Simplified Implant Dentistry By Dr. Mahler

Simplified Implant Dentistry Through Innovative

Implant Design

Brian A. Mahler, D.D.S., P.L.C.10550 Warwick Avenue

Fairfax, VirginiaUSA

Placed March 1985, photo July 2004

Southern Implants

Company background Products Unique products What they do for me and my patients

Southern Implants

Dental Implant Division founded 1987 Other medical device sister companies

Prosthetic heart valvesArtificial back discs

Six Southern Medical Groups

Dental Implant Division founded 1987 Other medical device sister companies Significant studies

Southern Implants

Tawse-Smith A., Payne A.G.T., Kumara R., Thomson W.M. One-stage operative procedure using two different implant systems: A prospective study on implant overdentures in the edentulous mandible. Clin Implant Dent Relat Res 2001; 3-4; 185-193.

Watson G.K., Payne A.G.T., Purton D.G., Thomson W.M. Mandibular overdentures: Comparative evaluation of prosthodontic maintenance of three different implant systems during the first year of service. Int J Prosthodont 2002; 15: 259- 266.

Tawse-Smith A., Payne A.G.T., Kumara R., Thomson W.M. Early loading of unsplinted implants supporting mandibular overdentures using a one-stage operative procedure with two different implant systems: A 2-year report. Clin Implant Dent Relat Res 2002; 4: 33-42.

Daly P.F., Pitsillis A., Nicolopoulos S., Occlusal reconstruction of a collapsed bite by orthodontic treatment, pre-prosthetic surgery and implant supported prostheses. A case report. SADJ 2001; 56-6; 278 – 282.

Dellow A.G., Driessen C.H., Nel H.J.C. Scanning Electron Microscopy evaluation of the interfacial fit of interchanged components of four dental implant systems. Int J of Prosthodont 1997 10; 216 – 221.

Peer Reviewed Publications

Nikellis,I., Levi A., Niccolopoulos, C. “Immediate loading of 190 endosseous dental implants: A prospective observational study of 40 patient treatments with up to 2-year data” Int J Oral and Maxillofac Implants 2004; 19(1): 116-123.

Boyes-Varley J.G., Lownie J.F., Howes D.G., Blackbeard G.A. Surgical modifications to the Branemark Zygomaticus Protocol in the treatment of the severely resorbed maxilla: a clinical report. Int J Oral Maxillo Facial Implants 2003.

Boyes-Varley J.G., Lownie J.F., Howes D.G., Blackbeard G.A. Surgical modifications to the Branemark Zygomaticus protocol. COIR 2002; 13-4; xxxii

Butz, S.J., Huys,LW. Long-term success of sinus augmentation using a synthetic alloplast: in 20 patients, a 7 year clinical report. Implant Dent. 2005 Mar; 14(1):36-42.

Boyes-Varley J.G., Lownie J.F., Howes D.G. The Zygomatic Implant Protocol in the treatment of the severely resorbed maxilla. SADJ 2003; 58:3; 106-114.


Esposito M., Grusovin, M.G., Coulthard, P., kThomsen, P., Worthington, H.V. A 5-year follow-up comparative analysis of the efficacy of various osseointegrated dental implant systems: a systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2005 Jul-Aug;20(4):557-68.

Hall JA., Payne AG., Purton DG., Torr B., A randomized controlled clinical trial of conventional and immediately loaded tapered implants with screw-retained crowns. Int. Journal of Prosthodontics 2006 Jan-Feb;19(1):17-9.

Hall JA., Payne AG., Purton DG., Torr B., Duncan WJ., DeSilva RK., Immediately restored, single-tapered implants in the anterior maxilla: prosthodontic and aesthetic outcomes after 1 year. Clin Implant Dent Relat Res. 2007 Mar;9(1):34-45.

Vandeweghe S, Ackermann A, Bronner J, Hattingh A, Tschakaloff A, De Bruyn H. A Retrospective, Multicenter Study on a Novo Wide-Body Implant for Posterior Regions. Clin Implant Dent Relat Res. 2009 Dec 3.


