The use of computer-guided flapless

implant surgery and four implants

placed in immediate function to support
a fixed denture: Preliminary results
after a mean follow-up period of
thirteen months
Paulo Malo, DDS,a Miguel de Araujo Nobre, RDH,b and
Armando Lopes, DDSc

Statement of problem. There is a need for clinical evidence for the of use of computer tomography and CAD-CAM
technology for surgical planning and fabrication of a custom surgical template in the rehabilitation of complete eden-
tulous jaws with a prosthesis supported by 4 implants placed in immediate function.

Purpose. The purpose of this study was to report on the preliminary clinical outcomes of survival and bone loss for
prosthodontic rehabilitation using computer-guided flapless implant surgery and 4 implants placed in immediate
function to support a fixed denture.

Material and methods. This clinical study included 23 consecutively treated patients (18 maxillae and 5 mandibles).
Ninety-two implants were placed supporting fixed complete dentures followed between 6 and 21 months (mean of
13 months). Recall examinations included clinical evaluation of implant mobility, patient-reported discomfort, sup-
puration, and infection. The radiographic assessment included the determining of the marginal bone level at 6 and 12
months. A cumulative implant survival rate was calculated, and data were analyzed with descriptive statistics.

Results. The overall cumulative implant survival rate at 1 year was 97.8%, with 97.2% and 100% in the maxilla and the
mandible, respectively. The average marginal bone loss was 1.9 mm at the 1-year follow-up.

Conclusions. The results of this study indicate that, within the limitations of this preliminary study, this treatment
modality for completely edentulous jaws is predictable with a high survival rate. (J Prosthet Dent 2007; 97: S26-S34.)

Clinical Implications
Based on the results of this preliminary study, the rehabilitation of
completely edentulous jaws with a fixed prosthesis supported by
4 implants placed in immediate function, placed with flapless
surgery, computer-aided technology, and implant tilting is a
viable treatment modality.

The use of fixed complete dentures 1 to 5 years of follow-up).1-11 One of orly, and they are well anchored, the
placed in immediate function rep- these protocols is the All-on-4 con- probability for good treatment out-
resents a valid treatment option for cept (Nobel Biocare AB, Goteborg, comes is high (97.6% for the maxilla
completely edentulous patients, al- Sweden), with which, through the and 96.7% to 98.2% for the mandible
lowing for placement of the implants placement of 4 implants, it is possible at 1-year follow-up).12-15 It has also
(with flap elevation) and the prosthe- to rehabilitate the completely eden- been demonstrated that tilting of im-
sis during the same procedure and tulous jaw with minimum bone vol- plants could be advantageous, as lon-
with high survival rates in both the ume and avoiding, in most situations, ger implants may be placed with good
maxilla (between 93% and 99.2% with bone augmentation procedures. Pro- cortical anchorage in optimal posi-
1 to 5 years of follow-up) and man- vided the implants are placed stra- tions for prosthetic support and re-
dible (between 93.2% and 100% with tegically, 2 posteriorly and 2 anteri- duce the length of the cantilever.16,17

