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Software governance using retrospectives: A case study

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In this paper we present our study on the implementation of the retrospective practice in software development projects. Specifically, we describe the retrospective practice and present its impact on the development process of a specific large-scale project. Our study shows that a team can steer its process evolution systematically by retrospectives, identifying process issues, discussing their nature, and deciding on mechanisms for their improvement. For the purpose of our research, we use five process elements: work procedures, policies, metrics, roles, and decision rights. Based on the data analysis of the retrospectives conducted in our case study, we illustrate each category and demonstrate how it is refined along the project timeline. We suggest using the retrospective practice as a qualitative data gathering tool that assists the governance process of a development project.

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• process lifecycle
• reflective practitioner
• retrospectivse
• software governance

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• 10.1109/SWSTE.2012.11

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• Case Study Computer Science 100%
• Evolution Process Mathematics 100%
• Development Process Mathematics 100%
• Qualitative Data Mathematics 100%
• Development Project Social Sciences 100%
• Process Element Computer Science 50%
• Software Development Computer Science 50%
• Data Analysis Computer Science 50%

T1 - Software governance using retrospectives

T2 - 2012 IEEE International Conference on Software Science, Technology and Engineering, SWSTE 2012

AU - Dubinsky, Yael

AU - Hazzan, Orit

N2 - In this paper we present our study on the implementation of the retrospective practice in software development projects. Specifically, we describe the retrospective practice and present its impact on the development process of a specific large-scale project. Our study shows that a team can steer its process evolution systematically by retrospectives, identifying process issues, discussing their nature, and deciding on mechanisms for their improvement. For the purpose of our research, we use five process elements: work procedures, policies, metrics, roles, and decision rights. Based on the data analysis of the retrospectives conducted in our case study, we illustrate each category and demonstrate how it is refined along the project timeline. We suggest using the retrospective practice as a qualitative data gathering tool that assists the governance process of a development project.

AB - In this paper we present our study on the implementation of the retrospective practice in software development projects. Specifically, we describe the retrospective practice and present its impact on the development process of a specific large-scale project. Our study shows that a team can steer its process evolution systematically by retrospectives, identifying process issues, discussing their nature, and deciding on mechanisms for their improvement. For the purpose of our research, we use five process elements: work procedures, policies, metrics, roles, and decision rights. Based on the data analysis of the retrospectives conducted in our case study, we illustrate each category and demonstrate how it is refined along the project timeline. We suggest using the retrospective practice as a qualitative data gathering tool that assists the governance process of a development project.

KW - process lifecycle

KW - reflective practitioner

KW - retrospectivse

KW - software governance

UR - http://www.scopus.com/inward/record.url?scp=84864835853&partnerID=8YFLogxK

U2 - 10.1109/SWSTE.2012.11

DO - 10.1109/SWSTE.2012.11

M3 - ???researchoutput.researchoutputtypes.contributiontobookanthology.conference???

AN - SCOPUS:84864835853

SN - 9780769547169

T3 - Proceedings - 2012 IEEE International Conference on Software Science, Technology and Engineering, SWSTE 2012

BT - Proceedings - 2012 IEEE International Conference on Software Science, Technology and Engineering, SWSTE 2012

Y2 - 12 June 2012 through 13 June 2012

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Retrospective Project Analysis: How to Do It and Why Is It Important?

Learn why analyzing your projects after they’re over is important and how to do it right!

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Give us 30 minutes and we’ll show you how we can help you achieve better results.

What’s the hardest part about being responsible for the management of an entire project? Is it getting your employees to do their job? Delegating tasks? Making sure all the deadlines are met? Facing clients? All of the above?

Let’s face it, being a manager has never been easy. You always end up being accountable for whatever goes wrong. And things will go wrong. But there’s one quality that all good project managers have - they analyze their projects to prevent problems and then they analyze them again to learn from their mistakes.

This article is all about the importance of project analysis and how using a software for time tracking projects can help in some aspects of this process.

Insightful can help you analyze every project!

When should you do project analysis.

Optimally, all the time. It might sound over the top, but the process of analyzing your progress, re-evaluating expectations, projecting your success and looking back at what you’ve done so far should never stop. What you look at during this analysis, however, might change depending on when you do it.

First of all, the analysis should start even before the project does. This phase is important for managing client expectations, projecting costs, estimating how much the project is likely to take, as well as planning the specific steps necessary to accomplish it.

This analysis should continue throughout the entire project. If you’re using project management time tracking software, it will run during the whole process and you can stop after each milestone or periodically to evaluate what you’ve done thus far, what needs to be done next and whether there’s any reason to change the way you work.

And finally, after everything is done and the project is officially completed, you should do one more retrospective analysis. This is the part that we’re going to focus on in this text.

So let’s take a look at what you need to evaluate, how you can use time tracking projects data to provide additional basis for analysis, as well as what the point of all this really is.

Aspects of Retrospective Project Analysis

When you’re looking back at what your team has accomplished during the project’s timeline, there are three broad aspects of the project that you should be looking at and evaluating: functionality, time and cost. We’ll discuss each of those in more detail.

Functionality

Functionality refers to whether or to what extent your team managed to complete the ultimate goal of the project. In other words, it’s the question of whether the result of the project was successful.

