1. 1. Dental Implants Angled (tilted) implants John Beumer III DDS, MS Allesandro Pozzi DDS Division of Advanced Prosthodontics, UCLA Thisprogramofinstruc1onisprotectedbycopyright.Nopor1onofthis programofinstruc1onmaybereproduced,recordedortransferredbyany meanselectronic,digital,photographic,mechanicaletc.,orbyanyinforma1on storageorretrievalsystem,withoutpriorpermission.
2. 2. Tiltedimplants Fourimplants Siximplants Pterygoid implants Zygoma1c implants
3. 3. TiltedImplantsEdentulousMaxilla Whenrestoringtheedentulousmaxillawhatdoesthistermindicate? Posteriorimplantsare1lteddistallyatabouta30degreeangleandplaced paralleltotheanteriorwallofthemaxillarysinus
4. 4. TiltedImplantsEdentulousMaxilla Whyaretheyadvantageousintheedentulousmaxilla? vLongerimplantsinthedistalposi1ons vImprovedprimarystability vDistalimplantsexitmoreposteriorlyreducingthelengthofthecan1lever
5. 5. Eliminatestheneedforsinusaugmenta1on Eliminatestheneedforzygoma1cimplants Enablesfabrica1onofanimplant-supportedrestora1oninmany pa1ents Enablesimmediateloadinginselectedpa1ents TiltedImplantsEdentulousMaxilla
6. 6. Biomechanicsarefavorable Moreanteriorposterior(A- P)spread Longerimplantsinthedistal posi1onsthanifplaced axially Shortercan1leversrequired torestoretheposterior occlusion A-P Spread TiltedImplantsEdentulousMaxilla Whydotheywork? Notethedierence betweenthepa1ents rightwhereimplantsare angled,andtheleVwhere implantsareplacedaxially CourtesyDr.O.Jensen
7. 7. Biomechanicsarefavorable Finiteelementanalysishasshownthattheuseof1ltedimplants ismuchmorefavorablebiomechanicallythanusingshorter implantswithaxialinclina1ons(Bevilacquaetal,2010). CourtesyDr.P.Pera TiltedImplantsEdentulousMaxilla Whydotheywork?
8. 8. Successratesareabove90%(Ma^ssonetal,1999;Krekmanovetal, 2000;Maloetal,2011;Tealdoetal,2014).Tealdoetal(2014)has themostlongtermfollow-updata. TiltedImplantsEdentulousMaxilla
9. 9. Threeapproaches Allonfour(Nobel) Onlyfourimplantsareplaced Angledabutmentsusedtoosettheanglesoftheimplants Prosthesisisplacedimmediately Columbusbridgeprotocol Fourtosiximplantsareplaced Angledabutmentsusedtoosettheanglesoftheimplants Prosthesisisplacedwithin24hours Co-axisimplants Fourmoreimplantsareplaced Co-axisimplantsareused.Angula1oncorrec1onissubgingival andeectedbytheangula1onoftheimplantplaborm
10. 10. AllonfourMaxilla (perNobel) Veryspecicdeni1on: Useof4implantstosupportanimmediatelyloadedxedprosthesis usedtorestoreeithertheedentulousmaxillaandmandible
11. 11. Allonfour (perNobel) Computerguidedtreatmentplanningandandfully guidedimplantplacementispreferred Whatiscomputerguidedtreatment planningandsurgicalplacement?
12. 12. Fullyguidedsurgeryimpliesthatthe surgicaltemplateswiththeirdrill sleeves(bushings)controltheposi1on, angula1on,diameteraswellasthe depthoftheimplantosteotomysites* Thesurgicaltemplateissecuredwith bonescrewsoranchorpins Allonfour (perNobel) *Seelectureen1tledcomputerguidedtreatmentplanningandimplantsurgeryfordetails. Drill Sleeves (Bushings)
13. 13. Allonfour (perNobel) Theprosthesisispreparedpriortoimplantsurgeryand deliveredimmediatelyaVerimplantplacement Forimmediateloadingtheimplantsmustbeanchoredwithsucient primarystabilitytowithstandocclusalfunc1on Thismayrequirethattheapicalpor1onoftheposteriorimplants engagethecor1callayersofboneassociatedwiththeparanasal sinuswalls.
