Table Of ContentEsthetic Implant Restoration in the Edentulous Maxilla: A Simplified Protocol
Esthetic Implant
Restoration in
the Edentulous
Maxilla
A Simplified Protocol
Karim Dada,
DDS
Private Practice in Implant Surgery
Paris, France
Marwan Daas,
DDS
Private Practice in Prosthetics
Paris, France
With collaboration from
Paulo Malo,
DDS
Quintessence Publishing Co, Inc
Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Beijing,
Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, Singapore,
and Warsaw
Dedication
To Esther and Dorothée. To Lucie, Clara, and Sarah.
First published as Esthétique et implants pour l’édenté complet maxillaire in French in 2011 by
Quintessence International in Paris, France.
Library of Congress Cataloging-in-Publication Data
Dada, Karim, author.
[Esthétique et implants pour l’édenté complet maxillaire. English]
Esthetic implant restoration in the edentulous maxilla : a simplified protocol / Karim Dada, Marwan
Daas ; with collaboration by Paulo Malo.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-86715-645-4 (hardcover)
I. Daas, Marwan, 1968- author. II. Malo, Paulo, 1961- author. III. Title.
[DNLM: 1. Dental Implantation, Endosseous--methods. 2. Jaw, Edentulous--rehabilitation. 3. Den-
tal Implants. 4. Dental Prosthesis, Implant-Supported--methods. 5. Esthetics, Dental. 6. Maxil-
la--surgery. WU 640]
RK667.I45
617.6’93--dc23
2014011123
© 2014 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
4350 Chandler Drive
Hanover Park, IL 60133
www.quintpub.com
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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval sys-
tem, or transmitted in any form or by any means, electronic, mechanical, photocopying, or other-
wise, without prior written permission of the publisher.
Editor: Bryn Grisham
Design: Ted Pereda
Production: Angelina Sanchez
Printed in China
Contents
Preface vi
Introduction vii
1 Esthetic Analysis 1
2 Preparatory Phase 55
3 Implant Indications 87
4 Immediate Loading and Provisionalization 119
5 Types of Prostheses 133
6 All-on-Four Concept 175
Index 195
Esthetic Checklist Back pocket
Preface
The main purpose of this book is to give readers a straightforward clinical guide to help them treat
the fully edentulous maxilla with newly available technology and to successfully face the real chal-
lenge of this clinical situation: obtaining an esthetic integration of the restorations with predictable
results. This book is not a simple description of the available therapeutic options; on the contrary,
it promotes a treatment strategy based on standardized esthetic analysis. This treatment modality
focuses on the importance of the preparatory phase and on the quality of the original removable
prosthesis, which is often neglected in conventional treatments and can frequently be the reason
for esthetic or functional disappointments. It is a crucial prerequisite to the success of this therapy.
This book also describes the possibilities of immediate loading, providing a fixed prosthesis short-
ly after the surgery, and the use of flapless surgery, all of which can be used to limit as much as
possible the postoperative difficulties for the patient.
The extensive illustrations in proportion to the text may surprise the reader. We chose this presen-
tation because it seems to better correspond to the clinical aim of the book. We also thought it was
the most effective way to convey the key points needed to begin performing this kind of treatment.
However, even if this book provides a synthesis of information, it is not without scientific basis. The
treatment protocol has been validated by several peer-reviewed publications and is supported by the
initial results of long-term follow-up.
A standardized esthetic analysis is an essential communication tool between members of the
treatment team, which includes the prosthodontist, dental technician, surgeon, dental assistant,
and patient, among others. The principles of teamwork that we have valued for so many years are
crucial for today’s patients. Teamwork demands perfect coordination, and that is the foundation of
this book.
In this spirit of teamwork, we have collaborated on this project with Dr Paulo Malo and his team,
who have unparalleled clinical experience and never stop developing new treatment strategies for
the fully edentulous patient. Their focus is on reducing the number of implants used, simplifying
surgical and prosthetic protocols, avoiding bone grafting, and developing treatment strategies that
will be applicable to the largest number of patients and by the largest number of clinicians. The
result of this collaboration is the final chapter on the all-on-four treatment concept, a contribution
for which we are deeply grateful.
Acknowledgments
All our thanks to Drs Michel Pompignoli and Michel Postaire, for their friendship and unflagging
support. To Dr Marc Danan, for the quality of his surgical work documented in some of the cases
in this book and for our long and amicable collaboration. To Serge Tissier, and the entire team of
his dental laboratory, for the consistent quality of his prosthetic work and his people-centered ap-
proach to collaboration with the many practitioners who rely on him. To Dr Christian Knellesen, our
editor, for his belief in this project and his encouragement. To everyone on our treatment team: the
secretaries, assistants, contributors, correspondents . . . without whom this book would never have
seen the light of day.
vi
Introduction
Prevalence
A high proportion of the world population is fully edentulous. According to prospective studies in the
United States, the number of patients who are fully edentulous in one or both arches will continue
to grow, from 33.6 million in 1991 to almost 38 million by 2020 (Fig 1).
