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IMPLANTOLOGY

SOLUTIONS
MARCH 2022

2 C E C R E D I T S C A S E R E P O R T

IMPLANT OVERDENTURE THERAPY TRANSITIONAL IMPLANTS

Dual-Arch Implant Long-term Results of

Overdenture Maxillary Full-Arch
Treatment Protocols Reconstruction Using
Michael D. Scherer, DMD, MS Transitional Implants:
A Case Report With
20-Year Follow-up
Klenise S. Paranhos, DDS, MS; Stuart J. Froum, DDS;
Natacha Reis, DDS; and Sang-Choon Cho, DDS

SUPPORTED BY AN UNRESTRICTED GRANT FROM CARESTREAM • Published by AEGIS Publications, LLC © 2022
 Full-Arch
Reconstruction: of Continuing Education in Dentistry

MARCH 2O22 | www.compendiumlive.com

Strategies for Present-Day PUBLISHER

Matthew T. Ingram

and Future Needs

C
of Continuing Education in Dentistry
SPECIAL PROJECTS DIRECTOR
C. Justin Romano

SPECIAL PROJECTS COORDINATOR

June Portnoy
onsidered by many to be an ideal treatment of Continuing Education in Dentistry
MANAGING EDITOR
for the replacement of teeth in completely Bill Noone

edentulous patients, dental implant ther- CREATIVE

Claire Novo
apy is often the “answer” for those seeking
EBOOK DESIGN
the natural dental function—and the sense Jennifer Barlow

of permanence—that once only their natural teeth offered.

Yet despite its numerous advantages, full-arch restoration
utilizing implant therapy may pose significant challenges
for many patients. Some patients are hesitant to commit
to the surgery involved in the procedure, while others may
balk at the cost. Offering such patients the opportunity to
receive alternative therapies, such as removable prostheses,
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that can be converted to implant-supported prostheses at a Printed in the U.S.A.

future date is a compelling approach to patients who require

full-arch rehabilitation. To achieve this, clinicians must
understand the treatment strategies that will help pave the
way for future implant placement.
This edition of the Compendium clinical eBook series pro-
vides a continuing education article that examines treat-
ment planning for full-arch reconstruction with implant
overdentures. In this article, strategies that help clinicians
maintain the ability to convert the implant overdenture into
Chairman & Founder
a fixed restoration at a future date are detailed. A long-term Daniel W. Perkins
case report is also featured in this eBook, highlighting the Vice Chairman & Co-Founder
Anthony A. Angelini
steps involved in a full-arch reconstruction using transi-
Chief Executive Officer
tional implants. Karen A. Auiler

Compendium’s educational content is focused on bring- Corporate Associate

Jeffrey E. Gordon
ing proven solutions to the practice, including those that Media Consultant, East
Scott MacDonald
improve patient experience and practice management. Visit
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Editor-in-Chief AEGIS Publications, LLC
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2 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com

 CONTINUING EDUCATION IMPLANT OVERDENTURE THERAPY

Dual-Arch Implant Overdenture

Treatment Protocols
Michael D. Scherer, DMD, MS

ABSTRACT: Patients who require transitioning from natural teeth to dental implants
present a unique challenge to clinicians. When evaluating decision-making processes,
clinicians must determine the best restorative treatment options for the patient. Fixed
and removable treatment options may both become ideal possibilities for a patient,
depending on the patient’s clinical presentation. Patients who are interested in fixed
options but may not have the financial resources to be able to afford this more expensive
alternative often may choose removable overdenture solutions. This article discusses
ideal treatment planning strategies for patients interested in dual-arch overdenture
restorations and reviews a clinical case describing this treatment.

LEARNING OBJECTIVES

• Discuss common modalities • Describe presurgical site • Explain sequential and logical
used for implant treatment of assessment protocols for diagnostic and treatment
edentulous patients or patients patients with terminal dentition planning steps for implant
with terminal dentition overdenture therapy

T
reating patients who present with
a failing dentition remains a chal-
lenge for many clinicians. While
the rate of edentulism has steadily
decreased over the decades since
the 1970s, full-mouth reconstruction for pa-
tients requesting and/or needing it has gen-
erally remained a common aspect of clinical
practice.1 The transition of patients from natu-
ral teeth to dental implant restorations can be
significantly trying for both the clinician and
patient from both an esthetic and functional
aspect.2,3 While it is difficult to quantify when
a patient has reached the point of a failing or
failed dentition, the general consensus is that
DISCLOSURE: The author has no disclosures to report.
the dentition is terminal when the patient has
insufficient teeth to maintain function, and
often the patient needs to transition toward
the edentulous state.4 This article discusses
how to evaluate and treat patients who de-
sire dual-arch implant treatment options and
describes a clinical case that presented to the
author’s practice.
Full-Arch Restorative Options
Several common modalities exist for implant
treatment options for edentulous patients or
patients with terminal dentition. They include
tissue-supported complete dentures, implant-
retained overdentures, implant-supported

