L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes

Management of Edentulism and the Terminal Dentition: Maxilla Fixed¹

Clin A/Prof Glen Liddelow BDSc(WA), MScD(WA), DClinDent(Syd), MRACDS(Pros), FPFA, FICD, FRACDS

BRÅNEMARK CENTRE PERTH — Associated Brånemark Osseointegration Centre, Perth

Treatment Strategies for the Edentulous Jaw²

Lecture Introduction: Fixed Prosthesis for the Maxilla³⁴⁵⁶

Lecture 3 — Fixed Prosthesis, Maxilla

• Maxillary complete denture prosthetics
• Mandibular prosthodontics
• Mn IOD
• Mn IFP (Least maintenance)
• Review at 12 months (75% satisfied)

Friberg B, Jemt T. Rehabilitation of edentulous mandibles by means of four TiUnite implants after one-stage surgery: a 1-year retrospective study of 75 patients. Clin Implant Dent Relat Res. 2010; 12 Suppl 1:56-62.

Friberg B, Jemt T. Rehabilitation of edentulous mandibles by means of five TiUnite implants after one-stage surgery: a 1-year retrospective study of 90 patients. Clin Implant Dent Relat Res. 2008; 10(1):47-54.

Lecturer — Maxillary Fixed Options

Patients increasingly seek a fixed maxillary solution because they want their own teeth back rather than a removable prosthesis.

• A maxillary overdenture remains removable, covers much of the palate, affects taste and speech, and allows the face to collapse when removed, producing a markedly sunken appearance.
• Maxillary treatment may involve axial implants, tilted implants to avoid the sinus, grafted bone, zygomatic implants, or combinations of zygomatic and anterior implants.
• Four or six implants may be used; quad zygomatic treatment is an option when no usable maxillary bone remains.
• The prosthesis must provide facial-tissue support comparable to the support previously provided by the denture flange.

Evolution of Immediate Loading Protocols⁷

1. 1991 — Single stage surgery and immediate loading — T-033C
2. 1994 — Routine lower jaw on 4 implants, immediate loading
3. 1998 — Branemark Novum — T-086
4. 2000 — Immediate loading maxilla
5. 2003 — Teeth in an hour (NobelGuide)
6. 2008 — Immediate loading of Zygoma implants

Lecturer — Immediate Loading

Immediate loading is used to place patients into fixed teeth more quickly, but its feasibility depends on several clinical factors.

• Relevant factors include the quality of the native bone, implant stability, the amount of load placed on the implants, and the patient’s medical and behavioral risk factors.
• Native bone provides the option of loading when adequate stability is achieved, but healing and biological stability remain important even when immediate loading is selected.

• Tooth loss is followed by substantial reduction of the alveolar bone, which contributes to loss of lip support.
• Assessment should include the previous prosthesis, the lip support it provided, facial aesthetics before treatment, tooth and gingival display during smiling, and individual upper-lip movement.
• Facial support also decreases with age as musculature and collagen change, contributing to wrinkles; the amount of support required differs between patients.

Lecturer — Facial Aesthetics

The goal is not merely to replace teeth but to maintain or improve the patient’s facial appearance.

• Before-and-after assessment should examine facial creases, vermilion support, changes in the lips and perioral tissues, and the appearance of the face with the proposed prosthesis.
• The prosthesis should be designed in relation to the patient’s existing facial form rather than according to a single idealized appearance.

Lecturer — Lip Support

A traditional denture flange supports the lips and perioral musculature, whereas an implant bridge cannot simply reproduce the flange because the tissues behind it must remain accessible for cleaning.

• The replacement must allow toothbrushing, flossing, use of a water jet, and use of interdental cleaning aids.
• Reducing the bulk of the flange-like support can cause the upper lip to collapse inward, particularly with a thin upper lip.
• Upper-lip mobility and individual orofacial musculature must be considered when designing the prosthesis.

Lecturer — Ridge Reduction

Ridge reduction may be necessary to create a prosthetic contour that provides adequate facial support while remaining cleansable.

• Reducing the ridge can allow the bridge contour to approach the support previously provided by a denture flange.
• Excessive reduction may improve prosthetic space and facial support but can also remove bone needed for implant placement.
• The amount of reduction must be planned in relation to the desired prosthetic contour and the available implant sites.

Lecturer — Tooth Position

Implant-supported teeth can be positioned more freely than denture teeth because the implant prosthesis is rigid, while denture teeth generally need to remain close to the ridge to avoid destabilizing the denture.

• Tooth position should be determined before implant placement and related to facial aesthetics, lip support, phonetics, the transition to natural gingiva, and final implant position and angulation.
• Digital smile design involves drawing on photographs and quantifying desired changes.
• Successful treatment requires close coordination between the dental laboratory and clinic during design and fabrication.

Lecturer — Replacement Classifications

FP1 replaces only the teeth, without replacing gingival or mucosal tissue, whereas FP2 includes some pink tissue replacement.

• FP1 is often presented as an ideal, but it may be limited in patients who have lost teeth and supporting bone.
• Even when tissue grafting creates papillae and root coverage, the result may still have long contours and small papillae, producing a band-like appearance if the ceramics are not carefully designed.

Patient Assessment and Factors to Consider

Sequelae of Tooth Loss⁸⁹

Factors to consider

• Initial aesthetic expectation
• Current dentition, prostheses

Facial Aesthetics and Lip Support

What are the issues?

Facial Aesthetics¹⁰

What are the issues?

Lip Support¹¹

Ridge Reduction and Facial Support¹²

Ridge Reduction¹³

Facial Support

Ridge Reduction — Facial Support¹⁴

Lecturer — Facial Support

Facial support was compared between a traditional denture and an implant-supported bridge.

