10.59987/ads/2018.4.167-174
AIM: The increase in the average age of the population leads to an increasing incidence of many different systemic diseases, often associated with partial or total edentulism. In particular, diabetes plays a significant role in patients’ implant-prosthetic rehabilitation, as it has a direct effect on the oral cavity. The aim of this case report is to illustrate the rate of implant survival, marginal bone loss and any intraand post-operative complications in patients with type II diabetes, undergoing fixed prosthetic rehabilitation according to the All-on-Four method, in a two-years of follow-up.
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M. Nagni
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Annali di stomatologia
hyperglycemia
All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review
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M. Nagni
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Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy
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hyperglycemia
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174
All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review
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                                                                                                   Original article


All-on-four rehabilitation in patient with type II
diabetes mellitus: case report and literature review

Francesco Orlando*1                                         Results
Irene Cusenza*
Serena Ferri*                                               No implants were lost during the follow-up period. The
Costanza Ferraro*                                           marginal bone loss was comparable to literature results
Matteo Nagni*2                                              related to implant-retained prosthetic rehabilitations in
                                                            healthy patients. No intra- and postoperative complica-
*
    Dental School, Vita-Salute San Raffaele University,     tions were reported.
    Milan, Italy and Department of Dentistry, IRCCS San
    Raffaele Hospital, Milan, Italy                         Conclusion
1
    Fellow MSc, Dental School, Vita-Salute San Raffaele     Maintaining a good glycemic control, able to favor the
    University, Milan, Italy and Department of Dentistry,   compensation of diabetes, the insertion of implants can
    IRCCS San Raffaele Hospital, Milan, Italy               be considered a safe procedure. The constant monitor-
2
    MSc, Dental School, Vita-Salute San Raffaele Univer-    ing of the patient and his adherence to a strict hygiene
    sity, Milan, Italy and Department of Dentistry, IRCCS   protocol are fundamental to promote implant survival
    San Raffaele Hospital, Milan, Italy                     and early identification of complications.

Corrisponding author:                                       Introduction
Matteo Nagni                                                The increase in the average age of the population leads
nagnimatteo@hotmail.it                                      to an increase in the incidence of various systemic dis-
                                                            eases such as diabetes. At the same time fixed rehabili-
                                                            tation of partial or total edentulous patients with systemic
Abstract
                                                            diseases, associated with the increase in the average
AIM: The increase in the average age of the popula-         age, could be increasingly required (1, 2).
tion leads to an increasing incidence of many differ-       Diabetes mellitus is a complex metabolic disease, de-
ent systemic diseases, often associated with partial        fined by the ADA (American Diabetes Association) as a
or total edentulism. In particular, diabetes plays a        group of metabolic diseases characterized by elevated
significant role in patients’ implant-prosthetic reha-      blood glucose levels (hyperglycemia) that result from the
bilitation, as it has a direct effect on the oral cavity.   body’s inability to produce or use insulin (3). There are
The aim of this case report is to illustrate the rate of    four types of diabetes: type I diabetes, an autoimmune
implant survival, marginal bone loss and any intra-         disease characterized by an absolute deficiency of in-
and post-operative complications in patients with           sulin, caused by destruction of pancreatic ß-cells, that
type II diabetes, undergoing fixed prosthetic reha-         affects approximately 5-10% of the population and tends
bilitation according to the All-on-Four method, in a        to occur at a young age; type II diabetes, caused by the
two-years of follow-up.                                     association between a peripheral resistance to the ac-
                                                            tion of insulin and an inadequate secretory response
Keywords: All-on-Four, systemic diseases, immedi-           of pancreatic ß-cells (“relative insulin deficiency”), rep-
ate loading, diabetes, hyperglycemia.                       resents the majority of cases of late-onset diabetes;
                                                            drug- or chemical-induced diabetes; and gestational di-
Materials and methods                                       abetes (4). Diabetes has a direct effect on the oral cav-
                                                            ity, manifesting itself through microangiopathy, altered
The patient, suffering from type II diabetes, presented     immune response and changes in salivary composition
edentulous regions and compromised residual teeth           (5). In cases of implant rehabilitations, diabetes, could
in both arches. Considering the need for a fixed reha-      interfere with the normal processes of osseointegration,
bilitation and, on the other hand, a severe bone loss       as the state of hyperglycemia has a negative effect on
in the posterior maxillary and mandibular sectors, we       osteoblastic regulation and BIC (Bone Implant Contact)
opted for a rehabilitation based on a reduced number        values (6, 7).
of implants, according to the “All-on-Four” method. Fol-    The diabetic patient’s treatment may exhibit two differ-
low-up examinations, aiming at assessing implant sur-       ent types of complications: the intra operative and the
vival and marginal bone loss, were performed one week       post-operative ones. The former group includes hy-
after surgery, after six months and then once a year for    poglycemic crisis, while the latter includes mucositis,
the following 24 months. Any intra- and postoperative       peri-implantitis, lack of implant osseointegration and
complications were noted to evaluate and monitor the        poor wound healing (8). Hypoglycemic crisis is defined
patient. Professional hygiene was performed every four      as an acute consequence of diabetic disease and usu-
months after surgery.                                       ally occurs when the patient had not taken their medi-
Annali di Stomatologia 2018; IX (4): 167-174                                                                               167
      All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review

