What is full-mouth rehabilitation, who is it for, and how does it proceed?

In a mouth with one tooth missing, the question is simple: what will go into that gap? If most teeth are missing, the remaining ones are loose, or bridges, fillings and crowns made over the years are causing one problem after another, the question changes: how will this mouth work as a whole? Full-mouth rehabilitation is the answer to this second question. The plan starts not from a single tooth but from how the two jaws will close together, the height of the face, lip support and speech sounds. When gaps are closed one by one, each new procedure has to fit the previous one; in a full-mouth plan, the bite is designed once and from the start.

The routes that lead to this treatment differ. The most common is advanced gum disease: when the bone holding the teeth has decreased over a wide area, the teeth become loose and are lost one by one. The second is the collapse of treatments built up over the years: bridge abutments with fractured roots, root canal treatments done again and again, crowns with decay underneath. The third is severe wear of the teeth: when teeth become shorter through clenching, acid or age, the height of the bite can drop. The fourth is jaws with no teeth after years of wearing a removable denture. Whichever it is, what they have in common is that the problem lies not in a single tooth but across the mouth.

In a jaw with no teeth, there are three main options. The NHS defines a complete denture as removable false teeth that replace all the teeth in a jaw and sit on the gums, and states that the denture can become loose as the gums and jawbone shrink over time. The second option is a removable denture that clips onto a few implants. The McGill consensus statement of 2002 recommended a removable denture held by two implants in the lower jaw as the first-choice standard of care for people with no teeth. The third is a full-arch bridge that is screwed or fixed to implants and that the patient cannot take out. The choice is decided by the condition of the bone, the opposing jaw, manual dexterity, expectations and budget together.

How many implants a fixed bridge needs is a frequently asked question, and the evidence does not point to a single number. A 2018 systematic review by the International Team for Implantology (ITI) examined 93 studies and found no significant difference in implant and prosthesis survival between fixed bridges carried on fewer than five implants in a jaw and those carried on five or more, with follow-up ranging from 1 to 15 years. The numbers most often reported were 4 in the upper jaw and 3 and 4 in the lower jaw in the fewer-implant group, and 6 in the upper jaw and 5 in the lower jaw in the more-implant group. The consensus report of the same meeting states that various numbers of implants can support full-arch fixed bridges. The right number for you is decided by the bone, the jaw and the biting force; we have covered this in detail on a separate page.

What determines the timeline most is the timing of loading, that is, when teeth are fitted onto the implants. A 2013 Cochrane review states that with the conventional route, implants are left unloaded for 3 to 8 months so that they fuse with the bone; the same review found no convincing difference in prosthesis or implant loss in the first year between implants loaded within the first week and implants loaded conventionally. A 2014 review of loading with fixed bridges in patients with no teeth also states that when cases are carefully selected, immediate loading gives survival similar to early and conventional loading, and that first-year implant survival was estimated at over 99 per cent with all three methods, but that many confounding factors affect the results.

With the conventional route, this waiting period lengthens the timetable. Extractions are done, a bone graft or sinus lift is added if needed, the implants are placed and months of fusion are waited for; during this time the patient usually wears a temporary denture, and then come new impressions and try-ins for the permanent teeth. In some plans that use immediate loading, a fixed temporary bridge is fitted in the first few days and replaced months later with the permanent bridge. With both routes, the first teeth fitted in the mouth are not the final teeth, and the treatment is spread across more than one stage and trip.

In the Implant72 protocol, the implants and the final fixed teeth are completed in 3 days, that is 72 hours. Because implants that anchor in the hard cortical bone deep in the jaw are used, in most cases a bone graft and months of waiting for fusion fall outside the plan; planning, surgery, try-ins and laboratory work follow one another in the same visit. The teeth fitted on day 3 are the final teeth; they are not removed months later and replaced with another bridge, and no second trip is needed. This timetable is the result when the conditions are met: the CBCT scan, your general health and the implants seating in the bone with the expected resistance during surgery determine the plan.