3 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com

 CONTINUING EDUCATION
overdentures, fixed complete dentures (hy-
brids), and individual crowns or fixed partial
denture reconstruction. A historical evaluation
of dental implant treatment reveals that many
patients are successfully treated with both im-
plant overdentures and fixed full-arch restora-
tions when transitioning from natural teeth or
edentulous arches.5-7 Patients who present to
the clinical environment requesting or need-
ing full-mouth reconstruction with either fixed
or removable prostheses often have failing
or failed dentition. Several factors go into a
patient’s decision-making process regarding
restoration, but an overall primary question a
clinician should ask is whether the patient is
comfortable with a removable dentition ver-
sus one that is fixed intraorally. If the patient
is tolerant of the removable option, long-term
follow-up studies have shown that satisfac-
tion with implant overdentures is similar to
that with fixed restorations.8,9
Patients who tend to select fixed restorations
are often most interested in overall chewing
ability, stability of the prosthesis, and the abil-
ity to eat harder and crunchier foods. In con-
trast, those who are more inclined to select re-
movable prostheses are often most interested
in simplicity, esthetics, phonetics, and ease
of cleaning. These criteria have been dem-
onstrated in several long-term evaluations of
patients who have undergone dental implant
treatment.10,11
Treatment Assessment
Prior to surgical or restorative procedures, the
treatment of patients with a terminal dentition
often requires a detailed evaluation and pre-
surgical site assessment to determine if the
patient is a suitable candidate for dental im-
plant treatment.12 Evaluation of the patient’s
treatment goals before proceeding with sur-
gical procedures is as important as examina-
tion of the patient’s dentition and/or edentu-
lous ridges. A complete diagnosis is a critical
first step in treating patients to ensure optimal
4 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
IMPLANT OVERDENTURE THERAPY
outcomes; improper treatment planning steps
may result in a less-than-ideal outcome. Pa-
tients who require full-arch reconstruction are
often substantially impacted by the health of
their remaining dentition and are often bur-
dened with fears and concerns about dental
treatment and extraction.13 Patient expectation
of dental implant treatment has been reported
as being quite high, and many patients desire
a solution that is functional, esthetic, pain-
free, lasts a lifetime, and can be attained at a
reasonable cost.14
Patients who choose implant overdenture
treatment typically opt for it because of the
dramatic improvement in quality of life im-
plant overdentures can provide when com-
pared to their cost.15 A prosthesis retained by
dental implants in the mandibular arch has
long been regarded as a safe and highly ef-
fective long-term treatment option.16,17 Addi-
tionally, the implant overdenture is the com-
monly accepted first choice standard of care
for the edentulous mandibular arch and has
been subject to numerous evaluations of its
cost-effectiveness.18,19
Number of Implants and Implant
Positioning for Overdentures
The use of sequential and logical diagnostic
and treatment planning steps for implant over-
denture therapy is important and may improve
treatment outcomes.20 The proper number of
implants along with proper positioning, angu-
lation, and distribution of the implants, as well
as the attachment system, are key factors in
enhancing treatment outcomes. Historically,
many authors have advocated for two dental
implants in the interforaminal space of the an-
terior mandible as the “de facto standard” in
implant overdenture therapy.21 While patient
satisfaction has been shown to be positive for
two-implant overdentures, further evaluations
have indicated that patients may be just as sat-
isfied and potentially more satisfied with the
use of additional implants around the maxillary
 CONTINUING EDUCATION
or mandibular arch.22 In the maxillary arch, the
number of implants is an important consider-
ation because many patients are motivated by
reducing palatal coverage of their prosthesis.23
In situations where the patient wishes for max-
illary implants to retain a minimal-coverage
prosthesis, treatment with four to six implants
with either splinted or unsplinted attachment
systems is recommended.24
Placement of implants for implant overden-
ture treatment is often based on anatomical
features and anecdotal evidence. The two-im-
plant mandibular overdenture historically has
been utilized with dental implants placed in
the interforaminal region in approximately the
canine positions. Implant placement limited to
this position is typically compounded by years
of denture or partial denture use resulting in
substantial posterior ridge resorption.20 In re-
sorbed anterior ridges, use of narrow-diameter
implants, ie, less than 3 mm in diameter, may
be optimal compared to placement of larger-
diameter implants with grafting procedures.
In posterior alveolar ridges where bone width
is greater but length is often limited, shorter
and wider implants may be optimally utilized.
Distribution and distance between implant-
retentive mechanisms remains an important
Fig 1.
Fig 1. Ideal implant positions for dual-arch over-
denture patients. In the maxillary arch, ideal
positions are the first/second molars, first/sec-
ond premolars, and lateral incisors. In the man-
dibular arch, ideal positions are the first
molars and canines.
5 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
IMPLANT OVERDENTURE THERAPY
factor for implant overdenture treatment, with
wider distribution and spacing between im-
plants tending to enhance retention and stabil-
ity of the prosthesis.25 When the opportunity
presents itself to place implants posterior to
the mental foramina for three to four implant
cases, retention and stability of the overden-
ture are greatly enhanced when implants are
placed distally, such as at the second premo-
lar, first molar, or second molar.26
Increasing the number of and spacing be-
tween implants may have an impact clinically
when considering its effect on both physical
properties, such as retention and stability, and
non-physical properties, such as patient accep-
tance and satisfaction. Increasing the number
of dental implants positively impacts patient
quality of life and satisfaction when it comes to
both the maxillary and mandibular arches.27,28
When considering placing an increased num-
ber of dental implants per arch, ie, four to six
implants, clinicians often place them in a wide-
ly distributed manner with substantial inter-
implant spacing to ensure adequate blood sup-
ply around the implants. Optimal positions for
implants in the maxillary arch are the first mo-
lar/second molar positions, first premolar/sec-
ond premolar positions, and lateral incisor po-
sitions; in the mandibular arch, ideal implant
positions are the first molar and canine posi-
tions (Figure 1).
To accommodate implant placement around
critical structures such as sinuses or nerves,
shorter dental implants with greater diameters
are optimal in posterior maxillary and man-
dibular ridges. In anterior maxillary or man-
dibular ridges where alveolar structures have
fewer critical anatomical areas, the bone tends
to be narrower and denser. In those anterior
ridge situations, longer dental implants with
narrower diameters are considered optimal.
Implant designs that favor wide aggressive
threads with platform-switching components
tend to be preferred in posterior maxillary and
mandibular alveolar ridges. Narrower threads
 CONTINUING EDUCATION
and slightly less aggressive design tends to
be favored in the anterior maxillary and man-
dibular arches.
By treating overdenture patients with four
or more implants per arch, clinicians maintain
the ability to convert an implant overdenture
restoration into a fixed restoration in the fu-
ture. While fixed and removable restorations
may reportedly be equally satisfactory to pa-
tients, anxiety and fear related to a remov-
able restoration may limit a patient’s desire