14. 14. AllonFourMaxilla (perNobel) Posi1onandangula1on Conven1onal Anteriorimplantsplacedinthelateral-centralinterproximal regionsandareparalleltooneanother Posteriorimplantalignedparalleltotheanteriorwallofthe maxillarysinus Angledabutmentsareonlynecessaryfortheposteriorimplants
15. 15. Ineortstoimproveprimaryimplantanchoragetwoother implantcongura1onshavebeenproposed(Jensenetal,2015) M-4Congura1on V-4Congura1on AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
16. 16. M-4 Fourimplantsplacedat30degreeanglestomissnasalandsinus pneuma1zedcavi1esinanM-shapedcongura1onwhenviewed onpanoramicradiography(Jensenetal,2015). AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
17. 17. WhenabundantboneispresentM-4implantcongura1onsin pa1entsprovidesexcellentsupportoftheprosthesiswith20mm betweenimplants.Thisarrangementrequiresli^leifanydistal can1lever. Angledabutmentsareusedonallfourimplants AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
18. 18. Pa1entwithmoderateresorp1onandtherecommendedimplant posi1oningwiththeaimofmaximizingA-Pspread Angledabutmentsareusedonallfourimplants A-Pspreadmaybysubop1malinthesepa1entsandunless primaryimplantanchorageisop1mal,loadingshouldbedelayed AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
19. 19. V-4 TheV-4designa1ondenotesfourimplantsplacedat30degree anglestomissthesinusandnasalcavi1esallconvergingtoward themidlineinaV-forma1on(Jensenetal,2015). Angledabutmentsareusedonallfourimplants AllonFourMaxilla (perNobel) Posi1onandangula1on
20. 20. (V-4implantcongura1onwithtrans-sinusimplants) Pa1entswithadvancedresorp1on.Thereiscommonlyadeciencyofbonemass suchthatposteriorimplantsgainlimitedxa1oninathinlateralnasalwall. Anteriorvomerimplantsareusuallywellxedinthenasalcrest. Apalatalviewdemonstra1ngimplantanchoragepoints.Theposteriorimplants aredirectedtowardmaximalbonemassatthelateralpyriform,whilethe anteriorimplantsareaimedtowardthemaximumavailablemidlinebonemass whichusuallyextendssuperiorlyintothenasalcrest(Vpoint). AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
21. 21. AllonfourMaxilla (perNobel) (V-4implantcongura1onwithtrans-sinusimplants) Underthesecircumstancesdelayedloadingis recommended CourtesyDr.O.Jensen
22. 22. Deni1veprostheses Allonfour (perNobel) CourtesyDr.M.Adams Consistsofaxedhybrid prosthesis Resindentureteeth Acrylicresin Metalsubstructure imbeddedwithinthe acrylicresin
23. 23. Allonfour (perNobel) Deni1veprostheses Consistsofaxed hybridprosthesis Resindentureteeth Acrylicresin Metalsubstructure imbeddedwithinthe acrylicresin CourtesyDr.M.Adams
24. 24. AllonFour (perNobel) Deni1on: Useof4implantstosupportanimmediatelyloadedxedprosthesis usedtorestoreeithertheedentulousmaxillaandmandible Exclusionarycriteria(Maxilla) Pa1entswithsignicantparafunc1onalac1vity Pa1entswithsevereClassIIorClassIIIjawrela1ons Anchoringthesurgicaldrillguideisdicult Unfavorablebiomechanics Pa1entswithopposingarchcomposedprimarilyofnatural den11on Itisdiculttoproperlycontroltheocclusioninsuchpa1ents
25. 25. Asmen1onedearlierthedeni1ontheAllonfour approachisuses4implantstosupportan immediatelyloadedxedprosthesisusedtorestore eithertheedentulousmaxillaandmandible Whataretheprerequisitesforimmediateloading?* AllonFour (perNobel)
26. 26. ImmediateLoading vFortheimplantstobecomeosseointegrated theymustremainimmobilizedduringthe healingperiod. vThereforeoneofthekeystosuccessful immediateloadingcon1nuestobethe eec1venessofprimaryimplantstability
