It’s time to end your love affair with dentures and move on to full-arch dental implant restorations

I love dentures. I love the endless adjustment appointments, the complaints that patients can’t chew their steak like they used to, and the fact that dentures just don’t stay where they’re supposed to. Give me all the dentures.

Figure 2: Traditional full lower denture — **Figure 2:** Traditional full lower denture

Got your attention, didn’t I? I thought so, because no dentist in his or her right mind would proclaim such absurdity. In fact, I’ll submit that when a denture case comes through the door, you want to sneak out the back and refer that patient to your dear friend and colleague down the street. That’s professional camaraderie at its finest. But it doesn’t have to be that way. Both you and your patients could have a complete 360-degree experience that can have a profound impact on your capacity as a clinical and professional provider and, ultimately, your patients’ quality of life.

The genesis for full-mouth reconstruction is varied. Although poor home care and oral hygiene are without doubt the crux of the issue, factors such as genetics, medications, systemic health issues, and circumstances beyond a patient’s control cannot be ignored. It is furthermore understood that edentulism affects our most vulnerable patient populations—the aging and the economically disadvantaged.

Let’s look at some numbers:

About 23 million Americans are completely edentulous.¹
Approximately 12 million are edentulous in one arch.¹
90% of those who suffer from edentulism have dentures.¹
It has been estimated that the adult population in need of one or two complete dentures will have increased from 33.6 million adults in 1991 to 37.9 million adults in 2020.²
About 15% of the edentulous population has dentures made every year.²
By 2020, the estimated unmet need for prosthodontic services will be 560 million hours (partial and fixed included).³

Figure 3: Traditional implant-supported overdenture—aka 'snap-on' denture — **Figure 3:** Traditional implant-supported overdenture—aka "snap-on" denture

What does all this mean? We are going to be busy. But our default restorative option doesn’t have to be dentures. Implants have undoubtedly made their way into our arsenal of considerations that can be presented to patients who are faced with a single or double full-arch reconstruction (figure 1).

What dialogue are you giving your patients after they are informed of the need to remove all their teeth? For that matter, what about the patients who already have dentures but are asking if they are candidates for implant-supported dentures?

There are five options for each of these patient groups:

No teeth at all. As absurd as this may sound, I have had patients opt for this and they couldn’t be happier. Is it ideal? Well, each to his own, I suppose.
A complete denture, which is essentially a piece of plastic that, unfortunately, most patients expect to function like real teeth due to misplaced high expectations and misunderstandings brought about by various media forums (figure 2).
An implant-supported overdenture or—more easily understood by many patients—a “snap-on” denture, which utilizes implants as anchors (figure 3).
All-on-4 (AO4) or a full-arch hybrid prosthesis that is fixed (figures 4 and 5).
Single implants across the arch in various positions to which single-tooth and bridge entities are fixed to mimic the natural dentition in a more natural way.

Figure 4: Definitive All-on-4 that had been in service for three years — **Figure 4:** Definitive All-on-4 that had been in service for three years

This should be your presentation to these patients every single time, even if they think they already know what they want or don’t want. Despite this, many of us don’t feel comfortable with or have knowledge regarding options 3, 4, and 5. Why is that?

I had a discussion with one of my colleagues who has a practice solely dedicated to implants. He is on the lecture circuit discussing his cases, challenges, and promoting the utilization of this tool that essentially changes the quality of life for many patients who otherwise are at the mercy of a piece of plastic. My question to him: Why aren’t implants used to their maximum potential with this particular patient population? His answer surprised me:

Intimidation on the provider end. This stems from the use of new materials, putting new systems in place for fabrication and subsequent hygiene, coordination with the oral surgeon, interims, understanding how the prosthesis functions (learning its limitations, etc.) (figures 6 and 7).

The financial breakdown. Is it really worth it? It’s true that there are multiple appointments at various points in the making of these prostheses, and as a result, the financial incentives (to many) are not justified because cranking out single crowns and fillings during all of these appointments would be more profitable. But would it really? Hence the reason many dentists refer these cases to a prosthodontist.

Figure 5: Interim All-on-4 — **Figure 5:** Interim All-on-4

Many dentists are interested, but they are unsure of or don’t have the network of knowledge or people to get started. As the dentist, you play a major role. But what about training for the oral surgeon, assistant, lab technician, and financial coordinator (billing and coding are huge)? Also, working with the implant representative to have all the right parts and pieces on hand is a consideration.

Patients’ ability to invest. Having a financial coordinator who is able to present options to these patients is often what can swing the pendulum in favor of full-arch restorations. You would be surprised how many patients commence with care when they have the right financing in place. Some of the most common questions regarding full-arch implant-supported restorations are indeed valid, and, with many of them, the jury is still in session:

How do you maintain these restorations? How often do you take them out? Should you take them out? (figures 8 and 9)

What materials do I use? Polymethyl methacrylate (PMMA)/acrylic with a titanium bar or full-arch zirconia? Is one or the other better with a single or double arch?

Figure 6: Implants being placed for a fixed hybrid — **Figure 6:** Implants being placed for a fixed hybrid

What happens when something goes wrong? What type of warranties are in place?

To these points of concern, my answer is simple. There really is no one-size-fits-all approach. My recommendation is to do your research into each of these questions so you can incorporate them into a customized treatment plan for each patient. Why? Because you can’t treat a frail, 85-year-old woman the same way you treat a man with masseter muscles the size of your fist.

Figure 7: Implants being placed for a fixed hybrid — **Figure 7:** Implants being placed for a fixed hybrid

In reality, each of these treatment options warrants a full-size discussion—from treatment planning to prosthesis fabrication, and from surgery to long-term care. Additionally, with the ever-increasing presence of 3-D imaging, there is even more information to take in. What’s exciting about this technology is that full-arch implant-supported restorations are becoming more predictable and successful.

Figure 8: Definitive All-on-4 removed after one year — **Figure 8:** Definitive All-on-4 removed after one year

The discipline of implants is vast, yet the potential to increase the quality of life for your patients with options that fit their needs and budgets is worth it. Being able to place full-arch implant restorations is a confidence and practice builder that warrants the investment, and you need to be right in the thick of it.

Let’s be honest—nobody likes telling a patient that it’s your first time doing a particular procedure, especially when their pocketbook, smile, and self-esteem are on the line. But once that first hurdle gets jumped, let’s just say the rest is history.

Figure 9: Double-arch fixed hybrid, 10-on-4 — **Figure 9:** Double-arch fixed hybrid, 10-on-4

References

1. Facts & figures. American College of Prosthodontists website. https://www.gotoapro.org/facts-figures/. Accessed December 30, 2019.

2. Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the United States in 2020? J Prosthet Dent. 2002;87(1):5-8. doi:10.1067/mpr.2002.121203

3. Douglass CW, Watson AJ. Future needs for fixed and removable partial dentures in the United States. J Prosthet Dent. 2002;87(1):9-14. doi:10.1067/mpr.2002.121204

Stacey L. Gividen, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Hamilton, Montana. She is a guest lecturer at the University of Montana in the Anatomy and Physiology Department. Dr. Gividen is the editorial director of Endeavor Business Media’s clinical dental specialties e-newsletter, Breakthrough Clinical, and a contributing author for DentistryIQ, Perio-Implant Advisory, and Dental Economics. She also serves on the Dental Economics editorial advisory board. You may contact her at [email protected].