to transition from natural teeth to artificial
substitutes.29 Cost and surgical complexity of
fixed restorations versus a removable option,
however, may preclude patients from decid-
ing on a fixed option. In clinical situations
where the patient may be ambivalent about
deciding on fixed versus removable treatment
options, the concept of the patient being able
to convert the restorations into fixed prosthe-
ses even after implants and restorations have
been placed is compelling. Thus, patients may
have less anxiety and fear about transitioning
to dental implants knowing that they have the
flexibility and assurance of secondary options
being available.
Case Report: Dual-Arch
Overdenture Treatment
A 58-year-old male patient with existing max-
illary and mandibular teeth presented with a
concern that he might need extensive dental
treatment. His clinical presentation includ-
ed multiple crowns, a fixed partial denture,
and numerous dental restorations. Addition-
ally, he had concerns about his periodontal
health after years of scaling and root plan-
ing procedures (Figure 2). Clinical examina-
tion revealed that while the patient presented
with minimal caries and teeth fractures, he
had generalized moderate to severe chronic
periodontitis.
With his history of poor periodontal health,
and concerned about potentially undergoing
another round of periodontal scaling and/or
6 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
IMPLANT OVERDENTURE THERAPY
Fig 2.
Fig 2. Patient presented with a failing dentition due
to extensive periodontal disease and was interested
in full-mouth reconstruction with dental implants.
surgical intervention, the patient requested
full-arch extraction and dental implant treat-
ment options instead of conservative ap-
proaches. Over the course of 15 years he had
been seen regularly for routine periodontal
maintenance with periodic scaling and root
planing procedures as his periodontal condi-
tion worsened. The clinician and patient dis-
cussed the potential for osseous surgery and
more definitive procedures; however, the pa-
tient expressed an interest in an expedited
treatment that would not require additional
periodontal procedures.
The patient indicated that he was interest-
ed in a nonremovable, fixed treatment option
but was concerned regarding costs of the pro-
cedure and inquired about a more affordable
option. After extensive discussion regarding
treatment, two options were presented to the
patient. The first was maxillary and mandibu-
lar full-arch, screw-retained hybrid restorations
(all-on-X). The second option was maxillary
and mandibular overdentures treated with four
to six implants on the maxillary arch and two
to four implants on the mandibular arch. The
patient expressed interest in the first treatment
option; however, when presented with the cost
of fixed restorations, he requested the second
option comprising the overdenture treatment. A
 CONTINUING EDUCATION
Fig 3.
Fig 5.
discussion regarding the number and position
of implants was conducted, and the patient opt-
ed for a maximum number of implants per arch
to ensure he would have the flexibility of con-
verting his overdenture prostheses into fixed
ones in the future if he so desired.
Impressions using an intraoral optical scan-
ner (TRIOS®, 3Shape, [alternatively: iTero®,
Align Technology; i700, Medit]) were made
of the patient’s maxillary and mandibular den-
tition. Photographs were taken, and a cone-
beam computed tomography (CBCT) scan
was made. The CBCT images were manipu-
lated using a dental implant planning software
(Invivo, Anatomage, [alternatively: Implant
Studio®, 3Shape; exoplan, exocad]), and vir-
tual implants were planned for placement into
widely distributed and spaced regions of the
maxillary and mandibular arches (Figure 3).
Virtual implants were virtually placed into the
positions of teeth Nos. 2, 4, 6, 11, 13, and 15
in corresponding maxillary root sockets and
the positions of teeth Nos. 19, 22, 27, and 30
in corresponding mandibular root sockets.
7 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
IMPLANT OVERDENTURE THERAPY
Fig 4.
Fig 3. After a CBCT scan was made, virtual im-
plants were placed in widely distributed positions
on the maxillary (six implants) and mandibular
(four implants) arches. Fig 4. Maxillary overden-
ture abutments were placed. Fig 5. Mandibular
overdenture abutments were placed.
The patient returned for extraction and den-
tal implant placement. Anesthetic (lidocaine)
was administered, and all maxillary and man-
dibular teeth were extracted. Immediately af-
ter extraction, implant osteotomies were pre-
pared, and dental implants (ETIII SA, Hiossen,
[alternatively: LOCATOR® Overdenture Im-
plant System, Zest Dental Solutions; Lega-
cy3™, Implant Direct]) were placed. All of
the implants achieved primary stability and
insertion torque of 30 Ncm or higher. Cover
screws were placed onto each implant, and
bone grafting material (xenograft) was placed.
Primary closure was achieved using chromic
gut sutures, and the interim prostheses were
placed. The patient was instructed to maintain
a soft-food diet for 2 to 3 months during the
osseointegration period.
The patient returned and implants were as-
sessed for integration and implant exposure
procedures. A crestal incision was made and
healing abutments were placed; at the time
of uncovery, tissue measurements were made
from the top of the implant platform to the
superior portion of the tissues. Two weeks
later, the patient returned and overdenture
abutments (LOCATOR® R-Tx, Zest Dental So-
lutions, [alternatively: ERA, Sterngold; Hader,
 CONTINUING EDUCATION
Fig 6.
Fig 7.
Fig 8.
Fig 9.
Fig 6. Panoramic radiograph confirmed complete
adaptation of the abutments to the implants prior
to torquing the abutments. Fig 7. Denture hous-
ings were placed onto each abutment and optically
scanned using an intraoral scanner. Fig 8. Maxillary
(left) and mandibular (right) overdenture frame-
works were designed using a laboratory software.
The framework designs would be 3D printed using
cobalt-chrome. Fig 9. Complete overdenture pros-
theses using acrylic resin and denture.
8 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
IMPLANT OVERDENTURE THERAPY
Preat]) in tissue heights corresponding to the
measured tissue depths were placed (Figure
4 and Figure 5). After placement of the abut-
ments, a panoramic radiograph was made to
confirm complete adaptation of the abutments
to the dental implants (Figure 6). Abutments
were torqued to manufacturer’s recommend-
ed torque values, and denture housings were
placed on top of each abutment (Figure 7).
Optical scans of the maxillary and mandibular
arches were made using the intraoral impres-
sion scanner. The patient’s existing denture
was relieved and relined with a silicone-based
soft reline material (CHAIRSIDE®Soft, Zest
Dental Solutions, [alternatively: Coe-Soft™,
GC America; Ufi Gel SC, Voco]). The inta-
glio and cameo surfaces of the maxillary and
mandibular prostheses were optically scanned
using the intraoral scanner.
The optical scan files were imported into a
dental laboratory planning software (Dental
System, 3Shape, [alternatively: DWOS Den-
tal Software, Straumann Group; DentalCAD,
exocad]) and overdenture frameworks were de-
signed (Figure 8). The framework designs were
sent to a dental laboratory for 3D printing the
frameworks in cobalt-chrome. Using the exist-
ing interim dentures as a guide, denture teeth
(Pala® Mondial®, Kulzer, [alternatively: Veracia
SA, Shofu; SR Vivodent®, Ivoclar Vivadent])
were placed onto the completed frames and as-
sessed, with the patient approving the final es-
thetics and tooth arrangement (Figure 9). The
prostheses were completed using conventional
acrylic processing techniques.
The patient returned for placement of the
final prostheses. Housings were attached to
the top of each of the abutments, and compos-
ite resin (CHAIRSIDE® Attachment Process-
ing Material, Zest Dental Solutions, [alterna-
tively: Quick Up®, Voco; Pattern Resin, GC
America]) was placed into the recesses (Fig-
ure 10). The prostheses were seated onto the
edentulous ridges, and housings were attached
to the prostheses intraorally. After complete
 CONTINUING EDUCATION IMPLANT OVERDENTURE THERAPY