      cations regularly and had not adequately eaten before
      the appointment (9). Mucositis and peri-implantitis are
      defined as inflammatory lesions of the tissues surround-
      ing an implant. Peri-implant mucositis is defined as an
      inflammatory lesion limited to the surrounding mucosa of
      an implant, whereas peri-implantitis is defined as an in-
      flammatory lesion of the mucosa affecting the supporting
      bone resulting in a loss of osseointegration, thus causing
      a likely decrease in implant success (10). The failure to
      osseointegrate the implant is another occurring post-op-
      erative complication. Osseointegration implies a firm, di-
      rect, and lasting connection between the vital bone and
      the titanium implants (11). In conclusion, we recall the           Figure 2. Intraoral photo: presence in the mandible of an
      incomplete soft tissue healing, caused by high blood glu-          incogruous prosthesis anchored to dental elements.
      cose levels and non-enzymatic protein glycation, leading
      to AGE formation (12) which alters the permeability of
      the endothelium, releases inflammatory cytokines and               ative complications, determined by her general state of
      growth factors, and increases the expression of adhe-              health. A professional oral hygiene session was carried
      sion molecules and chemokines, thus leading to delayed             out during the preoperative phase; subsequently, con-
      wound healing (13,14).                                             ventional impressions were taken for the study models;
      The aim of this case report was to illustrate implant sur-         these were also used for the prosthetic component of
      vival rate, marginal bone loss and possible intra- and             the treatment. This was followed by radiographic inves-
      post-operative complications in patients with type II dia-         tigations including an OPT (orthopantomography, a first
      betes undergoing fixed prosthetic rehabilitation, accord-          level examination) which allowed an overall assessment
      ing to the All-on-Four method, at two years follow-up.             of the jaws (Fig. 3). But, only after performing a CBCT
                                                                         (Cone Beam Computed Tomography, second level ex-
      Case report                                                        amination), it was possible to evaluate the bone volume
                                                                         of the maxilla. After carefully classifying the patient’s
      A 60-year-old woman came to the Department of Den-
                                                                         bone density, defined as D3, and attentively performing
      tistry of the IRCCS San Raffaele Hospital with the wish
                                                                         all preoperative procedures, surgery could be sched-
      to have an implant-prosthetic rehabilitation of the lower
                                                                         uled. One hour before surgery, 2g of Amoxicillin and
      arch. The patient was submitted to an anamnestic ques-
                                                                         Clavulanic Acid (Augmentin, GlaxoSmithKline, Brussels,
      tionnaire which showed that she suffered from type II
                                                                         Belgium) were administered as a preventive measure.
      diabetic pathology. To assess the state of the disease, it
                                                                         The surgical phase was performed under local anaes-
      was decided to perform laboratory tests in which the val-
                                                                         thesia (Optocaine 20 mg/ml with adrenaline 1:80,000;
      ues of Hba1c 7% (glycosylated haemoglobin) and gly-
                                                                         Molteni Dental, Florence, Italy). Some dental elements
      caemic levels <180 mg/dl were analysed. The tests’ re-
                                                                         considered hopeless were avulsed (Fig. 4).
      sults were normal and her diabetes resulted to be under
      control, making the patient an excellent candidate for im-
      plant therapy. The frontal view of the patient’s smile can
      be observed in Figure 1. Intraoral examination revealed
      the presence of an incongruous prosthesis anchored to
      dental elements that functioned as prosthetic abutments
      (Fig. 2). Among the various treatment options, given the
      presence of edentulous areas, the placement of implants
      according to the “All-on-Four” method was considered
      the most valid. After the signing of the informed con-
      sent and the implant-prosthetic treatment, the patient
      was made aware of the possible intra- and post-oper-