This could be difficult to quantify and not even the best project time tracking software will be able to tell you how well you’ve done what you were supposed to do. Therefore, it’s crucial that you take a look back at the project outline and initial requirements and compare that to your final result.

Did you manage to do everything you were supposed to? Did you do it in a way that you’d expected? Was that the best way possible? What were the biggest weaknesses? What could you have done differently?

You should ask yourself and your team all of these questions to figure out whether the project was a success and what you can learn from any potential mistakes. Client feedback can also be a huge source of insight for this part, because that’s ultimately what matters the most.

This part of the analysis is a lot easier because now you have implemented time tracking for projects to do most of the work for you. It’s you, however, who will need to sort out the data and draw conclusions. The key here is to carefully choose which time tracking metrics you want to focus on.

First, let’s see what kind of data your employee reporting software can give you. The basic functionality is time tracking, so right off the bat, you’ll be able to know how much time each employee spent on each particular task. You’ll also know which tools and resources your team used to accomplish those tasks, as well as what you wasted the most time on.

When you compare this time tracking projects reports with the deadlines you’ve set at the beginning, you can tell whether everything went according to plan and what could be improved. You should also try to analyze how long certain types of tasks took, which ones were most problematic and what the biggest time-wasters were.

The last part of your analysis is calculating the final cost of the project and comparing that with your initial estimate. If the numbers don’t match, try to figure out where all the extra money left - did you extend your deadline, did you need more resources, did you have some unforeseen expenses or was it something else?

The good news is that this part of the analysis should be fairly easily measurable. For instance, some of the best project time tracking app solutions let you set an hourly rate for your employees and then they calculate billable hours, which can give you a pretty good idea of how much of your budget went on manpower.

At the end, try to decide which were the necessary costs, as well as where you could have saved money and how.

The Importance of Project Analysis

Retrospective analysis is a critical part of any project. And there’s really no excuse for not doing it because, as we’ve discussed, much of your work can be done with the use of a simple time tracker, which is typically a very lightweight software and compatible with different operating systems (you can have project time tracking software Mac or Windows version), so any team can implement it and use it for gathering data on different projects.

So let’s quickly summarize all the benefits that a well-done retrospective project analysis can offer to your team and your company:

• Evaluating performance and team dynamic: Taking a look back will give you a chance to estimate how well your team has been working, whether the delegation was optimal, and what could be improved. Evaluation process is a major part of growing and becoming more competent and stronger as a team.
• Reporting to the client: A final holistic review of the project is an excellent way to show the client that you’re accountable and professional. So be critical, objective, accurate and detailed.
• Gaining insights to help you with future project management: The more project analyses your team goes through, the more informed you’re going to be about what you can expect on future projects. You’ll be able to delegate the tasks better, plan the process in a more optimal way, set more realistic deadlines, etc.

Learning from your mistakes is almost as important as successfully going through the project. Whether you’re using time tracking projects data or doing the analysis on a review session with your team, you’re sure to get a lot of valuable insights that will not only help you with evaluation and client reporting for this project, but will also make future endeavors even more successful.

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Incremental method evolution in global software product management: A retrospective case study

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Learning in the Large - An Exploratory Study of Retrospectives in Large-Scale Agile Development

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• Open Access
• First Online: 17 May 2018
• Cite this conference paper

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• Torgeir Dingsøyr 9 , 11 ,
• Marius Mikalsen 9 ,
• Anniken Solem 10 &
• Kathrine Vestues 11  

Part of the book series: Lecture Notes in Business Information Processing ((LNBIP,volume 314))

Included in the following conference series:

• International Conference on Agile Software Development

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Many see retrospectives as the most important practice of agile software development. Previous studies of retrospectives have focused on process and outcome at team level. In this article, we study how a large-scale agile development project uses retrospectives through an analysis of retrospective reports identifying a total of 109 issues and 36 action items as a part of a longitudinal case study. We find that most of the issues identified relate to team-level learning and improvement, and discuss these findings in relation to current advice to improve learning outcome in large-scale agile development.

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Reflection in Agile Retrospectives

Counteracting Agile Retrospective Problems with Retrospective Activities

Recurring opinions or productive improvements—what agile teams actually discuss in retrospectives.

• Agile software development
• Software engineering
• Team performance
• Post mortem review
• Process improvement

1 Introduction

Retrospective meetings are extremely important in agile methods. The Agile Practice Guide describes them as “ the single most important practice in agile development ” [ 1 ] and in his much read book on Scrum and XP, Kniberg states that retrospectives are the “ number - one - most - important thing in Scrum ” [ 2 ]. According to the 11th State of Agile report [ 3 ], the retrospective is the third most used agile practice. We find many suggestions on how to conduct retrospectives in the agile practitioner literature such as [ 4 , 5 ] and online Footnote 1 .

The purpose of retrospectives is to explore the work results of a team in an iteration or a phase in order to “ learn about, improve, and adapt its process ” [ 1 ]. The advice offered in the agile community has mainly focused on learning and improvement for the team, while such practices also have a potential to provide learning both on the individual level and for a larger project or organization.

