Show Your Work: A Traditional Touch to All-on-X Treatment by Dr. Elizabeth DiBona

A fixed-hybrid approach that, at the patient’s request, avoided dentures and full IV sedation

by Dr. Elizabeth DiBona

1. Save maxillary teeth and perform root canal; crowns and implants where needed.
2. Extract all maxillary teeth and place a conventional denture.
3. Extract all maxillary teeth, place implants and restore with an implant hybrid prosthesis.
4. Restore the lower anterior with a fixed partial denture (FPD) from #22–#27.

1. Obtaining all diagnostic records is important for all cases, but especially for large cases like this: photos, study models (these days, STL intraoral scans) and CBCT scans (Figs. 3 and 4).
2. Full-face portrait photography taken at the correct angle is also important in treatment planning. You want a straight angle, so the patient’s head is not tilted up or down. I also like an exaggerated smile photo to see where the smile line might be.
3. Alginates or STL file study models were taken to create an immediate temporary denture after extractions.
4. A two-stage surgery was chosen for this patient because of his existing periodontal disease. He also wished to do it without IV anesthesia.
5. Extraction of maxillary teeth; place patient in complete maxillary denture. This decision was made because the patient had not quite demonstrated he could maintain his opposing teeth, and we wanted him to be stable with his periodontal condition on the mandibular arch before starting implants.
6. Extractions, grafting and insertion of an immediate denture.
7. After the patient wore the denture for four months, we took a CBCT scan and then moved forward with implant planning for a hybrid maxillary prosthesis.
8. Implants were to be placed using a CBCT scan and clear surgical pilot guide (Hybridge lab).
9. We hired a dental technician (Thomas Kuun from Vital Dental Laboratory) to arrive after surgery to do the denture conversion to fixed hybrid.
10. The final impression was taken approximately four months after implant placement. I used a sectioned replica of the temporary prosthesis, sat each section, radiographed it, luted the pieces together and adjusted occlusion as needed.
11. Sat final prosthesis with full zirconia FP3 after four months. (I worked with Roe Dental Laboratory on the final.)

Fig. 3: CBCT scan slice after extraction of the maxillary arch. I would consider doing future similar cases as an FP1 so I don’t have to remove any bone during the implant surgery.

Fig. 4: Planning for this case was done through Hybridge; implants were Biohorizons Tapered Internal Hex Laser-Lok.

1. The mandibular arch had periodontally involved teeth. We removed lower incisors and did a fixed tooth-supported bridge from #22–#27.
2. Put the patient on frequent recalls and postoperative visits to monitor periodontal status and improve his home care.

Fig. 5: When doing these freehand, I use a trough guide (replica of denture with a slot cut out) so I can ensure correct implant positioning.

Fig. 6: Angled abutments were used at positions #11 and #13.

Fig. 7: Interrupted sutures with Vicryl. The tissue on the palate was thinned to ensure no excess bulk of tissue after the alveoloplasty was performed. Buccal has sufficient keratinized tissue.

Fig. 8: Denture being converted. I hired a lab technician to do the conversion.

• Take a lot of training/CE before starting these cases. One of the training programs I’ve enjoyed was Hybridge—I don’t typically use their protocol now, but they are great concepts nonetheless. The American Academy of Implant Dentistry (AAID) MaxiCourses are amazing; there are so many of these all around the U.S. and even abroad now. If you want to get more into digital planning, Drs. Danny Domingue and Cory Glenn hold a course called Digital Dental Masters, and although I’ve not taken this specific course, I’ve learned a lot from both doctors at other conferences. Dentaltown offers a slew of online CE courses about implants, and be sure to join the AAID if you want to network more and for another way to learn more about course options, rather than just relying on Google!
• Decide if these types of cases are really right for your practice. Honestly, single-tooth implants are more profitable for me. Unless you’re doing high volume, these cases have high overhead and lower profit margins. They’re also complex and although you can plan a lot of treatments in one day, you need to commit to at least a five-year guarantee for your patient. Many of these patients come from backgrounds of very poor home care, and then you’re putting a $35,000 prosthesis in their mouth and hoping that now they learn to care for their teeth. This leads me to …
• Screen patients carefully. We now check overall health for things like vitamin D levels, and I make patients get physicals from their primary care physicians within six months of starting treatment in my office. You want to know if patients have undiagnosed sleep apnea or severe parafunctional habits. Is their A1C under 7? I recently had a patient get a physical and she had no idea she had diabetes, so now she’ll wait to get her A1C under control and then we’ll pick up on her dental implants. Are they committed to their home care and maintenance protocols? Getting patients in great shape before starting treatment will benefit all parties involved.
• Find an amazing lab to work with. I get tired during a surgery like this, so having a dental technician to help makes a huge difference in the outcome at the end of the (long) day. Likewise, develop a good relationship with your dental implant reps and they’ll help prepare the case with you—and they might even help chairside, because there are a lot of small parts flying around.
• Train your team. They have to understand these types of cases to talk to patients about them. Hygienists also might need some training on how to help patients clean these prostheses. Per the American College of Prosthodontists, you don’t need to remove these prostheses to clean them—in fact, they should be easy to clean by both patient and hygienist—but you’ll need to train your patient on how to get under there. Most of my patients love Waterpik attachments.

Dr. Elizabeth DiBona received her bachelor’s degree from Brown University and her DMD from Boston University School of Dental Medicine, where she graduated magna cum laude. She completed an advanced general dentistry residency at BU. She is a third-generation dentist. DiBona’s practice in Exeter, New Hampshire, combines an assortment of specialists into a robust, 4,000-square-foot multidisciplinary office. A diplomate of the American Board of Oral Implantology, she has amassed more than 1,000 hours of continuing education credit hours and a growing collection of implant accreditations.