Fig 10. Fig 11. Fig 12.

Fig 10. Denture housings were placed onto each abutment and recesses prepared within the prosthe-
ses. Composite resin was placed into each recess and the prosthesis placed onto the edentulous ridge.
After complete polymerization, the prostheses were removed. Fig 11. Processing inserts were replaced
with definitive nylon inserts. Fig 12. At a follow-up appointment approximately 2 weeks post-treatment,
the patient indicated he was satisfied with the esthetics, fit, function, and insertion/removal of the
prostheses.

polymerization, the processing inserts were
removed, and medium-strength nylon inserts
were placed into the housings within the den-
ture (Figure 11). The patient was given in-
structions on inserting and removing the pros-
theses and was satisfied with esthetics, fit, and
form of the restorations (Figure 12).
The patient again returned and reported gen-
eral comfort, easy insertion and removal, and
satisfaction with the stability of the prosthe-
ses for chewing and speaking. Approximately
1 year after placement of the prostheses, the
patient returned for a long-term follow-up and
reported that the prostheses were performing
well and he did not wish to transition to a fixed
prosthesis. He indicated that he was comfort-
able with his decision and happy with the final
result, and was glad that he still had the flex-
ibility to transition to a fixed prosthesis in the
future if he wanted to do so.
Conclusion
Full-arch reconstruction with implant overden-
ture therapy is a predictable treatment for long-
term success for patients who are comfortable
with removable prostheses. Patients who re-
quest full-arch reconstruction with dental im-
plants are often unsure of whether to transition
from natural teeth to fixed or removable res-
torations. For some patients, the decision can
lead to anxiety and fear of moving forward with
their dental treatment. In this article, the treat-
ment of a patient treated with dual-arch over-
denture restorations was described. While the
patient was satisfied with the prosthetic result,
having the assurance that he could still transi-
tion from a removable restoration to a fixed
one was a primary motivator for the patient
to continue with dental treatment. By having
numerous implants placed in a widely spaced
distribution, the patient was able to achieve a
stable removable prosthesis that will be able
to also support a fixed prosthesis in the future.
ABOUT THE AUTHOR
Michael D. Scherer, DMD, MS
Assistant Clinical Professor, School of Dentistry, Loma Linda
University, Loma Linda, California; Clinical Instructor,
University of Nevada Las Vegas, Las Vegas, Nevada;
Private Practice limited to Prosthodontics and Implant
Dentistry, Sonora, California; Fellow, American College of
Prosthodontists
Queries to the author regarding this course may be submitted to
authorqueries@aegiscomm.com.
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attachment type and palatal coverage on oral per-
ception and patient satisfaction in maxillary im-
plant-supported complete denture patients. Niger
J Clin Pract. 2019;22(5):669-674.
24. Sadowsky SJ, Zitzmann NU. Protocols for
the maxillary implant overdenture: a systematic
review.  Int J Oral Maxillofac Implants. 2016;31
suppl:s182-s191.
25. Scherer MD, McGlumphy EA, Seghi RR, Cam-
pagni WV. Comparison of retention and stability of
two implant-retained overdentures based on im-
plant location. J Prosthet Dent. 2014;112(3):515-521.
26. Scherer MD, McGlumphy EA, Seghi RR, Cam-
pagni WV. Comparison of retention and stability of
implant-retained overdentures based upon implant
number and distribution.  Int J Oral Maxillofac Im-
plants. 2013;28(6):1619-1628.
27. Mumcu E, Bilhan H, Geckili O. The effect of at-
tachment type and implant number on satisfaction
and quality of life of mandibular implant-retained
overdenture wearers.  Gerodontology. 2012;29(2):
e618-e623.
28. Di Francesco F, De Marco G, Gironi Carnevale UA,
et al. The number of implants required to support
a maxillary overdenture: a systematic review and
meta-analysis. J Prosthodont Res. 2019;63(1):15-24.
29. Borges GA, Barbin T, Dini C, et al. Patient-
reported outcome measures and clinical assess-
ment of implant-supported overdentures and fixed
prostheses in mandibular edentulous patients:
a systematic review and meta-anaysis. J Prosthet
Dent. 2020:S0022-3913(20) 30694-6.
 CONTINUING EDUCATION QUIZ 2 Hours CE Credit

