Angled implants
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Dental Implants Angled (tilted) implants John Beumer III DDS, MS Allesandro Pozzi DDS Division of Advanced Prosthodontics, UCLA This program of instruc1on is protected by copyright ©. No por1on of this program of instruc1on may be reproduced, recorded or transferred by any means electronic, digital, photographic, mechanical etc., or by any informa1on storage or retrieval system, without prior permission.
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Transcript of Angled implants
- 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. Tiltedimplants Fourimplants Siximplants Pterygoid implants Zygoma1c implants
- 3. TiltedImplantsEdentulousMaxilla Whenrestoringtheedentulousmaxillawhatdoesthistermindicate? Posteriorimplantsare1lteddistallyatabouta30degreeangleandplaced paralleltotheanteriorwallofthemaxillarysinus
- 4. TiltedImplantsEdentulousMaxilla Whyaretheyadvantageousintheedentulousmaxilla? vLongerimplantsinthedistalposi1ons vImprovedprimarystability vDistalimplantsexitmoreposteriorlyreducingthelengthofthecan1lever
- 5. Eliminatestheneedforsinusaugmenta1on Eliminatestheneedforzygoma1cimplants Enablesfabrica1onofanimplant-supportedrestora1oninmany pa1ents Enablesimmediateloadinginselectedpa1ents TiltedImplantsEdentulousMaxilla
- 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. Biomechanicsarefavorable Finiteelementanalysishasshownthattheuseof1ltedimplants ismuchmorefavorablebiomechanicallythanusingshorter implantswithaxialinclina1ons(Bevilacquaetal,2010). CourtesyDr.P.Pera TiltedImplantsEdentulousMaxilla Whydotheywork?
- 8. Successratesareabove90%(Ma^ssonetal,1999;Krekmanovetal, 2000;Maloetal,2011;Tealdoetal,2014).Tealdoetal(2014)has themostlongtermfollow-updata. TiltedImplantsEdentulousMaxilla
- 9. Threeapproaches Allonfour(Nobel) Onlyfourimplantsareplaced Angledabutmentsusedtoosettheanglesoftheimplants Prosthesisisplacedimmediately Columbusbridgeprotocol Fourtosiximplantsareplaced Angledabutmentsusedtoosettheanglesoftheimplants Prosthesisisplacedwithin24hours Co-axisimplants Fourmoreimplantsareplaced Co-axisimplantsareused.Angula1oncorrec1onissubgingival andeectedbytheangula1onoftheimplantplaborm
- 10. AllonfourMaxilla (perNobel) Veryspecicdeni1on: Useof4implantstosupportanimmediatelyloadedxedprosthesis usedtorestoreeithertheedentulousmaxillaandmandible
- 11. Allonfour (perNobel) Computerguidedtreatmentplanningandandfully guidedimplantplacementispreferred Whatiscomputerguidedtreatment planningandsurgicalplacement?
- 12. Fullyguidedsurgeryimpliesthatthe surgicaltemplateswiththeirdrill sleeves(bushings)controltheposi1on, angula1on,diameteraswellasthe depthoftheimplantosteotomysites* Thesurgicaltemplateissecuredwith bonescrewsoranchorpins Allonfour (perNobel) *Seelectureen1tledcomputerguidedtreatmentplanningandimplantsurgeryfordetails. Drill Sleeves (Bushings)
- 13. Allonfour (perNobel) Theprosthesisispreparedpriortoimplantsurgeryand deliveredimmediatelyaVerimplantplacement Forimmediateloadingtheimplantsmustbeanchoredwithsucient primarystabilitytowithstandocclusalfunc1on Thismayrequirethattheapicalpor1onoftheposteriorimplants engagethecor1callayersofboneassociatedwiththeparanasal sinuswalls.