• Anthropometric mask technology was used to evaluate changes in facial support between the pre-treatment prosthesis and proposed restoration.
• Three-dimensional simulations can help evaluate how prosthetic changes may affect facial support.
• The desired outcome is to maintain or improve facial support without creating a prosthesis that cannot be cleaned.

Tooth Position and Aesthetics Within the Face¹⁵¹⁶

The Face — Determination of tooth position within the face

What are the issues?

Tooth aesthetics and function¹⁷

Digital Planning and Work-Up

Digital Smile Design and Facebow Transfer^{1819202122232425}

This page consists of figures only; the slide text serves solely as image labels.

Coachman C, Calamata M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. Quintessence Dental Technology 2012

Lecturer — Prosthetically Driven Planning

Radiographic work-up relates the available bone to the planned restoration.

• A CAT scan or cone-beam scan is used to evaluate the available bone.
• A trial prosthesis determines where implants should be placed in relation to the intended teeth.
• The screw access should ideally emerge through an appropriate area of the tooth rather than through an unaesthetic or anatomically disruptive position.
• An implant placed at an unsuitable angle may require a large restorative bulge that looks non-anatomical, interferes with the tongue, and makes cleaning difficult.
• Implant positions may involve native bone, grafted bone, zygomatic bone, or other extra-alveolar positions.
• The key objective is for the implants to emerge through the basic position of the planned bridge and adapt properly to the prosthesis.

Lecturer — Digital Smile Design

Tooth position can be planned using analog denture principles or digital smile design.

• Digital smile design involves drawing on images of the patient, quantifying the changes to be made, and planning the appearance of the final teeth.
• The design process must be coordinated with the laboratory.
• Once tooth position and required lip support have been determined, implant positions can be planned in relation to the proposed teeth.

Digital Ruler

“Real Face Bow”

Junction between implant and prosthetic tooth determines lip support and phonetic surface

Image shows a collection of custom dental prosthetic devices (dentures or implant-retained suprastructures) against a black background.

Radiographic Work-Up and Prosthetically Driven Planning^{26272829303132}

The Face

Transfer to radiographic work up and NobelClinician software

Double Scan

Planning implant placement — prosthetically driven

NobelConnect

• Critical for complex interdisciplinary treatment

Implant Surgical Pathways³³

Graftless

• Axial

• Tilted

• Immediate loading

• Implants engaging the zygoma Grafting

• Sinus

• Labial onlay

• Ridge splitting

• GBR

• Interpositional

• Distraction osteogenesis

• LeFort 1

• Free tissue transfer

Grafting material options:

• Autogenous
• Allograft
• Xenograft
• Synthetic
• BMPs
• Gene therapy

Lecturer — Surgical Planning

The surgical pathway depends on the available bone and the intended prosthetic result.

• The choice is influenced by the amount and location of available bone, the position of the sinus, the desired tooth position, the required facial support, and the patient’s risk profile.
• Straight axial implants are uncommon in abundant maxillary bone because many patients do not have sufficient bone.
• Implant placement should begin with the prosthetic plan, followed by identification of the bone that can support the implants.

Clinical Studies: Axial Implants Without Grafting³⁴³⁵

Studies restoring the edentulous maxilla with fixed prostheses — axial implants, no grafting:

Study	Design	Patients	Implants	Surg Proc	System	FDPs	Obs period	Survival Implants %	Survival FDP %
Adell et al 1981	pros	146	981	Conventional	Branemark	146	9 yr	81	89–96
Adell et al 1983	pros	73	529	Conventional	Branemark	73	5?–10	82 (5y), 81 (10y)	100 (5y), 88 (10y)
Adell et al 1990	pros	277	1789	Conventional	Branemark	277	5–15	84 (5y), 78 (15y)	84 (5y), 78 (15y)
Carlsson et al 2000	pros	13	75	Conventional	Branemark	13	15	93	–
Jemt et al 2002	pros	58	349	Conventional	Branemark	58	5	91	93
Engfors et al 2004	retro	44	282	Conventional	Branemark	44	5	93	–
Jaffin et al 2004	–	34	236	Immed loading	Straumann	34	5	92	–
Ortop et al 2004	pros	54	356	–	Branemark	54	5	90	95
Degidi et al 2005	retro	45	388	Immed loading	various	45	5	98	–
Rasmussen et al 2005	pros	16	91	Conventional	Astra	16	10	97	100
Cannizzarro et al 2007	pros	33	202	Immed loading	Zimmerman	21	1	100	100

Tilted implants, no grafting:

• Maxilla: 13-year follow-up
• 17-year follow-up
• Mandible: 24-year follow-up

Lecturer — Axial Implant Studies

Axial implants are placed in a relatively straight, tooth-axis position, and long-term studies extend back to the early 1980s. The studies discussed showed high success rates when sufficient bone is available, and native bone can provide enough stability for immediate loading.

Clinical Studies: Tilted Implants Without Grafting³⁶³⁷³⁸

Superstructure cementation

Axial CT scan (C1) and osseous contour details

Studies restoring the edentulous maxilla with fixed prostheses — tilted implants, no grafting:

Study	Design	Patients	Implants	Surg Proc	System	FDPs	Obs period	Survival Implants %	Survival FDP %
Mattson et al 1999	pros	15	86	conventional	Branemark	15	3	99	–
Malo et al 2005	retro	32	128	immed loading	Branemark	32	1	98	–
van Steenberghe 2005	pros, multi	27	164	immed loading	Branemark	27	1	100	100
Capelli et al 2007	pros, multi	41	246	immed loading	3i	41	3	98	100
Malo et al 2007	pros	18	72	immed loading	Branemark	18	2	97	–
Rosen et al 2007	retro	19	103	conventional	Branemark	19	8–12	97	–
Tealdo et al 2008	pros	21	111	immed loading	3i	21	1	93	100
Testori et al 2008	pros	41	246	immed loading	3i	41	1–3	99	100

Del Fabbro M, Bellini CM, Romeo D, Francetti L. Tilted Implants for the Rehabilitation of Edentulous Jaws: A Systematic Review. Clin Implant Dent Relat Res. 2011.

Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6.

Studies restoring the edentulous maxilla with fixed prosthesis — tilted implants, no grafting:

No significant difference in failure rate or marginal bone levels between axial and tilted implants.

Menini M, Signori A, Tealdo T, Bevilacqua M, Pera F, Ravera G, Pera P. Tilted implants in the immediate loading rehabilitation of the maxilla: a systematic review. J Dent Res. 2012;91(9):821-7.

Del Fabbro M, Bellini CM, Romeo D, Francetti L. Tilted Implants for the Rehabilitation of Edentulous Jaws: A Systematic Review. Clin Implant Dent Relat Res. 2011.

Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6.

Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011;106(6):359-66.

Maló P, Araújo Nobre MD, Lopes A, Rodrigues R. Double Full-Arch Versus Single Full-Arch, Four Implant-Supported Rehabilitations: A Retrospective, 5-Year Cohort Study. J Prosthodont. 2015;24(4):263-70.

Advantages of Tilted Implants³⁹⁴⁰

• Allows for placement of longer implants — immediate loading

• Allows for improved anchorage in dense bone

• Allows for further distal extensions

• Does not have a negative effect on load distribution

• Relatively easier surgery compared to sinus lifting

• Implants may be tilted anterior or posterior to the sinus to avoid it and increase implant distribution without grafting.

• The further anterior the implant position, the better the bone was described as being.

Lecturer — Treatment Sequence

A tilted-implant treatment sequence may include several restorative and laboratory steps.

• Remove teeth requiring extraction and place the implants.
• Register the jaw using closed-tray impression copings and record the relationship between the implants and the planned teeth.
• Mount the records in an articulator, take a splinted implant impression, and create a model and provisional bridge.
• In one example, the provisional bridge remained in function for 15 years, illustrating the reported durability of this treatment.

Graftless Full-Arch Outcomes: All-on-4 and All-on-6

All-on-4 Outcomes⁴¹⁴²⁴³

CBCT showing dental implants with sinus lift

• 20 maxillae, 18–42 months, prospective single cohort, immediate loading
• Implant survival: 100%
• Marginal bone loss: 0.8 ± 0.4 mm axial, 0.9 ± 0.5 mm tilted
• No statistical difference in axial vs tilted implants

Agliardi E, Panigatti S, Clericò M, Villa C, Malò P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: interim results of a single cohort prospective study. Clin Oral Implants Res. 2010 May;21(5):459-65.

• 61 maxillae, 1–5 yrs, prospective single cohort, immediate loading
• Implant survival: 98.36%
• Marginal bone loss: 0.9 ± 0.7 mm
• No difference in axial vs tilted implants

Agliardi EL, Francetti L, Romeo D, Del Fabbro M. Immediate rehabilitation of the edentulous maxilla: preliminary results of a single-cohort prospective study. Int J Oral Maxillofac Implants. 2009 Sep-Oct;24(5):887-95.

• Tilted implants may be incorporated to avoid the sinus and allow a fixed bridge without grafting.

Systematic Review: All-on-4 Outcomes⁴⁴

• 13 papers
• 4804 implants, 1201 prostheses within 48 hrs
• 99% success at 3 yrs (implants)
• 99.9% success at 3 yrs (prosthesis)
• Bone loss 1.3 ± 0.4 mm at 3 yrs
• No significant difference between axial and tilted implants
• Most failures with smokers and bisphosphonate medication
• Short-term results

S. B. M. Patzelt, O Bahat, BDS, M. A. Reynolds, J. R. Strub, The All-on-Four Treatment Concept: A Systematic Review. Clin Oral Impl Res 2013

Lecturer — Implant Number Selection

The lecturer described four- and six-implant treatment as having approximately the same success rate.

• The number of implants should be considered together with bone quality, loading conditions, patient risk, bruxism, and the opposing dentition.
• In patients with high loading or other risk factors, the number of implants may need to be considered carefully rather than applying a fixed protocol to every patient.

All-on-6 Outcomes⁴⁵⁴⁶

• 41 maxillae, mean 22-month follow-up, prospective multi-center, immediate loading
• 4 axial implants, 2 tilted
• Implant survival: 98.8%
• Marginal bone loss: 0.9 ± 0.4 mm axial, 0.8 ± 0.5 mm tilted
• No difference in axial vs tilted implants
• Prosthesis success rate: 100%

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.

• 19 patients with 4 or 6 implants, tilted distal implants
• 8–12 year follow-up, mean 10 years (pre-All-on-4)
• Implant success: 97%
• Marginal bone loss: 1.2 mm
• No difference in axial vs tilted implants

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.

Implant Failure and Risk Assessment

Causes of Implant Failure

Multifactorial Reasons for Bone Loss⁴⁷

• Cause / effect / association
• Early failure
• Late failure
  • Periimplantitis model
  • Patient-related factors
  • Due to inadequate healing in the first place — lower BIC — degree of sustainable osseosufficiency

Lecturer — Osseous Sufficiency

Osseous sufficiency is the degree to which bone has integrated with and can sustainably support the implant.