In this article, we focus on the practice of learning and improving through retrospectives in large-scale agile development. The research agenda for large-scale agile development has identified knowledge-sharing as an important topic [ 6 ]. This is a particularly challenging area of work, as such projects consists of several development teams with dependencies between teams and typically involve complex integration with existing ICT systems in projects that are critical for companies or societies [ 7 ].

We structure this article as follows: First, we provide background on studies of retrospective practices and prior studies on analysing content and effect of retrospectives and formulate research questions. Second, we present an exploratory case study and method for analysis of retrospectives. Third, we discuss what the retrospectives have addressed and what could be done to improve the learning outcome of retrospectives in the large and suggest directions for future research.

2 Background

Given the importance of retrospectives in agile development, the topic has received relatively little attention in scientific studies. A review of previous studies on IT retrospectives finds a multitude of definitions of retrospectives, descriptions of a number of outcomes, different practices described, and “ no project retrospective measurements given to confirm […] whether outcomes have been successfully achieved ” [ 8 ].

Kniberg [ 2 ] describes a retrospective practice as a team exercise lasting 1–3 h where a team identifies what has been «good», what «could have been better» and «improvements», and suggest voting on the improvements to focus on in the next iteration. The practices described in the research literature [ 8 ] typically involve additional steps, for example including root cause analysis in order to analyse topics identified before deciding on action items to include in the next iteration.

In a study of retrospective practices at team level, Lethinen et al. [ 9 ] found that most discussions were related to topics close to and controllable by the team, but that topics that could not be resolved at the team level due to their complexity nevertheless recurred over time.

Many previous studies have seen retrospectives as an arena for reflection to enable learning and process improvement [ 10 ]. Andryiani et al. [ 11 ] studied retrospectives with a framework describing stages of reflection as reporting, responding, relating, reasoning and reconstructing. A finding is that agile teams may not achieve all levels of reflection simply by performing retrospective meetings. The study found that “ important aspects discussed in retrospective meetings include identifying and discussing obstacles, discussing feelings, analysing previous action points, identifying background reasons, identifying future action points and generating a plan ” [ 11 ].

We have not been able to identify studies of retrospectives in large-scale development, but a blog post describes how Spotify conducted large-scale retrospectives Footnote 2 in «one big room» in a format similar to world café [ 12 ]. Advice in one of the large-scale development frameworks, Large-Scale Scrum (LeSS), Footnote 3 is to hold an «overall retrospective» after team retrospectives, to discuss cross-team and system-wide issues, and to create improvement experiments.

We do not know of studies investigating the learning effect of retrospectives, but a summary of relevant theories of learning such as Argyris and Schön’s theory of learning and Wenger’s communities of practice can be found in one overview article [ 13 ], which discusses learning on individual-, team-, and organizational level. Argyris and Schön distinguish between smaller improvement («single loop learning») and more thorough learning («double loop learning»).

In this explorative study, we ask the following research questions: 1. How are retrospectives used in a large - scale agile development project? 2. What could be done to improve the learning outcome of retrospectives in large - scale agile projects?

We are currently conducting a longitudinal case study [ 14 ] of a large-scale development project. The case was selected as it is one of the largest development projects in Scandinavia, and is operating in a complex environment with heavy integration with other ICT systems.

The customer organization has 19 000 employees, and close to 300 ICT systems. A new solution will require changes to 26 other systems. The project uses a stage-gate delivery model with 4 stages (analysis of needs, solution description, construction, and approval, similar to a previous project described in [ 15 ]). We followed the first release, with 37 developers in four development teams. Teams had a Scrum-master, one or two application architects, one or two testers, and up to ten developers. The project uses the Scrum-method, with three-week iterations, starting with a planning meeting and ending with a demo and retrospective.

The project has three main releases, and this article is based on an analysis of minutes of meetings from 10 retrospectives in the first release. The minutes include iterations 3 to 9, with an exception of iteration 6, when no retrospective was held due to summer holidays. The minutes cover a 5-month period.

We have limited the study to an analysis of retrospective minutes from two of the four teams. The minutes describe who were present in the face-to-face meeting, a list of issues that went well, a list of issues that could be improved and most often a list of action items. The length of the minutes varied from half a page to two pages. The minutes were posted in the project wiki.

We all read three minutes individually, and then jointly established a set of categories, taken from the Scrum guide Footnote 4 , which describes the purpose of the sprint retrospective as an arena for inspecting how the last sprint went with regards to the categories «people», «relationships» (merged with people), «process», and «tools». We added the categories «project» and «other teams» to specifically address the large-scale level. These categories were used to code issues and action items.

The analysis of minutes from retrospectives in Table  1 shows the issues recorded by the teams during the seven iterations. Most issues were related to «process» (41) and «people and relationships» (30). In the following, we describe issues that emerged in selected categories, and then present the resulting action items as recorded in the minutes.

Due to space limitations, the following results describe the issues we found relating to the categories that shed most light on how large-scale agile development influences the teams. These are «process» (41 reported issues), «project» (10 reported issues) and «other teams» (7 reported issues).