a
Private practice, Lisbon, Portugal.
b
Private practice, Lisbon, Portugal.
c
Private practice, Lisbon, Portugal.
The Journal of Prosthetic Dentistry Malo et al
June 2007 s27
Using surgical software (No- The medical history and clinical For radiographic guide prepara-
belGuide; Nobel Biocare AB) and observations were recorded and pan- tion, the patients’ previously worn
a computerized tomography scan oramic radiographs and a CT scan pros-thesis was used, when ad-
(CT scan), data can be transferred were examined. For the mandible, equate, or a newly fabricated re-
into a 3-dimensional (3-D) implant the anatomical inclusion criterion movable prosthesis was used.
planning program to allow for accu- was a residual ridge crest at least 4 When a new removable pros-
rate planning and placement of im- mm wide, buccolingually, and greater thesis was fabricated, an impression
plants.18 A surgical template and a than 8 mm high in the interforaminal was made with silicone (Zhermack
fixed acrylic resin implant-supported area. For the edentulous maxilla, the SpA, Badia Polesione, Rovigo, Italy)
prosthesis are fabricated, ensuring anatomical inclusion criterion was to obtain the final casts. Maxilloman-
precision of transfer from the vir- a residual ridge crest of a minimum dibular relation records, including the
tual to the planned prosthesis, im- of 4 mm wide, buccolingually, and making of an interocclusal record and
mediately after clinical implant place- greater than 10 mm high from canine a trial insertion of the tooth arrange-
ment through a flapless surgery, and to canine (Fig. 1). The patients were ment, were accomplished. Six buccal
allowing for rehabilitation with the categorized according to the residual and 3 palatal holes, 1.5 mm wide and
same level of success as in flap sur- ridge dimension: simple (residual 1 mm deep, were made at different
gery.18-20 These aspects of minimally ridge greater than 5 mm wide), me- levels in the removable prosthesis and
invasive and simplified surgery, along dium (an irregular residual ridge 4-5 were filled with a radioopaque marker
with reducing the treatment time and mm wide), or complex (an irregular (gutta-percha; SDI, Bayswater, Victo-
postsurgical discomfort, are benefi- residual ridge less than 4 mm wide) ria, Australia). A silicone (Zhermack
cial to the patient.21 The aim of the from canine to canine in the maxilla SpA) interocclusal record was made
present study was to evaluate the sur- and in the interforaminal area in the as a radiographic index, and a CT
vival rate of implants placed, using mandible. The distribution of the 23 scan was obtained of the prosthesis
this immediate-function treatment patients according to the degree of with the same orientation as in the
protocol. The protocol consisted of difficulty was 12, 6, and 5 situations mouth. The computer planning fol-
placing 4 implants in immediate func- with simple, medium, and complex lowed the Procera CadDesign proce-
tion using a flapless surgical proce- degrees of difficulty, respectively. Pa- dure, using a software planning pro-
dure and computer-aided technology, tients were excluded from this study if gram (Procera; Nobel Biocare AB)19
and tilting the implants in completely they presented with insufficient bone (Fig. 2), to transfer the CT images
edentulous patients. volume, remaining teeth that could into a 3-D computer image program
interfere with implant placement, in- that allowed planning for exact place-
MATERIAL AND METHODS sufficient mouth opening to accom- ment of the implants. The plan was
modate surgical instruments (at least then sent to a manufacturing facility
Twenty-three patients with eden- 50 mm), or whenever bone reduction (Nobel Biocare AB) that fabricated
tulous arches were consecutively in- was needed for a high smile line in the and delivered the surgical template.
cluded and treated in a private prac- maxilla, irregular bone crest, or thin The laboratory process consisted of
tice in Lisbon, Portugal. The patients bone crest. fabricating a working cast from the
were included if they provided written
informed consent to participate in
this study. A total of 92 implants (No-
belSpeedy; Nobel Biocare AB) with an
oxidized surface (TiUnite; Nobel Bio-
care AB) were placed between Feb-
ruary 2005 and May 2006. Seventy-
two implants were placed in the max-
illa and 20 implants in the mandible,
supporting 23 fixed complete den-
tures (18 in the maxilla and 5 in the
mandible). The implants were pos-
itioned in the same location, as if a
flap were raised.14,15 The procedure
was based on the planning data,22
and a prosthesis was manufactured 1 Preoperative intraoral view.
prior to the implant surgery and was
immediately inserted after surgery.
Malo et al
s28 Volume 97 Issue 6
surgical template, mounting the cast ministered daily in a regression mode to the opposing arch (Fig. 6) and sta-
onto an articulator, then fabricat- (15 mg to 5 mg) from the day of sur- bilized with anchor pins (Nobel Bio-
ing an all-acrylic resin fixed complete gery until 4 days postoperatively.14,15 care AB) (Fig. 7). After placement of
denture (Figs. 3 through 5). Antiinflammatory medication (ibu- the surgical template, flapless implant
The surgical procedures for both profen, 600 mg; Ratiopharm, Lda, surgery was performed, following the
jaws were performed under local an- Carnaxide, Portugal) was adminis- manufacturer’s instructions, using
esthesia with articaine chlorhydrate tered for 4 days postoperatively (twice a drill protocol (NobelGuide; Nobel
with epinephrine 1:100,000 (Scan- daily) starting on day 4. Analgesics Biocare AB) (Fig. 8). After implant
dinibsa 4%; Inibsa, Barcelona, Spain). (clonixine 300 mg; Clonix; Janssen- placement, the surgical template was
All patients were sedated with diaze- Cilag Farmaceutica, Lda, Barcarena, removed, and the anterior abutments
pam (Valium 10 mg; Roche, Amadora, Portugal) were given on the day of (Multi-Unit abutments; Nobel Bio-
Portugal) prior to surgery. Antibiotics surgery and postoperatively for the care AB) were placed first, followed by
(amoxicillin 875 mg and clavulanic first 3 days, if needed. Antiacid medi- the posterior abutments (30-degree
acid 125 mg; Labesfal, Campo de cation (omeprazole, 20 mg; Sandoz, Angulated abutments; Nobel Bio-
Besteiros, Portugal) were given 1 hour Lisboa, Portugal) was given on the care AB), using a custom jig manufac-
prior to surgery and daily for 6 days day of surgery and once daily for 6 tured in the laboratory (Fig. 9). The
thereafter. Prednisone (5 mg) (Meti- days postoperatively. prefabricated prosthesis was placed
corten; Schering-Plough Farma, Lda, The surgical template was oriented immediately, achieving immediate
Agualva-Cacem, Portugal) was ad- in the patient using a surgical index fit function, and minor adjustments of

2 Computer planning. 3 Surgical template.

4 Surgical index. 5 Maxillary screw-retained acrylic resin fixed complete

denture.