• Implant stability transitions from initial mechanical stability to biological stability through fibrin, collagen, osteoblast activity, and bone-to-implant contact.
• Biological stability takes approximately one year to reach full strength, although stability is already relatively good at approximately four or five months.
• Bone-to-implant contact is not 100%: the best cases may reach approximately 80%, while some functional implants remain at approximately 30%.
• Excessive loading during healing can interfere with osseous sufficiency.

Bruxing Patient With Immediate Loading

A heavily bruxing patient treated with four implants and loaded immediately may experience greater stress while biological stability is not yet complete. If plaque-related inflammation is added, the implant-supporting tissues may be further compromised.

Koka S, Zarb G. On osseointegration: The healing adaptation principle in the context of osseosufficiency, osseoseparation and dental implant failure. Int J Pros 2012;25:48-52.

Zarb G. Implantomania: Prosthodontics at a crossroads. Int J Pros 2012;25:180-185.

Albrektsson T, Buser D, Sennerby L. On crestal/marginal bone loss around dental implants. Int J Pros 2012;25:320-322.

Members — T Albrektsson, D Buser, S Chen, D Cochran, H De Bruyn, T Jemt, S Koka, M Nevins, L Sennerby, M Simion, T Taylor, A Wennerberg.

Patient Risk Factors and At-Risk Cases⁴⁸

Patient Risk Factors⁴⁹

Primary Factors	Secondary Factors
Opposing natural dentition	Smoker
Poor bone density	Bone volume
Bruxer
Male

• The common factor among many of these risks, apart from smoking, is increased loading.
• Medical history, smoking, bruxism, bone quality, and the opposing dentition should be assessed before selecting an immediate-loading or graftless protocol. Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6

Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011;106(6): 359-66.

74% of failures occurred within 12 months of placement

Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6

Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011;106(6): 359-66.

Implant Stability in the Maxilla⁵⁰

Implant Stability⁵¹

Mechanical	Biological
Surgery
2m
3m
6m
1yr	100

Mechanical stability of maxillary bone is 3–4× lower than functional resistance to load of mandibular bone. Implants are not as stable cf mandibular bone.

Lecturer — Maxillary Stability

Mechanical stability is present immediately after placement and is related to the torque required to place the implant, but it decreases as the initial forces relax.

• Biological stability develops as a fibrin network forms, collagen is produced, and osteoblasts and other cells create bone-to-implant contact.
• The transition between mechanical and biological stability is critical when implants are loaded immediately.
• The lower density of maxillary bone makes implant stability and healing more challenging than in the mandible.

Axis scale: 100, 80, 60, 40, 20, 0 — Surgery (Mechanical) vs Time (Biological).

Maxillary bone type 3–4× lower functional resistance to load — implants not as stable cf mandibular bone.

Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6

Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011; 106(6): 359-66.

• Depending on the loading, four implants may be insufficient for complete stability, resulting in lower BIC and greater susceptibility to integration breakdown, opportunistic infection and bone loss.
• Exacerbated if other patient factors, e.g. smoking, diabetes, IL-1 phenotype, hx of perio, AI disease, etc.
• All-on-4 may not be appropriate for larger arch form and greater load.

Chung S, McCullagh A, Irinakis T. Immediate loading in the maxillary arch: evidence-based guidelines to improve success rates: A review. J Oral Implantol. 2011;37:610-21.

Management of the Atrophic Maxilla: Augmentation

Augmentation⁵²

Iliac Crest Grafting Considerations⁵³

Iliac Crest grafting

Maxillary Bone Graft Considerations⁵⁴

• Donor site

• Recipient site preparation

• Fixation

• Implant installation delayed vs immediate

• Post graft radiological requirements

• Complications

• Bone may be harvested from the lateral wall or lateral oblique ridge for anterior augmentation.

• Grafted blocks may be fixed with screws and covered with membranes.

• Grafting can combine autogenous bone, bovine bone, and other grafting materials.

MINIMUM 1 YEAR TREATMENT PLAN

Lecturer — Iliac Crest Grafting

Iliac crest grafting was described as a difficult and prolonged treatment for both patients and clinicians.

• Patients could be unable to wear their dentures for months.
• Some studies showed survival rates of approximately 75%, and the overall results discussed were approximately 80%, so this approach is no longer used in the same way.

Sinus Lift Lateral Window Studies⁵⁵⁵⁶⁵⁷

Studies restoring the edentulous maxilla with fixed prostheses — Sinus Lift Lateral Window

Study	Design	Patients	Implants	Surg Proc	System	Graft material	FDPs	Obs period	Survival Implants %	Survival FDP %
Watzek et al 1998	retro	20	145	conventional	Frialit, IMZ	Autogenous	5	1-6	95	-
Johansson et al 1999	retro	39	131	immed load	Branemark	Autogenous HA	36	3	75	95
Wannfors et al 2000	RCT	40	150	immed & conventional	Branemark	Autogenous	40	1-6	84	-
Raghoebar et al 2001	retro	75	326	immed & conventional	Branemark	Autogenous	27	1-10	91	-
Hallman et al 2002	pros	21	67	conventional	Branemark	Autogenous, BioOss	21	1	82	-
Bektor et al 2004	retro	64	437	immed & conventional	Branemark	Autogenous	56	5-6	75	100

Lateral Window Treatment Course

In the example discussed, a lateral window was created and the Schneiderian membrane was carefully elevated to form the roof of the augmented space.

• The sinus was filled with a mixture of bovine and autogenous bone.
• Blocks were used to augment the anterior ridge, fixed with screws, and covered with membranes.
• Implants were placed after grafting and a bridge was subsequently fabricated.
• The complete process took approximately one and a half years, and the patient could not wear her denture for approximately four months.

