Full Arch Immediate Load: Thoughts?

Immediate load requires a bite force capability assessment to prevent an overload. I take a bite force capability on every implant patient

I have been performing full arch immediate load cases since 2007, and am in favor of this modality whenever it is appropriate. Having said that, I am opposed to all-on-4 type of protocols that require significant bone reduction in many cases. I recall an all-on-4 presentation at an AAOMS implant conference in Chicago several years back, where gummy smile cases were shown, and it was apparent that easily more than 5 mm of alveolus was removed to hide the prosthetic/gingival junction. When I asked the presenter if he would do the same thing to his own mother/sister/wife, he refused to answer. We all know there is a better way to approach these cases when the patient has existing dentition or adequate bone for a non-pink restoration. Recreating papilla and proper gingival architecture is not that hard if managed from the initial fully loaded provisional restoration. However, this approach requires a non-cookbook surgical approach that I believe many clinicians are uncomfortable with. Financial limitations appear to be a major motivator for the McImplant model, but there are alternative ways to make full arch implant therapy more affordable, including billing by time and materials, and limiting the final restoration to less expensive materials. Full arch cases in my office range from $12,500 to $50,000 or more per arch depending on the patient's goals, as well as, the number of procedures that will be necessary to achieve those goals. Routinely sacrificing perfectly good bone and soft tissue is often an indicator that the clinician lacks the proper tissue augmentation skills. These skills are not that difficult to attain, but requires some motivation on the clinician's part to see what is possible.

Very hard to comment as not enough information supplied i.e. CT scan and xrays, proper photos, health, sex, and age of the patient, etc.....in this situation.

Apparently my post was misleading..... I am not asking for case specific comments but rather what others feel about the "protocol" for full arch immediate load cases. I have personally taken a step in the other more conservative direction as I think the interarch space requirements are rather excessive for many cases. It was not meant to discuss bite force capability or lack of diagnostic information.

I have been immediately loading both mandibular and maxillary cases for more than 25 years. I splint all implants by laser welding gold bars to splint the implants on the day I place the implants. I have had excellent results with very low implant loss. But. the prosthesis must be absolutely ridged and passive.

Thank you for your question and clearly it will stir up thought and discussion. Of course it will be hard to gain consensus (put a 100 dentists in a room and you will get 100 different opinions). I personally do not feel immediate loading is necessary. I have always used various methods to avoid immediate loading. Given the statistical increase in failure rates I find it hard to justify immediate loading. I would never advocate excessive reduction of bone. My aim is always to retain as much bone as possible. You may gather I am not an advocate of all on 4 (or 5 or 6) or the recommended protocols. I must point out that my aim is almost always to retain teeth in as many cases as possible and therefore implants are more of a second option if teeth are present. I feel that implants are a brilliant way to replace missing teeth, but I am wary of wholesale removal of teeth for the sake of implants. However I must point out that I tend to be very conservative with my philosophy. Once teeth are gone they cannot be put back. Once bone is gone it can be difficult to replace. In my opinion, it is important to remember that implants are not perfect and are not always successful even if they do not fail. A wise dentist told me 45 years ago when I was a student: a good amalgam is better than a bad crown (modern adhesive resins were not available in those days). I tend to extend that thought to say: a well restored tooth is better than a bad implant. The dilemma for us as a profession is to decide what we (as practitioners) can do well. Can we properly restore a tooth? Sometimes we can and sometimes not. Can we place an implant knowing with certainty that it will have a successful outcome? At this point of time, I think that many times, the predictability of a good outcome for a properly restored tooth may be better than an implant. Of course this is a very general statement and consideration must be given to individual circumstances. But it would be prudent for us all to be cautious about wholesale extraction of teeth in favour of implants.

Dr Gerke, Amen I will add that a neglectful patient will destroy an implant as well as a tooth. The dental profession seems to have somehow given the impression to the public, at least in my realm, that dental implants are the salvation for neglected natural dentition.