                                                                         Figure 3. Orthopantomography that shows the condition of
                                                                         the jaw bones and residual elements.




      Figure 1. Extraoral photo.                                         Figure 4. Post-extractive socket.

168                                                                                         Annali di Stomatologia 2018; IX (4): 167-174
F. Orlando et al.




Figure 5. Crestal incision and bilateral release incisions.
                                                                Figure 7. Tilted implant.




Figure 6. Full-thickness buccal flap.                           Figure 8. Axial and tilted implants.


The mandibular edentulous ridge was incised with a
crestal incision and bilateral release incisions from the
first molar region to the contralateral side and a sub-
periosteal dissection was performed on the lingual and
buccal surfaces (Fig. 5). A full-thickness buccal flap was
then lifted to expose the buccal bone wall and to get an
optimal view of the mental foramen (Fig. 6).
Once the incisions had been made and the flaps lifted,
implant placement was possible. In the mandible, the
two posterior implants (dimensions length and diame-
ter) (TTx, Winsix, Biosafin, Ancona, Italy) were placed         Figure 9. Placement of abutments.
bilaterally immediately anteriorly to the mental foramen
(Fig. 7). It is important to underline that, following the
All-on-Four protocol, the posterior implants are inserted
following an inclined trajectory of about 25-30 degrees
with respect to the occlusal plane. In fact, they emerge
at the level of the second premolar, in order to decrease
the length of the cantilever and maintain a large distance
between the implants. The central implants, on the other
hand, are inserted following a trajectory perpendicular to
the occlusal plane (Fig. 8).
The insertion torque was between 30 and 40 Ncm before
final implant placement, thus achieving high primary sta-
bility and immediate functionality.                             Figure 10. Flap repositioning and suture.
To compensate for the lack of parallelism between the
posterior implants and the prosthetic screw, angled             Then the prosthetic phase started, which included the
abutments (Extreme Abutment, EA Winsix, Biosafin)               delivery of a provisional prosthesis and the taking of
were placed at 30°. The anterior implants, on the other         impressions for the fabrication of the definitive one: a
hand, were fixed at 17° to allow optimal access for the         few hours after surgery, a screw-reinforced, metal-rein-
prosthetic screw ((Fig. 9). After these steps, which were       forced, acrylic provisional prosthesis with ten teeth was
essential for the prosthetic part, the previously lifted flap   delivered (no cantilevers were used in the provisional
was repositioned and adjusted with 4-0 nonabsorbable            prostheses).
suture (Vicryl; Ethicon, Johnson & Johnson, New B run-          The torque for the tightening the prosthetic screws was
swick, NJ, USA), ((Fig. 10). Immediately after surgery,         20 N. Eventually the screw access holes were covered
an OPT was performed to verify the correct placement of         with temporary resin (Fermit, Ivoclar Vivadent, Naturno,
the implants ((Fig. 11).                                        Bolzano, Italy) ((Fig. 12).