Dual-Arch Implant Overdenture Treatment Protocols

Michael D. Scherer, DMD, MS

TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/IMPOVERDENTURE

ENTER PROMO CODE: CCEDDUALARCH

1. Generally, the dentition is considered terminal 6. To accommodate implant placement around

when the patient: critical structures such as sinuses or nerves in
A. requests full-mouth reconstruction. posterior maxillary and mandibular ridges:
B. is uncomfortable with a removable prosthesis. A. shorter implants with greater diameters are
C. is unable to achieve good phonetics. optimal.
D. has insufficient teeth to maintain function. B. longer implants with narrow diameters are
ideal.
2. Patients who choose removable prostheses are C. implants with less aggressive thread design
often most interested in simplicity, esthetics, are needed.
and: D. short, narrow-diameter implants are
A. ease of cleaning. recommended.
B. exceptional chewing ability.
C. a highly stable prosthesis. 7. Clinicians can maintain the ability to convert
D. the ability to eat hard, crunchy foods. an implant overdenture restoration into a fixed
restoration in the future by:
3. Patient expectation of dental implant treatment A. using no more than two implants per arch.
has been reported as being: B. using four or more implants per arch.
A. extremely low. C. using locator-type overdenture abutments.
B. somewhat low. D. narrowly spacing the distribution of implants.
C. slightly high.
D. quite high. 8. In the case presented, the patient was
interested in a nonremovable, fixed treatment
4. The two-implant mandibular overdenture option but was concerned regarding:
historically has been used with dental implants A. length of treatment time.
placed in the: B. esthetics.
A. first molar positions. C. postoperative pain.
B. second premolar positions. D. costs.
C. central incisor positions.
D. interforaminal region in the canine positions. 9. To have the flexibility of converting his
overdenture prostheses into fixed ones in the
5. Wider distribution and spacing between future, the patient in this case opted for:
implants tends to: A. screw-retained hybrid restorations.
A. weaken retention and stability of the B. the fewest number of implants possible.
prosthesis. C. a maximum number of implants per arch.
B. enhance retention but weaken stability of the D. extensive periodontal scaling and root planing.
prosthesis.
C. enhance retention and stability of the 10. At the patient’s 1-year follow-up, the
prosthesis. prostheses reportedly were performing:
D. enhance stability but not retention of the A. poorly, and the patient desired a fixed
prosthesis. prosthesis.
B. well, and the patient did not wish to
transition to a fixed prosthesis.
C. well, but the patient now wanted a fixed
prosthesis.
D. below the patient’s expectations.

Course is valid from 2/1/22 to 2/28/25. Participants must at-

tain a score of 70% on each quiz to receive credit. Participants
receiving a failing grade on any exam will be notified and per-
mitted to take one re-examination. Participants will receive an
annual report documenting their accumulated credits, and are
urged to contact their own state registry boards for special CE
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AEGIS Publications, LLC, is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identify-
ing quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of
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11 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com

 CASE REPORT TRANSITIONAL IMPLANTS

Long-term Results of Maxillary

Full-Arch Reconstruction Using
Transitional Implants: A Case
Report With 20-Year Follow-up
Klenise S. Paranhos, DDS, MS; Stuart J. Froum, DDS; Natacha Reis, DDS; and Sang-Choon Cho, DDS

ABSTRACT: Because of their documented long-term success rates, dental implants

have become a predictable treatment option to replace hopeless or missing teeth.
However, full-arch transition from a hopeless dentition to a prosthesis supported by
dental implants remains a challenge. One treatment option for this process is the use
of transitional implants, an approach that allows for the transitioning of full-arch
reconstructions from teeth to implant-supported prostheses without immediate load-
ing the permanent implants or the need for provisional removable partial dentures.
This article, which presents a long-term clinical case report, describes the steps and
sequence of therapy involved in transitioning from a hopeless dentition to a maxillary
full-arch implant-supported fixed prosthetic rehabilitation with the use of transitional
implants, avoiding removable provisional prostheses. An assessment of the 20-year
follow-up, dental implant survival rates, and marginal bone loss is also presented.

ABOUT THE AUTHORS Natacha Reis, DDS

Klenise S. Paranhos, DDS, MS
Clinical Assistant Professor, Ashman Department of
Periodontology and Implant Dentistry, and Assistant
Group Practice Director, Cariology and Comprehensive
Care, New York University College of Dentistry,
New York, New York; Diplomate, International
Congress of Oral Implantologists; Private Practice,
Chappaqua, New York
Stuart J. Froum, DDS
Adjunct Clinical Professor and Director of Clinical
Research, Ashman Department of Periodontology and
Implant Dentistry, New York University College of
Dentistry, New York, New York; Private Practice,
New York, New York
Fellow, Advanced Program for International
Dentists in Implant Dentistry, Ashman Department of
Periodontology and Implant Dentistry, New York
University College of Dentistry, New York, New York;
Diplomate, International Congress of Oral Implantologists
Sang-Choon Cho, DDS
Clinical Associate Professor and Program Director,
Advanced Program for International Dentists in Implant
Dentistry, Ashman Department of Periodontology and
Implant Dentistry, New York University College of
Dentistry, New York, New York; Chairman, Implant
Dentistry Research and Education Foundation Scientific
Advisory Board; Diplomate, International Congress of
Oral Implantologists; Private Practice, New York,
New York

DISCLOSURE: The authors declare no conflicts of interest, and this article was produced without any industrial financial support.
There were no financial relationships between any of the authors and the manufacturers of products involved in the study.

