The University of Western Australia Management of Edentulism and the Terminal Dentition -Maxilla Fixed Clin A/Prof Glen Liddelow BDSc(WA), MScD(WA), DClinDent(Syd), MRACDS(Pros), FPFA, FICD, FRACDS BRÅNEMARK CENTRE PERTH Associated Brånemark Osseointegration Centre ... Perth 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 jaw <table> <tr> <th></th> <th></th> <th></th> <th></th> </tr> </table> _figures/img_8312e355e09095a9.webp) _figures/img_363cc3af73f3ffeb.webp) _figures/img_5e6fd8a95d97930f.webp) _figures/img_87a42b31d9ae8373.webp) Treatment strategies for the edentulous jaw A clinical photograph showing a complete denture set, consisting of the maxillary and mandibular arches with artificial teeth arranged in occlusion. The image displays the full prosthetic appliance against a dark background. Clinical photo: An occlusal view of a mandibular denture base, showing the U-shaped arch form and a circular hole in the anterior region for implant attachment. Clinical photo: The intaglio (tissue-facing) surface of a complete upper denture prosthesis, revealing a metal framework embedded within the acrylic base. Several circular metallic abutments or housing components are visible along the arch, indicating the attachment points for an implant-retained system. A clinical photograph of a fixed dental prosthesis, specifically an implant-supported full-arch bridge (often referred to as an All-on-4 or similar concept). The image shows the underside of the prosthetic arch with a metal framework and four visible screw access holes for attachment to implants, along with a row of artificial teeth. # Lecture 3 Fixed Prosthesis Maxilla _figures/img_00e6cbadbdf2d1b6.webp) Lecture 3 — Fixed Prosthesis, Maxilla The image is a composite figure containing multiple clinical photographs and radiographs illustrating fixed prosthodontic treatments. It features panoramic X-rays and 3D reconstructions showing various implant configurations (including zygomatic implants), alongside close-up photos of prosthetic dental arches with visible abutments. # Treatment strategies for the edentulous jaw Maxillary complete denture prosthetics - Mandibular prosthodontics - Mn IOD - Mn IFP (Least maintenance) - Review at 12 months (75% satisfied) Treatment strategies for the edentulous jaw - 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. _figures/img_9d733706dca61990.webp) _figures/img_88da8d402284b4f6.webp) *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.* > [!note] 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. A composite image consisting of eight panoramic radiographs arranged in a grid. Each X-ray demonstrates the rehabilitation of edentulous jaws using various configurations of dental implants and prosthetic arches, showing different numbers of fixtures and support angles. A composite image displaying eight panoramic dental radiographs arranged in two rows. Each X-ray reveals a patient's jaws fitted with implant-supported prosthetics, characterized by numerous vertical metallic posts (implants) anchoring horizontal bars and denture structures within the maxilla and mandible. 1991 - Single stage surgery and immediate loading - T-033C 1994 - Routine lower jaw on 4 implants, immediate loading 1998 - Branemark Novum - T-086 2000 - Immediate loading maxilla 2003 - Teeth in an hour ( NobelGuide) 2008 - Immediate loading of Zygoma implants _figures/img_d13435f178c55b20.webp) 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 > [!note] 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.== > [!note] 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. > [!note] 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. > [!note] 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. > [!note] 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. > [!note] 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. A circular logo featuring a central hourglass-like shape with a textured pattern, surrounded by the text 'ASSOCIATED BRÅNEMARK OSSEOINTEGRATION CENTER' arranged in a circle. # Sequelae of tooth loss Sequelae of tooth loss # Factors to consider Initial aesthetic expectation Current dentition, prostheses _figures/img_ec7d62f7aa56c1b0.webp) _figures/img_2d9b2a79107f660b.webp) _figures/img_fdfa2b635ad05040.webp) _figures/img_b7df88b05337ce8f.webp) Factors to consider - Initial aesthetic expectation - Current dentition, prostheses A close-up, black-and-white clinical photograph showing a frontal view of a smiling patient's mouth. The image focuses on the upper anterior teeth and the lip line to demonstrate the initial aesthetic expectation mentioned in the slide text. Clinical photo: A black-and-white intraoral photograph showing the maxillary anterior teeth with a retractor. The image displays significant crowding and malalignment of the upper front teeth, illustrating the 'current dentition' mentioned in the slide text. A close-up, black-and-white clinical photograph of a patient's mouth in a relaxed position. The image shows the lips slightly parted to reveal the upper anterior teeth, which appear to be prosthetic crowns or veneers. Clinical photo: A black-and-white close-up of a person's mouth showing the teeth in a relaxed, slightly open position. The image illustrates the current dentition and natural tooth alignment, serving as a visual example for assessing initial aesthetic expectations. # WHAT ARE THE ISSUES? ## Facial Aesthetics What are the issues? #### Facial Aesthetics # WHAT ARE THE ISSUES? Lip Support What are the issues? #### Lip Support # Ridge Reduction *Facial Support* #### Ridge Reduction *Facial Support* # Ridge Reduction ## *Facial Support* #### Ridge Reduction — Facial Support > [!note] 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. > [!note] 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. # Ridge Reduction #### Ridge Reduction The Face Determination of tooth position within the face The Face — Determination of tooth position within the face W H A T A R E T H E I S S U E S ? **Tooth aesthetics and function** <div style="display: flex; justify-content: center;"> <table style="border-collapse: collapse; width: 100%;"> <tr> <td style="width: 50%; vertical-align: top; text-align: center;"> </td> <td style="width: 50%; vertical-align: top;"> </td> </tr> </table> </div> _figures/img_da0ca39397e3f147.webp) _figures/img_e2f6e5b72a31433c.webp) What are the issues? #### Tooth aesthetics and function A black-and-white clinical photograph showing the anterior maxillary teeth in a state of disrepair. The image depicts severe crowding, overlapping incisors, and significant structural damage to several teeth, illustrating the issues that necessitate aesthetic treatment. Clinical photograph showing a frontal view of the maxillary and mandibular anterior teeth in occlusion. The image highlights the alignment, shape, and surface texture of the incisors and canines. Since the text on this slide functions only as labels for the specific images above it and provides no context on its own, the entire page is treated as a figure. _figures/img_f7d65e092ce47d77.webp) _figures/img_fb8c67b85d19e8b4.webp) *This page consists of figures only; the slide text serves solely as image labels.