I feel its import to add to my earlier comment. I always use 6 implants in the maxilla and 5 in the mandible with immediate load fixed prosthesis. The laser welded gold bar ridgedly splints all implants together from day one.

perhaps you should not have titled it Immediate load protocol. Removing bone is a prosthetic consideration . You have to have enough room to make an adequate prosthesis. sometimes there is no other choice but to remove bone. Your question obviously has nothing to do with immediate loading. I prefer English tea

When is a total edentulous, i consider an " all on..." as a possible treatment plan. But if i have 3-4 treatable teeth, i don't extract for the sake of " all on ". I think is unbiological. I do implants next to them. And metal-ceramic crowns / bridge solely on implants or both on teeth and implants in a full arch one piece prosthesis. Generally don' t cut bone. Try to restore the biology, not the esthetic. Nowadays, dentists deliver esthetic white teeth no matter how ( many teeth go out , much bone is cut off etc). This is the new era, the new paradigm. All white in one day. Remark. As dentists do implants all day long or some extract 12-24 teeth in one day and implant titanium screws, do we know for certain that dental implants have no side effects on general health?!

Hello Dr. Carter: with all due respect I feel you are deflecting the answers here that ARE Germain to the Question and your last reply reflects that. If I take your question at face value, “What do we think of the “Protocol” and you seemed to focus on the reduction of bone needed and that it was immediate load. If that is a correct assessment, then my answer is the “Protocol is accurate, well documented for 25 years in the retro-spective literature and yes bone is reduced as needed for the specific case outcome ( which means the prosthetic longevity). What do I think of that? If you are doing this type of prosthesis, then that bone reduction is necessary. In your lead up to the question you specified “immediate load”. That is the Malo protocol. I do not like immediate load in general. I do like full arch implant and prosthetic restoration when it is indicated for the edentulous or soon to be edentulous patient. I have very specific criteria I look at and the answer you need to hear does come from the SPECIFICS. From the first interview with the patient, from the quality of impressions, face bow, bite reg, accurate analysis of this information, OVD, RVD, bone density, bone volume, final occlusion, opposing occlusion, compressive forces and sheer forces, lever arms, moment arms on implants and on prosthesis, esthetic expectations, temporaries, finals, saliva, bacteria, hygiene. The answer to everything is : It Depends. Those who ask need to know what it depends on! I always say to GP Doctors and to Specialist Doctors, if the restoring doctor does not know more about the surgery than the surgeon, they need to take some surgery courses and if the surgeon does not know more about the prosthetics than the restoring doctor, they should take prosthetic courses. Of course this in all my opinions but without in depth discussion we are doing the Malo technique a dis- service and also, any other techniques used. If you feel uncomfortable about removing so much bone then have your restorative doctor give you another option. BTW I am a GP. Sincerely Leonard

Dr. Carter: I read my response over and maybe I still haven't given the basic answer you asked. Vertical bone removal is used in many procedures and the extent of removal, again, depends on what is being accomplished prosthetically. Immediate dentures often require this much bone removal. 25 years of retro spective literature shows success, not long term complications. Personally I would consider TMJ studies more important on long term problematic issues. The amount of sheer and compressive force available from full arch implant restorations is incredible. As a periodontist, you know that break down around a tooth is through the path of least resistance. A non functional cusp in hyperocclusion may cause gingival irritation, cusp fracture, bone loss, pulp trauma, root fracture. They all started with occlusion and correct balancing of the teeth and neuro muscular and TMJ system. Sincerely Leonard

If a patient is adamant about leaving with teeth after extraction, implants placed adjacent to sockets and having an immediate temporary denture, what protocols do you favor? Seems some bone reduction may need to be done.

Dear Friends It brings to mind my very first multi-unit abutment case an all on six approach. After a ct scan I was shure I cannot afford to throw away precious bone tissue at all. The day of surgery i realised the same in practice, but put the multi units in for immediate load. I took an impression than realized how wrong I was at the very beginning. I discarded 6 multi abutments, and paid "my course" for Zirconzahn Premill Cad-cam semented abutments. The results became anatomic and sustainable by patient for years now. Also I learned that it is not for the dentist will for fashion but always the patient personal anatomy has to decide!