Southern Implants

6 major clinical trials in peer reviewed journals with excellent results

Chosen by The Branemark Centre in

Gothenburg for their Maxillary Immediate Loading Protocol

High level studies

According to a review in JOMI, Aug. 2005 by ESPOSITO

There are only 4 manufacturers in the world with high level data to prove efficacy of use over a 5 year period

Southern Implants

Southern Implants Nobel Biocare Straumann Astra

A 5-year Follow-Up Comparative Analysis of the Efficacy of Various Osseointegrated

Dental Implant Systems

No differences in regard to failures and marginal bone levels after 5 years of function

High success rates can be achieved for all these systems analyzed after 5 years of loading

Esposito et al JOMI Aug 2005

Restorative Connections: Proprietary or Not?

Numerous good restorative connections

Southern restorative systems are not proprietary

EXTERNAL HEX

INTERNAL MORSE TAPER

& OCTOGON

INTERNAL TRI-LOBE

Southern’s 3 Restorative Connectors

Very Wide Product Range

Three non proprietary connections

“Expanding Proven Concepts”

Tri-Nex Implant

Internal Tri-Lobe Compatible with

Nobel Biocare™ Select Connection

Tri-Nex Implant

1. Remain compatible with other connectors

2. Make improvements over other designs

(Replace Select™)

Tri-Nex Implant

4 Diameters (3.5, 4.3, 5.0, 6.0)

5 Lengths (8.5, 10.5, 12, 13.5, 16.5)

Desired Improvements of other Tri-Lobe Designs

Minimize flowering fractures Improve primary stability in immediate placement

Minimize flowering fractures

Weak point

Cross Section of 3.5 TriNex Implant

Thicker wall to minimize fracture

or distortion

Platform switch

Binon’s work showedless fit of componentsincreases chances of

screw loosening



or distortion

Platform switch

Internal Hex for insertion



or distortion

Platform switch


Smaller polished collar0.6mm vs. 1.5mm


Minimize flowering fractures Improve primary stability in immediate placement


Threads extending to apex of implant

Extending threads to apex of implant yields better primary stability for immediate implant placement

Increase surface area


Improvements of other Tri-Lobe Designs

Thicker wallPlatform switch

Smaller polished collar0.6mm vs. 1.5mm

Threads extending to apex of implant


Compatible w/ Nobel Biocare

Southern Implants Enhanced Surface

The surface is enhanced using a proprietary method of size specific surface abrasion followed by chemical conditioning

Since 1991 and well studied

Southern Implants

Comparative Surface Analysis of 9 Implant Systems

Bernard J.P., Szmukler-Moncler S., Belser U.C., Samson J.

University of Geneva

2004: Academy of Osseointegration: San Francisco

Southern has a reproducible process

Southern surface is not easily injured

No remnant blasting material found

Efficient is being effective without wasting time, effort, or expense

It implies the least costly production means without sacrificing quality

Efficient is being effective without wasting time, effort, or expense

Save dentist’s time Shorten total treatment time Eliminate unnecessary procedures Save in components and materials cost Save in laboratory cost Minimize post treatment modifications or repairs

Schropp L, Isidor F. Timing of implant placement relative to tooth extraction. J Oral Rehabil. 2008 Jan;35 Suppl 1:33-43. Review.

Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate implants from 1988 to 2004. Int J Oral Maxillofac Implants. 2006 Jan-Feb;21(1):71-80.

Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19 Suppl:12-25. Review.

Immediate Implant Placement

Immediate implant placement shortens treatment time, decreases the number of surgical procedures, and often eliminates need for grafting

When certain parameters are met, long term results of immediate implant placement appears comparable to delayed placement

Single rooted relatively easy, but multi-rooted teeth difficult

Molar sockets are too large and complex to allow for immediate placement of conventional implants

Delayed placement will result in longer treatment time and often a bone graft will be required

Bone grafts are costly and time consuming

The Problem Molar sockets are too large and too complex to allow for

easy immediate placement of current implants

When left to heal first, maxillary molar extraction sites often require bone grafting of sinus floor

Multiple procedures lead to longer treatment time, cost, and possible resistance to implant treatment

Placement into one socket of multi- rooted site may create bio-mechanical and prosthetic compromises