- 14. AllonFourMaxilla (perNobel) Posi1onandangula1on Conven1onal Anteriorimplantsplacedinthelateral-centralinterproximal regionsandareparalleltooneanother Posteriorimplantalignedparalleltotheanteriorwallofthe maxillarysinus Angledabutmentsareonlynecessaryfortheposteriorimplants
- 15. Ineortstoimproveprimaryimplantanchoragetwoother implantcongura1onshavebeenproposed(Jensenetal,2015) M-4Congura1on V-4Congura1on AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
- 16. M-4 Fourimplantsplacedat30degreeanglestomissnasalandsinus pneuma1zedcavi1esinanM-shapedcongura1onwhenviewed onpanoramicradiography(Jensenetal,2015). AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
- 17. WhenabundantboneispresentM-4implantcongura1onsin pa1entsprovidesexcellentsupportoftheprosthesiswith20mm betweenimplants.Thisarrangementrequiresli^leifanydistal can1lever. Angledabutmentsareusedonallfourimplants AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
- 18. Pa1entwithmoderateresorp1onandtherecommendedimplant posi1oningwiththeaimofmaximizingA-Pspread Angledabutmentsareusedonallfourimplants A-Pspreadmaybysubop1malinthesepa1entsandunless primaryimplantanchorageisop1mal,loadingshouldbedelayed AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
- 19. V-4 TheV-4designa1ondenotesfourimplantsplacedat30degree anglestomissthesinusandnasalcavi1esallconvergingtoward themidlineinaV-forma1on(Jensenetal,2015). Angledabutmentsareusedonallfourimplants AllonFourMaxilla (perNobel) Posi1onandangula1on
- 20. (V-4implantcongura1onwithtrans-sinusimplants) Pa1entswithadvancedresorp1on.Thereiscommonlyadeciencyofbonemass suchthatposteriorimplantsgainlimitedxa1oninathinlateralnasalwall. Anteriorvomerimplantsareusuallywellxedinthenasalcrest. Apalatalviewdemonstra1ngimplantanchoragepoints.Theposteriorimplants aredirectedtowardmaximalbonemassatthelateralpyriform,whilethe anteriorimplantsareaimedtowardthemaximumavailablemidlinebonemass whichusuallyextendssuperiorlyintothenasalcrest(Vpoint). AllonFourMaxilla (perNobel) Posi1onandangula1on CourtesyDr.O.Jensen
- 21. AllonfourMaxilla (perNobel) (V-4implantcongura1onwithtrans-sinusimplants) Underthesecircumstancesdelayedloadingis recommended CourtesyDr.O.Jensen
- 22. Deni1veprostheses Allonfour (perNobel) CourtesyDr.M.Adams Consistsofaxedhybrid prosthesis Resindentureteeth Acrylicresin Metalsubstructure imbeddedwithinthe acrylicresin
- 23. Allonfour (perNobel) Deni1veprostheses Consistsofaxed hybridprosthesis Resindentureteeth Acrylicresin Metalsubstructure imbeddedwithinthe acrylicresin CourtesyDr.M.Adams
- 24. AllonFour (perNobel) Deni1on: Useof4implantstosupportanimmediatelyloadedxedprosthesis usedtorestoreeithertheedentulousmaxillaandmandible Exclusionarycriteria(Maxilla) Pa1entswithsignicantparafunc1onalac1vity Pa1entswithsevereClassIIorClassIIIjawrela1ons Anchoringthesurgicaldrillguideisdicult Unfavorablebiomechanics Pa1entswithopposingarchcomposedprimarilyofnatural den11on Itisdiculttoproperlycontroltheocclusioninsuchpa1ents
- 25. Asmen1onedearlierthedeni1ontheAllonfour approachisuses4implantstosupportan immediatelyloadedxedprosthesisusedtorestore eithertheedentulousmaxillaandmandible Whataretheprerequisitesforimmediateloading?* AllonFour (perNobel)
- 26. ImmediateLoading vFortheimplantstobecomeosseointegrated theymustremainimmobilizedduringthe healingperiod. vThereforeoneofthekeystosuccessful immediateloadingcon1nuestobethe eec1venessofprimaryimplantstability
- 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. ImmediateLoadingWhenIsitFeasible? Thedegreeofini1alboneanchorage v Skillofthesurgeon.Immediateloadingisnotfor beginners Considerbicor1calstabiliza1onwhenpossible Youmusta^empttoengagetheinnerandouterdiameterof theimplantwithbonewhenappropriate Inser1ontorqueinexcessof45N/cm ISQs70andabove v Volumeanddensityoftheboneassociatedwithimplant site Siteswithdensetrabecularbonearepreferred Longerimplantsaregenerallypreferred Bicor1calanchoragemaybenecessary Clinicalissuestobeconsidered:
- 29. Implantselec1on Tapered,selftappingwithsharply pitchedthreads Implantplacementprocedure Semi-guidedorfullyguidedispreferred overfreehandprepara1onofthe osteotomysiteandinser1onofthe implants Immediateloading Allon4perNobel Requirementsforsuccessfuloutcomes
- 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. Characteris1csoftheimmediateloadprosthesis* Rigidityandcrossarchstabiliza1on Passivet Minimizethecan1leverandbendingmoments Occlusion Clinicalremounts Balancedar1cula1on *Asuccessfuloutcomerequiresthattheimplantsremainimmobile (lessthan100micronsofmovement)(Maniatopoulosetal,1986; Szmuckler-Moncler,2000)duringthehealingphase. Immediateloading Requirementsforsuccessfuloutcomes
- 32. Compliantpa1ent Manipulateoralhygieneaids Followpostopera1veinstruc1ons.Theyinclude: Liquiddietfortherst3weeks Frequentoralrinseswithwarmsaltwaterrinsesbeginning 24hoursaVersurgery. Twiceperdayoralrinseswithchlorhexidinebeginning4 dayaVerdeliveryandcon1nuingfor10days. MechanicalsoVdietforanother3weeks. Avoidclenchingandbruxing Immediateloading Requirementsforsuccessfuloutcomes
- 33. AllonfourMaxilla (perNobel) Why? Thesurgeryistechniquesensi1ve Requiresbicor1calstabiliza1oninmany pa1ents Oldtechnologyandmaterials Itsaxedprosthesis Poorlipandfacialsupport SpeechandhygieneaccessareoVen incompa1ble Requiresagreatdealofinterocclusalspace Esthe1cs Cost Twoprostheses Angledabutmentsareexpensive Bewareofonesizetallapproach AtUCLAwebelievefewpa1entsarewellservedwiththisapproach CourtesyDr.M.Adams
- 34. Allonfour-Maxilla Issuesofconcern Thesurgeryistechniquesensi1ve Bicor1calstabiliza1onofimplantsisoVenrequired TranssinusimplantsoVenrequiredtoachievethe desiredamountofA-Pspread Highlevelofsurgicalskillrequired Ifyouloosejustoneimplantyouloosetheprostheses CourtesyDr.O.Jensen
- 35. AllonfourMaxilla (perNobel) Issuesofconcern Deni1veprosthesis(Fixedhybridprosthesis)usesold technologyandmaterials Dentureteethsubjecttowearandfracture Acrylicresinsubjecttowearandoralcontamina1on CourtesyDr.M.Adams
- 36. Issuesofconcern Deni1veprosthesis(Fixedhybridprosthesis)usesold technologyandmaterials Dentureteethsubjecttowearandfracture Acrylicresinsubjecttowearandoralcontamina1on AllonfourMaxilla (perNobel) CourtesyDr.K.Lyons
- 37. AllonfourMaxilla (perNobel) Issuesofconcern Deni1veprosthesis(Fixedhybridprosthesis)usesold technologyandmaterials Dentureteethsubjecttowearandfracture Acrylicresinsubjecttowearandoralcontamina1on
- 38. AllonfourMaxilla (perNobel) Issuesofconcern Itsaxedprosthesis Poorlipandfacialsupport SpeechandhygieneaccessareoVenincompa1ble Requiresagreatdealofinterocclusalspace Ifinsucienttheprosthesismaynotbeabletowithstandthe rigorsoffunc1on Esthe1csTheprosthesisjunc1onisdesignedtobesuperiorto thesmileline
- 39. AllonfourMaxilla (perNobel) Issuesofconcern-Maxilla Esthe1csandlackoflipsupport Pa^ernofresorp1onfollowinglossofteethleadstoa pseudoclassIIIjawrela1on Itisnotpossibletoproperlysupportthelipofmostsuch pa1ents Adentureangeisneeded
- 40. AllonfourMaxilla (perNobel) Issuesofconcern Hygieneaccessandspeechar1cula1on Whenyouprovidehygieneaccess,speechar1cula1onis compromised. Whenyouclosethespacesusedforhygieneaccesstopermit properspeechar1cula1on,hygieneiscompromised. CourtesyDr.M.Adams
- 41. AllonfourMaxilla (perNobel) Issuesofconcern Hygieneaccessandspeechar1cula1on Whenyouclosethespacesusedforhygieneaccesstopermit properspeechar1cula1on,hygieneiscompromised. Notetheplaquethathasaccumulatedonthe1ssuesideofthisAllon Fourprosthesis CourtesyDr.M.Adams
- 42. Asaresultmanyprosthodon1stsprefertheuseofeither implantsupportedorimplantassistedoverdentures. Advantages: Be^erhygieneaccess Be^erlipsupport Be^eresthe1cs Lesscostlyforthepa1ent Whatarethealterna1ves?