In terms of process , there were issues such as that the build breaks too often, design takes too much capacity from the team, that they would like more consistent use of branching in Git (tool for version control and code sharing), and that frequent check-ins makes it difficult to terminate feature-branches. The following excerpt illustrates how process issues manifest: “ A lot of red in Jenkins [a continuous integration tool], which makes it difficult to branch from «develop» ”. Other issues were concerned with quality control and routines in the team, such as the need for better control and routines for branching of the code, need for more code reviews, too many and messy Jira (issue tracker) tasks, and architects have limited time to follow up on development. Issues concerning lack of structure for bug reporting were reported as such: “ Structure concerning tests, bugs are reported in all possible ways – Mails – Skype – face to face, very difficult to follow up and have continuity in test/bugfix etc. ”

Project issues are related to the overall organisation of the project as a whole. Such issues were far less frequently reported, and those we found included having updated requirements for user stories when entering sprints, that solutions designs should be more detailed, product backlog elements should be ready before sprint start, and addressing how developers move between teams. The following illustrates how one team reports the need for more technical meetings between teams on a project level: “ Review of code/project, all meetings are about organisation, but it should be one meeting about how our code/setup/project looks from a technical perspective ”.

Finally, for the category other teams , i.e. how teams interact in a multi-team setting, we found how there were issues with regard to how teams “takes instructions” from several different parties, and how there was challenges in detecting dependencies in the code before you develop and test. The following excerpt from the retrospective minutes illustrates how one team is not involved sufficiently in the planning of refactoring: “ We want to be notified in advance when there are big refactorings or other significant changes in the codebase, before it happens ”.

The retrospective minutes also contains actions decided on by the teams. In total, the two teams identified 36 action items, where most were related to «process» and to «other topics». We show the distribution and provide examples of action items in Table  2 .

5 Discussion

We return to discuss our two research questions, starting with how are retrospectives used in a large - scale agile development project?

We found that retrospectives were used at team level, where short meetings were facilitated by the scrum master and reported in minutes on the project wiki. Minutes were available to everyone in the project, including customer representatives.

Our analysis of topics addressed in the retrospectives shows that most of the issues identified as either «working well» or «could be improved» related to process , followed by people and relationships . In the «large-scale» categories project and other teams we found in total 17 issues of the total 109. However, as shown in the results, many of the issues described as process were related to the scale of the project, such as identifying challenges with the merging of code or detailing of specifications before development would start. We find, however, that teams mainly deal with team-internal issues in retrospectives.

The analysis of the action items shows that 6 of the 36 action items identified during the work on the release were in the «large-scale» categories. However, we see that some of the action items in the other categories are related to scale. One example is the item “organizing an introduction round for new team members” in the category people and relations , which describes an action item which would not be necessary on a single-team project. However, our impression is also here that most action items concern issues at the team level.

We have not been able to conduct an analysis of the effect of retrospectives at team level. We consider that such meetings give room to develop a common understanding of development process, tasks and what knowledge people in the team possess, what in organizational psychology is referred to as shared mental models [ 13 ] and have been shown to relate to team performance. A common critique of retrospectives is that teams meet and talk, but little of what is talked about is acted upon. We have not been able to assess how many of the 36 identified action items were acted upon, but found in one minute that “all action items suggested to the project management has been implemented”. The 36 action items identified can be considered small improvement actions. Given the short time spent on retrospectives, they do not seem to facilitate «deep» learning («double loop» learning in Argyris and Schön’s framework). Having minutes public could also lead to critique being toned down or removed completely.

This leads us to discussing our second research question - w hat could be done to improve the learning outcome of retrospectives in large - scale agile projects?

In the background we pinpointed particular challenges of large-scale agile development such as dealing with a high number of people and many dependencies [ 7 ]. A retrospective can be used for a number of purposes. Prior studies in organizational psychology suggest that in projects with many teams, the coordination between teams are more important than coordination within teams [ 16 ]. It is reason to believe it would be beneficial to focus attention on inter-team issues in large projects. The LeSS framework suggests organizing inter-team retrospectives directly after the team retrospectives. Alternatively, teams can be encouraged to particularly focus on inter-team issues as part of the team retrospectives. A challenge in the project studied is that the contract model used may hinder changes, for example the contract model specifies handover phases between companies involved in the analysis of needs phase and the solution description and development phase . However, given the limitations, it is important that the project adjusts work practice also on inter-team level to optimize use of limited resources.

This exploratory study has several limitations, where one is that we have only analysed minutes available on the project wiki from two of four teams.

6 Conclusion

Many in the agile community regard retrospectives as the single most important practice in agile development. It is therefore interesting to know more about how retrospectives are practiced in large-scale development where there is a dire need to learn and improve as many participants are new to the project, the customer organization, and to the development domain. We found that short retrospectives were conducted at team level and mostly addressed issues at the team-level. The action items mainly addressed team level issues. Most actions also seem to relate to smaller improvements, what Argyris and Schön call «single-loop learning».

A large-scale project will benefit from learning and improvement on the project level, and this would be strengthened by following the advice from LeSS by facilitating retrospectives at the project level. Further, to shift learning effects towards «double-loop learning», we suggest that more time is devoted to the retrospectives.

In the future, we would like to initiate retrospectives at the inter-team level, explore the types of issues that are raised, and also gain more knowledge about perceptions of retrospectives by interviewing project participants.