12 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com

 CASE REPORT
S
ince the introduction of implant
osseointegration by Brånemark in
the 1960s, the use of implant-sup-
ported restorations as a treatment
option as opposed to conventional
prosthodontic restorations has increased, espe-
cially in completely edentulous arches.1 While
long-term clinical studies have been published
that demonstrate the success of dental implant-
supported restorations,1-3 most studies docu-
ment implant-supported prostheses’ survival
and success rates on a relatively short- or me-
dium-term basis. Patients may have concerns
about the risks and successful long-term out-
comes of implant-supported prostheses when
presented with a choice between them versus
conventional restorative options.4,5
In full-arch edentulous patients, treatment
options for provisional restorations include
extraction of hopeless teeth followed by use
of a complete removable denture, sequential
extraction of hopeless teeth and retention of
questionable teeth to use as abutments for
fixed prostheses, or extraction of hopeless
teeth and use of transitional implants (TIs) as
abutments for fixed provisional prostheses.
TIs are narrow-diameter implants (1.8 mm to
2.4 mm)6 that can be used as abutments, allow-
ing patients undergoing bone/soft-tissue aug-
mentation procedures to function with fixed
provisional restorations rather than remov-
able complete dentures. Clinically, this en-
ables non-loaded healing of augmented soft
and hard tissues following implant placement.
Moreover, with the use of a fixed temporary
restoration, the clinician and patient can assess
function and esthetics prior to the fabrication
of the final fixed restoration.7,8
Fixed hybrid screw-retained restorations
supported by implants have been shown to be
a highly predictable treatment option for res-
toration of an edentulous arch, offering sim-
plicity of use, reduced cost, and ease in repa-
rability.9 The purpose of this long-term clinical
case report is to describe the steps involved in
13 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
TRANSITIONAL IMPLANTS
transitioning from an edentulous maxilla with
hopeless teeth to a full-arch implant-support-
ed denture using TIs to support the provisional
prosthesis. It presents the diagnosis, treatment
planning, and sequence of therapy of a fully
edentulous maxilla and partially edentulous
mandible with implant-supported prostheses.
An assessment of the 20-year follow-up, im-
plant survival rates, and marginal bone loss
is also provided.
Case Report
Diagnosis and Treatment Plan
In 1998, a 57-year-old female patient present-
ed to the Ashman Department of Periodontol-
ogy and Implant Dentistry at New York Uni-
versity College of Dentistry (NYUCD) with
the chief complaint of, “My teeth are mobile,
and I don’t want to wear anything removable
in my mouth.” Her medical history was un-
remarkable. She was a nonsmoker and non-
drinker. Her past dental history included loss
of several teeth due to periodontal disease
and caries.
Clinical and radiographic examinations
were carried out and revealed multiple miss-
ing teeth, nonrestorable teeth, periodontal dis-
ease, and bone loss (Figure 1 and Figure 2).
The final treatment plan that was then pro-
posed to and accepted and signed by the pa-
tient included extraction of all remaining teeth
in the maxilla, delivery of a provisional fixed
restoration supported by six transitional im-
plants, bilateral sinus augmentation, place-
ment of eight to 10 conventional implants,
and an implant-supported porcelain-fused-to-
metal or hybrid (screw-retained) restoration.
For the mandible, the plan included extraction
of teeth Nos. 29 and 32 and placement of im-
plants in sites Nos. 18, 19, 20, 29, 30, and 31,
with three splinted implant-supported fixed
crowns on each side. The patient, however,
decided to proceed only with the maxillary
restoration and have the mandibular implants
and restorations done in private practice.
 CASE REPORT
Fig 1.
Fig 3.
Provisionalization
Preliminary impressions of both arches with
alginate and a bite registration were taken. A
wax-up was made to fabricate first a chairside
maxillary fixed provisional using the remain-
ing maxillary teeth as abutments and subse-
quently a laboratory-processed maxillary fixed
provisional using TIs in sites Nos. 3, 5, 8, 9,
12, and 14, and hopeless teeth Nos. 6, 11, and
16 as abutments, and also to fabricate maxil-
lary radiographic and surgical stents. The pa-
tient was referred for a computerized axial to-
mographic (CAT) scan.
Placement of Transitional Implants
Teeth Nos. 10, 14, and 15 were extracted after
achieving local anesthesia (2% lidocaine with
1:100,000 epinephrine, Henry Schein Dental,
henryschein.com). Teeth Nos. 6, 11, and 16
14 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
TRANSITIONAL IMPLANTS
Fig 2.
Fig 4.
Fig 1. Initial occlusal view of maxillary arch.
Fig 2. Initial panoramic radiograph. Fig 3. Maxillary
arch after placement of TIs. Fig 4. Maxillary arch
with TI connective bar placed.
were retained as temporary abutments for the
provisional. A midcrestal incision was made
with a 15C blade, and a full-thickness flap was
reflected with a periosteal elevator. Osteoto-
mies were created with a 1.3 mm pilot drill at
sites Nos. 3, 5, 8, 9, 12, and 14 using a surgi-
cal stent. Six TIs (Dentatus MTI™, Dentatus,
dentatus.com) were placed using a right-angle
handpiece driver and then tightened manually
with the winged socket key (Figure 3).
Gingival protective plastic spacers were
placed over the squared TI heads to prevent
flowing acrylic or composite from interlock-
ing into the wider implant heads (onto the
assembly). A titanium connective bar was in-
serted through the TI grooves facing upward,
passing palatally to remaining tooth No. 6,
through the palatal cusp of tooth No. 11, and
through the central fossa of tooth No. 16, and
 CASE REPORT TRANSITIONAL IMPLANTS

aligned to follow the contour of the edentu-
lous ridge (Figure 4). Modular copings were
placed over the TIs/TI bar in a clamp-like ap-
proach, engaging the gingival protective spac-
ers (Figure 5).
Acrylic resin was then added to the metal
bar. The bar was removed to verify a parallel
path of insertion and then placed back into
the proper position. The maxillary fixed pro-
visional prosthesis was relined with acrylic
over the metal bar, abutments, and TIs (Figure
6). The titanium bar was incorporated into the
transitional provisional prosthesis. The patient
was instructed to close into a previously de-
termined vertical dimension of occlusion until
polymerization of the reline material occurred.
Primary closure was achieved with silk su-
tures. Periapical radiographs were procured,
and postoperative instructions were given to
the patient, who was prescribed an antibiotic
(amoxicillin 500 mg every 8 hours for 1 week),
analgesic (ibuprofen 600 mg every 8 hours as
needed), and mouthrinse (0.12% chlorhexi-
dine for 10 days) (Peridex™, 3M Oral Care,
3m.com). The provisional prosthesis was ad-
justed and cemented with carboxylate cement
(Durelon™, 3M Oral Care). The healing pro-
cess was uneventful, with no infection, in-
flammation, or pain.
Sinus Augmentation
One month later, right and left sinus aug-
mentation procedures were performed using
a lateral window approach. The provisional
prosthesis was removed prior to the surgical
procedures. Midcrestal, mesial, and distal ver-
tical incisions were made, and full-thickness
flaps were elevated to expose the lateral wall

Fig 5. Fig 6.

Fig 7. Fig 8.

Fig 5. Maxillary arch with modular copings over the TIs after TI bar was removed. Fig 6. Frontal view
after insertion of provisional restoration into the TIs and abutment teeth. Fig 7. Panoramic radiograph
after placement of TIs and bilateral sinus augmentation with provisional prosthesis. Fig 8. Maxillary
arch after removal of provisional, with the healing uneventful.