39
36.75
e
l
p
o
e
p
of 35.5
s
n
o
i
l
l
i
M
34.25
33
1991 2000 2010 2020
Fig 1 Evolution of edentulism in the United States. (Data from Douglas et al.1)
This phenomenon can be explained by a longer life expectancy, which is estimated to be rising by 1.5
to 3 months every year, and the proportional increase in edentulous patients. In 2050 in the United
States, there should be more than 50 million people older than 65 years, and people more than 60 years
old should represent more than one-third of the population. In 2050, there will be three times more
people older than 75 years and four times more people older than 85 years than there were in 2000. In
2010, almost a quarter of the United States population older than 65 years was fully edentulous. Today,
there is also limited access to health care for certain segments of the population who are in precarious
vii
Introduction
Box 1 Removable complete denture
Indications: Disadvantages:
• Prior use of a removable denture • Negative psychologic impact
• Favorable ridge for support and retention • Low control over ridge resorption
• Absolute contraindications for surgery • Lower functional efficiency
Advantages:
• Simple and reversible treatment
• Low cost
Box 2 Implant-supported overdenture
Advantages: Disadvantages:
• I mproved stability and retention of the complete • I ntensive maintenance in terms of time and cost
denture for the patient and the clinician
• E asier hygiene and maintenance than with a fixed • I ncreased growth of anaerobic microbial flora,
prosthesis resulting in more peri-implantitis than is observed
with fixed prostheses
circumstances or have inadequate insurance cov- Removable complete denture
erage.
However, aged and poor people are not the Box 1 presents the indications and advantages
only ones who are fully edentulous. Every social as well as the disadvantages of treatment with
class is affected, as are many young people. The a removable complete denture. Within the par-
rise of patient numbers coincides with increased adigm of implant-supported treatment,2 fab-
expectations in terms of treatment comfort and rication of a provisional removable complete
efficiency, despite a deteriorating oral situation. denture allows:
While an edentulous mandible is functionally
more difficult for the patient than an edentulous • Validation of the planned occlusal scheme in
maxilla, the latter is more difficult for the clini- conjunction with the mandible
cian to treat and obtain a good esthetic result. • Assessment of the interocclusal space avail-
Indeed, there are multiple parameters to take able for the surgical and prosthetic stages
into account that can be challenging for the in- • Facilitation of the continuity of the surgical
experienced clinician. Regardless of how com- and prosthetic treatment
fortable and functional a maxillary prosthesis • Preview of the definitive esthetic result
may be, patients are often not satisfied unless it • Assurance that the provisional restoration
is also meets their esthetic expectations. Hence, of the implants will create fewer micromove-
there is a high demand for an implant-supported ments
restoration in the edentulous maxilla. However,
implant placement has to respect certain condi- Implant-supported overdenture
tions to guarantee a high success rate.
Although implant-supported overdentures have
been described extensively in the literature,3
in the authors’ opinion their only indication
Therapeutic Options
is cases in which implants have already been
placed in the anterior maxilla and, because of
The therapeutic approach to treating the fully their position, cannot be restored with a fixed
edentulous maxilla has substantially evolved prosthesis (because of the span) and the pa-
with the emergence and success of implant tient refuses placement of more implants. Box
dentistry. For the patient with an edentulous 2 describes the advantages and disadvantages of
maxilla, three solutions can be considered: implant-supported overdentures.
The authors’ experience has shown two
1. Removable complete denture (conventional) things: (1) The biomechanical behavior of this
2. Implant-supported overdenture (bar system) kind of restoration is not satisfying over time
3. Fixed implant-supported prosthesis and generates a disproportionate need for
viii
Therapeutic Options
Treatment with a removable implant-supported overdenture
a b
c d
e f
Fig 2 (a) Initial intraoral view. The patient presents with an implant-supported bar with three ball attachments to sta-
bilize an overdenture. (b) Occlusal view of the prosthesis, which has been reinforced with a metal portion, in which the
matrix of the ball attachments are embedded. (c) View of the intaglio, which shows many instances of relining result-
ing from the separation of the matrix from the attachments. At this stage, the attachments are no longer retentive, and
the patient wants to improve her comfort during chewing while maintaining an identical prosthetic scheme. (d) Intra-
oral view after removal of the bar. Despite an unfavorable mucosal environment in the right sector, the implants were
clinically osseointegrated and did not show peri-implant disease. (e) View of the abutments supporting the bar. Be-
cause of the decrease in the available prosthetic space generated by these abutments, the planned retention bar will
need to be placed directly on the implants. (f) Mixed impression in polyether and plaster that will be used to fabricate
the planned implant-supported prosthesis.
maintenance. (2) Prevalence of peri-implantitis As a general rule, when four implants are con-
is significantly higher than with a fixed denture. sidered to treat a fully edentulous maxilla, the au-
Furthermore, failure rates reported in the liter- thors prefer to place the implants so that a fixed
ature for implants supporting maxillary overden- solution may be offered to the patient. Figure 2
tures are significantly higher than those clas- presents the clinical case of a patient treated
sically allowed for this kind of treatment in the with a removable implant-supported overdenture.
mandible4: When combined, the results of recent
studies showed failure rates around 19%.5
ix