Whichever route is chosen, full-mouth rehabilitation is a commitment to maintenance. A 2012 review pooling studies that followed fixed bridges on implants in patients with no teeth for at least 5 years showed that complications arose continuously with time and fatigue: after 5 years, 29.3 per cent of bridges had had no complications at all, and after 10 years, 8.6 per cent. The most common problems were fracture or chipping of the veneering material, screw fracture and bone loss around the implants. The authors stress that these events may not lead to the loss of an implant or bridge, but they do require repair, maintenance, time and cost. These data also cover bridges made with older materials; even so, the message is clear: regular check-ups and, if planned, measures such as a night guard are part of the treatment.

The first list shows situations in which full-mouth rehabilitation is generally the right approach, and the second list situations in which another step is needed first or a smaller treatment may be enough. The CBCT scan and examination give the final decision.

The sequence below is a general framework. With the conventional route these steps are spread over months; in the Implant72 protocol, the part from surgery to the final teeth is completed in the same visit, in 3 days.

1. 1

   Assessing general health and medicines

   You are asked about diabetes, heart disease, blood thinners, osteoporosis medicines, any history of radiotherapy and smoking. If needed, the opinion of the relevant doctor is requested; this step determines whether surgery can be done safely.

2. 2

   CBCT scan and oral examination

   A three-dimensional CBCT scan shows the height, width and density of the bone and the position of the sinuses and nerves. A gum examination and X-rays reveal which teeth can be kept and which cannot be saved.

3. 3

   Planning the bite and appearance

   How the two jaws will close together, the height of the bite, lip support, tooth length and the smile line are decided. With worn teeth, the height of the bite may need to be changed; in one review, most of the dentists surveyed reported that they had observed patients adapting well to the new height, and the literature also supports the jaw muscles adapting to this change.

4. 4

   Deciding on the option

   A decision is made between a full denture, an implant-retained removable denture or a fixed bridge on implants. For a fixed bridge, the number and positions of the implants are planned according to the bone and biting force.

5. 5

   Extractions and surgery

   Teeth that cannot be saved are extracted and the implants are placed. With the conventional route, if a bone graft or sinus lift is needed, these are added as separate stages and healing is waited for.

6. 6

   Try-ins and fitting the teeth

   With the conventional route, impressions, try-ins and the permanent teeth come after fusion; a temporary denture usually comes in between. In the Implant72 protocol, the try-ins and the fitting of the final fixed teeth are done within the same 3-day visit, and the teeth fitted on day 3 are the final teeth.

7. 7

   Check-ups and maintenance

   The gums and bone continue to heal; small adjustments to the bite can be made at check-ups. In the long term, regular cleaning, checks around the implants and, if needed, a night guard are part of the treatment.

The options below are different answers to the same problem. Each has its pros and cons; the right one is decided by the bone, your health and your expectations together.

The following are mistakes commonly seen in full-mouth rehabilitation, and what they cost. They show the questions you should ask whichever clinic you go to.

Healing varies with the method chosen. The course below is a general framework for a fixed bridge on implants; the follow-up plan your dentist gives you takes priority.

1. The first few days

   Swelling, mild bleeding and tenderness are normal. A cold compress, soft foods and the medicines you are given are the basic rules of this period.

2. The first few weeks

   The tongue, lips and cheeks get used to the new teeth; there may be a brief change in speech. Chewing gradually returns to normal.

3. The first few months

   The gums and the bone around the implants continue to heal. The bite is assessed at check-ups and small adjustments are made if needed.

4. The long term

   Regular professional cleaning and checks around the implants continue. Reviews show that screw and veneer problems can arise over the years; a problem noticed early can be solved with a small repair.

We do not give figures here, because full-mouth rehabilitation is not a package but a plan built around the individual. The items that determine the scope and cost:

One jaw or both

Doing both jaws together increases the scope of procedures, materials and laboratory work.

The method chosen

The scope differs markedly between a full denture, an implant-retained removable denture and a fixed bridge on implants.

Bone condition and extra surgery

With the conventional route, if a bone graft or sinus lift is needed, an extra procedure and waiting time are added.

Number of stages and trips

In plans where temporary teeth are replaced with permanent ones months later, extra appointments and trips add to the cost.

Materials and maintenance

The bridge material, a night guard and long-term maintenance appointments are part of the total cost.