Full Mouth Reconstruction & Implants | Dr. Jiang Xinzhi (Prosthodontics) | CMCS Shanghai

About Dr. Jiang Xinzhi

Dr. Jiang Xinzhi is Director of Prosthodontics at Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine — China's premier centre for advanced dental and maxillofacial care and a national reference institution for complex prosthodontic rehabilitation, dental implantology, and full-mouth reconstruction. He is recognised for his expertise in full-mouth implant-supported rehabilitation, complex prosthetic design, sinus floor augmentation, and the multidisciplinary management of patients with severe dentition loss, advanced periodontal disease, and compromised alveolar bone. Dr. Jiang's practice is defined by the philosophy that full-mouth reconstruction is not a dental procedure — it is a rehabilitation of the entire stomatognathic system, in which the restoration of masticatory function, vertical dimension, occlusal stability, and facial aesthetics must be planned as an integrated whole from the first consultation, because every decision made at the implant planning stage determines the functional and aesthetic outcome of the final prosthesis. His department at Shanghai Ninth People's Hospital has established one of China's most comprehensive prosthodontic rehabilitation programmes, integrating CBCT-based implant planning, periodontal surgery, sinus floor augmentation, guided implant placement, CAD/CAM prosthetic fabrication, and structured long-term maintenance into a unified care pathway for patients with complex dentition loss.

Case Overview

Mr. William Hargreaves (pseudonym), a 58-year-old British retired civil servant based in Shanghai, presented with a decade-long history of progressive tooth loss, now reduced to three Grade III mobile residual roots (upper left 4 and 5, lower right 4) with no functional dentition remaining. Clinical examination revealed severe generalised alveolar bone resorption, collapsed vertical dimension, facial ageing from loss of lower facial height, and severely compromised masticatory function — the patient was restricted to a soft diet. CBCT demonstrated insufficient posterior maxillary bone height with proximity to the sinus floor, and adequate but reduced-density mandibular bone. A multidisciplinary team led by Dr. Jiang Xinzhi — including prosthodontics, implantology, and periodontics — designed a staged full-mouth rehabilitation: periodontal therapy and residual root extraction; bilateral maxillary sinus floor elevation (internal lift technique) with simultaneous implant placement; six maxillary implants and four mandibular implants; provisional prostheses during osseointegration; and full-arch fixed implant-supported definitive prostheses. At one-year follow-up, all ten implants were stable with bone levels within normal limits, masticatory function was fully restored, and the patient reported significant improvement in facial appearance, confidence, and quality of life.

Patient Background

• Name / Nationality: Mr. William Hargreaves (pseudonym) — British; 58-year-old retired civil servant based in Shanghai
• Age / Sex: 58-year-old male
• Chief Complaint: Progressive tooth loss over 10 years; severely impaired masticatory function; restricted to soft diet; facial ageing; unclear speech; requesting full-mouth rehabilitation
• Dental history: Progressive tooth mobility and loss beginning 10 years ago; periodontal basic treatment at another institution 10 years prior; no specialist dental care since; residual roots left untreated
• Smoking history: 30-year smoking history (approximately 10 cigarettes per day); ceased smoking 1 year prior to presentation — smoking cessation confirmed before implant planning
• No systemic contraindications: No hypertension, diabetes, cardiac disease, haematological disorders, or infectious disease; no drug allergies — systemic health confirmed suitable for implant surgery
• Extraoral examination: Facial symmetry preserved; lower facial height reduced — loss of vertical dimension from dentition loss; lip commissures drooping; increased facial wrinkling; aged facial appearance. Temporomandibular joints non-tender; mouth opening normal; no mandibular deviation on opening
• Intraoral examination: Upper arch — edentulous except for upper left 4 and 5 residual roots, Grade III mobility, erythematous and oedematous gingiva. Lower arch — edentulous except for lower right 4 residual root, Grade III mobility, mild gingival inflammation. Generalised severe gingival recession; severe alveolar bone resorption reaching the apical third and furcation areas at multiple sites. Occlusal relationship disrupted; vertical dimension collapsed. Oral mucosa otherwise normal — no ulceration or masses