The Solution

Develop an implant design and surgical protocol to facilitate immediate implant

placement into molar sites

This would optimize / preserve available bone and significantly reduce the time,

complexity, and cost of treatment

The MAX Implant for

Molar Replacement

Bucco-palatal = 10.7 mm

range = 7.4 -14 mm

M D

B P

7.9

10.7

Cervical dimensions

Maxillary first molar

Mesio-distal = 7.9 mm

Range = 6.4 -10.9 mm

Woelfel 1990

Bucco-lingual = 9.0 mm

Range = 7.3 -11.6 mm

M D

B P

7.9

10.7

Cervical dimensions

Mandibular first molar

Mesio-distal = 9.2 mm

Range = 7.7-12.4 mm

M D

9.2

L B

9.0

Woelfel 1990

MAX Implant Design

Large diameter implant Greater tapered body

– Preserve apical inter-radicular bone– Fits tapering sockets– Avoid lateral sinus penetration– Avoid adjacent roots– Easier primary stability

Platform switching External and internal connectors

MAX Implant Range

8mmØ8mmØ 9mmØ9mmØ

Self tapping flutesExternal Hex

Tri-Nex Connection

OCT Connection

Courtesy of Andrew Ackermann, BChD, MChD

Section root and remove carefully preserving buccal plate

Socket Preparation

Instruments same as tapered implants until final

Round bur to create pilot hole

Twist drills to enlarge

4.0mm, 5.0mm, 6.0mm tapered final shaping drill

Final dedicated MAX shaping drill

Dedicated drills

Place deep enough, even buccal plate

Place deep enough

Final Dedicated MAX Shaping Drill

Six total: One for each length and diameter of implants

8mm diameter MAX

7mm length

9mm length

11mm length

9mm diameter MAX

7mm length

9mm length

11mm length

Careful sectional removal of molar to preserve buccal plate

Pilot Drills and Tapered Drills in Inter-Radicular Bone

Preserve thin buccal plate

Not cover with tissue

23 months

Buccal plate preserved

Tapered drills may be difficult to control when socket voids or irregular walls exist

MAX TAP/DRILL

– Concentric drilling difficult

– Dedicated taps

– Very dense bone

– Some use in most sites

Dedicated Osteotome

Bone Deformation

Where to use the osteotome instead of a drill

Thin bone plates – drilling is high risk

Sinus communication

Where bone expansion can be achieved

Final Dedicated MAX Osteotomes

Six total: One for each length and diameter of implants

8mm diameter MAX

7mm length

9mm length

11mm length

9mm diameter MAX

7mm length

9mm length

11mm length

MAX Implant Dedicated Instruments

Drills Taps Osteotomes

Three dedicated instruments to facilitate MAX placement

Immediate Placement of the MAX Implant Follows the Same Principles as Immediate

Placement of a Single Rooted Tooth

Intact perimeter bone required

No significant infection

Adequate countersink for bone level implant

Avoid contact with facial plate

MAX osteotomy site preparation requires adjustments in surgical techniques facilitated by dedicated drills, taps, and osteotomes

Complications Inadequate soft tissue

Often due to not placed deep enough Damaging buccal plate

Minimal Oral-Antral Bone Dimension

Smoker / Immediate loading

Immediate loading

FAILURES

Be Aware of Interproximal Dimensions

Inadequate inter-radicular bone width to adjacent tooth

A Retrospective, Multicentre Study on a Novo Wide Body Implant for Posterior Regions. Vandewege S, Ackermann A, Bronner J, Hattingh A, Tsjachaloff A, De Bruyn. Clinical Implant Dentistry and Related Research. 2009 Dec 3 (epub)

•93 MAX implants in 75 patients•69 one stage approach, 24 in healed bone•29 immediately loaded •Mean follow up of 14 months (range 6-34 months)•Implant survival of 95.7%

MAX Implant

May be placed immediately into a significant percentage of molar sockets

The short term outcome of treatment has been excellent

The potential duration, cost, morbidity and complexity of molar replacement has been substantially reduced

The Co-Axis Implant

Threaded implant with a 12° and 24° angle correction built into it

Co-Axis Implant Requirements 12 & 24 degree angulation in implant

Threaded implant– Primary stability– Immediate restoration

Surface enhanced tapered implant

Use existing surgical protocol

Use existing surgical components and drills

Use existing restorative components*

© 2009 Southern Implants, Inc. All rights reserved.

