Rehabilitation of the Fully Edentulous Patient
A Critical Review of Current Implant Protocols
1. Introduction
Full-arch rehabilitation has evolved from delayed loading protocols toward immediate function solutions. At the same time, the clinical focus has shifted from a purely osteointegration-driven approach to prosthetically driven planning, in which tooth position and smile design dictate the surgical strategy.
Today, predictable outcomes depend not only on implant placement, but on a comprehensive understanding of restorative space, biomechanics, and long-term maintenance.
2. Analysis of Restorative Space and Biomechanical Limitations
The success of protocols such as All-on-4 or All-on-6 depends strictly on the availability of adequate interocclusal restorative space.
Structural Requirements
For a hybrid fixed prosthesis—whether metal-acrylic or monolithic zirconia—a vertical restorative space of approximately 12–15 mm is generally required.
Consequences of Insufficient Space
Inadequate restorative height inevitably leads to:
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Insufficient prosthetic material thickness
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Increased incidence of prosthetic fractures
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Limited access for oral hygiene
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Higher risk of peri-implant disease
Anteroposterior (AP) Discrepancy
Skeletal Class II or Class III discrepancies present significant biomechanical challenges. Prosthetic compensation through excessive cantilevers generates lever forces that may compromise prosthetic screw stability and marginal bone integrity.
3. The Ethical Dilemma: Alveoloplasty or Mutilation?
Prophylactic bone reduction to create adequate restorative space remains one of the most debated topics in contemporary implant dentistry.
From a clinical standpoint, alveoloplasty should not be considered mutilation when its purpose is to ensure prosthetic mechanical viability and a functional, esthetic soft tissue transition.
Nevertheless, informed consent is essential. Patients must understand that the reduction of healthy bone represents a therapeutic compromise aimed at achieving a durable fixed rehabilitation.
When patients refuse osteotomy, more conservative alternatives—such as implant-supported overdentures—should be prioritized, as they require less restorative space and better preserve residual bone volume.
4. Management of the High Smile Line: Hybrid Prosthesis vs. Overdenture
Achieving esthetic success in patients with a high smile line represents one of the greatest clinical challenges.
Hybrid Fixed Prosthesis
Hybrid prostheses allow complete control over artificial gingival architecture. To position the prosthesis–mucosa junction above the upper lip during maximum smile, a compensatory osteotomy is often required.
Overdenture
Overdentures provide excellent lip support through the acrylic flange; however, in patients with high lip mobility, increased prosthetic bulk may compromise esthetics.
5. Technological Advances
Guided Surgery and Immediate Loading
Digital planning has significantly improved surgical accuracy while minimizing operative trauma.
High-Strength Materials
The use of high-performance polymers (PEEK / Pekkton) and translucent zirconia enables thinner restorations with superior fatigue resistance compared to conventional acrylic materials.
Zygomatic Implants
Zygomatic implants have become an established ethical and functional alternative in cases of severe maxillary atrophy, avoiding extensive bone grafting procedures.
6. Conclusions and Clinical Consensus
The “ideal” rehabilitation of the fully edentulous patient is not defined by a universal protocol, but by an individualized, shared clinical decision-making process.
Current clinical consensus supports the following principles:
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Digital planning must precede any surgical intervention.
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Prosthetic design must allow full access for hygiene and maintenance.
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When restorative space is insufficient and bone reduction is not accepted, hybrid fixed prostheses should be abandoned in favor of more conservative solutions such as overdentures or graft-based rehabilitations.
Warm regards,
Dr. Bernardo Grobeisen
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