Annali di Stomatologia 2018; IX (4): 167-174                                                                                169
      All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review




           Figure 11. OPT to check implants placement.




      Figure 12. Provisional prosthesis.                                 Figure 13. Mucosa after suture removal.


      Approximately four months after surgery, the definitive            Follow-up
      prosthesis will be delivered and, unlike the provisional
      prosthesis, the latter will have an occlusion reproducing          Follow-up visits, aimed at clinical and radiographic ex-
      the patient’s natural dentition, i.e. it will have a cantilever    amination, were performed one week after implant
      distal to the first molar.                                         placement. Subsequently, at three months, six months
      Post-surgical indications included the use of a post-sur-          and then annually until a two-year follow-up was at-
      gical dressing and rinsing with a solution containing              tained. The patient was instructed, by a dental hygienist,
      chlorhexidine digluconate (0.12% or 0.2%), twice a day             in mechanical plaque control using an electric or manual
      for 10 days. In addition, the use of 1 g Amoxicillin and           toothbrush, interproximal brushes and Super Floss (Oral
      Clavulanic Acid (Augmentin, GlaxoSmithKline) twice dai-            B, Procter & Gamble, Cincinnati, OH, USA). While, pro-
      ly for 7 days after surgery and non-steroidal anti-inflam-         fessional oral hygiene procedures were performed every
      matory drugs (Ibuprofen 600 mg, Brufen, Abbott Labo-               three months, after implant placement.
      ratories, Chicago, IL, USA) was recommended should it
      be deemed necessary. Lastly, the patient was advised to            Parameters evaluated
      eat a liquid diet and to avoid any brushing trauma to the
      surgical site, as well as smoking. The patient underwent           Implants survival rate. Implant survival rate is based
      a follow-up visit after one week and the sutures were              on the number of implants that were not lost or removed,
      removed at the same time (Fig. 13).                                during the follow-up period (15).

170                                                                                         Annali di Stomatologia 2018; IX (4): 167-174
F. Orlando et al.