Co-Axis with Industry Compatible Connections

Angled fixture mount allows symmetrical rotation when inserted

How Do You Place This Implant?

dimple on most coronal side of restorative platform

0.6mm thread pitch

Fixture and mount

WHY?

Tilted Implants Used to avoid anatomical structures Eliminate many grafting procedures Decreases treatment time and cost Do tilted implants work long term?

Tilted Implants Literature Review

1. Sütpideler M. Eckert SE, Zobitz M. An KN. Finite element analysis of effect of prosthesis height, angle of force application, and implant offset on supporting bone. Int J Oral Maxillofac Implants. 2004 Nov-Dec;19(6):819-25.2. E, Griggs JA, Powers JM, Englemeier RL. Effect of abutment angulation on the strain on the bone around an implant in the anterior maxilla: a finite element study. J Prosthet Dent. 2007 Feb;97(2):85-.3. Cehreli MC, Iplikcioğlu H, Bilir OG. The influence of the location of load transfer on strains around implants supporting four unit cement-retained fixed prostheses: in vitro evaluation of axial versus non-axial loading, J Oral Rehabil. 2002 Apr;29(4):394-400.4. Brosh T, Pilo R, Sudai D. The influence of abutment angulation on strains and stresses along the implant/bone interface: Comparison between 2 experimental techniques. J Prosthet Dent 1998;79:328-334.5. Clelland NL, Lee JK, Bimbenet OC, Brantley WA. A three-dimen sional finite element stress analysis of angled abutments for an implant placed in the anterior maxilla. J Prosthodont 1995; 4:95-1006. MC, Lplikçioğlu H. In vitro strain analysis and off-axial loading on implant supported fixed partial dentures. . Implant Dent. 2002;11(3):286-92.7. O’Mahony A, Bowles Z, Woolsey G, Robinson SJ, Spencer P. Stress distribution in the single-unit osseointegrated dental implant: finite element analyses of axial and off-axial loading. Implant Dent. 2000;9(3):207-18.8. Clelland NL, Gilat A, McGlumphy EA, Brantley WA. A photoelastic and strain gauge analysis of angled abutments for an implant system. Int J Oral Maxillofac Implants. 1993;8(5):541-8.9. Celletti R, Pameijer Ch, Bracchetti G, Donath K, Persichetti G, Visani I. Histologic evaluation of osseointegrated implants restored in nonaxial functional occlusion with preangled abutments. Int J Periodontics Restorative Dent. 1995 Dec;15(6):562-73.10. Barbier L, Schepers E . Adaptive bone remodeling around oral implants under axial and nonaxial loading conditions in the dog mandible. Int J Oral Maxillofac Implants. 1997 Mar-Apr;12(2):215-23.


11. SF, Wolfinger GJ, Balshi TJ. Analysis of 356 pterygomaxillary implants in edentulous arches for fixed prosthesis anchorage. Int J Oral Maxillofac Implants. 1999 May-Jun;14(3):398-406.12. Balshi SF, Wofinger GJ, Balshi TJ. Analysis of 164 titanium oxide-surface implants in completely edentulous arches for fixed prosthesis anchorage using the pterygomaxillary region. Int J Oral Maxillofac Implants. 2005 Nov-Dec;20(6):946-52.13. Valerón JF, Valerón PF. Long-term results in placement of screw-type implants in the pterygomaxillary-pyramidal region. Int J Oral Maxillofac Implants. 2007 Mar-Apr;22(2):195-200.14. Ahlgren F, Størksen K, Tomes K. A study of 25 zygomatic dental implants with 11 to 49 months' follow-up after loading Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):421-5.15. Aparicio C, Ouazzani W, Garcia R, Arevalo X, Muela R, Fortes V. A prospective clinical study on titanium implants in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a follow-up of 6 months to 5 years. Clin Implant Dent Relat Res. 2006;8(3):114-22.16. Becktor JP, Isaksson S, Abrahamsson P, Sennerby L. Evaluation of 31 zygomatic implants and 74 regular dental implants used in 16 patients for prosthetic reconstruction of the atrophic maxilla with cross-arch fixed bridges Clin Implant Dent Relat Res. 2005;7(3):159-65.17. Farzad P, Andersson L, Gunnarsson S, Johansson B. Rehabilitation of severely resorbed maxillae with zygomatic implants: an evaluation of implant stability, tissue conditions, and patients' opinion before and after treatment. Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):399-404.18. Eger DE, Gunsolley JC, Felmman S. Comparison of angled and standard abutments and their effect on clinical outcomes: a preliminary report. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):819-23.19. Sethi A, Kaus T, Sochor P. The use of angulated abutments in implant dentistry: five-year clinical results of an ongoing prospective study. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):801-10.20. Sethi A, Kaus T, Sochor P, Axmann-Krcmar D, Chanavaz M. Evolution of the concept of angulated abutments in implant dentistry: 14-year clinical data. Implant Dent. 2002;11(1):41-51.


21. Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants. 2000 May-Jun;15(3):405-14.22. Maló P, Nobre Mde A, Petersson U, Wigren S. A pilot study of complete edentulous rehabilitation with immediate function using a new implant design: case series Clin Implant Dent Relat Res. 2006;8(4):223-32.23. Rosén A, Gynther G. Implant treatment without bone grafting in edentulous severely resorbed maxillas: a long-term follow-up study. J Oral Maxillofac Surg. 2007 May;65(5):1010-6.24. Calandriello R, Tomatis M. Simplified treatment of the atrophic posterior maxilla via immediate/early function and tilted implants: A prospective 1-year clinical study. Clin Implant Dent Relat Res. 2005;7 Suppl 1:S1-12.25. Krennmair G, Fürhauser R, Krainhöfner M, Weinländer M, Plehslinger E. Clinical outcome and prosthodontic compensation of tilted interforaminal implants for mandibular overdentures. Int J Oral Maxillofac Implants. 2005 Nov-Dec;20(6):923-9.26. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: a clinical, radiologic, and periotest study. Clin Implant Dent Relat Res. 2001;3(1):39-49.27 Msu ML, Chen FC, Kao HC, Cheng CK. Influence of off-axis loading of an anterior maxillary implant: a 3-dimensional finite element analysis. Int J Oral Maxillofac Implants. 2007 Mar-Apr;22(2):301-9.28. Zampelis A, Rangert B, Heijl L. Tilting of splinted implants for improved prosthodontic support: a two-dimensional finite element analysis. J Prosthet Dent. 2007 Jun;97(6 Suppl):S35-43.29. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Fabbro MD. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res. 2008 Dec;10(4):255-63. 30. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL. Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32.

Tilted Implants Literature Review31. Capelli M. Zuffettii F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: a multicenter clinical study. Int J Oral Maxillofac Implants. 2007 Jul-Aug;22(4):639-44.32. Rosén A, Gynther G. Implant treatment without bone grafting in edentulous severely resorbed maxillas: a long-term follow-up study J Oral Maxillofac Surg. 2007 May;65(5):1010-6.33. Bedrossian E, Rangert B, Stumpel L, Indresano T. Immediate function with the zygomatic implant: a graftless solution for the patient with mild to advanced atrophy of the maxilla. Int J Oral Maxillofac Implants. 2006 Nov-Dec;21(6):937-42.34. Koutouzis T, Wennström JL. Bone level changes at axial- and non-axial-positioned implants supporting fixed partial dentures. A 5-year retrospective longitudinal study. Clin Oral Implants Res. 2007 Oct;18(5):585-90. Epub 2007 Jun 3035. Cruz M, Wassall T, Toledo EM, da Silva Barra LP, Cruz S. Finite element stress analysis of dental prostheses supported by straight and angled implants. Int J Oral Maxillofac Implants. 2009 May-Jun;24(3):391-403.36. Lin CL, Wang JC, Ramp LC, Liu PR. Biomechanical response of implant systems placed in the maxillary posterior region under various conditions of angulation, bone density, and loading Int J Oral Maxillofac Implants. 2008 Jan-Feb; 23(1):57-64.37. Al-Ghafli SA, Michalakis KX, Hirayama H, Kang K. The in vitro effect of different implant angulations and cyclic dislodgement on the retentive properties of an overdenture attachment system. J Prosthet Dent. 2009 Sep;102(3):140-7.38. Bellini CM, Romeo D, Galbusera F, Agliardi E, Pietrabissa R, Zampelis A, Francetti L. A finite element analysis of tilted versus nontilted implant configurations in the edentulous maxilla Int J Prosthodont. 2009 Mar-Apr;22(2):155-7.39. Fortin T, Isidori M, Bouchet H. Placement of posterior maxillary implants in partially edentulous patients with severe bone deficiency using CAD/CAM guidance to avoid sinus grafting: a clinical report of procedure Int J Oral Maxillofac Implants. 2009 Jan-Feb;24(1):96-102.prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32. Epub 2008 Jan 3.


