No obsidian-L7 Dental School Maxilla fixed notes

Treatment Strategies for the Edentulous Jaw: Fixed Prosthesis Maxilla¹

Treatment Options²

• Complete Denture
• Implant Overdenture
• Implant Detachable Prosthesis
• Fixed Prosthesis

Lecture Introduction³⁴

Lecture 3⁵

Fixed Prosthesis: Maxilla

Treatment strategies for the edentulous jaw

Treatment of Edentulism⁶

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.

Immediate Loading of Edentulous Jaws

Timeline and Clinical Milestones⁷

• 1991: Single stage surgery and immediate loading (T-033C)
• 1994: Routine lower jaw on 4 implants, immediate loading
• 1998: Brånemark Novum (T-086)
• 2000: Immediate loading maxilla
• 2003: Teeth in an hour (NobelGuide)
• 2008: Immediate loading of Zygoma implants

Sequelae of Tooth Loss⁸

Factors to Consider⁹

• Initial aesthetic expectation
• Current dentition, prostheses

Facial Aesthetics and Lip Support¹⁰

Clinical Evaluation¹¹

• Left: Before photo—darker teeth, more visible wrinkles, and uneven smile line.
• Right: After photo—brighter, whiter teeth, smoother skin, and a more defined smile.

Lip support assessment.

Ridge Reduction and Facial Support¹²¹³¹⁴

Evaluation of ridge reduction and facial support.

Tooth Position Within the Face¹⁵

The Face¹⁶

Determination of tooth position within the face.

Where do you want your front teeth?

Tooth Aesthetics and Function¹⁷

Key considerations regarding tooth aesthetics and functional requirements.

Phonetic and Functional Analysis¹⁸

• M-Ah
  • Interocclusal rest space: 4 mm
  • Dental exposure (Mx): 2–3 mm
• F, V
  • Vermillion border: 1 mm lingual
• E
  • Interlabial space occupied by Mx teeth: 72%
• S
  • Mandibular movement: Horizontal 2 mm
  • Interarch space: 2 mm

Fradeani M. Esthetic Analysis: A systematic approach to prosthetic treatment. Quintessence, Illinois. 2004. Spear F, Kokich V, Mathews D. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137:160-169. Pound E. Let “s” be your guide. J Prosthet Dent. 1977;38:482-489.

Digital Smile Design

Clinical Applications¹⁹

• Ability to quantify changes to technician
• More useful for tooth-borne prosthetics – limitations with face bow
• Visualisation of final result
• Patient communication

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

Face Bow and Digital Tools^20212223

Digital ruler.

Tooth outline.

“Real Face Bow”

Treatment Planning and Virtual Surgery

Implant and Prosthetic Tooth Junction²⁴²⁵

The junction between the implant and prosthetic tooth determines lip support and the phonetic surface.

Radiographic Workup and NobelClinician²⁶

The Face²⁷

Transfer to radiographic workup and NobelClinician software.

Prosthetically Driven Implant Placement²⁸

Planning implant placement is prosthetically driven.

NobelClinician Planning – Virtual Surgery²⁹

NobelClinician - Danielle Fox

Treatments

• Dental Code (x1!)
• Scan
• Edit CT scan

Software

• Scanner Orientation
• Refine Curve
• CT Preset
• Future Images
• Transfer Locations
• Slices
• Panoramic
• Perpendicular
• OK / Cancel

NobelConnect and Interdisciplinary Treatment³⁰³¹³²

Interaction Mode

• Brush
• Save
• Undo
• Radio
• Level / Window
• Change Workspace
• Set Focus
• Screenshot
• Rulers

Stereo Evaluation

• ( ) Attach to Core
• ( ) Attach to Guide
• (t) Master Model
• ( ) Treatments
• ( ) Teeth (7)
• ( ) Nerves (2)
• ( ) Teeth (3)
• ( ) Primelines (2)
• ( ) Registration (2)
• ( ) Space (4)

Use Slices File

• Critical for complex interdisciplinary treatment

Implant anchorage is then prosthetically directed.

Implant Surgical Pathways³³

Primary Pathway	Sub-Method / Description	Advanced Options / Materials
Graftless	Axial	Immediate Loading
	Tilted	Anterior sinus posterior sinus pterygoid Zygoma other
Grafting ↓	Sinus Labial onlay Ridge splitting GBR Interpositional Distraction Osteogenesis LeFort 1 Free tissue transfer	Material Categories: • Autogenous • Allograft • Xenograft • Synthetic • BMPs • Gene Therapy