See for example https://plans-for-retrospectives.com/en/?id=32-64-113-13-67 and http://www.funretrospectives.com/ and https://labs.spotify.com/2017/12/15/spotify-retro-kit/ .

https://labs.spotify.com/2015/11/05/large-scale-retros/ .

https://less.works/less/framework/index.html .

http://www.scrumguides.org/ .

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This work was conducted in the project Agile 2.0 supported by the Research Council of Norway through grant 236759 and by the companies Kantega, Kongsberg Defence & Aerospace, Sopra Steria, Statoil and Sticos.

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Dingsøyr, T., Mikalsen, M., Solem, A., Vestues, K. (2018). Learning in the Large - An Exploratory Study of Retrospectives in Large-Scale Agile Development. In: Garbajosa, J., Wang, X., Aguiar, A. (eds) Agile Processes in Software Engineering and Extreme Programming. XP 2018. Lecture Notes in Business Information Processing, vol 314. Springer, Cham. https://doi.org/10.1007/978-3-319-91602-6_13

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Case report article, immediate loading in partially edentulous patients with fixed implant-supported restorations cases report.

• 1 Graduate School, China Medical University, Shenyang, China
• 2 Department of Stomatology, General Hospital of Northern Theater Command, Shenyang, China
• 3 Graduate School, Dalian Medical University, Dalia, China

Objectives: This article reports on four rare cases involving multiple trauma-induced adjacent missing anterior teeth in the maxillary or mandibular region. These cases were successfully treated using a 4-axial implant-based alternative insert and an immediate loading protocol.

Material and methods: This series of cases was summarized by retrospective study that 4 patients who received a total of 20 immediately loaded implants. These patients had suffered from trauma-induced loss of 8–9 adjacent anterior teeth. The 4-axial-implants were inserted with the assistance of digital pioneer drill guides. The surgical procedure involved alveolar bone trimming or ultrasonic osteotomy, eliminating the need for traditional large-area bone augmentation. Pre- and post-operative CBCT was matched using DTX Studio Implant software, the deviation of implant between actual position and preoperative design was measured and compared using SPSS software package.

Results: The average follow-up duration 48 months after implant prostheses, the cumulative retention rate of the implants was 100%, the marginal bone loss averaged 0.53 mm (SD 0.15 mm), and buccal plate bone loss averaged 0.62 mm (SD 0.41 mm).

Conclusions: This retrospective clinical report demonstrates the successful treatment of several patients with multiple adjacent maxillary or mandibular anterior teeth using four implant-supported screws to fix the frame and employing immediate loading. The approach resulted in long-term stable clinical outcomes. Moreover, the method not only shortens the period of edentulism but also facilitates easy disassembly, maintenance, and cleaning. Consequently, it emerges as a highly favorable clinical option for patients suffering from extensive tooth loss.

1 Introduction

The sixth ITI Treatment Guide offers comprehensive schemes for implant restoration of multiple adjacent missing teeth in the esthetic zone, offering clear recommendations for restoring 1–6 teeth ( 1 ). However, the ITI Treatment Guide does not specifically recommend an optimal number of implants for patients who have lost over 8 adjacent anterior teeth but are not completely edentulous ( 2 ). Traditionally, the treatment approach for these patients involves segmental implant restoration, synchronized or earlier bone augmentation, and delayed loading ( 3 ). Unfortunately, this approach is associated with complications, including suboptimal aesthetic outcomes, lengthy treatment periods, significant trauma, and challenges related to extensive bone grafting ( 4 ). Patients often experience vertical and/or horizontal loss of soft and hard tissues, particularly in the maxillary anterior region, which is aesthetically challenging to rehabilitate ( 5 , 6 ). Achieving satisfactory aesthetics often requires repeated guided bone regeneration and connective soft tissue augmentation, which increase the risk of operational and aesthetic failures. Patients not only desire “functionally stable implants” but also seek esthetic and functional rehabilitations within a shorter treatment time ( 7 ). Using traditional bone grafting surgery or free inferior alveolar nerve grafting not only increases the surgical difficulty and prolongs the operation time but also adds to the patient's expenses ( 8 ). The fifth Consensus Statements of the International Team for Implantology (ITI) propose that while the primary goals in the anterior esthetic zone are to achieve optimal esthetics and long-term stability without complications, secondary goals should also be considered to save chairside time and costs, alleviate postoperative pain or discomfort, and shorten healing time ( 9 ). Taking inspiration from the concept of All-on-4®, a protocol has been developed: 4-axial-implant alternated insert using 3D printed surgical guides for patients who have lost 8–10 adjacent maxillary or mandibular anterior teeth ( 10 ). This approach is being called Part-on-4, avoids the need for bone grafting through osteotomy and utilizes one-piece screw-fixed frameworks for immediate loading ( 11 , 12 ). The remaining natural molars serve as occlusion supports. Part-on-4 simplifies surgery, shortens the edentulous period, and reduces the risk of residual bonding agents. Clinical cases and long-term follow-up observations have demonstrated the favorable clinical outcomes of Part-on-4. In this article, the purpose of this case series report is to present this part on 4 clinical protocol and report anecdotally the outcome for patients treated this way.