40. Bevilacqua M, Tealdo T, Pera F, Menini M, Mossolov A, Drago C, Pera P. Three-dimensional finite element analysis of load transmission using different implant inclinations and cantilever lengths . Int J Prosthodont. 2008 Nov-Dec;21(6):539-42.41. Agliardi EL, Francetti L, Romeo D, Taschieri S, Del Fabbro M. Immediate loading in the fully edentulous maxilla without bone grafting: the V-II-V technique. Minerva Stomatol. 2008 May;57(5):251-9, 259-63.42. Zampelis A, Rangert B, Heijl L.Tilting of splinted implants for improved prosthodontic support: a two-dimensional finite element analysis. J Prosthet Dent. 2007 Jun;97(6 Suppl):S35-43. Erratum in: J Prosthet Dent. 2008 Mar;99(3):167.43. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Fabbro MD. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res. 2008 Dec;10(4):255-63. Epub 2008 Apr 1.44. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL. Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32. Epub 2008 Jan 3.45. Cruz M, Wassall T, Toledo EM, da Silva Barra LP, Cruz S. Finite element stress analysis of dental prostheses supported by straight and angled implants Int J Oral Maxillofac Implants. 2009 May-Jun;24(3):391-403.46. Kao HC, Gung YW, Chung TF, Hsu ML. The influence of abutment angulation on micromotion level for immediately loaded dental implants: a 3-D finite element analysis. Int J Oral Maxillofac Implants. 2008 Jul-Aug;23(4):623-3047. Las Casas EB, Ferreira PC, Cimini CA Jr, Toledo EM, Barra LP, Cruz M. Comparative 3D finite element stress analysis of straight and angled wedge-shaped implant designs. Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):215-25.48. Markarian RA, Ueda C, Sendyk CL, Laganá DC, Souza RM. Stress distribution after installation of fixed frameworks with marginal gaps over angled and parallel implants: a photoelastic analysis. J Prosthodont. 2007 Mar-Apr;16(2):117-22.


Tilted implants are a safe and effective treatment that has many benefits for the patient

Tilted Implants Avoid sinus and nerve without grafts Decreases treatment time and cost Increased patient acceptance Angle corrected abutments required

Added componentsAdded componentsSmaller screwsSmaller screwsAdded modes of failureAdded modes of failureIncreased costIncreased costIncreased timeIncreased time

Large Screw RetainedLarge Screw Retained RestorationsRestorations

2 mm minimum distance To correct angle

More time and cost than going direct to implant

Potential aesthetic problems

Angle corrected abutments often require tabling of bone

Templates for lab to mouth

Co-Axis Implant

Tilted implants are effective and benefit patients

Intermediate abutments cost time and money

Co-Axis Implant usually eliminates the need for intermediate abutments

Anatomy and/or bone loss often lead to less than ideal implant location in the maxillary anterior making their restoration difficult

Problem:

Maxillary anterior often requires facial emergence Cemented provisional

– Time consuming and trapped cement– Difficult to retrieve

Direct to implant provisional– Time consuming– Must replicate esthetics each time remove provisional

Intermediate abutment

Co-Axis Implant Development

It was determined by digital photographic analysis and cephalometric evaluation that an angle correction of 12 degrees would allow for vast majority of maxillary anterior implant restorations to be screw retained

Edentulous areas

C. Nikolopoulos, Oral SurgeonP. Youvanoglou, Pros.G. Ioannou, Technican

Co-Axis Implant

No intermediate abutments No tabling bone

Co-Axis 24ºExternal hex with slightly shorter screws and healing components

Restoring implants that intersect

Four on the floor– Angle implants distal to mental foramen increase AP spread– Requires intermediate abutment

The Co-Axis Implant

Co-Axis implant may be placed into available bone while leaving the restorative platform in an optimal position