Diagnostic Workup

Panoramic Radiograph

• Alveolar bone: Generalised severe alveolar bone resorption in both arches; reduced bone density in the maxilla and mandible
• Residual roots: Upper left 4 and 5 and lower right 4 residual roots confirmed; no periapical radiolucency — no acute periapical pathology
• Maxillary sinuses: Bilateral maxillary sinuses visible; posterior maxillary bone height appears reduced — CBCT required for precise measurement

Cone Beam CT (CBCT)

• Maxilla — posterior regions: Insufficient bone height in the posterior maxillary regions; residual bone height above the sinus floor insufficient for standard-length implants in some areas — sinus floor elevation required before or simultaneous with implant placement
• Maxilla — anterior regions: Adequate bone height and width for implant placement without augmentation
• Mandible: Overall bone volume adequate for implant placement; bone density mildly reduced in some regions — implant site selection and length optimised accordingly
• Critical anatomy: Inferior alveolar nerve canal position mapped bilaterally; mental foramen positions identified; maxillary sinus floor contour and membrane thickness assessed — all critical for safe implant trajectory planning

Study Model Analysis

• Diagnostic wax-up: Study models fabricated; diagnostic wax-up performed to visualise the planned final prosthetic outcome, establish the target vertical dimension of occlusion, and confirm implant positions relative to the planned prosthetic tooth positions — the prosthetic-driven implant planning approach

Dr. Jiang's pre-treatment assessment: The CBCT is the foundation of the implant plan. Before we place a single implant, we need to know exactly where the sinus floor is, where the inferior alveolar nerve is, what the bone density is at each planned implant site, and whether the bone volume is sufficient for the implant diameter and length we need to support the prosthesis. In this patient, the posterior maxilla is the challenge — the sinus has pneumatised into the space left by the missing teeth, and there is not enough bone height for a standard implant without lifting the sinus floor. The internal lift technique is appropriate here because the residual bone height is sufficient to achieve primary implant stability at the time of the lift — we do not need to stage the sinus lift and the implant placement as separate procedures. The mandible has adequate bone. The plan is six implants in the maxilla and four in the mandible — ten implants total to support full-arch fixed prostheses in both jaws.

Multidisciplinary Team Discussion and Treatment Strategy

The MDT convened by Dr. Jiang Xinzhi included prosthodontics, implantology, and periodontics. The treatment sequence was designed to address the biological prerequisites for implant success before proceeding to surgical and prosthetic phases.

Phase 1 — Periodontal therapy: Full-mouth ultrasonic scaling and hand instrumentation to eliminate calculus and plaque; oral hygiene instruction; inflammation control before any surgical intervention.

Phase 2 — Residual root extraction: Extraction of all three Grade III mobile residual roots under local anaesthesia; healing of extraction sockets before implant placement.

Phase 3 — Sinus floor elevation and implant placement: Internal sinus lift (osteotome technique) at posterior maxillary sites with insufficient bone height; simultaneous implant placement where primary stability achievable. Six maxillary implants (upper left 2, 3, 6; upper right 2, 3, 6); four mandibular implants (lower left 3, 6; lower right 3, 6).

Phase 4 — Provisional prostheses: Fabrication and delivery of provisional implant-supported prostheses during the osseointegration period — restoring function and aesthetics while protecting the healing implants and allowing the patient and clinician to evaluate the planned vertical dimension and occlusal scheme before committing to the definitive prosthesis.

Phase 5 — Definitive prostheses: Full-arch fixed implant-supported definitive prostheses in both arches following confirmed osseointegration (maxilla 6 months; mandible 3–4 months); CAD/CAM fabrication; individualised abutments; occlusal adjustment to final stable occlusion.

Treatment Course

Phase 1 — Periodontal Therapy

Full-mouth ultrasonic scaling and hand scaling and root planing performed across two appointments. Oral hygiene instruction provided — modified Bass brushing technique, interdental brushes, and chlorhexidine rinse. At two-week review, gingival inflammation had resolved significantly — erythema and oedema reduced, bleeding on probing reduced. Periodontal status confirmed stable before proceeding to extraction.