- 43. Alterna1vetreatment Overdenture Implantassisteddesign CombinedimplantandsoV 1ssuesupport Resilienta^achmentsposteriorly
- 44. Alterna1veTreatment Overdenture Implantsupporteddesign Supportderived fromimplants Milledbarwith a^achments
- 45. AllonfourMaxilla (perNobel) Addi1onalissuesofconcern Interocclusalspace 15-17mm Smileline ManycliniciansusingtheAllonfourapproach adviseplacingthejunc1onbetweenthe prosthesisandthemucosaabovethelipline duringahighsmile Thismayrequireremovalofexcessiveamounts ofbone CourtesyDr.S.Lewis CourtesyDr.P.Pera
- 46. AllonfourMaxilla (perNobel) Addi1onalissuesofconcern Interocclusalspace 15-17mm Smileline Becauseofthedesignoftheprosthesis, addi1onalreduc1onofboneisrequiredifthe smilelineishigh.Onemmofaddi1onal bonereduc1onnecessaryforeverymmthe smilelineisabovetheCEJ CourtesyDr.S.Lewis CourtesyDr.P.Pera
- 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. Addi1onalissuesofconcern Interocclusalspace Fractureoftheprosthesismayoccuerwhenthereisinsucient interocclusalspacetofabricateaprosthesisofsucientbulkto withstandocclusalfunc1on. AllonfourMaxilla (perNobel)
- 49. Allon4conceptEdentulousMaxilla Overdenturesmaybepreferred Advantages Implantsupported Be^eresthe1cs Lipsupportprovidedbyadentureange Be^erspeechar1cula1on Be^erhygieneaccess
- 50. Whatabouttheuseof1lted implantsintheedentulousmandible? Maybenecessarywhenanappropriateanteriorposterior (A-P)spreadcannotbeobtainedusingaxialinclina1ons.
- 51. WhatistheminimalA-Pspreadnecessarytofabricate axedprosthesisfortheedentulousmandible? Lengthofimplants Minimumlength-7mm Numberofimplants Minimumnumber-4 A-PSpread Minimumamount1cm (A-Pspread) (A-Pspread)
- 52. AnteriorPosteriorSpreadandthelengthofthecan1leverextension A-PSpread (1cmormore) Can1leverlengthshouldnotexceed21mestheA-Pspreadora maximumof20mm. WhenA-Pspreadislessthan1cmitmaynotbepossibleto restoretheposteriorden11onbecauseoflimitsofthecan1lever Can9lever Length WhatistheminimalA-Pspreadincombina1on withthelengthofthecan1lever,necessarytofabricate axedprosthesisfortheedentulousmandible?
- 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. ConsequencesofinsucientA-P spreadandexcessivecan1leverlength Result Mechanicalfailures Implantoverload Inthispa1enttheresult wasrecurrentfracturesof theprosthesisretaining screws(arrows).
- 55. InsucientA-Pspreadcombinedwithexcessivecan1leverlength(34 mmontheleVsideand26mmontherightside) Result: Mechanicalfailure-Implantfracture Implantoverloadandlossofboneanchoringtheimplant Inthispa1entacombina1onofexcessivecan1leverlengthand insucientA-Pspreadleadtoimplantoverloadandaresorp1ve remodelingresponseoftheadjacentboneandimplantfracture. ConsequencesofinsucientA-P spreadandexcessivecan1leverlength
- 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. BiomechanicsandA-PspreadCasereport Siximplantshavehavebeenplaced,A-Pspreadisonlyabout5mm.Thecan1lever extensionmustbelimitedto10mmandthisisinsucienttorestoretheposterior den11onwithaxedprosthesis. Whatwouldhaveabe^erop1onforthispa1ent?