The Journal of Prosthetic Dentistry Malo et al

June 2007 s29

6 Surgical template positioned intraorally. 7 Surgical template stabilized with anchor pins.

8 Implant placement. 9 Jig for placing abutments in correct position.

the occlusion were performed when the implants were required to fulfill adjusted for an estimated orthogo-
needed (Figs. 10 through 12). the following criteria: clinical stabil- nal position of the film. The reference
The patients were enrolled in an ity, patient reported function without point for the reading was the implant
implant maintenance program (Table any discomfort, absence of suppura- platform (the horizontal interface be-
I) and instructed to eat a soft diet for tion, infection, or radiolucent areas tween the implant and the abutment),
2 months. After 4 months, if the im- around the implants at 10 days and and marginal bone remodeling was
plants were judged stable, the patient 2, 4, 6, and 12 months postsurgically. defined as the difference in marginal
had the option of replacing the fixed To evaluate implant stability, pros- bone level relative to the bone level at
acrylic resin complete denture with theses were removed and implants time of surgery. The radiographs were
a fixed metal-acrylic resin or metal- individually evaluated by attaching grouped as follows: implant inser-
ceramic complete denture. Of the an impression coping (Nobel Biocare tion, 6 months, and 1-year follow-up.
23 patients, 15 opted to replace the AB) to the abutment or implant and The marginal bone level measure-
prosthesis with a metal-ceramic fixed checking mobility. ments were performed by an in-
complete denture, while 4 patients re- Periapical radiographs were made dependent radiologist at Goteborg
ceived a metal-acrylic fixed complete at implant insertion and again at 6 University. Implant survival and bone
denture, and 4 patients retained the and 12 months. A conventional ra- resorption data at baseline and 6 and
acrylic resin fixed complete denture. diograph holder (Super-bite; Hawe 12 months were analyzed with de-
No patients dropped out of this Neos, Bioggio, Switzerland) was scriptive statistics.
study. To be classified as surviving, used, and its position was manually
Malo et al
s30 Volume 97 Issue 6

10 Postoperative intraoral view.

11 Postoperative panoramic radiograph.

12 Postoperative occlusal view of maxillary prosthesis.

The Journal of Prosthetic Dentistry Malo et al

June 2007 s31

Table I. Postsurgical maintenance protocol

Maintenance Protocol

Day of surgery Oral hygiene procedures; explanation of treatment phases and

(Day 1) maintenance procedures to the patient; application of chlorhexidine
and hyaluronic acid gels after surgery; evaluation of occlusion;
instructions to avoid prosthesis overload.

Day 10 Panoramic and periapical radiographs; removal of prosthesis for

disinfection and cleaning; administration of chlorhexidine gel; control
of suppuration by finger pressure; evaluation of occlusion;
administration of hyaluronic acid gel; instructions to avoid prosthesis
overload; evaluation for fracture or loosening of prosthetic components.

Month 2 Oral hygiene procedures; removal of prosthesis for cleaning and

disinfecting; administration of chlorhexidine gel; control of suppuration
by finger pressure; instructions to avoid prosthesis overload; evaluation
for fracture or loosening of prosthetic components.

Month 4 Oral hygiene procedures; removal of prosthesis for cleaning and

disinfecting; administration of chlorhexidine gel; evaluation of
occlusion; evaluation for inflammation/infection; evaluation for fracture
or loosening of prosthetic components.

Month 6 or at Periapical radiographs; oral hygiene procedures every 4 months without

definitive prosthesis removal of prosthesis; evaluation of occlusion; evaluation for
placement inflammation/infection.

Month 12 and after Periapical annual radiographs; oral hygiene procedures every 6 months
without removal of prosthesis; evaluation of occlusion; evaluation for
inflammation/infection.