2 Material and methods

2.1 basic information of patients.

Patient gender, age, date of operation, edentulous zone, implant site, implant information, osteotomy height, primary stability, and abutment selection were recorded for each patient ( Table 1 ).

Table 1 . Basic information of patients undergoing part-on-4.

2.2 Materials and instruments

The following materials and instruments were used: KaVo oral cone beam computed tomography (CBCT) and orthopantomograph (Kavo Company, Germany), Nobel On 1® Base, healing caps, and Nobel implanter (Kavo Company, Germany), NobelReplace Conical Connection and NobelParallel Conical Connection implants, multi-unit abutment (MUA-Plus), Mectron PiezoSurgery® piezosurgery system (Mectron Company, Italy), and digital implanting operation guides (Color Cube, Tianjin, China).

Four patients with a loss of 8–10 adjacent maxillary or mandibular anterior teeth, who desired fixed restorations, presented to the Department of Stomatology, General Hospital of Northern Theater Command between 2016 and 2022. All four patients included in the study had multiple anterior teeth loss due to trauma. They were treated using a standardized approach, and both clinical and imaging data were complete. Follow-up visits were conducted as scheduled. We waived the requirement for obtaining informed consent from patients and obtained approval from the Ethics Committee. This decision was based on the nature of our clinical retrospective study, which solely utilized pre-existing clinical records without administering additional treatment or imposing any risk or breach of patient confidentiality. The study received Institutional Review Board approval from the General Hospital of Northern Theater Command (No. 2022050).

2.3 Surgical procedure

CBCT scans were taken to record the relevant data and determine the implant positions ( Figure 1 ). A careful review of the patients' clinical and radiographic findings was conducted. Prior to implant placement, informed consent was obtained from each patient. 3D implant planning software (Nobel Clinician, Nobel Biocare USA) was used to optimize the placement of 4 implants in each arch based on the existing bone volume of each patient. Digital guide plates were designed and printed using 3Shape software (3Shape Company, Denmark). The evaluation included centric occlusion, esthetics, phonetics, and occlusal vertical dimension, with intraoral photos taken to document the state of the remaining teeth and soft tissues. Subsequently, a one-stage surgical approach was employed for the placement of all implants. The surgeries were performed under local anesthesia using Primacaine adrenaline 1/100,000 (Produits Dentaires Pierre Rolland, France). The bone surface was exposed by creating flaps, and for patients with insufficient alveolar crest width or unfavorable bone shape, ultrasonic osteotomy (4–6 mm) or high-speed drill bone trimming (0–3 mm) was performed. Digital surgical guides were used to prepare holes. Two implants with an insertion torque of 35–45 N/cm were placed in the anterior zone (maxillary central incisor or mandibular lateral incisor) and the premolar zone (first or second premolar) of each patient. For patients with sufficient maxillary bone volume, the bone surface below the framework was prepared in a fossa ovalis shape. Nobel MUA-Plus abutments or Nobel On 1® bases were then screwed on. After placing the healing caps, the soft tissues were readapted and sutured back into position using trans-gingival techniques. Postoperative CBCT scans were recorded to assess the accuracy of implantation site, buccal plate thicknesses, and distance from the inferior alveolar nerve canal. Temporary prostheses were fabricated using chairside impressions and worn on the same day, followed by an occlusion examination ( Figure 2 ). Sutures were removed after one week, and clinical and radiographic examinations were conducted during the 3-month postoperative visit. Definitive impressions and face-bow transfer were performed, and temporary resin-cut frameworks were created. After try-in, the frameworks were confirmed to be accurate. The final prostheses, Ti-supported zirconia frameworks, were prepared and delivered 4–6 months after surgery. Subsequent follow-up visits with imaging and clinical periodontal examinations were scheduled annually ( Figure 3 ).

Figure 1 . Preoperative CBCT: 32, 43, 42, 44 (FDA) measure the bone height of the implant site and simulate the placement of implants to evaluate the three-dimensional position.

Figure 2 . Surgical process images: ( A ) preoperative intraoral situation; ( B ) after all implants were implanted, the bone surface was leveled. ( C ) The Nobel MUA-Plus abutments have been screwed onto the implants; ( D ) make an immediate prosthesis and wear it in the mouth on the same day.

Figure 3 . 3-year follow-up images: ( A ) intraoral occlusal photograph: illustrating the occlusal relationship of the screw-fixed final restoration when worn in the patient's oral cavity; ( B ) the gingival tissue condition at 6 months postoperative during the final restoration; ( C ) photos of the occlusal surfaces inside the mouth after the placement of the final restoration, showing the emergence areas located either in the lingual sulcus or on the occlusal surface; ( D ) the curved cross-sectional image after the placement of the final restoration shows that the prosthesis is fully seated and the marginal bone around the implant is stable.