15 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com

 CASE REPORT
Fig 9.
Fig 9. Impression with soft-tissue material for final provisional prosthesis. Fig 10. Occlusal view showing
use of surgical guide for implant placement.
of the maxillary sinuses. A surgical high-speed
round bur with copious irrigation was used to
create the lateral windows. The Schneiderian
membranes were elevated, and the maxillary
sinuses were filled with bone-graft material
(Bio-Oss® large particles, Geistlich Pharma
North America, dental.geistlich-na.com) and
a collagen membrane (Bio-Gide®, Geistlich
Pharma North America) was contoured and
placed over the windows. Primary closure was
achieved with silk sutures.
Postoperative instructions were given to the
patient, and the same medications as previ-
ously described were prescribed again. A pano-
ramic radiograph was taken (Figure 7). The
provisional prosthesis was adjusted and re-
cemented. The healing process was unevent-
ful, with no infection, inflammation, or pain.
Implant Surgeries
Nine months after bilateral sinus augmenta-
tion, the TI at site No. 3 was removed and
three implants (Straumann® ITI SLA®, 4.1 mm
x 12 mm, Straumann, straumann.com) were
placed in sites Nos. 2, 3, and 4, and one im-
plant (Biomet 3i™, 3.25 mm x 13 mm, Zimmer
Biomet, zimmerbiometdental.com) was placed
in site No. 6 following extraction of this tooth
with an immediate placement protocol using
16 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
TRANSITIONAL IMPLANTS
Fig 10.
a surgical guide and a torque of 35 Ncm. A
cover screw was placed on implant No. 6 and
healing abutments were placed on the other
three implants. Two weeks later, the TI on site
No. 14 was removed and one implant (Biomet
3i, 5 mm x 15 mm) was placed in site No. 11
with an immediate placement protocol, and
two implants (Straumann ITI SLA, 4.1 mm
x 12 mm) were placed in sites Nos. 13 and
14 using a surgical guide with a torque of 35
Ncm. A cover screw was placed on implant
No. 11, and healing abutments were placed on
implants Nos. 13 and 14. Tooth No. 16 was
then extracted under the same local anesthe-
sia used previously.
Three weeks later (Figure 8), an impression
was taken (Figure 9) for a laboratory-processed,
screw-retained, implant-supported provisional
prosthesis. Six months later, the TIs on sites
Nos. 5, 8, 9, and 12 were removed, and two
implants (Biomet 3i, 3.25 mm x 13 mm) were
placed in sites Nos. 8 and 10 using a surgical
guide, and cover screws were placed (Figure
10). The fixed laboratory-fabricated provision-
al prosthesis was screwed in on implants Nos.
2, 3, 4, 13, and 14 (Figure 11). After 4 months,
the patient presented with uneventful healing,
and second-stage surgery was performed on
implants Nos. 6, 8, 10, and 11 (Figure 12).
 CASE REPORT TRANSITIONAL IMPLANTS

Fixed hybrid screw-retained restorations supported by

implants have been shown to be a highly predictable
treatment option for restoration of an edentulous arch

Prosthetic Phase
A final impression was made (Figure 13). Inter-
occlusal registration also was taken and a face-
bow was recorded. A buccal matrix and teeth
set-up were fabricated to evaluate the available
space for the final prosthesis as well as occlu-
sion, esthetics, and phonetics. Custom abut-
ments were screwed in on implants Nos. 6, 8,
10, and 11, and octa abutments were screwed
in on implants Nos. 2, 3, 4, 13, and 14. The fit Fig 11.

was verified by periapical radiographs. Metal

frames (one anterior section and two posterior
sections) were tried-in for passive fit, a bite
registration was recorded, and a pick-up im-
pression was performed. Two interlocks, one
in each extremity of the anterior segment, were
included (Figure 14).
The implant-supported, screw-retained, hy-
brid acrylic complete denture in the maxilla
and the mandibular implant fixed prostheses Fig 12.
were delivered after torquing the custom abut-
ments to 32 Ncm and the octa abutments to
35 Ncm, and metal frames, including the in-
terlocks, were tried-in. After consensus was
obtained on the phonetics, occlusion, and es-
thetics (Figure 15), the fit was verified by
periapical radiographs. The patient, who was
very satisfied with the result, was instructed
in proper oral hygiene.

Follow-up Fig 13.

Follow-up appointments were scheduled at 1
week, 2 weeks, 4 weeks, 6 months, and 1 year
post-insertion. Radiographs and clinical ex-
aminations showed peri-implant soft tissue and
marginal bone levels, and the prostheses were
stable (Figure 16). Oral hygiene instructions
Fig 11. Frontal view after insertion of laboratory-
processed maxillary fixed provisional restoration
into implants Nos. 2, 3, 4, 13, and 14.
Fig 12. Maxillary arch healed after second-stage
surgery of the anterior implants. Fig 13. Maxillary
arch with impression copings splinted for final
impression.

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 CASE REPORT TRANSITIONAL IMPLANTS

Fig 14. Fig 15.

Fig 16. Fig 17.

Fig 18. Fig 19.

Fig 14. Maxillary arch with metal framework. Fig 15. Maxillary arch with final prosthesis. Fig 16. Pano-
ramic radiograph at 1-year follow-up. Fig 17. Panoramic radiograph at 5-year follow-up. Fig 18. Pano-
ramic radiograph at 20-year follow-up. Fig 19. CBCT at 20-year follow-up.

were reinforced, and maintenance was sched-
uled every 3 to 6 months. At the 5-year fol-
low-up visit, the patient exhibited excellent
peri-implant soft-tissue health, stable mar-
ginal bone levels, and good stability of pros-
theses (Figure 17).
In 2020, the patient presented to the NYUCD
Periodontology and Implant Dentistry Clin-
ic. A clinical examination and radiographic
evaluation showed that the patient’s maxil-
lary arch still exhibited good peri-implant
soft-tissue health and stable marginal bone
level with slight bone loss on implants Nos.
2, 6, 8, and 11 (Figure 18 through Figure 20).
The maxillary prosthesis showed adequate sta-
bility with a slight chipped suprastructure on
the porcelain on the right side. The patient was
advised to substitute the implant-supported,
screw-retained hybrid acrylic complete den-
ture in the maxilla with a fixed, implant-sup-
ported, screw-retained prosthesis, which she
declined due to financial considerations.