Axial Implants Without Grafting³⁴

Studies Restoring the Edentulous Maxilla with Fixed Prostheses³⁵

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 yr	82 (5y), 81 (10y)	100 (5y), 88 (10y)
Adell et al 1990	pros	277	1789	Conventional	Branemark	277	5–15 yr	84 (5y), 78 (15y)	84 (5y), 78 (15y)
Carlsson et al 2000	pros	13	75	Conventional	Branemark	13	15 yr	93	—
Jemt et al 2002	pros	58	349	Conventional	Branemark	58	5 yr	91	93
Engfors et al 2004	retro	44	282	Conventional	Branemark	44	5 yr	93	—
Jaffin et al 2004	—	34	236	Immed loading	Straumann	34	5 yr	92	—
Ortop et al 2004	pros	54	356	—	Branemark	54	5 yr	90	95
Degidi et al 2005	retro	45	388	Immed loading	various	45	5 yr	98	—
Rasmussen et al 2005	pros	16	91	Conventional	Astra	16	10 yr	97	100
Cannizzaro et al 2007	pros	33	202	Immed loading	Zimmer	21	1 yr	100	100

Tilted Implants Without Grafting³⁶

Tilted implants no grafting

Follow-up Outcomes³⁷

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

Clinical Outcomes of Tilted Implants³⁸

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

Maxillary Fixed Prostheses Outcomes³⁹

Studies restoring the edentulous maxilla with fixed prostheses using tilted implants without grafting show:

• 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.

Clinical Advantages⁴⁰

• 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

All-on-4 Outcomes^41424344

• 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 statistically significant 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 years 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.

Systematic Review Findings⁴⁵

• 13 papers
• 4,804 implants, 1,201 prostheses loaded within 48 hours
• 99% implant success at 3 years
• 99.9% prosthesis success at 3 years
• Marginal bone loss: 1.3 ± 0.4 mm at 3 years
• No significant difference between axial and tilted implants
• Most failures occurred with smokers and patients on 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

All-on-6 Outcomes⁴⁶⁴⁷

• 41 maxillae, mean 22-month follow-up, prospective multicenter 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 Factors

Causes of Implant Failure

Multifactorial Reasons for Bone Loss⁴⁸

• Cause / effect / association
• Early failure
• Late failure
  • Peri-implantitis model
  • Patient-related factors
  • Due to inadequate healing initially (lower bone-to-implant contact [BIC] and degree of sustainable osseosufficiency)

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 crestral/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

Patient Risk Stratification⁴⁹

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

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 Over Time

74% of failures occurred within 12 months of placement.

Failure Modes Over Time⁵⁰

• Mechanical stability
• Biological stability

Timeline milestones: Surgery → 2 months → 3 months → 1 year

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.

Maxillary Bone Considerations⁵¹

• Timeline / mechanical transition: Surgery → 2 months → 3 months → 1 year
• Maxillary bone demonstrates 3–4× lower functional resistance to load; implants are not as stable compared to 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.

Factors Contributing to Failure in Immediately Loaded Maxillae⁵²

• Depending on loading, four implants may be insufficient for complete stability, resulting in lower bone-to-implant contact (BIC) and greater susceptibility to integration breakdown, opportunistic infection, and bone loss.
• Risk is exacerbated by patient factors such as smoking, diabetes, IL-1 phenotype, history of periodontitis, and autoimmune disease.
• The All-on-4 concept may not be appropriate for larger arch forms and greater functional loads.

Chung S, McCullagh A, Irinakas 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 With Augmentation⁵³

Augmentation

Iliac Crest Grafting⁵⁴

Maxillary Bone Graft Considerations⁵⁵

• Donor site
• Recipient site preparation
• Fixation
• Implant installation: delayed vs. immediate
• Post-graft radiological requirements
• Complications

Minimum 1-year treatment plan

Sinus Lift Lateral Window Outcomes⁵⁶

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	Brånemark	Autogenous HA	36	3	75	95
Wannfors et al. 2000	RCT	40	150	immed & conventional	Brånemark	Autogenous	40	1–6	84	—
Raghoobar et al. 2001	retro	75	326	immed & conventional	Brånemark	Autogenous	27	1–10	91	—
Hallman et al. 2002	pros	21	67	conventional	Brånemark	Autogenous, Bio-Oss	21	1	82	—
Bektor et al. 2004	retro	64	437	immed & conventional	Brånemark	Autogenous	56	5–6	75	100

Systematic Review Findings⁵⁷

• Implant survival more variable in augmented sinuses (36–100%, average ~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

References

Graziani, F., Donos, N., Needleman, I., Gabriele, M., and Tonetti, M. (2004). Comparison of implant survival following sinus floor augmentation procedures with implants placed in pristine posterior maxillary bone: a systematic review. Clinical Oral Implants Research, 15, 677–682.

Pjetursson, B. E., Tan, W. C., Zwahlen, M., and Lang, N. P. (2008). A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Journal of Clinical Periodontology, 35(8 Suppl), 216–240.

Nkenke, E., and Stelzle, F. (2009). Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review. Clinical Oral Implants Research, 20(Suppl 4), 124–133.