2.4 Radiographic and clinical periodontal examination

This case series report analyzes the mean deviation at the implant platform and implant apex, as well as the angular deviation, while utilizing digital pioneer drill guides. Pre- and post-operative CBCT was matched and integrated using DTX Studio Implant software, the deviation of implant between actual position and preoperative design was measured and compared using SPSS software package. During each follow-up visit, panoramic radiographs or CBCTs were performed to evaluate the positions of marginal bones and the thickness of the labial or buccal plate using ImageJ 1.48 software. The measured value is corrected according to the length of the inserted implants to avoid the error caused by the distortion of the image film. The bone level of each implant was measured at the proximal and distal points, and the difference between the bone level after operation and the bone level at the last follow-up was the bone loss at the edge of the implant during the follow-up period. All measurements were repeated three times a week by three trained surveyors, and self-consistency was tested ( Figure 4 ). The measurements are calibrated with reference to the standard length ( h ) of the implant. The distances from the contact points between the implant and the alveolar bone to the plane of the implant root are denoted as h1, h2 immediately after the surgery, and h3, h4 at the last follow-up visit. The marginal bone loss (MBL) of the implant, denoted as Δh (measured in mm), at the follow-up time t (in years) is calculated using the formula: Δh = [(h1-h3) + (h2-h4)]/2. Furthermore, the peri-implant area was examined by doctors using a standard procedure to check for bleeding or suppuration. Peri-implantitis was defined as bleeding, suppuration, or bone resorption ≥2 mm in the peri-implant area discovered during probing examination, based on established criteria. Mechanical complications such as porcelain breakage, screw fracture, and prosthesis fracture were recorded annually. The gingival index was also recorded during the follow-up period, following the criteria set by Löe and Li et al. ( 13 , 14 ). Finally, the survival rate and success rate of implants, marginal bone loss, and labial or buccal plate loss were calculated based on established criteria ( 15 , 16 ). These measurements and evaluations provide important data to assess the clinical outcomes and effectiveness of the treatment approach.

Figure 4 . Data measurement: ( A ) DTX studio implant software deviation analysis: (a) implant platform (b) implant apex (c) implant angular; ( B ) measuring marginal bone resorption image using imageJ 1.48 software.

Each patient undergoes clinical and radiographic evaluations during follow-up visits at 3 months, 6 months, and 1 year post-surgery. According to the study findings, the mean deviation was as follows while using digital pioneer drill guides: the implant platform 1.28 mm ± 0.74 mm, apex 1.43 mm ± 0.75 mm, angular 4.21° ± 1.91°. During the follow-up of these 4 patients, none of the patients experienced pain, paresthesia, or other adverse symptoms the implant survival rate was 100%, comprising the absence of mobility, the absence of subjective complaints such as pain or paresthesia, the absence of peri-implant infection, and the absence of continuous radiolucency around the implant ( 17 ). The average gingival index was 0.28, indicating mild inflammation. That all implants remained in place and functional. Radiographic evaluations, including orthopantomography and CBCT, showed no significant alveolar bone resorption. The marginal bone loss averaged 0.53 mm (SD 0.15 mm), and buccal plate bone loss averaged 0.62 mm (SD 0.41 mm) ( Table 2 ). These values indicate a stable peri-implant bone level. The implant success rate was also 100%, indicating successful integration and functional outcomes. During each reexamination, the prostheses were removed for examination and cleaning. However, no screw loosening, porcelain breakage, or fracture was observed. Minimal dental calculus and soft dirt accumulation were detected below the bridge, which were cleaned and polished. No abutment loosening was noticed. After each reexamination, the prostheses were reattached intraorally and manually screwed on. The patients' pronunciation, retroflexion, and plosive sound capabilities were examined, ensuring the restoration's functional outcomes. The patients were provided with information regarding oral hygiene maintenance and self-cleaning of the screw-fixed frameworks to ensure long-term success and durability of the restorations.

Table 2 . Follow-up of patients undergoing part-on-4.

4 Discussion

4.1 merits and demerits of part-on-4.

Trauma-induced loss of consecutive teeth often leads to extensive horizontal and vertical bone defects. To address these bone deficiencies and determine the optimal site for guided implant placement, complex bone augmentation surgeries are typically required ( 18 , 19 ). However, these surgical interventions can have drawbacks, such as compromising the aesthetic outcome due to mucosal scarring. The incidence rates of complications associated with these procedures were relatively high, a weighted mean gain of 8.04 mm and complications rate of 47.3% for distraction osteogenesis, 4.18 mm and 12.1% for guided bone regeneration (GBR) and 3.46 mm and 23.9% for bone blocks ( 20 ). Furthermore, a meta-analysis has shown that the implant success rate following complex bone augmentation procedures is only 75% during 1- to 5-year follow-up, indicating a relatively high risk of failure ( 21 ). This highlights the unpredictable clinical risks and potential complications associated with these bone augmentation surgeries ( 22 ). In summary, while various bone augmentation surgeries can achieve favorable clinical outcomes, the high incidence rates of complications and unpredictable risks of extensive bone grafting associated with operative wounds should be taken into consideration.

