Introduction: Receiving both surgical and
prosthetic rehabilitation in one single visit, a signature of any immediately
loading protocol in general and All-On-4®
procedures in particular, has been undoubtedly incredibly rewarding for the
patient- thus one of the reasons for the enormous explosion in popularity.
Although relying “only” on four implants, the entire All-On-4® rehabilitation process is highly
delicate and complex procedure, requiring unison in-sink multidisciplinary
performance of the entire restorative team in order to successfully restore
each patient!
Nevertheless, having to puzzle together multiple extractions
of terminal dentition; apply bone remodeling reciprocal to model planning; define
adequate trajectory of newly placed implants; correctly redirect angles of the
prosthetic abutments; totally rearranged occlusal plane and reestablish new esthetic smile line based on
visualizing calculation attempt to
restore originally collapsed
vertical dimension;; conclusively convert entirely new tooth set-up
makeover into the screw-retained interim prosthesis delivered at the end of the
entire surgical and prosthetic procedure -is
obviously not always that easy to accomplish, especially not in one visit!
Background:
In a traditional All-On-4®protocol performed on already fully edentulous patient
both surgical and prosthetic restorative parts and procedures are well
documented both by the clinicians as well as the implant manufacturers and
therefore fairly recognizable.
.
Already in a very early stage of implant dentistry (1970),
Brånmark et all1 have
determined that standard protocol needed for proper osseointegration of
maxillae (upper jaw) and mandible ( lower jaw) was 6 months respective 3 months
of proper healing time until the implants are to be exposed in 2nd
stage surgery and loaded with
prosthesis. In 1989 Albertsson and Zarb2 as well as many
others after them3,4,5
have concurred with that protocol as a standard for rehabilitation of
the fully edentulous patients.
In a traditional All-On-4®protocol performed on already fully
edentulous patient both surgical and prosthetic restorative parts and
procedures are well documented both by the clinicians as well as the implant
manufacturers and therefore fairly recognizable.
Being an alternative to any grafting, maxillary sinus
elevation or other bone-augumentation procedure, the traditional All-On-4® surgical distinction is based on
placing four (4) intraforaminal implants
for supporting the entire edentulous jaw.
Two anterior implants are placed vertically with a
perfectly straight trajectory and with the implant access hole distally of the
second lateral and the middle of the canine.
Consecutively, two posterior implants are placed still
before foramina, but tilted in order to maximize AP spread thus minimizing the
cantilever length. That surgically astute approach, introduced by Paolo Maló in 1993, is substantially
decreasing the overall complexity and morbidity of the entire procedure thus
probably being one of the main factors for explosive popularity of the
technique when restoring edentulous population. Consequently all four (4)
implants are prosthetically extended with standardized and of the shelf taper
prosthetic abutments, called Multi-Unit abutments. The Multi-Unit abutments for
two frontal anterior implants, are straight or as a 17˚ alternative and in the
back on the posterior tilted implants, as a 30˚ alternative.
However a common denominator for most All-On-4® procedures reported lately by other
authors6,7 it doesn’t focus
on restoring genuine fully edentulous patients anymore but it consist of
removing all existing terminal dentition, remodeling the bone by optimizing new
horizontal ridge level and repositioning of the new smile line creating a total
makeover.
With the implants placed immediately into the
fresh extraction socket and if primary stability is achieved, the industry
recommendations is to proceed consecutively with the immediate loading of the
implants delivering the prosthetics at the very same moment of surgery.
Therefore it is of importance to highlight that in the
context of All-On-4® immediate
loading restoratives there are two (2) groups of what is considered as to be fully
edentulous patients: A.) currently fully edentulous ( i.e no dentition
present) and B.) fully edentulous to be ( terminal dentition to be removed
until no teeth present).
It is to be recognized
that both groups are distinctively different when comparing its diagnostic and
planning options hence diverse surgical and restorative characteristic approach
to follow.
As an example, the value of DICOM CT-scan data and
advances of current computerized guided dentistry is unfortunately still not that
effective on the patient with terminal dentition as it is for traditional fully edentulous All-On-4® patients due to very preexistence of
dentition that will be initially removed first in conjunction with the surgical
phase of the All-On-4® protocol, hence not justifying for any
functional STL file reproduction nor rapid prototype guide stent being pre-made.
