The History Of The Refresh Smile Procedure

The Refresh Smile concept was introduced to provide an efficient graftless fixed restoration for the terminal dentition or edentulous patient. The concept utilizes just 4 implants, tilting two posterior implants to avoid grafting (Graftless Solution) and in many cases allows placement of a fixed immediate prosthesis. The design allows for greater load distribution utilizing an initial acrylic prosthesis without a cantilever. It offers patients an opportunity to reduce the transition time from a terminal dentition or a complete denture to a new secure fixed oral rehabilitation. The Refresh Smile concept allows this procedure to be performed safely and predictably with a team approach through education, support and experience.

The history and evolution of the current day treatment is quite interesting and well documented. Dr. Paul Schnitman from Harvard published in the Journal of Oral Implantology (1990) on an immediate fixed interim prostheses supported by 3 implants during the healing of the submerged final implants. It was during these studies that it was found that the majority of the immediately placed and loaded implants integrated. These implants were documented at a 10 year follow up study. In 1997 Tarnow, et al., published a study, (International Journal of Oral & Maxillofacial Implants 1997), using a similar methodology placing 5 implants and submerging 5. They documented 1-5 year data illustrating that the immediate load of the maxilla was a viable treatment option. Branemark published 10 year survival rates of a fixed prostheses on four and six implants, (Clinical Oral Implants Research 1995). These were not immediately loaded but there was no difference in prostheses survival between the 4 or 6 implant cases. At the time of this study the only implants available were either 7 or 10 mm in length. The TILTED IMPLANT was introduced by Yvan Fortin and Bo Rangert in 1993 in Gothenburg Sweden as part of a graftless solution supporting the Marius Bridge. A retrospective study was done in Clinical Implant Dentistry and Related Research 2002.

Yvan tilted his implants beginning in 1992, Bo, an engineer, began working on the biomechanics of why the concept was working. Initially Yvan was doing a 2 stage procedure. Bo encouraged Paulo Malo to attempt a single staged procedure based on his biomechanical studies and the concept of cross arch stabilization. Mattesson (J Oral & Maxillofacial Surg 1999) published on tilted Maxillary implants without bone grafting in severely resorbed maxillas. Rangert, et al., published on tilting posterior mandibular and maxillary implants for improved prosthesis support, (Int J Oral Maxillofacial Implants 2000).

With knowledge gained by Bo Ranger working with Yvan Fortin the way was paved for immediate loading of tilted implants by Dr. Paulo Malo. Malo tied together the immediate load with the use of 4 implants. The posterior 2 being tilted to bring about the concept marketed today as “The All ON FOUR”. Dr. Malo’s first documented cases with the All ON FOUR lower jaw began in April of 1998 and for the upper jaw in February 2001. The ALL ON FOUR concept was introduced by Nobel Biocare in September 2004.

Malo published in the Journal of the American Dental Association (2011), a longitudinal study of the survival of All on 4 implants in the mandible up to 10 years of follow up. A total of 245 patients with 4 implants each were included in this study. Patient and implant success rates were 94.8% and 98.1% respectively at 5 years and 93.8% and 94.8 % at 10 years. The prostheses survival rate was 99.2 % with up to 10 years follow up. His unpublished maxillary survival rates in 2011 were 98.4% for the implants and 99.7% for the prosthesis. This was at 8 years and included a total of 1014 patients and 4056 implants 64 of which were lost.

If the two posterior implants are torqued in to greater than 35 Newton’s Force the prosthesis can be fixed upon 3 implants. If less than 3 implants are secure to 35 Newton’s Force, or the 2 posterior implants are less than 35 Newton’s Force, a removable prosthesis is used.

The natural progression of the AO4 concept and experience illustrates well the importance it has found in our treatment regimens available to restore health and function to the stomatognathic system. Despite its emergence of popularity through corporate centers and mass marketers it must not be overlooked as a safe, efficient and proven treatment modality when considering reconstruction of form and function for our edentulous and terminal dentition patients.