27. 27. Ini1alPrimaryStability (Firstday) Func1onof: vLocalbonequan1tyandquality vImplantgeometry Taperedbe^erthancylindricalbecauseyou haveabe^erchanceofmaximizingbone contactwiththeinternalandexternal diametersoftheimplant vSurgicalprocedure(skill) Inser1ontorqueinexcessof45N/cm ISQs70andabove Twomainfactors: 1.Amountofini1albonecontact 2.Lateralcompressionoftheosteotomysitecrea1nglocal compressionstresses CourtesyDr.C.Stanford
28. 28. ImmediateLoadingWhenIsitFeasible? Thedegreeofini1alboneanchorage v Skillofthesurgeon.Immediateloadingisnotfor beginners Considerbicor1calstabiliza1onwhenpossible Youmusta^empttoengagetheinnerandouterdiameterof theimplantwithbonewhenappropriate Inser1ontorqueinexcessof45N/cm ISQs70andabove v Volumeanddensityoftheboneassociatedwithimplant site Siteswithdensetrabecularbonearepreferred Longerimplantsaregenerallypreferred Bicor1calanchoragemaybenecessary Clinicalissuestobeconsidered:
29. 29. Implantselec1on Tapered,selftappingwithsharply pitchedthreads Implantplacementprocedure Semi-guidedorfullyguidedispreferred overfreehandprepara1onofthe osteotomysiteandinser1onofthe implants Immediateloading Allon4perNobel Requirementsforsuccessfuloutcomes
30. 30. Immediateloading Allon4perNobel Requirementsforsuccessfuloutcomes Assessmentofimplantanchorage Torquevalues-45N/cmormore RFAvalues(resonancefrequency analysis)70andabove Dontovertorqueforthismayimpair thebalanceofthebiologicprocesses associatedwithosseointegra1on (OSullivanetal,2000;Bashutskietal2009;Cha etal,2015) Excessivelevelsoftorqueincreasesthezoneof deadanddyingosteocytesleadingtoincreased resorp1onandadisrup1onofthebalanceof remodelingandrepairmechanisms
31. 31. Characteris1csoftheimmediateloadprosthesis* Rigidityandcrossarchstabiliza1on Passivet Minimizethecan1leverandbendingmoments Occlusion Clinicalremounts Balancedar1cula1on *Asuccessfuloutcomerequiresthattheimplantsremainimmobile (lessthan100micronsofmovement)(Maniatopoulosetal,1986; Szmuckler-Moncler,2000)duringthehealingphase. Immediateloading Requirementsforsuccessfuloutcomes
32. 32. Compliantpa1ent Manipulateoralhygieneaids Followpostopera1veinstruc1ons.Theyinclude: Liquiddietfortherst3weeks Frequentoralrinseswithwarmsaltwaterrinsesbeginning 24hoursaVersurgery. Twiceperdayoralrinseswithchlorhexidinebeginning4 dayaVerdeliveryandcon1nuingfor10days. MechanicalsoVdietforanother3weeks. Avoidclenchingandbruxing Immediateloading Requirementsforsuccessfuloutcomes
33. 33. AllonfourMaxilla (perNobel) Why? Thesurgeryistechniquesensi1ve Requiresbicor1calstabiliza1oninmany pa1ents Oldtechnologyandmaterials Itsaxedprosthesis Poorlipandfacialsupport SpeechandhygieneaccessareoVen incompa1ble Requiresagreatdealofinterocclusalspace Esthe1cs Cost Twoprostheses Angledabutmentsareexpensive Bewareofonesizetallapproach AtUCLAwebelievefewpa1entsarewellservedwiththisapproach CourtesyDr.M.Adams
34. 34. Allonfour-Maxilla Issuesofconcern Thesurgeryistechniquesensi1ve Bicor1calstabiliza1onofimplantsisoVenrequired TranssinusimplantsoVenrequiredtoachievethe desiredamountofA-Pspread Highlevelofsurgicalskillrequired Ifyouloosejustoneimplantyouloosetheprostheses CourtesyDr.O.Jensen
35. 35. AllonfourMaxilla (perNobel) Issuesofconcern Deni1veprosthesis(Fixedhybridprosthesis)usesold technologyandmaterials Dentureteethsubjecttowearandfracture Acrylicresinsubjecttowearandoralcontamina1on CourtesyDr.M.Adams