Marginal bone loss. Intra oral radiographs, using the         Intra- and post-operative complications. The patient,
parallel cone technique, were taken after implant place-      thanks to adequate glycemic control (20), did not suffer
ment, at three, six, twelve months and once a year for        from hypoglycemic crisis during the surgical procedure.
the following two years of follow-up. To evaluate mar-        No clinical signs of mucositis and peri-implantitis were
ginal bone progression, the measurements were per-            observed during the two-year follow-up. This was made
formed using Digora 2.5 software (Soredex, Tuusula,           possible by the patient’s inclusion in a maintenance
Finland). First, the instrument was calibrated (pixel/        program of professional oral hygiene and control of the
mm), using the diameter of the implants as the unit.          diabetic pathology (21). The literature suggests that mu-
Then, changes in the height of the peri-implant mar-          cositis is caused by the accumulation of biofilm that inter-
                                                              rupts host-microbe homeostasis at the implant-mucosal
ginal bone with respect to the most coronal part of the
                                                              interface, resulting in an inflammatory lesion. Mucositis
implant fixture and the contact point between the im-
                                                              is a reversible condition, so the clinical implication is that
plant fixture and the marginal crest were measured. To
                                                              optimal biofilm removal is a prerequisite for the preven-
evaluate bone, a line passing over the shoulder of the
                                                              tion and management of mucositis (22). Based on these
implant was considered as a reference point for meas-         considerations, it was agreed that periodic clinical and
urement from which a straight line was drawn parallel         radiographic controls should always be performed after
to the long axis of the implant to the most coronal point     implant placement to allow for the possible diagnosis of
where the bone made contact with the fixture, both me-        mucositis and peri-implantitis. Intra-oral radiographs,
sially and distally. The software automatically provided      taken during the follow-up period, confirmed that os-
the distance between the two points measured in milli-        seointegration had taken place. They showed intimate
meters. To reduce human error, this measurement was           contact between bone and implant, with an apparent ab-
made by different operators, and the mean of the three        sence of interposed fibrous tissue. The osseointegration
measurements was considered.                                  of the patient’s implants was promoted by the correct
Then, to calculate the marginal bone level, a mesial          implant placement, based on the primary stability, which
measurement was taken, a distal measurement was               was obtained by an insertion torque of 30 N (23).
taken and then the average of the mesial, distal and the
average between the two values of a single implant site       Discussion
was calculated.                                               According with the clinical considerations examined, it
                                                              will be necessary to follow an adequate diagnostic path-
Intra-operative and post-operative complications.             way, to obtain a predictable result of the implant-pros-
                                                              thetic therapy of the diabetic patient. During the first visit,
 Intra-operative             Post-operative                   in fact, the general medical and dental history plays a
 complications               complications                    crucial role and allows the clinician to reach an adequate
                                                              knowledge of the patient’s general and dental health sta-
                             Mucositis and peri-implantitis
                                                              tus (24). An anamnesis is followed by an extra- and in-
 Hypoglycaemic crisis        Lack of osseointegration         tra-oral examination; the latter paying particular attention
                                                              not only to the dental elements present in the oral cavity
                             Insufficient wound healing       but also to the soft tissues surrounding the tooth or locat-
                                                              ed on the edentulous ridges (25, 26).
                                                              Before a diabetic patient undergoes oral surgery, it is
Results                                                       necessary to establish the type of diabetes and the de-
Implant survival rate. In the clinical case presented, the    gree of glycaemic control. Robertson C et al., in a review
diabetic patient who received implant rehabilitation, pre-    of the literature, describe the criteria to establishing the
sented laboratory tests appropriate for implant insertion.    diagnosis of diabetes and to identifying individuals at high
No implants were lost during the follow-up period. It is      risk of developing the disease. They suggest that if pa-
stated that the survival rate, two years after surgery, was   tients with controlled diabetes maintain a Hba1c value of
100% (16,17).                                                 <7%, then it will be possible to proceed with surgery (27).
                                                              In the literature review, by Ramu C. et al., the indications
Marginal bone loss. Both axial and tilted implants            for antibiotic prophylaxis in dental practice are stated.
                                                              For patients with uncontrolled diabetes, antibiotic proph-
showed marginal bone loss comparable to that of the
                                                              ylaxis is considered mandatory as they are more sus-
healthy patient (17-19).
                                                              ceptible to oral infections. On the other hand, antibiotic
                                                              prophylaxis is recommended for patients with controlled
   MARGINAL                                                   diabetes, both in the case of minor and major surgery
     BONE             Axial implants       Tilted implants    (28). For these reasons, in agreement with the authors,
     LOSS                                                     the patient was given 2g of Amoxicillin and Clavulanic
                                                              acid one hour before surgery, as a preventive measure.
 6 months (mm)          0.61 ± 0.75            0.66 ± 0.58    The most serious complication, that a diabetic patient
                                                              can experience during oral surgery, is a hypoglycemic
   1 year (mm)          0.85 ± 0.83            0.86 ± 0.91    crisis. To prevent this fact, it is important to make sure
                                                              that the patient has taken their usual medication and
  2 years (mm)          0.86 ± 0.78            0.88 ± 0.64    eaten regularly before the appointment (29). If the pa-
                                                              tient has lost consciousness due to hypoglycemic crisis,

