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- 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