36. 36. Issuesofconcern Deni1veprosthesis(Fixedhybridprosthesis)usesold technologyandmaterials Dentureteethsubjecttowearandfracture Acrylicresinsubjecttowearandoralcontamina1on AllonfourMaxilla (perNobel) CourtesyDr.K.Lyons
37. 37. AllonfourMaxilla (perNobel) Issuesofconcern Deni1veprosthesis(Fixedhybridprosthesis)usesold technologyandmaterials Dentureteethsubjecttowearandfracture Acrylicresinsubjecttowearandoralcontamina1on
38. 38. AllonfourMaxilla (perNobel) Issuesofconcern Itsaxedprosthesis Poorlipandfacialsupport SpeechandhygieneaccessareoVenincompa1ble Requiresagreatdealofinterocclusalspace Ifinsucienttheprosthesismaynotbeabletowithstandthe rigorsoffunc1on Esthe1csTheprosthesisjunc1onisdesignedtobesuperiorto thesmileline
39. 39. AllonfourMaxilla (perNobel) Issuesofconcern-Maxilla Esthe1csandlackoflipsupport Pa^ernofresorp1onfollowinglossofteethleadstoa pseudoclassIIIjawrela1on Itisnotpossibletoproperlysupportthelipofmostsuch pa1ents Adentureangeisneeded
40. 40. AllonfourMaxilla (perNobel) Issuesofconcern Hygieneaccessandspeechar1cula1on Whenyouprovidehygieneaccess,speechar1cula1onis compromised. Whenyouclosethespacesusedforhygieneaccesstopermit properspeechar1cula1on,hygieneiscompromised. CourtesyDr.M.Adams
41. 41. AllonfourMaxilla (perNobel) Issuesofconcern Hygieneaccessandspeechar1cula1on Whenyouclosethespacesusedforhygieneaccesstopermit properspeechar1cula1on,hygieneiscompromised. Notetheplaquethathasaccumulatedonthe1ssuesideofthisAllon Fourprosthesis CourtesyDr.M.Adams
42. 42. Asaresultmanyprosthodon1stsprefertheuseofeither implantsupportedorimplantassistedoverdentures. Advantages: Be^erhygieneaccess Be^erlipsupport Be^eresthe1cs Lesscostlyforthepa1ent Whatarethealterna1ves?
43. 43. Alterna1vetreatment Overdenture Implantassisteddesign CombinedimplantandsoV 1ssuesupport Resilienta^achmentsposteriorly
44. 44. Alterna1veTreatment Overdenture Implantsupporteddesign Supportderived fromimplants Milledbarwith a^achments
45. 45. AllonfourMaxilla (perNobel) Addi1onalissuesofconcern Interocclusalspace 15-17mm Smileline ManycliniciansusingtheAllonfourapproach adviseplacingthejunc1onbetweenthe prosthesisandthemucosaabovethelipline duringahighsmile Thismayrequireremovalofexcessiveamounts ofbone CourtesyDr.S.Lewis CourtesyDr.P.Pera
46. 46. AllonfourMaxilla (perNobel) Addi1onalissuesofconcern Interocclusalspace 15-17mm Smileline Becauseofthedesignoftheprosthesis, addi1onalreduc1onofboneisrequiredifthe smilelineishigh.Onemmofaddi1onal bonereduc1onnecessaryforeverymmthe smilelineisabovetheCEJ CourtesyDr.S.Lewis CourtesyDr.P.Pera
47. 47. AllonfourMaxilla (perNobel) Addi1onalissuesofconcern Interocclusalspace 15-17mm Smileline Wefeelthatthereareotheralterna1ves whichbe^erservethepa1ent(i.e.the Columbusbridgeprotocolanddelayed loadingusingmetal-ceramicoramonolithic zirconiaprosthesis) CourtesyDr.S.Lewis CourtesyDr.P.Pera
48. 48. Addi1onalissuesofconcern Interocclusalspace Fractureoftheprosthesismayoccuerwhenthereisinsucient interocclusalspacetofabricateaprosthesisofsucientbulkto withstandocclusalfunc1on. AllonfourMaxilla (perNobel)
49. 49. Allon4conceptEdentulousMaxilla Overdenturesmaybepreferred Advantages Implantsupported Be^eresthe1cs Lipsupportprovidedbyadentureange Be^erspeechar1cula1on Be^erhygieneaccess
50. 50. Whatabouttheuseof1lted implantsintheedentulousmandible? Maybenecessarywhenanappropriateanteriorposterior (A-P)spreadcannotbeobtainedusingaxialinclina1ons.