Systematic reviews of studies restoring the edentulous maxilla with fixed prostheses — Sinus Lift Lateral Window

• Implant survival more variable in augmented sinuses (36–100%, avg ~90%)
• Amount of residual bone height is an important prognostic factor
• No evidence for the superiority of autogenous bone compared to substitutes
• Heterogeneous studies do not allow definitive statements

Graziani F, Donos N, Needleman I, Gabriele M, Tonetti M. Comparison of implant survival following sinus floor augmentation procedures with implants placed in pristine posterior maxillary bone: a systematic review. Clin. Oral Impl. Res. 15, 2004; 677–682.

Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. J Clin Periodontol. 2008;35(8 Suppl): 216-40.

Nkenke E, Stelzle F. Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review. Clin Oral Implants Res. 2009;20 Suppl 4:124-33.

Rickert D, Slater JJ, Meijer HJ, Vissink A, Raghoebar GM. Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes. A systematic review. Int J Oral Maxillofac Surg. 2012;41(2):160-7.

Zygoma Implants: Studies and Treatment Planning

Zygoma Implant Survival Studies⁵⁸

Studies Restoring the Edentulous Maxilla with Fixed Prostheses — Zygoma Implants⁵⁹

Study	Design	Patients	Zyg Implants	Surg Proc	System	FDPs	Obs period (yrs)	Survival Implants %	Survival FDP %
Vrielinck et al 2003	Pros	29	67	conventional	Branemark	10	1	93	-
Branemark et al 2004	Pros	28	52	conventional	Branemark	27	5-10	94	96
Hirsch et al 2004	Pros	66	124	conventional	Branemark	58	1	98	97
Malevez et al 2004	Retro	55	103	conventional	Branemark	55	4	100	-
Becktor et al 2005	Retro	16	31	conventional	Branemark	16	1-6	90	-
Ajlgren et al 2006	Pros	13	25	conventional	Branemark	4	1-4	100	-
Bredrossian et al 2006	Pros	14	28	immed loading	Branemark	14	1-4	100	100
Farzad et al 2006	Pros	11	22	conventional	Branemark	11	1-4	100	-
Davo et al 2007	Retro	18	36	immed loading	Branemark	18	1	100	100
Duarte et al 2007	Pros	12	48	immed loading	Branemark	12	2.5	96	-
Penarrocha et al 2007	Retro	21	40	conventional	Branemark	21	1-4	100	-
Bredrossian et al 2010	Pros	36	74	conv/immed	Branemark	36	7	97.3	100
Miglioranca et al 2012	Pros	25	40	immed loading	Branemark	25	8	97.5	95.2
Aparicio et al 2014	Retro	22	41	conventional	Branemark	22	10	97.7	100
Davo et al 2013	Pros	42	69	immed loading	Branemark	37	5	98.5	100
Malo et al 2014	Retro	39	92	immed loading	Branemark	39	5	98.8	100
Davo et al 2015	Pros	14	64	immed loading	Branemark	14	5	100	100

Lecturer — Zygoma Implant Context

Zygoma implants engage the zygomatic arch and became an alternative to extensive grafting in severely atrophic maxillae.

• Early studies associated with Brånemark reported survival rates from approximately 95% to 100%.
• Systematic reviews also showed very high success rates.

Systematic Reviews⁶⁰

• Overall survival rate 96.7% including cancer patients
• Intramaxillary immediate loaded (9 studies, 458 implants, 8 failures): ZI 98.3%
• 5 cases of sinusitis, all resolved

Chrcanovic BR, Abreu MH. Survival and complications of zygomatic implants: a systematic review. Oral Maxillofac Surg. 2013;17(2):81-93.

• 25 articles
• Overall survival rate 97.8% (1541 ZI, 33 failures)
• Failure generally in the first year due to infection and sinusitis

Goiato MC, Pellizzer EP, Moreno A, Gennari-Filho H, Dos Santos DM, Santiago JF Jr, Dos Santos EG. Implants in the zygomatic bone for maxillary prosthetic rehabilitation: a systematic review. Int J Oral Maxillofac Surg. 2014;43:748-757. Review.

Patient Satisfaction With Zygoma Implants

Satisfaction Studies⁶¹

• 16 pts: all satisfied; 50% with some complaints (50% prosthesis, 38% implants)
• 22 pts: 84% satisfaction above 80% (32% had 100% satisfaction)
• Satisfaction (high) approaching the general population

Sartori et al. Evaluation of Patients Rehabilitated with Zygomatic Fixtures. J Oral Maxillofac Surg 2012;70:314-9.

Aparicio et al. The Long Term Use of Zygomatic Implants: A 10 Year Clinical and Radiographic Report. Clin Impl Dent Relat Res 2012.

Wang F, Monje A, Lin GH, Wu Y, Monje F, Wang HL, Davó R. Reliability of four zygomatic implant-supported prostheses for the rehabilitation of the atrophic maxilla: A systematic review. IJOMI 2015;30:293-298.

Lecturer — Patient Treatment Goals

Zygoma treatment can provide fixed teeth for patients who cannot tolerate or wear an upper denture.

• The approach addresses the need for a fixed prosthesis and improved facial support.
• It can be used in situations with little or no conventional implant bone.
• Prosthetic design and cleansability remain important even when zygoma implants provide the surgical foundation.

Bedrossian Treatment Planning Guidelines by Zone^6263646566

Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study. IJOMI 2010;25:1213-1221.

Treatment Planning Guidelines⁶⁷

Zones 1, 2 & 3 — Traditional Axial implants

Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study. IJOMI 2010;25:1213-1221.