- 58. BiomechanicsandA-PspreadCasereport Either Tiltedimplantswithfourimplantsandaxedprosthesis Placementoftwoimplantsandanoverdenture
- 59. TiltedimplantsMandible Pa1entselec1on Pa1entswithsquarearchforms Pa1entsdemonstra1ngananteriorloop ofthementalnerve Thistechniquewillimproveimplant distribu1onpa^ern(increasetheA-P spread)formorefavorablebiomechanics
- 60. TiltedimplantsMandible Usesandadvantages Squarearchforms Avoidtheanteriorloopoftheinferioralveolarnerve Shortensthecan1lever Minimizestheriskofbiologicandmechanicalfailures
- 61. Anteriorimplantsshouldbe placedinthelateralincisor posi1ons Notetheposi1onofthese anteriorimplants TiltedimplantsMandible Posi1oningofimplants CourtesyDr.N.Barakat
- 62. Inpa1entswithaCawoodClassVorVImandiblethereis li^leaddi1onalbenetfrom1ppingtheposteriorimplants Treatment of the rely Resorbed Mandible ferior rows) e of the Underthesecircumstancesit isbesttoplacetwoimplants andmakeanoverdenture TiltedimplantsMandible
- 63. Exclusionarycriteria CawoodClassVorVImandible Tippingtheposteriorimplantposteriorisonlyvaluablewhen thereisatleast3-4mmofboneoverthenerve TiltedimplantsMandible CourtesyDr.O.Jensen
- 64. Computerguidedtreatmentplanningandimplantplacement preferred Theprosthesismaybedeliveredimmediatelyifop1mal anchorageisachieved TiltedimplantsMandible
- 65. TheColumbusBridge Useofangledimplantstorestoretheedentulousmaxilla Onlyselectgroupofpa1entqualify Pa1entswithfavorablejawrela1onsandbone contoursarepreferred.ThosewithpseudoclassIII jawrela1onsarenotconsideredgoodcandidates Prosthe1cvolumeandsmilelineiscarefully evaluated 4-6implantsareplaced Pterygoidimplantsusedwhennecessary
- 66. TheColumbusBridge Useofangledimplantstorestoretheedentulousmaxilla Surgicalprotocol Tapered,selftapingimplantswith externalhexused Anteriorimplantsplacedintooth posi1ons Implantsofatleast13mminlengthare desired Implantsplacedwithfreehanddrilling withtheaidofasurgicaltemplate Implantinser1ontorqueshouldexceed 40N/cm Angled,conicalabutmentsareusedin theposteriorposi1ons Noboneregenera1vetechniquesused CourtesyDr.P.Pera
- 67. TheColumbusBridge Useofangledimplantstorestoretheedentulousmaxilla Impressionsmadeimmediatelyfollowingimplantplacement Metalframeworkwaxedandcastbasedonadiagnos1cwax-up/ trialdenturesetup Itmustbesucientlyrigidtoresistbending Rigidgoldorpalladiumalloysareused Theprosthesisisdesignedwithoutcan1levers Thefunc1onalandesthe1csurfacesoftheprovisionalarerestored withdentureteethandacrylicresin Prosthesisisscrewretained Prosthesisdeliveredwithin24hoursofimplantplacement Deni1veprosthesisfabricated4monthsfollowingimplantsurgery Prosthodon1cprotocol
- 68. TheColumbusBridge (Avariantoftheallonfourconcept) Provisionalisdeliveredwithin24hoursandisresinwithametalsubstructure CourtesyDr.P.Pera
- 69. Finishedprosthesis.Usuallytheprovisional isreplacedduringtherstyear. TheColumbusBridge (Avariantoftheallonfourconcept) Delivery Oneyearlater CourtesyDr.P.Pera
- 70. CourtesyDr.D.Howes Subcrestalvssupracrestal angula1oncorrec1on However,surgicalplacementismoredemanding Co-axisimplants Co-axisimplantsareused Twoprostheses $825/angledabutment Subcrestalispreferred
- 71. Advantagesof Coaxisimplant Lesscost Screwretained Prosthodon1candtechnicalsimplicity Standardprosthe1ccomponentry CourtesyDr.D.Howes Subcrestalvssupracrestalangula1oncorrec1on AngledabutmentsvsCoaxisimplants However,surgicalplacementismoredemanding Co-axisimplants
- 72. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera) Retrospec1vestudiespublishedduringthelastseveralyearsand recentliteraturereviews(Papaspyridakosetal,2014,Gallucciet al,2014)appeartoindicatethatimmediateloadprosthesescan beemployedwithsuccessintheedentulousmaxilla.However thereportofTealdoandcolleagues(2014)isperhapsthemost revealing.