Our approach aimed to insert implants without bone subtraction or osteotomy in the maxillary anterior zone where are the esthetics crucial zone. The mandible anterior zone is not part of the esthetic zone, often with thin and blade-shaped alveolar ridge crest after tooth extraction. However, in cases with the sufficient bone height present, osteotomy may be a better choice for reconstructing bone width in the mandible anterior zone. Among the five cases, the osteotomy height was ≤3 mm in four cases and 4–7 mm in one case, the average osteotomy height was 2.03 mm, and the average bone width increment was 2.47 mm. Conversely, when the osteotomy height is suitable, the prosthesis/soft tissue junction (PSTJ) can be better hidden below the smile line, and the gingival margin and gingival papilla can exhibit more standardized shapes, without negative aesthetic effects ( 23 ).The osteotomy procedure is particularly suitable for patients with excessive gingival display, and the bone platform created after osteotomy should be positioned at least 4 mm below the smile line ( 5 , 24 ). In cases where osteotomy was performed, we used Nobel MUA abutments without conducting gingival compression shaping due to insufficient keratinized gingiva. This method creates a natural gum line shape with fewer appointments. Osteotomy treatment resulted in great cosmetic outcomes and no loss of vertical bone tissue for Part-on-4 cases.

Additionally, this method is not entirely freehand implantation but involves designing a digital implant guide based on the oral structure of the patient and the surgical plan. The ideal three-dimensional position of the implants is accurately transferred to the surgical procedure using the guide, providing more precise operational guidance, including the positioning, angle, and depth of the implant socket ( 25 ). Immediate loading also reduces the edentulous period for patients, meeting their aesthetic and functional needs.

4.2 Indications of part-on-4

When a patient loses more than eight adjacent maxillary or mandibular anterior teeth, the number of available implant sites becomes restricted. In such cases, we recommend considering the following five points:

(1) Avoid the midline: The implant design should aim to position the two front implants as close to the lateral incisors as possible, avoiding placement along the midline. Eliminating cantilevers is necessary to ensure stability and support.

(2) Design the implant positions to allow for alternative, parallel, and symmetrical placement. This approach facilitates even distribution of horizontal stresses among the implants, enhancing overall stability.

(3) Utilize digitized guides to ensure accurate implant placement, achieve precise positioning, and minimize the margin for error.

(4) Optimal placement of prosthetic screw-access holes should be considered not only in the middle of the tooth tongue promontory but also between adjacent teeth when achieving mesiodistal positioning becomes challenging. This practice ensures appropriate access for maintenance and prevents complications.

(5) Factors such as patient age, gender, and living habits (e.g., overbite, overjet, smoking, neglect of oral hygiene) should be considered and addressed through oral hygiene education and maintenance guidance.

Additionally, the lower anterior zone surrounding the opening of the sublingual gland is susceptible to dental calculus accumulation, which presents a persistent challenge despite comprehensive oral hygiene education and maintenance guidance. This observation also applies to patients undergoing full-arch implant restoration. Screw-fixed bridges offer the advantage of being disassembled, cleaned, and maintained.

5 Conclusions

The Part-on-4 treatment offers significant advantages for patients with the loss of 8–9 consecutive maxillary or mandibular anterior teeth and stable posterior occlusion. It minimizes the duration of edentulism, enables regular disassembly, maintenance, and cleaning, making it a favorable clinical approach for this specific group of patients. Gingival shaping can enhance aesthetic outcomes when there is sufficient soft and hard tissue. In cases of inadequate bone volume, osteotomy serves as a viable alternative to bone grafting, reducing potential complications and wounds. Throughout the follow-up period, no substantial changes in labial bone plate thickness or marginal bone loss were observed, while the surrounding keratinized gum tissue remained healthy. However, it is essential to acknowledge that long-term clinical and aesthetic effects of the Part-on-4 treatment and osteotomy necessitate further research due to limited long-term observations and controlled studies. Continued research is crucial in evaluating the long-term efficacy, sustainability, and outcomes of Part-on-4 and osteotomy procedures for managing edentulous patients.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by General Hospital of Northern Theater Command Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

SW: Data curation, Formal Analysis, Investigation, Methodology, Software, Writing – original draft, Writing – review & editing. SD: Data curation, Investigation, Supervision, Writing – review & editing. RC: Data curation, Investigation, Methodology, Software, Writing – review & editing. ZW: Data curation, Formal Analysis, Supervision, Writing – review & editing. YT: Conceptualization, Project administration, Supervision, Validation, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

We wish to express our sincere gratitude to the patients for their cooperation, and to all colleagues of Department of Stomatology of the General Hospital of Northern Theater Command for their technical support.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Abbreviations

CBCT, cone beam computed tomography; 3D, three dimensions; Part-on-4, 4-axial-implant alternated insert using 3D printed surgical guides for patients who have lost 8–10 adjacent maxillary or mandibular anterior teeth.

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Keywords: multiple adjacent missing, esthetic zone, screw-fixed framework, osteotomy, immediate load, case report

Citation: Wang S, Duan S, Chen R, Wang Z and Tang Y (2024) Immediate loading in partially edentulous patients with fixed implant-supported restorations cases report. Front. Oral. Health 5:1369494. doi: 10.3389/froh.2024.1369494

Received: 12 January 2024; Accepted: 24 April 2024; Published: 7 May 2024.

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© 2024 Wang, Duan, Chen, Wang and Tang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Yulong Tang [email protected]

This article is part of the Research Topic

Oral Health Care for Vulnerable and Underserved Populations