Zones 1, 2 — Traditional Axial and Tilted implants

Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study. IJOMI 2010;25:1213-1221.

Zone 1 only — Traditional Axial and Zygomatic implants

Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study. IJOMI 2010;25:1213-1221.

Insufficient bone in all zones — Quad Zygoma

Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study. IJOMI 2010;25:1213-1221.

Lecturer — Treatment Planning Zones

The maxilla was divided into three treatment-planning zones.

• The anterior zone generally has the best bone.
• The premolar or pre-canine zone and the molar zone complete the treatment-planning division.
• These zones help determine whether treatment should involve axial implants, tilted implants, zygoma implants, or combinations of these approaches.

Ridge reduction affects implant length and AP spread

Zones labeled on the diagram: Zone 3, Zone 2, Zone 1, Zone 2, Zone 3

Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T. Fixed-prosthetic implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J Oral Maxillofac Surg. 2008;66(1):112-22.

Ridge Reduction, Implant Length and AP Spread⁶⁸⁶⁹⁷⁰

Ridge reduction affects implant length and AP spread

Zones labeled on the diagram: Zone 3, Zone 2, Zone 1, Zone 2, Zone 3

Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T. Fixed-prosthetic implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J Oral Maxillofac Surg. 2008;66(1):112-22.

Ridge reduction affects implant length and AP spread

Zones labeled on the diagram: Zone 3, Zone 2, Zone 1, Zone 2, Zone 3

Maló P, Nobre Md, Lopes A. Immediate loading of “All-on-4” maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol. 2013;6(3):273-83.

Ridge reduction affects implant length and AP spread

Zones labeled on the diagram: Zone 3, Zone 2, Zone 1, Zone 2, Zone 3

Goiato MC, Pellizzer EP, Moreno A, Gennari-Filho H, dos Santos DM, Santiago JF Jr, dos Santos EG. Implants in the zygomatic bone for maxillary prosthetic rehabilitation: a systematic review. Int J Oral Maxillofac Surg. 2014;43(6):748-57.

Lecturer — Ridge Reduction Effects

Ridge reduction affects both restorative space and implant placement.

• If only a small amount of ridge reduction is needed, treatment may remain straightforward.
• With greater reduction, smaller implants may be required, implants may need to be positioned trans-sinus, and implants may need to extend into the zygoma.
• Implant length and position must be evaluated after determining the amount of ridge reduction needed for the prosthesis.
• The final decision depends on the residual ridge, required facial support, planned tooth position, available implant bone, and the need for an acceptable anteroposterior spread.

Home Care and Prosthetic Design

Home Care Patient Aids and Cleansibility⁷¹⁷²⁷³

Home Care Patient Aids

Cleansibility

Lecturer — Home Care Access

Cleansability is particularly important in the maxilla, and the prosthesis should balance facial support with access for home care.

• Useful aids include water jets, interdental brushes or “pixters,” and floss where access permits.
• Concave or bulky surfaces can trap plaque, spirochetes, and other deposits, contributing to peri-implant inflammation.
• If implants are not placed deeply enough or the prosthesis is poorly designed, excessive tissue contours may require surgical reduction to restore cleansability.

• Convex tissue fitting surface

• A convex surface allows a water jet to pass along and clean the entire tissue-fitting area

Definitive Bridge Options for Both Jaws⁷⁴

Definitive Bridge Options — Both Jaws

• Mandible — acrylic resin
• Maxilla — more wear resistant
  • Ceramic if possible

Lecturer — Opposing Materials

Using acrylic on the lower jaw and ceramic on the upper jaw allows one material to wear rather than having both arches wear against each other in the same way.

• Material selection should account for the opposing dentition, bruxism, wear, fracture risk, patient comfort, and cleansability.

Maxillary Bridge Options: Framework Materials⁷⁵

Procera Titanium Hybrid with Acrylic Teeth⁷⁶

Need occlusal splint.

• Maintenance medium but relatively easy to fix
• Retread 5–7 years for wear
• Staining around margins
• Acrylic resin fractures
• Tooth fractures

Torsello F, di Torresanto VM, Ercoli C, Cordaro L. Evaluation of the marginal precision of one-piece complete arch titanium frameworks fabricated using five different methods for implant-supported restorations. Clin Oral Implants Res. 2008;19(8):772-9.

Hjalmarsson L, Örtorp A, Smedberg JI, Jemt T. Precision of fit to implants: a comparison of Cresco™ and Procera® implant bridge frameworks. Clin Implant Dent Relat Res. 2010;12(4): 271-80.

Lecturer — Acrylic Maintenance

Titanium-reinforced acrylic bridges may be used for full-arch treatment, but acrylic teeth and prosthetic materials commonly require replacement or refurbishment approximately every five to seven years.

• Typical maintenance includes staining, fracture, replacement of denture teeth, and retreatment or refurbishment of the prosthesis.

PFM — Gold Cemented Framework⁷⁷

Gold prices are getting crazy — US$11K for this one!

Lecturer — Gold Frameworks

Gold porcelain-fused-to-metal frameworks were used for severe bruxers, but gold was described as heavy and increasingly unaffordable.

• The lecturer noted that the gold cost had been approximately 11,000 US dollars even about 10 years earlier, and that gold frameworks are no longer commonly used in the described treatment approach.

Maintenance low but expensive and difficult to fix.