- 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. Theprosthesesfortheimmediateloadpa1entsweredesignedwithoutdistal can1levers,customizedmetalframeworkswerefabricatedofpalladiumalloy, occlusalsurfaceswererestoredwithresin,andtheocclusalschemeusedwas groupfunc1on. Reproducibleperiapicalradiographsusingcustomizedlmholderswere obtainedatdeliveryandatsubsequent12monthintervalsinordertoassess bonelevelsaroundtheimplants. Thecumula1veimplantsurvivalratewas93.9%fortheimmediateloadgroup and95.9%forthedelayedloadgroup.Nopa1entlostmorethanoneimplant. Inbothgroups,almostalloftheimplantlosseswerewithin12monthsof implantplacement. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera)
- 75. Alloriginalxedprosthesesremainedinfunc1onbutseveralrequired altera1onsorrepairs,mostsecondarytofracturesassociatedwiththeresin veneers.Howevertherewerenofracturesassociatedwiththemetal frameworks. Meanbonelossaroundimplantswasgreaterforthedelayedgroupthanfor theimmediateloadgroup. DataTiltedimplantsandimmediateloading CourtesyDr.P.Pera)
- 76. Allon6withPterygoidImplants Preferredwhenopposingmandibleisdentate
- 77. Withguidedworkupandsurgicalprocedurestheprosthesis canbedesignedandfabricatedpriortoimplantplacement Allon6withPterygoidImplants
- 78. Avoidssinusaugmenta1on Improvesimplantdistribu1onpa^erns,A-Pspreadand biomechanics Preferredifimmediateloadingisconsidered Successratesofpterygoidimplantscloseto90% (Candeletal,2012) Allon6withPterygoidImplants
- 79. Usedtoprovideposteriorsupportinfullarchandposterior quadrantprostheses Successratescloseto90%(Candeletal,2012) Allon6withPterygoidImplants
- 80. Allon6withPterygoidImplants
- 81. Allon6withPterygoidImplants Frameworkismadeof monolithiczirconia Crownsaremadeoflithium disilicateandcementedto theframework
- 82. Tiltedimplants-Posteriorquadrants Analterna1vetosinusaugmenta1on Computerguidedtreatmentplanningandimplant placementispreferred
- 83. Tiltedimplants-Posteriorquadrants Anteriorguidanceprovidedbynaturalden11on
- 84. Pterygoidimplants Combina1onof1ltedand pterygoidimplant Longerimplants Improvedbiomechanics Eliminatestheneedforsinus augmenta1on
- 85. Pterygoidimplants Iffullyguidedsurgeryisused,abutmentscanbe chosenormilledpriortosurgicalplacement
- 86. Pterygoidimplants Implantsplaced withtheaidofa surgicaltemplate Semi-guided surgical placementwas employed
- 87. Pterygoidimplants Combina1onof1ltedimplantandapterygoidimplant Eliminatestheneedforsinusaugmenta1on Occlusionisanteriorguidance
- 88. Zygoma1cimplants IntroducedbyBranemarkinthelate1980s Pa1entswithmoderatelyresorbedmaxillae Designedtobeusedinconcertwith2-4implantsplacedinthe anteriormaxilla Successrateshavebeenveryhighinconven1onalpa1ents (Branemark,2004;Aparicioetal,2006;Bedrossianetal,2006;Kahnbergetal,2007; Bedrossianetal,2012).
- 89. Zygoma1cimplants Complica1onsrarebutsignicant Oralantralstula Postopera1vemaxillarysinusi1s Peri-orbitalhematoma Facialswelling Penetra1onoftheorbit
- 90. Zygoma1cimplants Nolongerrecommendedforpa1entswithanintactpalate Distor1onofpalatalcontours Otherop1onsavailablethataremoreeec1ve. Tiltedimplants Pterygoidimplants Sinusaugmenta1on
- 91. Zygoma1cimplants Pa1entwasallergictoacrylicresin Zygoma1cimplantsusedtoavoidsinus augmenta1on Zygoma1cimplantsdidnotalterthecontours oftherestora1onorimpairthetonguespace
- 92. Zygoma1cimplants Usedforpa1entswithmajordefectsofthehardpalate UsefulforincompleterepairedcleVlipandpalatepa1ents Edentulousmaxillectomypa1entswithlargedefects Successrateshavebeengood (Schmidtetal,2004;Schmidt,2007) CourtesyA.Sharma
- 93. Zygoma1cimplants Issues Radia1oneects Hygieneaccess Longtermsurvivabilty Bestsuitedfortotalpalatectomydefects CourtesyA.Sharma
- 94. Zygoma1cimplants Prosthodon1cissues Twoimplantsperside Splintallimplantstogether Implantsupportedvsimplant assisteddesigndependson implantdistribu1onpa^ern Bestsuitedfortotalpalatectomydefects CourtesyA.Sharma
- 95. vVisitofr.orgforhundredsof addi1onallecturesonComplete Dentures,FixedProsthodon1cs ImplantDen1stry,Removable Par1alDentures,Esthe1cDen1stry andMaxillofacialProsthe1cs. vThelecturesarefree. vOurobjec1veistocreatethebest andmostcomprehensiveonline programsofinstruc1onin Prosthodon1cs