Additionally it is to be recognized that operationally there
are currently two (2) distinctive All-On-4®
restorative subgroups with a different modus operandi and different logistic:
First group, group A, represents a group of clinicians and
specialists that are embracing intimate interdisciplinary interaction operating
via so called “one-stop-shop” dental clinics that are focusing exclusively on
performing All-On-4® procedure.
Experience gathered through personal participation and other data reports high
level of predictability, repeatability and overall success.
Second group, group B, represents a typical stand-alone
dental office environment with the restorative team working only occasionally
and assembled temporarily for a particular procedure. Again, experience through
personal participation and gathered data reports there are varieties of
possible reasons that are impeding against ultimate stress-free success.
It is of importance to underline that this observation on
unequal outcome predictability within both groups had nothing to do with expertise
level of any particular part of the restorative All-On-4® teams since personal participation
in both environments witness to high level of special knowledge on the subject within
both groups.
However, it was conclusive
that both A and B group of representative All-On-4® restorative teams are experiencing numerous problems
along their All-On-Four protocols.
(again, based on the personal experience operating within
both groups)
Furthermore it is to recognize that repeatability alone
and high frequency performance of the same procedures is always contributing
factor to perform a task or a procedure with more conformity to pre-set quality
standards.
Despite all, the main observed difference was that group
A, belonging to specialized All-On-4®
dental implant centers, were (are) more
compliant with the protocol, interactive and almost instantaneously responsive
in resolving fast arising problems during the procedure while the group B
consisting of “independent” sole practitioners that are assembling parts of
their team occasionally for particular procedure ( 99% of traditional MO) have
had harder to “get back on track” after some major set-back, often caused while
performing previous task by other “ chain link” of the All-On-4® team i.e. other restorative team
member, whether being surgeon, periodontist, implant lab technician…
The major observation, that was most devastating for the
overall outcome was that the inclusion of the error was always undetected until
the very end of the procedure.
The second observation was that there was no distinct and
disciplined protocol compliance simply because there was nothing to comply to
i.e. lack of interconnecting roadmap guide to follow.
Not only this caused extremely discontent patient and disappointed restorative teams but possibly
great financial disruption.
Therefore based on all these observations and the
experience obtained from both representative experts groups restoring All-On-4® patients, the new methodology consisting
of several different tasks has been developed and continuously to be called Mo2 Maneuver representing all steps performed in coherence.
Mo2 Maneuver,
a patent-pending methodology, consist
of few different tools and tasks that becomes self-censoring blueprint based on
checks and balances, a guiding vehicle throughout the entire All-On-4® procedure.
Mo2 Maneuver is firmly
“forcing” each clinician, participant of particular All-On-4® protocol, to get out of their own
silos and in full compliance and self reliance ( i.e. no need to have error pointed out but detecting incompliance by
itself) reassuring predictably
successful protocol outcome ( i.e. no left, no right guessing, thus name
Maneuver) jand NO occlusal adjustment whatsoever!
Moreover Mo2 Maneuver
will for the first time allow clinicians to present the patient with the
representative mock-up of the new smile just 10-15 min into the lengthy
procedure!!
That has tremendously positive impact on the patient
positive attitude and cooperation throughout the entire procedure to follow
reducing burden from performing clinician(s) and increasing overall mutual
comfort!
There are several complex but also few main and defining moments
within a typical All-On-4® protocol in restoring patients with terminal
dentition to be ultimately resolved in full compliance..
These three (3) specific main reasons that could cause
failure of the entire All-On-4®
procedures are categorized as following:
-
Correlation of bone remodeling level
with the pre-op planning and creation of makeover smile within an interim
prosthesis. Possible scenario: The implant position is great but the bone
height optimization was not sufficient and not in compliance with model
preplanning resulting often in compromised or mechanically failed interim
prosthesis due to the lack of vertical space and compromising with the
dimension requirements
-
Reassurance of adequate implant trajectory
assuring proper esthetic and mechanical properties and functionality of the
interim prosthesis. Possible scenario: The prosthesis esthetics are great but
unsatisfactory implant position is impeding against achieving good esthetics
when the screw access holes exposed
-
Reassurance of proper prosthetic abutment
orientation reassures proper aesthetic as well as proper draw of insertion.