Use Co-Axis implants in locations where conventional implants would require a bone graft or result in the inability to easily or adequately restore the implant

Correct angle in implant, not the restoration

Co-Axis Implant Instrumentation

12 degree direction indicator (after twist)

12 degree direction indicator (after final shaping) in 10, 13 and 15mm

Options

Advantages of Co-Axis Implant

Increase AP spread in four on the floor cases without requiring intermediate abutments

Avoid maxillary sinus augmentation without requiring intermediate abutments

Eliminates tabling of bone in many situations

Allow lingual access opening for easier immediate restorations

Large screw retained restorations without requiring intermediate abutments

Is It Strong Enough With That Thin Wall?

Straight Implant Co-axis Implant

Same amount of titanium just more on one side than other

Finite element analysis3.75 mm Implant Ext. Hex

350N load at 22° to long axis 350N load at 22° to long axis

Finite element analysisCo-Axis 12 degree

Finite Element Analysis

Co-Axis Implant Development

Cyclic fatigue testing– 4.0mm and 5.0mm– Gold alloy screw to 32Ncm– Cycled 5 million times or to failure– 22 degrees to implant axis– 15 mm from restorative platform– 600 N

Results:All five samples withstood five million cycles without any screw loosening or component deformation

Pilot Clinical Study

225 Co-Axis implants were placed by 14 surgeons

24 month period 90% of the implants immediately or early loaded Restored with screw retained prostheses 2 implants (immediately loaded) lost 4 weeks

after placement 99.2% success rate over this time period

Serendipity

Making a fortunate discoverywhile searching for other things

Initially not use Co-Axis aesthetic single teeth

Noticed results appeared as good, often better

Eventually realized better aesthetic results

Mid-Facial Soft Tissue Recession in Single Tooth Restorations

Interproximal bone levels determined by bone on adjacent teeth

DeRouck, T. et. al. Single Tooth Replacement in the Anterior Maxilla by Means of Immediate Implantation and Provisionalization: : A review, JOMI, 2008

“management of papillia levels seem predictable”…”however maintaining the midfacial gingival

margin may be more problematical ”

Mid-Facial Soft Tissue Recession in Single Tooth Restorations

Interproximal soft tissue levels

determined by bone on adjacent teeth

26° 17°

Angle of Implant

10 degrees

More vertical placement of implantsUnder contouring of restoration Narrower healing capsPlatform switchingImmediate restoration

Increase amount of tissue

Vertical Placement of ImplantsIn Anterior Maxilla

Anatomy of the anterior maxilla often results in facially inclined implants that leads to long teeth

In same osteotomy site a Co-Axis implant will result in more mid-facial soft tissue than a straight implant

“Need my crown recemented”

Emergency immediaterestoration

Immediate implant placement & restoration

Final 13 monthspost insertion

Pre-op model

Atraumatic extraction

Out of occlusion

Post op instructions

The Co-Axis implant has two distinct axes to allow easier replication of the two

planes nature gave maxillary anterior teeth

© 2008 Southern Implants, Inc. All rights reserved.

Easier to develop natural emergence profile Fewer custom abutments required Less preparation of stock abutments Greater wall thickness of abutments

Cemented Restoration Advantages

Co-Axis allows for final screw retained crown Lingual access Recession no problem / porcelain within.5mm of implant No cement complications 100% retrievable Some labs not trained

Conclusions

1. Co-Axis implant significantly reduces the need for bone grafting

2. This implant allows for screw retained restorations in most cases and makes cemented cases easier

1. Co-Axis implant is useful where anatomy restricts conventional implant placement

2. Results in more mid facial soft tissue than a conventional straight implant placed in the same osteotomy site

1. Success rates are comparable to non Co-Axis implants

Co-Axis Implant

“The Co-Axis implant is like my cell phone. When I first got it I thought I would use it

occasionally, but as time passed I use this new technology more and more .”

Stuart Graves, D.D.S.

Co-Axis and MAX Implants Less grafting Less cost and fewer complications Eliminate components Shorter treatment time Increased patient acceptance Better mid-facial aesthetics Happier patients and staff

Thank You

Brian A. Mahler, D.D.S., P.L.C.10550 Warwick Avenue

Fairfax, [email protected]

Simplified Implant Dentistry By Dr. Mahler

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