51. 51. WhatistheminimalA-Pspreadnecessarytofabricate axedprosthesisfortheedentulousmandible? Lengthofimplants Minimumlength-7mm Numberofimplants Minimumnumber-4 A-PSpread Minimumamount1cm (A-Pspread) (A-Pspread)
52. 52. AnteriorPosteriorSpreadandthelengthofthecan1leverextension A-PSpread (1cmormore) Can1leverlengthshouldnotexceed21mestheA-Pspreadora maximumof20mm. WhenA-Pspreadislessthan1cmitmaynotbepossibleto restoretheposteriorden11onbecauseoflimitsofthecan1lever Can9lever Length WhatistheminimalA-Pspreadincombina1on withthelengthofthecan1lever,necessarytofabricate axedprosthesisfortheedentulousmandible?
53. 53. Anterior Posterior Spread A-P Spread (1 cm or more) Cantilever length should not exceed 2 times the A-P spread. CantileverLength WhatistheminimalA-Pspreadincombina1on withthelengthofthecan1lever,necessarytofabricate axedprosthesisfortheedentulousmandible?
54. 54. ConsequencesofinsucientA-P spreadandexcessivecan1leverlength Result Mechanicalfailures Implantoverload Inthispa1enttheresult wasrecurrentfracturesof theprosthesisretaining screws(arrows).
55. 55. InsucientA-Pspreadcombinedwithexcessivecan1leverlength(34 mmontheleVsideand26mmontherightside) Result: Mechanicalfailure-Implantfracture Implantoverloadandlossofboneanchoringtheimplant Inthispa1entacombina1onofexcessivecan1leverlengthand insucientA-Pspreadleadtoimplantoverloadandaresorp1ve remodelingresponseoftheadjacentboneandimplantfracture. ConsequencesofinsucientA-P spreadandexcessivecan1leverlength
56. 56. ImplantOverloadandBoneResorp1on MechanismsofImplantFailure vExcessiveocclusalloads vResul1ngmicrodamage(fractures, cracks,anddelamina1ons [arrows]) vResorp1onremodelingresponse ofboneisprovoked vIncreasedporosityofboneinthe interfacezonesecondaryto remodeling vViciouscycleofcon1nuedloading, moremicro-damage,more porosityun1lfailure (Howshawetal,1995;Brunskietal,2000;Myataetal,2002;Myamotoetal,2008;Nagasawaetal,2013)
57. 57. BiomechanicsandA-PspreadCasereport Siximplantshavehavebeenplaced,A-Pspreadisonlyabout5mm.Thecan1lever extensionmustbelimitedto10mmandthisisinsucienttorestoretheposterior den11onwithaxedprosthesis. Whatwouldhaveabe^erop1onforthispa1ent?
58. 58. BiomechanicsandA-PspreadCasereport Either Tiltedimplantswithfourimplantsandaxedprosthesis Placementoftwoimplantsandanoverdenture
59. 59. TiltedimplantsMandible Pa1entselec1on Pa1entswithsquarearchforms Pa1entsdemonstra1ngananteriorloop ofthementalnerve Thistechniquewillimproveimplant distribu1onpa^ern(increasetheA-P spread)formorefavorablebiomechanics
60. 60. TiltedimplantsMandible Usesandadvantages Squarearchforms Avoidtheanteriorloopoftheinferioralveolarnerve Shortensthecan1lever Minimizestheriskofbiologicandmechanicalfailures
61. 61. Anteriorimplantsshouldbe placedinthelateralincisor posi1ons Notetheposi1onofthese anteriorimplants TiltedimplantsMandible Posi1oningofimplants CourtesyDr.N.Barakat
62. 62. Inpa1entswithaCawoodClassVorVImandiblethereis li^leaddi1onalbenetfrom1ppingtheposteriorimplants Treatment of the rely Resorbed Mandible ferior rows) e of the Underthesecircumstancesit isbesttoplacetwoimplants andmakeanoverdenture TiltedimplantsMandible
63. 63. Exclusionarycriteria CawoodClassVorVImandible Tippingtheposteriorimplantposteriorisonlyvaluablewhen thereisatleast3-4mmofboneoverthenerve TiltedimplantsMandible CourtesyDr.O.Jensen
64. 64. Computerguidedtreatmentplanningandimplantplacement preferred Theprosthesismaybedeliveredimmediatelyifop1mal anchorageisachieved TiltedimplantsMandible