Problem-related Removal of prostheses for disinfection and cleaning and for testing
visit implants for infection and stability.

after 5 months. One implant in the The mean (SD) bone level relative to
RESULTS first molar position was lost in a pa- the implant platform at insertion was
tient who was a heavy bruxer (oppos- 0.2 mm (0.7 mm). The mean bone re-
The implant survival rates are pre- ing dentition presenting wear pat- sorption (SD) relative to the implant
sented in a life table (Table II). The terns). One implant in the lateral inci- platform was 1.9 mm (1.5 mm) with
cumulative survival rate at 1 year was sor position that was not stable at the a mean bone loss of 2.0 mm (1.6
98% (overall), 97% for the implants time of placement did not osseointe- mm) and 1.7 mm (0.9 mm) observed
placed in the maxilla, and 100% for grate. Both implants were reinserted for the maxilla and mandible, respec-
the implants placed in the mandible and were not included in the statis- tively. The bone resorption frequen-
(Table II). Fifty-one implants (55%) tical analysis in this study. The pros- cies are shown in Table III.
have passed the 1-year follow-up (43 theses in these 2 patients survived Eight patients experienced frac-
in the maxilla and 8 in the mandible). with the support of the remaining 3 ture of the acrylic resin complete den-
The mean follow-up time for the pa- implants. ture. Of these, 6 were heavy bruxers,
tients included in this study was 13 The radiographs for 51 implants 4 with opposing dentition presenting
months. were readable for assessment mar- wear patterns, 2 were self-reported
Two maxillary implants were lost ginal bone resorption for 51 implants. bruxers, and 2 did not follow instruc-
Malo et al
s32 Volume 97 Issue 6

Table II. Life table of cumulative survival rate for implants

Not Due for
Maxillary and Follow-up
Mandibular Number Failures Withdrawn Visit %
Placement to 6 months 92 2 0 20 97.8

6 to 12 months 90 0 0 39 97.8

1 to 2 years 51 0 0 51 97.8

Maxilla Only

Placement to 6 months 72 2 0 0 97.2

6 to 12 months 70 0 0 27 97.2

1 to 2 years 43 0 0 43 97.2

Mandible Only

Placement to 6 months 20 0 0 20 100

6 to 12 months 20 0 0 12 100

1 to 2 years 8 0 0 8 100

Table III. Bone level at surgery

Bone Level Bone Level Bone Level at
at Surgery at 6 Months 12 Months
Per Position* Per Position* Per Position*
Mean (mm) –0.2 –1.5 –1.9

SD (mm) 0.7 1.1 0.9

Number 51 28 36

Frequency (mm) N % N % N %

0 42 82.4 4 14.3 0 0

–0.1 to –1.0 6 11.8 6 21.4 6 16.7

–1.1 to –2.0 2 3.9 12 42.9 20 55.6

–2.1 to –3.0 0 0 4 14.3 7 19.4

>–3 1 2 2 7.1 3 8.3

*(Mesial + distal)/2

The Journal of Prosthetic Dentistry Malo et al

June 2007 s33
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1:S88-94. 19.Balshi SF, Wolfinger GJ, Balshi TJ. A Dr Paulo Malo
15.Malo P, Rangert B, Nobre M. “All-on-Four” prospective study of immediate functional Malo Clinic
immediate function concept with Brane- loading, following the Teeth in a Day proto- Avenida dos Combatentes, 43, 9º C, Ed.
mark System implants for completely eden- col: a case series of 55 consecutive edentu- Green Park
tulous mandibles: a retrospective clinical lous maxillas. Clin Implant Dent Relat Res 1600-042 Lisbon
study. Clin Implant Dent Relat Res 2003;5 2005;7:24-31. PORTUGAL
Suppl 1:2-9. 20.Balshi SF, Wolfinger GJ, Balshi TJ. Surgical Fax: 351 217 266 965
16.Aparicio C, Perales P, Rangert B. Tilted planning and prosthesis construction using E-mail: research@clinicamalo.pt
implants as an alternative to maxillary computer technology and medical imaging
sinus grafting: a clinical, radiologic, and for immediate loading of implants in the Acknowledgements
periotest study. Clin Implant Dent Relat pterygomaxillary region. Int J Periodontics The authors thank Mr Sandro Catarino for help
Res 2001;3:39-49. Restorative Dent 2006;26:239-47. with data management.
17.Krekmanov L, Kahn M, Rangert B, Lind- 21.Kupeyan HK, Shaffner M, Armstrong J.
strom H. Tilting of posterior mandibu- Definitive CAD/CAM-guided prosthesis for 0022-3913/$32.00
lar and maxillary implants of improved immediate loading of bone-grafted maxilla: Copyright © 2007 by the Editorial Council of
prosthesis support. Int J Oral Maxillofac a case report. Clin Implant Dent Relat Res The Journal of Prosthetic Dentistry.

The Journal of Prosthetic Dentistry Malo et al