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 CASE REPORT
Discussion
Rehabilitation of patients who refuse to wear
an immediate/interim complete removable
denture during the healing process is a chal-
lenge. Correct diagnosis, accurate implant
planning, and multidisciplinary teamwork are
key to ensuring successful results. The psy-
chosocial impact of having to use a removable
denture has been well-documented to have a
strong effect on these patients, their oral con-
dition, and their choosing dental interventions
that comprise fixed prostheses rather than re-
movable Fig 14.9,10
ones.
According to histological studies, TIs can
achieve successful osseointegration even
when immediate loaded.11,12 Moreover, one
study reported that 55% of TIs had torque val-
ues over 20 Ncm, which is considered a suc-
cessful osseointegration.13 In the present case,
TIs provided long-term stability, function, and
esthetics while other treatment procedures
were being carried out and osseointegration
of the permanent implants was taking place.
The advantages of using TIs for screw-re-
tained provisional restorations include: an
improved healing of extraction sites or alve-
olar ridge augmentation by preventing pre-
mature functional and nonpremature loading;
the avoidance of transmucosal loading dur-
ing the sinus augmentation healing period;
and support of the fixed provisional restora-
tions as well as maintenance of the vertical
dimension of occlusion. This may solve the
problem of loosening of fixed provisional res-
torations caused by cement washout. The TI-
supported provisionals are retrievable with-
out damaging the prostheses. Technical and
biological complications can be treated eas-
ily compared to cement-retained provisionals,
which is why screw-retained provisionals are
preferable.6,8,14 Provisional restorations based
on ideal prosthetic wax-ups allow for esthetic
modifications of teeth and tissue during the
healing period. The patient can participate
in selecting the color and size of their teeth,
19 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
TRANSITIONAL IMPLANTS
Fig 20.
Fig 20. Frontal view at 20-year follow-up.
which in turn can be easily modified during
Fig 15.
the temporary restorative phase. This allows
the patient to envision the final esthetic result.
TIs also allow fixation of the surgical template
during implant placement.4,5,7,8
Several disadvantages of using TIs should
be noted, however. Excessive forces on TIs in
poor bone quality may result in fracture or in-
terfere with the osseointegration of the TIs. A
minimum of 7 mm of bone and 6 mm to 7 mm
of occlusal space (4 mm abutment component
and 2 mm coping and restoration material) are
required. Also, proximity of the TIs to the per-
manent implants may interfere with osseointe-
gration of those implants. Increased cost and
chairtime as well as the possibility of fracture
during removal are also potential factors.4,5,7,8
Overall, TIs can be a valuable adjunct to im-
plant treatment. They enable successful osseo-
integration while patients remain in a fixed func-
tional provisional restoration throughout the
treatment period. Although TIs were designed
to be used on a short-term basis, they have been
shown to remain in function for rather long pe-
riods of time.15,16 In the presented case report,
the TIs lasted in function for up to 18 months.
Implant-supported acrylic hybrid prostheses
for full-arch reconstruction have been used
for a long time with high survival and success
rates of both implants and prostheses. The
most common problem with this type of pros-
thesis is the technical prosthetic complications,
especially chipping of acrylic teeth or fracture
in the posterior areas. These complications
 CASE REPORT
Provisional restorations based on ideal prosthetic
wax-ups allow for esthetic modifications of teeth
and tissue during the healing period
increase when the opposing arch compris-
es a natural dentition or implant-supported
fixed prosthesis. This complication was expe-
rienced in the present case report, as the pa-
tient, being in function with the hybrid resto-
ration for 20 years, showed areas of chipping
of the acrylic. Acrylic hybrid prostheses, how-
ever, are less costly, can achieve the desired
esthetics, and maintain function long-term.17-20
Dental implant follow-up/maintenance ap-
pointments are critical for the long-term suc-
cess of implant treatment. Poor oral hygiene
and lack of proper maintenance causing bac-
teria biofilm accumulation can lead to peri-
mucositis (soft-tissue inflammation around
dental implants) and, if not treated, progress
to peri-implantitis (bone loss around dental
implants). In addition, patients who previous-
ly had periodontal disease are more prone to
peri-implant disease, which increases the im-
portance of frequent recall visits. The patient
must be highly motivated to maintain good
oral hygiene and follow a strict maintenance
appointment schedule.21-23
Conclusion
The clinical implication of the presented case
report with maxillary full-arch rehabilitation
and mandibular partial-arch reconstruction af-
ter being in function for 20 years is that dental
implants can be successful over the long term
when either an immediate or delayed protocol
is used and whether or not bone augmenta-
tion is performed. Many patients present with
high expectations for immediate and esthetic
fixed restorations. However, such treatment is
not always possible in situations where bone
20 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
TRANSITIONAL IMPLANTS
quantity and quality are poor and/or the num-
ber of existing abutments do not allow for im-
mediate fixed temporization. In this case re-
port, the incorporation of transitional implants
was utilized to achieve immediate fixed tem-
porization, satisfying the patient’s needs as
well as preventing transmucosal loading dur-
ing the healing phases of sinus augmentation
and implant placement.
REFERENCES
1. 1. Brånemark PI, Adell R, Breine U, et al. Intra-
osseous anchorage of dental prostheses. I. Ex-
perimental studies.  Scand J Plast Reconstr Surg.
1969;3(2):81-100.
2. Ekelund JA, Lindquist LW, Carlsson GE, Jemt T.
Implant treatment in the edentulous mandible:
a prospective study on Brånemark system im-
plants over more than 20 years. Int J Prosthodont.
2003;16(6):602-608.
3. Fischer K, Stenberg T. Prospective 10-year co-
hort study based on a randomized, controlled
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 CASE REPORT
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21 COMPENDIUM EBOOK SERIES March 2022 | Volume 43 Number 2 www.compendiumlive.com
TRANSITIONAL IMPLANTS
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