Rickert, D., Slater, J. J., Meijer, H. J., Vissink, A., and Raghoobar, G. M. (2012). Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes. A systematic review. International Journal of Oral and Maxillofacial Surgery, 41(2), 160–167.

Zygoma Implants⁵⁸

Zygoma Implant Outcomes

Clinical Studies: Edentulous Maxilla Restored with Fixed Prostheses and Zygomatic 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	-
Beccctor 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

Zygoma Implant Systematic Reviews⁶⁰⁶¹

• 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% (1,541 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 Implants⁶²

• 16 patients:
  • All satisfied; 50% with some complaints (50% prosthesis, 38% implants)
• 22 patients:
  • 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.

Zygoma Treatment Planning Guidelines^6364656667

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

• 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

Maxillary Zone Distribution⁶⁸

• Zone 3
• Zone 2
• Zone 1

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 and Implant Length⁶⁹⁷⁰⁷¹

Ridge reduction affects implant length and AP spread.

Ridge reduction affects implant length and AP spread.

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.

• Zone 1
• Zone 2
• Zone 3
• 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.

Home Care and Cleansibility⁷²

Patient Aids⁷³

Cleansibility⁷⁴

• Convex tissue fitting surface

Centrix® – Point of clinical excellence® (Centrix.com)

Definitive Bridge Options

Considerations by Arch⁷⁵

• Mandible: Acrylic resin
• Maxilla: More wear resistant — ceramic if possible

Maxillary Bridge Options

Procera Titanium Hybrid with Acrylic Teeth⁷⁶⁷⁷

• Maintenance is medium, but relatively easy to fix
• Retread required every 5–7 years for wear
• Staining around margins
• Acrylic resin fractures
• Tooth fractures
• Need occlusal splint

Severe Bruxism

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.

PFM – Gold Cemented Framework⁷⁸

• Gold prices are getting crazy — US$11K for this one!
• Maintenance is low, but expensive and difficult to fix

PFM – CrCo Framework⁷⁹

• CAD/CAM framework: low cost, can have reasonable fit
• Maintenance: low, but expensive and difficult to fix
• Gingival replacement:
  • Composite (marginal staining)
  • Porcelain (aesthetics getting better)

PFM – Porcelain Fused to Titanium⁸⁰

• CAD/CAM Procera framework: low cost, excellent fit
• Maintenance: low, but expensive and difficult to fix
• Aesthetics of titanium porcelain: ordinary

Flexural Strength of Dental Materials⁸¹⁸²

Material Type	Examples	Flexural Strength (~MPa)
Feldspathic	Veneering porcelain, veneers	90
Pressable ceramics	Empress, Cergo, Optimal	150
Indirect composites	Belleglass, Cristobal	200
Pressable Lithium disilicate	Empr.2, e.max	300
Glass infiltrated ceramics	In-Ceram Alum.	400
Alumina	Procera	650
(Y-TZP) Zirconia	Procera, Lava, Allzirkon	1200

Flexural strength of current dental materials.

e.max Ceramic Crowns⁸³⁸⁴

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

Current Dental Materials⁸⁵

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

Full Zirconia⁸⁶⁸⁷⁸⁸

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

Titanium CAD/CAM framework / Stained monolithic zirconia segments

Maintenance Protocol and Preferences

Maintenance Protocol

Follow-Up Schedule⁸⁹

• Weekly for first 4 weeks, then every 6 weeks until 6 months
• Then every 3–6 months according to need

Radiographic Protocol

• OPG radiographs at bridge placement, 6 months, then yearly for 5 years
• Then every 2–3 years depending on history

Our Preferences⁹⁰⁹¹⁹²

• No pre-implant grafting

• Utilize available native bone

• Immediate loading

• Rigid prosthesis

• Cross arch splinting

Prosthetic replacement of soft tissue and facial support

Patient and Clinician Benefits

Patient Benefits⁹³

• 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

Clinician Benefits⁹⁴

• Increased predictability & safety
• Reduction in interim management
• Predictable prosthetic outcome

Closing

Thank you!⁹⁵

Affiliations

• Associated Brånemark Osseointegration Center, Perth, Australia
• The University of Western Australia

Contact Information

• Email: glenliddelow@gmail.com
• Website: www.branemarkcentre.com.au

Footnotes

1. Original PDF page 1: No obsidian-L7 Dental School Maxilla fixed notes, p.1 ↩

2. Original PDF page 2: No obsidian-L7 Dental School Maxilla fixed notes, p.2 ↩

3. Original PDF page 4: No obsidian-L7 Dental School Maxilla fixed notes, p.4 ↩

4. Original PDF page 5: No obsidian-L7 Dental School Maxilla fixed notes, p.5 ↩

5. Original PDF page 3: No obsidian-L7 Dental School Maxilla fixed notes, p.3 ↩

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