Hello, my name is Paul Weigl. I'm a teacher in the Goethe University, Frankfurt, Germany. We run there a program, a two-year program, MSc in Oral Implantology. The point is, if a patient is edentulous, we want to restore him and we want to follow his wishes, and of course, he wants to look nice, and he should have a fixed denture after the treatment. Therefore, a comprehensive planning is necessary. First, to evaluate the right restorative space. You see, if their restorative space is correct, it's changed the profile of the face dramatically in a very aesthetic one. However, to evaluate the right and correct occlusal vertical dimension, it's not so easy of the alveolar ridge. because we don't have any kind of literature telling us which is the right method to do. Therefore, we recommend you to have one-third of the lower part of the face as a landmark for the right restorative space in your treatment plan. On the other hand, we have to consider the alveolar ridge resorption, which can have very minor or very severe resorption. This will change, also, your fixed dental restoration. In that way, that we have here different kinds of the signs of the bridges. In the right, you see that we have to substitute the alveolar ridge a lot with materials of ceramic and of also a veneering of resin. The restoration has a different looking if you have only a small resorption of the alveolar ridge, you see the pontics and the crown are coming very nature like out of the soft tissue. Like, or with pontics, and it's giving you back a very nice smile. On the other hand, if you have to substitute the alveolar ridge, you have to do it with materials you will use in the prosthodontics, ceramics or veneering with resin. The next question is, the number of implants. How much we should use in the edentulous case, and of course the maximum is one implant for one missing tooth. The minimum today, in the literature, is called the four implants per jaw. The lower jaw and the upper jaw. If you have tilted one you can also extend the area which is used for giving the right bone on implants and the right support of implants. You see here on the literature from Mericske-Stern, that four implants are working very well here on the survival rate, which are very close to 100%. So, four implants are absolutely nice. The loading protocol: We can have a delayed loading three months after placement and the immediate loading at the same day. But you have to keep in mind that osseointegration is absolutely depending on a lack of micro-movement between implant and bone. This can be solved by, first, a good primary stability, a good anchoring of the implant in the bone. If not, you'll have to choose to a delayed loading protocol, no loads in the beginning for the first three months. But most patients want to have the restoration or even the temporary restoration immediately. So, the whole implant community moves more and more to the immediate loading and herefore you need a good primary stability of your implants. You can achieve it by osteotomy, which has a smaller diameter than the final implants to get a good anchoring. Or you use a very long tilted implant to get a good primary stability together with the splinting, and the data are very nice. In the end, you can also use implants with an aggressive thread. Anchoring perfectly, especially in the soft bone. The next planning step is: should you use guided surgery or go by free-hand placement? We recommend you strictly in edentulous jaw to use guided surgery, especially in case of a fixed prostheses. Because you have to place the implants in a proper way according to the final restoration, not to place an implant in a proximal space. This is important. Then we go to the work steps. First, the dental lab will evaluate the restorative space in a very conventional way which is a wax up. Or, we can also do it today by a digital way. The next working step is implant placement. Once again, we recommend you do it guided with a surgical stand or free-hand. Then, after placement in spacial immediate loading we produce a temporary bridge in a very conventional way. It's much more easier to do it by guided surgery and then you can have a prefabricated temporary bridge. With, on a milling denture, and, so you can bring in this bridge very fast and very easy. The next working step is, let me say, try in of a screw retained set-up to check all the parameters for occlusion, vertical space, and smile. And, this is a procedure which takes time and a lot of effort to get the right aesthetics and the right lips. You see it here on the pictures, what is before and after the try in. Last but not the least, the full arch restoration. A fixed one was manufactured in the dental lab. And, more or less you have to insert this final restoration mostly screw retained. In the end, you have to check the occlusion, which is in our department, edentulous to tooth. So you can have the same occlusion concept like on a natural dentition. You see here, this case, before he gets the treatment and after. Last but not least, the maintenance of this full arch restoration is also a big topic. The oral hygiene, if the oral hygiene is poor, you see a very big drop down to the survival rate and this is also a paper of our group which is dramatically if you don't have a good oral hygiene. So, we come to the summary. Restoring edentulous patients with implant supported fixed dental prostheses implicates following choices. Number of implants and loading protocol and the evaluation of the restorative space is mandatory and challenging. In the upper jaw, a check of smile design is also recommended. Thank you very much for your attention.