Phase 2 — Residual Root Extraction

Upper left 4 and 5 and lower right 4 residual roots extracted under local anaesthesia using atraumatic extraction technique — minimising alveolar bone loss at the extraction sites. Post-operative antibiotics, analgesics, and oral hygiene instructions provided. Sutures removed at one week; extraction socket healing confirmed satisfactory at four weeks before proceeding to implant surgery.

Phase 3 — Sinus Floor Elevation and Implant Placement

Maxillary sinus internal lift (osteotome technique): At the posterior maxillary implant sites where residual bone height was insufficient, the internal sinus lift was performed simultaneously with implant site preparation. The osteotome technique uses a series of progressively wider osteotomes to compact the crestal bone and gently elevate the sinus floor membrane through the implant osteotomy, without a lateral window approach. Bone substitute material was introduced through the osteotomy to augment the sub-sinus space. The technique is appropriate when residual bone height is sufficient to achieve implant primary stability — typically 4–6 mm or more — allowing simultaneous implant placement without a staged approach.

Implant placement — maxilla: Six implants placed at upper left 2, 3, 6 and upper right 2, 3, 6. All implants achieved satisfactory primary stability (insertion torque within the target range). Healing abutments placed; flap closed with interrupted sutures.

Implant placement — mandible: Four implants placed at lower left 3, 6 and lower right 3, 6. All implants achieved satisfactory primary stability. Healing abutments placed; flap closed.

Post-operative management: Prophylactic antibiotics for 5 days; analgesics; chlorhexidine rinse; soft diet for 4 weeks; no removable prosthesis loading during the healing period. Sutures removed at one week; healing confirmed satisfactory.

Dr. Jiang's operative note: The internal sinus lift is a technique that requires precise tactile feedback. You are elevating the Schneiderian membrane — the lining of the maxillary sinus — through a 4 mm osteotomy using an osteotome and mallet. The membrane is approximately 0.5 to 1 mm thick. If you perforate it, you have a sinus communication that can compromise the graft and the implant. The technique is to work slowly, in small increments, feeling the resistance change as the membrane lifts away from the sinus floor. When the resistance disappears, the membrane is elevated. In this patient, both posterior maxillary lifts were completed without membrane perforation. The implants achieved good primary stability at all six maxillary sites. That is the prerequisite for simultaneous placement — if primary stability is not achievable, you stage the procedure and place the implants after the graft has consolidated.

Phase 4 — Provisional Prostheses

Impressions taken at 8 weeks post-implant placement; provisional implant-supported fixed prostheses fabricated in both arches. Provisional prostheses delivered and adjusted — occlusal contacts verified, vertical dimension of occlusion established at the planned level, and aesthetics assessed. Patient reported satisfactory masticatory function and significant improvement in facial appearance with the provisionals. Provisional phase maintained for the full osseointegration period — 6 months for the maxilla, 3–4 months for the mandible — allowing the patient to adapt to the new vertical dimension and providing the clinical team with functional and aesthetic feedback before committing to the definitive prosthesis design.

Phase 5 — Definitive Full-Arch Fixed Implant-Supported Prostheses

Following confirmed osseointegration (clinical stability and radiographic bone levels within normal limits at all ten implant sites), definitive prosthetic procedures commenced. Open-tray implant-level impressions taken; individualised CAD/CAM titanium abutments designed and milled; full-arch zirconia-based fixed prostheses fabricated. Try-in of frameworks confirmed passive fit — the critical requirement for implant-supported fixed prostheses, as a non-passive fit generates chronic stress at the implant-bone interface and risks implant failure. Final prostheses delivered; occlusal adjustment performed to achieve bilateral simultaneous posterior contacts in maximum intercuspation and canine-guided lateral excursions. Patient reported immediate improvement in masticatory efficiency and comfort.

