Full Arch Fixed Implant Restoration for Posterior Support Loss

Patient M.Y., a 78-year-old female, presented with difficulty chewing due to lack of posterior support and resulting anterior teeth fracture. Treatment involved a fixed implant-supported full arch restoration with immediate implant placement and loading. The case required careful attention to prosthesis design for proper hygiene access and emergence profile, particularly given the patient's cognitive and physical limitations. The result provided the patient with restored chewing function and a cleanable prosthesis despite challenges with hand mobility.

Patient Overview

Patient M.Y. was a 78-year-old female who presented with functional concerns related to her ability to chew. She had experienced progressive loss of posterior support, which had led to complications with her anterior teeth. The patient had dementia, which affected her tolerance for dental appointments, and during the course of treatment sustained a broken wrist from a fall that temporarily limited her mobility and hand function.

Chief Complaint

The patient's primary concern was straightforward: "I want to be able to chew. I'm having difficulty chewing." She was seeking a solution that would restore her ability to eat comfortably and effectively.

Diagnostic Findings

Clinical examination revealed lack of posterior support that was contributing to anterior teeth fracture. The posterior sections had already experienced significant resorption, which created ample space for restorative materials. This resorption, while indicating bone loss, actually provided favorable conditions for prosthesis fabrication by allowing adequate room for proper contour and emergence profile, which are essential for hygiene access and long-term success.

Treatment Options Considered

Several treatment approaches were evaluated for this patient. Options included an implant-assisted removable partial denture, a complete removable lower denture with two implants for retention, and a fixed implant-supported full arch restoration. Each option offered different levels of function, stability, and maintenance requirements.  A complete removable denture even with supporting implants would likely be inadequate against the forces of a full complement of opposing natural upper teeth.  A removable partial denture would risk further deterioration of the anterior teeth again if the patient was not compliant with wearing it.

Selected Treatment Plan

A fixed implant-supported full arch restoration was selected because it was the most appropriate option—it would provide the patient with the best chewing outcome she desired. There was plenty of space for proper prosthesis fabrication, which is often a limiting factor in these cases but was not an issue here. In fact, the posterior sections had already been resorbed, resulting in ample space for restorative materials. This would allow for proper contour and emergence profile, which is essential for proper hygiene and access and long-term success.

The fixed option was chosen over removable alternatives because removable dentures would not provide the same level of functional chewing ability. Additionally, this patient had favorable anatomy for proper prosthesis fabrication due to the posterior resorption, which allowed for proper contour and emergence profile essential for hygiene, access, and long-term success. These advantages could not be achieved to the same degree with removable options.

Procedures Performed

The treatment sequence began with presurgical planning by the prosthodontist, including fabrication of a conversion prosthesis and surgical guide. The prosthodontist maintained direct involvement throughout the surgical phase, attending the surgery to ensure proper execution of the plan. The oral surgeon performed immediate implant placement with immediate loading under the supervision of the prosthodontist.

Following implant placement, the prosthodontist performed the conversion using a prefabricated bite orientation jig. After a healing period, the final prosthesis was fabricated and delivered. A follow-up appointment a few weeks after delivery included verification of passive fit via periapical radiographs and checking of screw tightness to ensure proper seating and stability.

Additional restorative work included zirconia crowns on teeth numbers eight and nine, as well as a single implant in the upper posterior region. These restorations were provided to correct damage in those areas that had resulted from the lack of posterior support.

Materials and Technologies Used

The case utilized standard materials and workflow, with the prosthodontist maintaining complete case control for workup and planning rather than outsourcing to the laboratory. The final prosthesis was milled using polymethyl methacrylate acrylic resin, which was selected based on the patient's financial considerations. Zirconia would have been another viable option had finances allowed.

Zirconia crowns were used for the upper anterior teeth, specifically teeth eight and nine. The treatment incorporated immediate implant placement and immediate load technology. Additional components included the conversion prosthesis, surgical guides, and prefabricated bite orientation jigs. Periapical radiographs were used for verification of passive fit and screw tightness during the follow-up phase.