65. 65. TheColumbusBridge Useofangledimplantstorestoretheedentulousmaxilla Onlyselectgroupofpa1entqualify Pa1entswithfavorablejawrela1onsandbone contoursarepreferred.ThosewithpseudoclassIII jawrela1onsarenotconsideredgoodcandidates Prosthe1cvolumeandsmilelineiscarefully evaluated 4-6implantsareplaced Pterygoidimplantsusedwhennecessary
66. 66. TheColumbusBridge Useofangledimplantstorestoretheedentulousmaxilla Surgicalprotocol Tapered,selftapingimplantswith externalhexused Anteriorimplantsplacedintooth posi1ons Implantsofatleast13mminlengthare desired Implantsplacedwithfreehanddrilling withtheaidofasurgicaltemplate Implantinser1ontorqueshouldexceed 40N/cm Angled,conicalabutmentsareusedin theposteriorposi1ons Noboneregenera1vetechniquesused CourtesyDr.P.Pera
67. 67. TheColumbusBridge Useofangledimplantstorestoretheedentulousmaxilla Impressionsmadeimmediatelyfollowingimplantplacement Metalframeworkwaxedandcastbasedonadiagnos1cwax-up/ trialdenturesetup Itmustbesucientlyrigidtoresistbending Rigidgoldorpalladiumalloysareused Theprosthesisisdesignedwithoutcan1levers Thefunc1onalandesthe1csurfacesoftheprovisionalarerestored withdentureteethandacrylicresin Prosthesisisscrewretained Prosthesisdeliveredwithin24hoursofimplantplacement Deni1veprosthesisfabricated4monthsfollowingimplantsurgery Prosthodon1cprotocol
68. 68. TheColumbusBridge (Avariantoftheallonfourconcept) Provisionalisdeliveredwithin24hoursandisresinwithametalsubstructure CourtesyDr.P.Pera
69. 69. Finishedprosthesis.Usuallytheprovisional isreplacedduringtherstyear. TheColumbusBridge (Avariantoftheallonfourconcept) Delivery Oneyearlater CourtesyDr.P.Pera
70. 70. CourtesyDr.D.Howes Subcrestalvssupracrestal angula1oncorrec1on However,surgicalplacementismoredemanding Co-axisimplants Co-axisimplantsareused Twoprostheses $825/angledabutment Subcrestalispreferred
71. 71. Advantagesof Coaxisimplant Lesscost Screwretained Prosthodon1candtechnicalsimplicity Standardprosthe1ccomponentry CourtesyDr.D.Howes Subcrestalvssupracrestalangula1oncorrec1on AngledabutmentsvsCoaxisimplants However,surgicalplacementismoredemanding Co-axisimplants
72. 72. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera) Retrospec1vestudiespublishedduringthelastseveralyearsand recentliteraturereviews(Papaspyridakosetal,2014,Gallucciet al,2014)appeartoindicatethatimmediateloadprosthesescan beemployedwithsuccessintheedentulousmaxilla.However thereportofTealdoandcolleagues(2014)isperhapsthemost revealing.
73. 73. Thepa1entsweredividedintotwogroupsanimmediateloadgroup(34 pa1ents)(prosthesisdeliveredwithin24hours)andadelayedloadinggroup (15pa1ents)(prosthesisdeliveredanaverageof8.75monthsaVerimplant placement).Thegroupswereunmatched. Allimplantsusedinthestudyhadacidetchedsurfaces,were4mmin diameterandatleast10mminlength.Straightwalledimplantswereplaced intohealededentuloussitesandtaperedimplantsplacedintoextrac1on sites. Fourtosiximplantswereplacedintheimmediateloadgroup,thedistal implantswere1lteddistallyandallimplantsachievedinser1ontorquesofat least40Ncm. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera)
74. 74. Theprosthesesfortheimmediateloadpa1entsweredesignedwithoutdistal can1levers,customizedmetalframeworkswerefabricatedofpalladiumalloy, occlusalsurfaceswererestoredwithresin,andtheocclusalschemeusedwas groupfunc1on. Reproducibleperiapicalradiographsusingcustomizedlmholderswere obtainedatdeliveryandatsubsequent12monthintervalsinordertoassess bonelevelsaroundtheimplants. Thecumula1veimplantsurvivalratewas93.9%fortheimmediateloadgroup and95.9%forthedelayedloadgroup.Nopa1entlostmorethanoneimplant. Inbothgroups,almostalloftheimplantlosseswerewithin12monthsof implantplacement. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera)