Annali di Stomatologia 2018; IX (4): 167-174                                                                                    171
      All-on-four rehabilitation in patient with type II diabetes mellitus: case report and literature review

      medical assistance should be sought; a solution of 25-30           to micro-vascular complications and delayed wound
      ml 50% dextrose or 1 mg glucagon should be injected                healing (41).
      intravenously; glucagon can also be administered intra-            In the retrospective study by Alberti et al., no difference
      muscularly or subcutaneously (30). According to Kidam-             in implant survival (survival rate) after 10 years was
      bi S. et al., patients receiving oral antidiabetics have a         shown in patients with diabetes (survival rate 96.5%),
      lower risk of developing hypoglycemic crises than those            compared to patients without diabetes mellitus (surviv-
      receiving insulin therapy (31).                                    al rate 94.8%) (42). According to the literature review,
      Holmstrup P. et al. state that, since diabetes mellitus            by Naujokat H. et al., in the first years after implant
      is a systemic inflammatory state, often associated with            placement, the survival rate of implants in patients
      periodontitis, in case of implant rehabilitation, the patient      with controlled diabetes does not differ from that of
      may have an increased risk of developing mucositis and             non-diabetics. However, when observed in the long
      peri-implantitis (32). In the literature, the correlation be-      term, about twenty years, the implant survival rate is
      tween hyperglycemia and the risk of peri-implantitis is            reduced in patients with controlled diabetes compared
      still a matter of discussion. Alberti A. et al., in their ret-     to non-diabetic patients (43).
      rospective study, evaluated the influence of diabetes on           Lorean A et Al., in their retrospective study, reported
      peri-implantitis and implant failure. They considered 204          that patients with high HbA1c values (8.1% to 10.0%)
      patients, treated with 929 implants. Of these, 19 were             had greater marginal bone loss than those with lower
      diabetic patients and most of them showed good control             HbA1c values (44). In agreement with this, Souto-Maior
      of their diabetic disease at the time of implant surgery.          JR et al., through a systematic review of the literature,
      Among the diabetic patients only one showed peri-im-               state that it is possible to observe marginal bone loss
      plantitis and another one showed increased implant                 that affects osseointegration (45). The factors that can
      failures. The results of these authors showed no asso-             contribute to implant failure, as already described, are
      ciation between peri-implantitis, diabetes mellitus and            many. However, according to the scientific review by
      implant failure (33). In contrast, Rekawek P. et al, in their      Mombelli et al., bacterial plaque has a negative role in
      retrospective cohort study, examined 286 patients treat-           the health of peri-implant oral tissues; in fact, the basis
      ed with 748 implants and found that diabetic patients had          of a correct management of the bacterial flora is home
      an increased risk of peri-implantitis. However, this risk          oral hygiene supported by professional services (46). It
      can be counteracted by placing patients on a mainte-               is necessary to underline how fundamentally important
      nance regimen with regular visits and professional oral            the synergy between the dental professional and the
      hygiene sessions (34).                                             dental hygienist is in the context of successful implant
      Another clinical aspect affected by diabetes is implant            rehabilitation, which, even more so in the treatment
      osseointegration. In the retrospective case-control study          and monitoring of patients with systemic pathologies,
      by Sghaireen MG et al. 257 subjects were included, 121             must be expressed because of the potential risks of
      with and 136 without diabetes; diabetes was defined as             any preoperative, intraoperative, and postoperative
      well controlled with a HbA1c of less than 8%. Implant              complications (47, 48).
      failure in the osseointegration process was observed in
      17 cases in the diabetes group (4.5%) and in 16 cases in
      the control group (4.4%), so that a non-significant differ-        Conclusion
      ence (p = 0.365) was concluded (35). Schwarz F. et al.,
                                                                         This case report could demonstrate that implant-pros-
      in their retrospective cohort study, evaluated immediate
                                                                         thetic rehabilitations in the totally edentulous patient
      loading in a patient with type II diabetes. In 108 diabetic
                                                                         with compensated diabetes could be safely applied.
      patients, immediately loaded implants showed identical
                                                                         Clinical studies should be performed to confirm this
      survival to those placed after 3 months (100% each)
                                                                         result.
      (36). In diabetic individuals, persistent hyperglycaemia
      suppresses osteoblastic activity and alters the response
      of parathyroid hormone which regulates calcium and                 References
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