Clinical Challenges

Despite the clinical procedures proceeding smoothly and the patient's expectations being fully met, several challenges arose during the course of treatment. The patient had a low threshold for even uncomplicated appointments, which required careful management of appointment length and complexity.

The patient was unable to come in for follow-up care for several weeks due to a broken wrist sustained from a fall. This injury also affected her dominant hand function, which had implications for her ability to perform hygiene procedures.

A significant technical challenge emerged when the laboratory overcontoured the prosthesis. This required considerable time and effort to correct in order to make the prosthesis acceptable and cleanable for the patient. Proper prosthesis contour is critical for hygiene access, and this adjustment was essential to ensure long-term success.

Final Outcome

Months after final delivery, the patient reported good comfort and function. She demonstrated the ability to clean the prosthesis easily due to the favorable design, despite the limited capacity of her dominant hand resulting from her injury. The patient's expectations were fully met, and she achieved the desired chewing outcome she had initially sought.

The overcontoured prosthesis was successfully corrected to make it acceptable and cleanable for the patient. Despite challenges related to her low threshold for appointments and a broken wrist from a fall that delayed follow-up care, the final result was successful. The patient expressed satisfaction with the fixed implant-supported restoration, which provided functional outcomes that would not have been achievable with the removable alternatives that were initially considered.

Clinical Lesson for Other Dentists

This case demonstrates that fixed implant-supported restorations are sometimes the best option, but only if attention is paid to final design from the beginning. Several key principles emerged from this treatment that are applicable to similar cases.

Patient selection.  Recognizing the disadvantages of common alternatives like a removable lover denture opposing a full complement of natural teeth or the potentially destructive disadvantages of an RPD if the patient forgets to wear it is important in treatment selection to meet the patient’s expectations. Also, the ability to create a prosthesis with not only passive fit but also excellent access for hygiene is critical. This design consideration often gets overlooked without proper planning by surgeons and laboratories.

General dentists usually rely on the surgeon and laboratory to perform the planning. However, taking the time to go to the surgeon's office and attend the surgery is what it takes to ensure all goes as planned and the result is a predictable outcome. Working with laboratories at a high level can avoid some mistakes but not all. The provider needs to be prepared to adjust the final result to make it ideal for the patient.

This level of involvement requires a thorough understanding of the goal and recognizes that the surgeon and laboratory are not as invested in the outcome as the restorative dentist, who will be the provider the patient turns to for follow-up care, maintenance, and addressing complications.

Specific design considerations include creating a convex tissue contact surface for access to cleaning. This is particularly important because in the event that the patient does not have the ability to clean, or they don't have the interest or motivation to clean, they can still maintain the implants. Providers must be prepared to adjust what the laboratory provides and should never place something in the patient's mouth that they cannot clean.

For the longevity of the implants, polished metal at the abutment junction is more favorable than porous acrylic that can harbor bacteria and adversely affect implant longevity. The restorative provider must take responsibility for the outcome rather than relying solely on the surgeon or laboratory. Proper planning, case control, and attention to passive fit, emergence profile and contour are essential for long-term success, hygiene, and patient satisfaction.

Treatment Results

• Patient achieved restored chewing function with good comfort months after final delivery
• Fixed implant-supported full arch restoration provided stable, functional prosthesis
• Prosthesis design allowed easy cleaning despite patient's limited dominant hand function from injury
• Immediate implant placement and immediate loading protocol successfully executed
• Passive fit verified through periapical radiographs with proper screw tightness confirmed
• Overcontoured laboratory prosthesis corrected to achieve proper contour and emergence profile for hygiene access
• Zirconia crowns on teeth eight and nine and single upper posterior implant successfully restored areas damaged by lack of posterior support
• Patient's expectations fully met despite behavioral challenges and delayed follow-up from fall-related wrist fracture
• Favorable prosthesis design with convex tissue contact surface enabled proper hygiene maintenance

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