PFM — CrCo Framework⁷⁸

• CadCam framework — low cost, can have reasonable fit
• Need occlusal splint
• Maintenance low but expensive and difficult to fix
• Gingival replacement — composite (marginal staining), porcelain (aesthetics getting better)

PFM — Porcelain Fused to Titanium⁷⁹

• CadCam Procera framework — low cost, excellent fit
• Maintenance low but expensive and difficult to fix
• Aesthetics of Ti porcelain ordinary

Flexural Strength of Dental Materials^80818283

Flexural Strength — Current Dental Materials

Material	Examples	Flexural Strength
Feldspathic	veneering porcelain, veneers	~90 MPa
Pressable ceramics	Empress, Cergo, Optimal	~150 MPa
Indirect composites	Belleglass, Critobal	~200 MPa
Pressable lithium disilicate	Empr.2, e-Max	~300 MPa
Glass infiltrated ceramics	In-Ceram Alum.	~400 MPa
Alumina	Procera	~650 MPa
(Y-TPZ) Zirconia	Procera, Lava, Allzirron	~1200 MPa

eMax Ceramic Crowns⁸⁴

• Layered anteriorly, monolithic posteriorly (300 MPa vs 90 MPa veneering porcelain)
• No gold component in Procera framework and no difference in cost for size of framework
• Maintenance low and generally just replacement of one crown
• Gingival replacement — composite (marginal staining) — can be retreaded relatively easily

Lecturer — Zirconia Strength

Some more translucent zirconias may have strength values around the level of E.max, approximately 350 MPa, rather than the approximately 1,200 MPa associated with stronger 3Y zirconia.

• The material selected must therefore be appropriate for the functional demands of the restoration.

Flexural Strength — Current Dental Materials

Lecturer — Material Selection

Material selection should account for the patient and the clinical situation rather than relying only on appearance.

• The lecturer contrasted aesthetic, more translucent materials with stronger, less translucent materials.

Material	Flexural Strength
Feldspathic — eg veneering porcelain, veneers	~90 MPa
Pressable ceramics — eg: Empress, Cergo, Optimal	~150 MPa
Indirect composites — eg: Belleglass, Critobal	~200 MPa
Pressable lithium disilicate — eg: Empr.2, e-Max	~300 MPa
Glass infiltrated ceramics — eg: In-Ceram Alum.	~400 MPa
Alumina — Procera	~650 MPa
(Y-TPZ) Zirconia — eg: Procera, Lava, Allzirkon	~1200 MPa

Zirconia and Hybrid Bridge Options⁸⁵⁸⁶

Full Zirconia⁸⁷

• Massive downside if framework fracture
• Industrial fabrication essential
• Need highly experienced technician → need occlusal splint
• Attention to detail
• More long term clinical research required

Ti CAD CAM framework / stained monolithic zirconia segments

Lecturer — Zirconia Selection

Full zirconia has improved aesthetically, but zirconia-to-zirconia contact provides little cushioning and can create a clacking sound that resonates through the patient’s head and may disturb family members.

• 3Y zirconia is stronger and less translucent, whereas higher-yttria and cubic zirconias are more translucent but weaker.
• The clinician should know the yttria content, zirconia phase, strength, translucency, manufacturer, milling process, and staining and glazing process.
• Multi-layered pucks may contain dentine-like gingival, graduated middle, and enamel-like incisal regions; strength depends partly on where the restoration is milled within the puck.
• Newer multi-layered formulations lack fully established five-, ten-, and twenty-year outcomes, and interfaces between layers may contain weaknesses through which cracks can propagate.
• Patients with little wear and minimal bruxism may tolerate a wider range of materials, whereas heavy bruxers may require monolithic 3Y zirconia with strength prioritized.
• Strength can be affected by staining, glazing, clinical adjustment, milling, water cooling, zirconia composition, and milling-unit quality. Glaze may be lost through function and may be rough against the opposing arch.
• The laboratory’s material, milling equipment, and manufacturing controls are important; zirconia printing was described as a developing technology that had not yet fully matured.

Maintenance Protocol and Clinical Preferences

Maintenance Protocol⁸⁸

• Follow-up weekly for first 4 weeks, then 6-weekly until 6 months
• Then 3–6 monthly according to need
• OPG radiographs at bridge placement, 6 months, then yearly for 5 years
• Then every 2–3 years depending on history

Lecturer — Maintenance Requirements

Maintenance also depends on how the prosthesis is designed and fabricated.

• Regular attention is needed for prosthetic cleansability, plaque control, home-care technique, prosthetic wear, fracture, staining, and replacement of acrylic teeth when required.
• Patients should be instructed in the use of water jets and interdental cleaning aids, and the tissue-fitting surfaces should remain accessible.
• Requirements are affected by the material used, the opposing dentition, bruxism, prosthesis design, implant position, and laboratory fabrication quality.

Our Preferences in Treatment⁸⁹⁹⁰⁹¹

No Pre-implant Grafting

• Utilize available native bone

Cross arch splinting

Rigid prosthesis shows cross arch splinting

Prosthetic replacement of soft tissue and facial support

Lecturer — Treatment Preferences

The lecturer favored fixed treatment in the maxilla when patients do not want a removable prosthesis and require facial support. The preferred pathway depends on the available bone and the patient’s functional and restorative requirements.

• Use axial implants when sufficient bone exists.
• Use tilted implants to avoid the sinus or engage denser bone.
• Consider grafting when indicated and zygoma implants in severely atrophic cases.
• Prostheses should be prosthetically directed, anatomical in contour, cleansable, and designed around the patient’s facial support requirements.
• For high functional loads, stronger and less layered materials may be preferred; material selection should reflect bruxism, wear, aesthetics, and function rather than simply choosing the most translucent option.

