before they invest in everything on 4 - 6 implants.
5) Allow more opportunity to make adjustments to the appearance and occlusion (bite) by a more gradual transition and ability to do more try in visits before the prosthesis is completed.

Some patients have extreme anxiety about any type of medical / dental care.

They avoid treatment for so long that ultimately they need major procedures on one or more teeth or even extensive full mouth treatment.

They may build up their fear level so high that they feel the only way to get needed treatment is with general anesthesia - sleeping through it all.

We hear radio ads and see printed ads on every media including the internet that offer patients the alternative of sleep dentistry. Some make it sound easy to have everything done in one session including cosmetic treatment. While this sounds wonderful at first glance, there are significant reasons not to undergo general anesthesia for complete dental care:

1) Local Anesthetics are much safer.

2) Some procedures, especially cosmetic procedures and very large restorative cases require interaction with the patient. Patients need to open and close, smile, offer their opinions and approval.

3) Many restorative procedures - from simple fillings through complete bridges or dentures require that the bite be checked. This can only feasibly be done with an alert and co-operative patient.

4) Many dental procedures require water cooling, irrigation and rinsing. When patients are completely sleeping, this is difficult and very compromised.

5) Complex dental work requires much time making and fitting temporary restorations. This will greatly extend the amount of time a patient remains under general anesthesia.

While there are certainly indications for complete general anesthetics, I believe that its use should be limited. Perhaps a few procedures that are the most fearful should be performed under general anesthetic. Some patients may have a medical condition or handicap that necessitates having dental treatment done while completely sleeping.

Other patients may just not be aware of other alternatives and some may simply not be trying to deal with their anxiety. Perhaps they would benefit from some of the techniques that we use:

1) Gradually overcome anxiety by having a small procedure done comfortably in order to gain their trust and ease their fears.

2) Witness that gentle technique, generous use of topical and local anesthetics, testing the effectiveness of the local anesthetic and a gentle approach to the treatment itself will improve their outlook and ability to deal with treatment.

3) Rather than be completely asleep, undergo sedation. By having Nitrous Oxide just prior to treatment and throughout the "scary" parts a patient can be relaxed. They will still be able to participate in checking the bite, having discussions, etc. when needed. An even greater level of sedation can be reached if Valium, Xanex or similar drug is taken roughly 30 - 60 minutes before treatment. Some patients may also benefit from having a sedative to get a good night's rest before. The best dental care is done carefully and with proper water cooling for instruments and rinsing for removal of bacteria, debris and having a clear area for use of impressions, adhesives and other materials. Most extensive dental treatment is not due to sudden trauma but rather the result of many months or years of not receiving care.

While it may sound tempting to have it all fixed in one day, this may not be the best in reality.