An Evidence-Based Protocol for Immediate Rehabilitation of the Edentulous Patient

Context: A procedure using 4 dental fixtures with an immediate-loaded prosthesis for totally edentulous patients is the focus of an evidence-based analysis that uses modern methodologies to review an innovative clinical technique. The long-term outcomes for this surgical and prosthetic treatment for previously or newly edentulated patients by clinical teams worldwide, as well as the author's clinical personal data in a referral-based private practice, are reported in this investigation.

Evidence Acquisition: An independent research dentist performed the literature review using terms that would identify articles commensurate with this article. The search years for keywords were limited to 2010 and 2011 because the purpose of the article was limited to current thinking and evidence on this specific technique. In this article, the author elected to restrict the literature search to journals that are commonly read and received in his clinical practice on a monthly basis. Because of the specific nature of this procedure, all historical references to the “all-on-4” procedure were also included in the database inquiries.

Evidence Synthesis: The literature search revealed that the investigated technique has been reported worldwide by multiple authors using retrospective clinical analyses. In the maxillary jaw, the range of implants placed was 27 to 980 fixtures with 1 to 7 years of follow-up, demonstrating a cumulative implant success rate range of 92.5% to 100%. The mandibular arch demonstrated cumulative success rates of 93.8% to 100% with 1 to 10 years of follow-up with a range of 18 to 980 fixtures being placed. The investigator's own personal clinical statistics compared favorably with other clinical teams, with a total of 120 fixtures being placed in both jaws with 6 years of follow-up with a cumulative survival implant success rate of 100%. Continuous stability of the definitive final prosthesis was above 99% in the largest reported review and 100% for this author's private practice.

Conclusion: Based on extensive reporting by multiple clinicians, the technique investigated is grounded in good bioengineering basic science, and demonstrates long-term clinical outcomes that can provide highly predictable long-term prosthetic stability for the edentulous patient. This highly focused critically appraised review of individual articles using 4 implants to support a fixed dental prosthesis provides clinicians and patients with a protocol that conservatively and immediately reduces the morbidity associated with the loss of teeth and removable prostheses traditional used to negate edentulism.

Introduction

Despite the acknowledged biologic phenomena of osseointegration, the field of implantology has also been presented with controversies by innovative clinicians and/or by the proposals of representative implant manufacturers. A short list of these discussions has focused on implant surface alterations, macro- and micro-geometric designs, implant body–abutment connections, and computer-enhanced implant placement. Many journal editorials, focused expert panel discussions, and entire dental conferences have been dedicated to the justification of various implant technologies.

Today's environment for basic research is different from the past hours spent in the library developing a literature review for a master's thesis with marking note cards, searching bookshelves, and talking to mentors. The advent of Internet searches in computer databases, international Web-based learning, and even Facebook has accelerated the access to scientific information at a pace never seen in academia and clinical practice.

Although the pace and volume of scientific information has dramatically increased, the basic procedures of scientific investigation, observation, and reporting remain the same regardless of the source of the media.

The American Dental Association has defined evidence-based dentistry as an “approach to oral health care that requires the judicious integration of systematic assessment of clinical relevant scientific evidence relating to the patient's oral and medical condition and history, together with the dentist's clinical expertise, and the patient's treatment needs and preferences.” The evidence-based process has been described in the epidemiological and scientific literature.¹

It is the intent of this author to use the principles of scientific investigation obtained more than 30 years ago during a master's thesis in graduate school along with the new tools of evidence-based dentistry to examine emerging changes in implant dentistry that are confounding the principles put forth by Dr Branemark (www.nobelbiocare.com/en_us/news-events/news/2012/p-i-br-nemark-celebrates-the-dual-anniversaries-of-osseointegration-with-nobel-biocare_7.aspx) more than 60 years ago. Traditionalists have vehemently condemned these innovative procedures, whereas early adaptors, manufacturers, and some entrepreneurs have promoted this concept as a significant advancement for patients who are about to become edentulous or those who are suffering from it. A procedure using 4 dental fixtures with an immediate-loaded prosthesis for the totally edentulous patient is the targeted topic of this article (Fig. 1).²