Patient and Clinician Benefits⁹²⁹³

Optimal Comfort

• Less invasive surgery
• Less pain and swelling
• Reduced chairtime

Cost Saving

• Much earlier return to work and social life

Fast Treatment

• Immediate function

• Increased Predictability & Safety

• Reduction in Interim Management

• Predictable Prosthetic Outcome

Lecturer — Fixed Treatment Benefits

Fixed treatment can restore teeth without covering the palate, avoid the inconvenience of removability, improve speech and taste compared with a palatal denture, and restore facial support. When immediate loading is appropriate, it can also provide teeth more quickly.

• Graftless or zygomatic pathways may reduce treatment time, the period without a wearable denture, the need for extensive grafting, and the complexity associated with hip-harvested bone.
• These benefits must be balanced against implant stability, loading risk, bone quality, cleansability, long-term prosthetic maintenance, and the limitations of newer restorative materials.

Closing and Contact Information⁹⁴

Eradication of Pathology

Thank you!

• glenliddelow@gmail.com
• www.branemarkcentre.com.au

BRÅNEMARK CENTRE, PERTH, AUSTRALIA

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Clinical Cases

Case: Female patient with FP2 prosthesis and facial aesthetics evaluation

Question

Scenario: A female patient is presented to evaluate her facial aesthetics, lip support, and the transition line of her prosthesis.

What’s shown: Before and after facial images showing creases and vermilion support. An intraoral view shows pink reproduction (FP2) and the patient’s smile line.

Consider: How to manage the transition line between the prosthesis and natural gingiva in relation to the smile line, and what type of prosthesis is appropriate.

Answer

Observations:

• The patient has an FP2 prosthesis with some pink reproduction.
• The color match between the natural gum and the prosthesis is not perfect.
• The transition line is positioned above the patient’s smile line.

Reasoning: If the smile line is above the transition line, the mismatch between the translucent natural gingiva and the porcelain or acrylic prosthesis will look terrible. By keeping the transition line above the smile line, the aesthetic discrepancy is hidden when the patient smiles.

Takeaway: The transition line between a prosthesis and natural gingiva must be kept above the smile line to avoid visible aesthetic mismatches.

Case: Male patient with a 15-year follow-up of an implant-supported bridge

Question

Scenario: A male patient who had teeth extracted and implants placed is presented to show long-term outcomes.

What’s shown: The patient’s provisional bridge and a follow-up image 15 years later.

Consider: What the long-term outcome and success rate of this type of implant-supported fixed bridge treatment is.

Answer

Observations:

• The patient received a provisional bridge after implant placement.
• The 15-year follow-up shows the final result and long-term stability.

Reasoning: The lecturer uses this case to demonstrate that immediate loading and provisionalization in the maxilla can yield highly successful long-term results, as the patient has maintained the restoration for 15 years without issue.

Takeaway: Immediate loading and provisional bridges in the maxilla can provide excellent, long-lasting outcomes.

Case: Female patient with an atrophic maxilla treated with a lateral window sinus lift

Question

Scenario: A female patient with an atrophic maxilla requires full arch reconstruction but has minimal bone.

What’s shown: Intraoperative images of a lateral window sinus lift, elevation of the Schneiderian membrane, placement of bovine bone and autogenous bone blocks fixated with screws, and covered with membranes. Post-operative images show the final bridge.

Consider: What surgical techniques are used to augment the atrophic maxilla, and what are the clinical implications and patient management challenges of this approach.

Answer

Observations:

• A lateral window sinus lift was performed to elevate the Schneiderian membrane.
• The sinus was filled with a mixture of bovine bone and autogenous bone blocks fixated with screws and covered with membranes.
• Implants were placed, and a final bridge was fabricated.
• The treatment took a year and a half, and the patient could not wear her denture for about four months.

Reasoning: While this traditional sinus lift and block grafting approach can successfully restore an atrophic maxilla, it requires a long treatment time and a prolonged period without a functional denture. This creates significant patient management issues and has a lower success rate compared to newer techniques like zygomatic implants.

Takeaway: Traditional lateral window sinus lifts with block grafting for atrophic maxillae are highly demanding, require long treatment times, and cause significant patient discomfort due to prolonged periods without a denture.

Case: Female patient with severe maxillary atrophy treated with semi-guided zygomatic implants

Question

Scenario: A female patient who has not been able to wear an upper denture for 10 years and has failing anterior mandibular teeth presents with severe maxillary atrophy.

What’s shown: Radiographic and clinical images showing a very thin, shallow ridge. Intraoperative images show a semi-guided zygomatic implant placement via a lateral wall approach, with 50mm long implants engaging the zygoma. Follow-up images at 6 years and 18 years show bone growth along the implant and the final restoration.

Consider: How to manage a patient with an extremely atrophic maxilla who cannot tolerate a denture, and what the long-term outcomes of this specific surgical approach are.

Answer

Observations:

• The patient had a very thin, shallow maxillary ridge and had not worn an upper denture for 10 years.
• Semi-guided zygomatic implants (approximately 50mm long) were placed, engaging the zygomatic arch, along with a lateral wall sinus lift.
• Follow-up at 6 and 18 years shows successful bone growth along the length of the implants into the sinus and a stable final restoration.

Reasoning: In cases of extreme maxillary atrophy where traditional grafting is insufficient or too burdensome, zygomatic implants bypass the need for extensive grafting by anchoring in the zygomatic bone. The semi-guided approach and lateral wall sinus lift allow for precise placement. The long-term follow-up demonstrates the high success and stability of this technique.

Takeaway: Zygomatic implants are a highly successful, long-term solution for patients with severe maxillary atrophy who cannot tolerate conventional dentures, avoiding the need for extensive bone grafting.

Footnotes

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