Possible scenario: bone optimization as well as the implants position is highly
satisfactory but due to the inadequate abutment positioning neither fundamental
functionality nor basic esthetics obtained.
To proactively address all abovementioned obstacles it is
simply to prescribe “All-On-4®
per Mo2 Maneuver” instead
of explaining lengthy procedural intent .
The box containing newly calculated interim prosthesis
together with the articles in a Mo2
Maneuver box that will tie all roles of restorative team
members into one sequential, surgical and prosthetic roadmap to follow,
reassuring pre-determined success of each particular procedural step alone, as
well as the entire All-On-4®
procedure as a whole.
It prevents
for possible error induced into the chain of events by a sole independent team
member and creates highly disciplined and effective interdisciplinary mutual
blueprint to be followed by the entire restorative team.
Mo2 Maneuver box contains following:
-
Mo2 Maneuver
Interim
Prosthesis, a signature and a ‘source code” of Mo2 Maneuver methodology including its exclusive
calculation and way of generating the
new makeover smile based on face and stone model reading formula! Partially
flange-less PMMA acrylic prosthesis that is again following the Mo2 Maneuver
method, thus it is instantaneously attached (snapped) to the opposing dentition
through the clasping mechanism!
This groundbreaking novel thinking is pre-setting the occlusion of Mo2
Maneuver interim prosthesis as a default key,
which is setting the foundation for the entire assembling procedure against the
implants.
The hands of the clinician
remain free and most important -the prefect orbital occlusion is pre-set and
reassured
The intaglio surface of the Interim Prosthesis is flat bedded and
uptakes the original vertical space as well as correlates to bone reduction guide used in the first phase
of All-On-4® surgical
procedure.
Therefore this revolutionary way of thinking doesn’t require any further
occlusal adjustment at the end of any All-On-4® procedure!
-
Bone Reduction
Guide, a vertical rim equivalent to dento-osseous vertical topography that
was removed from the patient’s mouth by surgical and restorative dentistry in
the starting phase of the All-On-4®
procedure. As
a diagnostic vertical key mold, the rim is to determine new bone remodeling
plane which will continuously become the platform for future implants.
-
Surgical
Bone Level Guide & Prosthetic Trajectory Guide, a transparent replica of the
Interim Prosthesis used by the performing surgeon to simply define optimal
implant trajectory despite raised flap and later by the restorative clinician
to define optimal Multi-Unit abutment trajectory. In this step the
surgeon will place four protocol implants correctly and within the contours of to interim prosthesis contours..
Results: The overall satisfaction was subjectively evaluated by
several involved clinicians as well as tvelve(12) featured All-On-4®
patients (# 5.maxillae only; # 4.mandible
only; # 3. Maxillae & mandible) and experience was extraordinary, positive
and significantly superior compared to experience with present All-On-4® protocols with no correlated
roadmaps to follow.
Mo2 Maneuver
reduces burden for the first time for the performing clinician(s) providing for
them explicit tools to follow a predetermined restorative roadmap and allowing
them to show to the patient the mock-up of the final result a just few minutes
into the procedure!
Conclusion: If performing All-On-4®
treatment following Mo2 Maneuver, the grand finale of the entire
procedure is spent on rewarding cherishing moments of a remarkable stress-free
makeover and the beginning of a new quality life for the patient instead of
seemingly never-ending adjustment of the occlusion and other misalignments!
Restorative value of what
become to be called Mo2 Maneuver
( pronounced ”mo square”) is showing superior result when compared to all other
existing All-On-4® protocols
both in the terms of user-friendliness and the overall patient satisfactory
rate, thus making it something that is worthwhile to be shared within dental
community!
The esthetic makeover is so powerful that it will always
result in enormous enthusiasm and positive cooperation by the patient
throughout the entire procedure!
Additionally, due to the development and procedural
efficiency of this methodology, further advantage has been detected in regards
to preparation work needed between the interim and final delivery phase!
Both the number of needed appointments and the time
requirements for the clinical appointments was decreased substantially, so much
so that in the best scenario only one additional visit was necessary!
Acknowledgment of tremendous efficiency improvement and
its multiple effect on clinicians’ overall performance will be measured from
the future empirical data collected on the subject and reported
accordingly.
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