Dr. Jiang's prosthetic note: The passive fit of the framework is the non-negotiable requirement in full-arch implant prosthetics. If the framework does not seat passively — if it requires force to seat, or if it rocks on the implants — it will generate bending moments at the implant-abutment interface with every occlusal load. Over time, those bending moments cause screw loosening, abutment fracture, or implant failure. We verify passive fit clinically with the Sheffield test — tightening one screw and checking whether the framework lifts at the opposite end — and radiographically by confirming complete seating at every implant connection. In this patient, the framework seated passively at the first try-in. That is the result of precise impressions, accurate model work, and careful CAD/CAM milling. When the fit is right, the prosthesis feels right to the patient immediately — no rocking, no discomfort, just function.

Post-treatment Management and Outcomes

Follow-up Schedule and Clinical Outcomes

• 1 month: Soft tissue healing confirmed; patient adapting well to new occlusion; minor occlusal adjustments made; oral hygiene reinforced
• 3 months: Masticatory function fully restored — patient able to eat all food types including hard foods; no prosthetic complications; implant stability confirmed clinically
• 6 months: Radiographic assessment — all ten implants with bone levels within normal limits; no peri-implant bone loss beyond the expected initial remodelling; gingival health maintained
• 1 year: All ten implants stable; no screw loosening, no prosthetic fracture, no peri-implantitis; patient maintaining excellent oral hygiene with interdental brushes and water flosser; annual professional maintenance scheduled

Patient-Reported Outcomes

• Masticatory function: Full restoration — patient able to eat all food types without restriction; masticatory efficiency subjectively and objectively improved
• Facial aesthetics: Significant improvement in lower facial height; lip support restored; facial wrinkling reduced; patient reported feeling visibly younger and more confident in social interactions
• Speech: Articulation normalised; no phonetic complaints
• Quality of life: Patient reported marked improvement in daily function, social confidence, and overall wellbeing

Expert Commentary — Dr. Jiang Xinzhi

1. Prosthetic-Driven Implant Planning: Why the Final Prosthesis Must Be Designed Before the First Implant Is Placed

The most common error in full-mouth implant rehabilitation is placing implants based on available bone and then designing the prosthesis around the implant positions. This approach produces implants in the wrong positions for the prosthesis — leading to cantilevers, unfavourable occlusal loading, compromised aesthetics, and prosthetic complications that are difficult or impossible to correct without explanting and repositioning the implants. The correct approach is the reverse: design the final prosthesis first — establish the target vertical dimension, the planned tooth positions, the occlusal scheme, and the aesthetic requirements — and then plan the implant positions to support that prosthesis. The diagnostic wax-up translates the prosthetic plan into a three-dimensional model that guides the surgical template and the implant trajectory. In this patient, the wax-up established the target vertical dimension and the planned tooth positions before a single implant was placed. Every implant was positioned to support the planned prosthesis — not to exploit available bone. The result is a prosthesis that functions and looks as planned, with implants in positions that distribute occlusal load optimally across the bone-implant interface.

2. The Maxillary Sinus: The Central Anatomical Challenge of Posterior Maxillary Implantology

The maxillary sinus is the dominant anatomical constraint in posterior maxillary implant planning. After tooth loss, the alveolar bone resorbs and the sinus pneumatises — expands downward into the space vacated by the tooth roots — progressively reducing the residual bone height available for implant placement. In patients with long-standing posterior maxillary edentulism, the residual bone height above the sinus floor may be as little as 2–3 mm — insufficient for any implant without augmentation. Sinus floor elevation — either by the internal (osteotome) technique or the lateral window technique — is the standard solution. The choice between techniques depends on the residual bone height: the internal technique is appropriate when there is sufficient bone for primary implant stability (typically 4–6 mm or more); the lateral window technique is required when the residual bone is insufficient for primary stability and a staged approach is needed. In this patient, the residual bone height at the posterior maxillary sites was sufficient for the internal technique with simultaneous implant placement — avoiding the additional surgical morbidity and the 6–9 month delay of a staged lateral window approach.