75. 75. Alloriginalxedprosthesesremainedinfunc1onbutseveralrequired altera1onsorrepairs,mostsecondarytofracturesassociatedwiththeresin veneers.Howevertherewerenofracturesassociatedwiththemetal frameworks. Meanbonelossaroundimplantswasgreaterforthedelayedgroupthanfor theimmediateloadgroup. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera)
76. 76. Allon6withPterygoidImplants Preferredwhenopposingmandibleisdentate
77. 77. Withguidedworkupandsurgicalprocedurestheprosthesis canbedesignedandfabricatedpriortoimplantplacement Allon6withPterygoidImplants
78. 78. Avoidssinusaugmenta1on Improvesimplantdistribu1onpa^erns,A-Pspreadand biomechanics Preferredifimmediateloadingisconsidered Successratesofpterygoidimplantscloseto90% (Candeletal,2012) Allon6withPterygoidImplants
79. 79. Usedtoprovideposteriorsupportinfullarchandposterior quadrantprostheses Successratescloseto90%(Candeletal,2012) Allon6withPterygoidImplants
80. 80. Allon6withPterygoidImplants
81. 81. Allon6withPterygoidImplants Frameworkismadeof monolithiczirconia Crownsaremadeoflithium disilicateandcementedto theframework
82. 82. Tiltedimplants-Posteriorquadrants Analterna1vetosinusaugmenta1on Computerguidedtreatmentplanningandimplant placementispreferred
83. 83. Tiltedimplants-Posteriorquadrants Anteriorguidanceprovidedbynaturalden11on
84. 84. Pterygoidimplants Combina1onof1ltedand pterygoidimplant Longerimplants Improvedbiomechanics Eliminatestheneedforsinus augmenta1on
85. 85. Pterygoidimplants Iffullyguidedsurgeryisused,abutmentscanbe chosenormilledpriortosurgicalplacement
86. 86. Pterygoidimplants Implantsplaced withtheaidofa surgicaltemplate Semi-guided surgical placementwas employed
87. 87. Pterygoidimplants Combina1onof1ltedimplantandapterygoidimplant Eliminatestheneedforsinusaugmenta1on Occlusionisanteriorguidance
88. 88. Zygoma1cimplants IntroducedbyBranemarkinthelate1980s Pa1entswithmoderatelyresorbedmaxillae Designedtobeusedinconcertwith2-4implantsplacedinthe anteriormaxilla Successrateshavebeenveryhighinconven1onalpa1ents (Branemark,2004;Aparicioetal,2006;Bedrossianetal,2006;Kahnbergetal,2007; Bedrossianetal,2012).
89. 89. Zygoma1cimplants Complica1onsrarebutsignicant Oralantralstula Postopera1vemaxillarysinusi1s Peri-orbitalhematoma Facialswelling Penetra1onoftheorbit
90. 90. Zygoma1cimplants Nolongerrecommendedforpa1entswithanintactpalate Distor1onofpalatalcontours Otherop1onsavailablethataremoreeec1ve. Tiltedimplants Pterygoidimplants Sinusaugmenta1on
91. 91. Zygoma1cimplants Pa1entwasallergictoacrylicresin Zygoma1cimplantsusedtoavoidsinus augmenta1on Zygoma1cimplantsdidnotalterthecontours oftherestora1onorimpairthetonguespace
92. 92. Zygoma1cimplants Usedforpa1entswithmajordefectsofthehardpalate UsefulforincompleterepairedcleVlipandpalatepa1ents Edentulousmaxillectomypa1entswithlargedefects Successrateshavebeengood (Schmidtetal,2004;Schmidt,2007) CourtesyA.Sharma
93. 93. Zygoma1cimplants Issues Radia1oneects Hygieneaccess Longtermsurvivabilty Bestsuitedfortotalpalatectomydefects CourtesyA.Sharma
94. 94. Zygoma1cimplants Prosthodon1cissues Twoimplantsperside Splintallimplantstogether Implantsupportedvsimplant assisteddesigndependson implantdistribu1onpa^ern Bestsuitedfortotalpalatectomydefects CourtesyA.Sharma
95. 95. vVisitofr.orgforhundredsof addi1onallecturesonComplete Dentures,FixedProsthodon1cs ImplantDen1stry,Removable Par1alDentures,Esthe1cDen1stry andMaxillofacialProsthe1cs. vThelecturesarefree. vOurobjec1veistocreatethebest andmostcomprehensiveonline programsofinstruc1onin Prosthodon1cs