3. Vertical Dimension of Occlusion: Restoring the Face, Not Just the Teeth

The vertical dimension of occlusion — the height of the lower face when the teeth are in maximum intercuspation — is determined by the dentition. When teeth are lost and not replaced, the vertical dimension collapses: the lower face shortens, the lip commissures droop, the nasolabial folds deepen, and the patient develops the characteristic aged appearance of the edentulous face. Restoring the vertical dimension is not merely a dental measurement — it is a facial rejuvenation procedure. The target vertical dimension must be established before the implants are placed, because the implant positions and the prosthetic design are both determined by the planned occlusal vertical dimension. In this patient, the collapsed vertical dimension was restored to the planned level through the provisional prostheses — allowing the patient to adapt to the new facial height over the osseointegration period and confirming that the planned dimension was comfortable and aesthetically appropriate before the definitive prostheses were fabricated. The patient's subjective experience of looking younger was the direct consequence of restoring the lower facial height that had been lost over a decade of progressive tooth loss.

4. Peri-Implant Maintenance: Why Implants Require Lifelong Professional Care

Dental implants are not maintenance-free. Peri-implantitis — the inflammatory destruction of the bone and soft tissue surrounding an implant, analogous to periodontitis around natural teeth — is the most significant long-term threat to implant survival. The risk factors for peri-implantitis include a history of periodontitis (as in this patient), smoking, poor oral hygiene, and inadequate professional maintenance. In a patient who has lost all natural teeth to periodontal disease, the biological susceptibility to peri-implantitis is the same as the susceptibility to periodontitis — the implants are in the same oral environment, with the same bacterial flora and the same host immune response, as the teeth that were lost. Lifelong professional maintenance — at least annually, and more frequently in high-risk patients — is not optional for implant patients; it is the biological prerequisite for long-term implant survival. At Shanghai Ninth People's Hospital, every full-mouth implant patient is enrolled in a structured maintenance programme from the day of prosthesis delivery, with annual radiographic assessment and professional cleaning of all implant surfaces. In this patient, the one-year radiographic assessment confirmed bone levels within normal limits — the direct consequence of excellent patient compliance with oral hygiene and professional maintenance.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mr. Hargreaves and his family from initial consultation through one-year follow-up, including: coordination of prosthodontic consultation with Dr. Jiang Xinzhi at Shanghai Ninth People's Hospital, Shanghai Jiao Tong University with priority appointment scheduling; bilingual review of all prior dental records and radiographs with clinical summary for the MDT; coordination of panoramic radiograph and CBCT with bilingual radiology report translation and implant planning interpretation; bilingual interpretation throughout all MDT discussions involving prosthodontics, implantology, and periodontics; bilingual explanation of the full staged treatment plan — including the rationale for each phase, the expected timeline, and the provisional and definitive prosthetic outcomes — with written English treatment summary provided to the patient; periodontal therapy appointment coordination with bilingual oral hygiene instruction support; residual root extraction coordination including local anaesthesia consent and bilingual post-operative care instructions; sinus lift and implant placement coordination including surgical consent, pre-operative preparation instructions, and bilingual post-operative care protocol; provisional prosthesis delivery coordination with bilingual occlusal adjustment explanation and dietary guidance; osseointegration monitoring coordination with bilingual clinical update summaries at each review appointment; definitive prosthesis delivery coordination including framework try-in interpretation, occlusal adjustment explanation, and bilingual prosthetic maintenance instructions; one-year follow-up coordination including radiographic assessment and professional maintenance scheduling with results communicated to the patient's dentist in the United Kingdom; and establishment of a long-term annual maintenance protocol with direct liaison between Dr. Jiang's team and the patient's dental provider overseas.

For international patients requiring full-mouth implant rehabilitation, complex prosthodontic reconstruction, or advanced dental implant surgery in Shanghai, Dr. Jiang Xinzhi's team at Shanghai Ninth People's Hospital, Shanghai Jiao Tong University represents prosthodontic expertise at the international frontier — combining CBCT-based prosthetic-driven implant planning, sinus floor augmentation, CAD/CAM full-arch prosthetics, and structured long-term maintenance to achieve complete functional and aesthetic restoration in patients with complex dentition loss. CMCS ensures that expertise is accessible: in the patient's language, with overseas dental providers informed at every step, from the first CBCT assessment through lifelong implant maintenance.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.