* A close-up clinical photograph of a patient's lower face in profile, showing the lips in a relaxed position with a slight gap between them that reveals the edges of the upper teeth. The image illustrates the concept of dental exposure and the interocclusal rest space. Clinical photo: A close-up, black-and-white lateral view of a patient's mouth showing the lips and teeth in slight separation. The image captures the profile relationship between the upper lip, lower lip, and the visible maxillary incisors. Coachman C, Calamata M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. Quintessence Dental Technology 2012 *Coachman C, Calamata M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. Quintessence Dental Technology 2012* > [!note] 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 _figures/img_44116d74d44294e9.webp) Digital Ruler A clinical intraoral photograph of the upper anterior teeth with digital ruler overlays (vertical bars with millimeter scales) superimposed to measure tooth height. White outlines trace the contours of the central and lateral incisors, demonstrating the application of the digital measurement tool. _figures/img_03c04211c052a10b.webp) A grayscale close-up clinical photograph of the maxillary anterior teeth, specifically showing the central incisors, lateral incisors, and canines. The image features white contour lines digitally overlaid to trace the anatomical outlines of each tooth crown against a dark background. “Real Face Bow” _figures/img_93400538960fccdf.webp) "Real Face Bow" A clinical photograph of a dental cast mounted in an articulator, displaying a full set of artificial teeth (dentures) in occlusion. The image illustrates the setup and alignment of the prosthetic teeth on the stone bases. **Junction between implant and prosthetic tooth determines lip support and phonetic surface** Junction between implant and prosthetic tooth determines lip support and phonetic surface The image provided is purely visual and contains no discernible, readable, or functional text. It displays a collection of custom dental prosthetic devices (dentures or implant-retained suprastructures) against a black background. No text was extracted. *Image shows a collection of custom dental prosthetic devices (dentures or implant-retained suprastructures) against a black background.* # The Face Transfer to radiographic work up and NobelClinician software _figures/img_9d2e0402b59665ed.webp) _figures/img_a9d86897946b2d4b.webp) The Face Transfer to radiographic work up and NobelClinician software A black-and-white close-up portrait of a woman's face, cropped to show the left eye, nose, lips, and dark hair. The word "The" is superimposed in a stylized grey font over the upper right area near the hairline. Clinical photo: A frontal close-up of the maxillary and mandibular teeth in occlusion, showing the alignment and morphology of the anterior dentition. Double Scan Double Scan Double Scan Planning implant placement - Prosthetically driven _figures/img_ae96df8f976996bc.webp) _figures/img_9f37d4241184a5c1.webp) _figures/img_822bd7a95ef1079d.webp) Planning implant placement — prosthetically driven This is a 3D CT scan reconstruction of an edentulous maxilla (upper jaw) showing virtual surgical planning for dental implants. Multiple cylindrical implant fixtures are superimposed onto the bone, demonstrating their planned angulation and position relative to the anatomical structures. A 3D digital rendering of a maxillary dental arch viewed from the palatal side, illustrating prosthetically driven implant planning. Several cylindrical implant components are superimposed onto the bone at various angulations and positions, indicating proposed placement sites relative to the existing teeth. A 3D CT reconstruction of the maxilla and mandible showing virtual implant planning. Multiple cylindrical implant fixtures are superimposed into the bone, with long axes indicated by thin lines extending outward to demonstrate their trajectory and prosthetic alignment. NobelConnect - Critical for Complex Interdisciplinary Treatment _figures/img_b0eaacf11a32b265.webp) NobelConnect - Critical for complex interdisciplinary treatment A network diagram illustrating the NobelConnect platform, showing a central laptop labeled 'Dental professional performing treatment' connected by lines to six surrounding laptops. The peripheral nodes represent different roles in the workflow: Referring dentist, Treatment partners, Expert opinion, Nobel Biocare, Imaging center, and Dental technician. _figures/img_0c5a440caab1902d.webp) A photograph of a dental prosthesis (bridge) showing multiple teeth with access holes on the occlusal surfaces. Grey arrows are superimposed on the image, pointing from the central incisors' access holes towards the posterior molars. <table><tr><td colspan="2"><b>Implant surgical pathways</b></td></tr><tr><td><b>Graftless</b></td><td><b>Grafting</b></td></tr><tr><td>Axial</td><td>Sinus</td></tr><tr><td>Tilted</td><td>Labial onlay</td></tr><tr><td>Immediate</td><td>Ridge splitting</td></tr><tr><td>Loading</td><td>GBR</td></tr><tr><td></td><td>Interpositional</td></tr><tr><td></td><td>Distraction Osteogenesis</td></tr><tr><td></td><td>LeFort 1</td></tr><tr><td></td><td>Free tissue transfer</td></tr><tr><td></td><td>+</td></tr><tr><td></td><td>Autogenous</td></tr><tr><td></td><td>Allograft</td></tr><tr><td></td><td>Xenograft</td></tr><tr><td></td><td>Synthetic</td></tr><tr><td></td><td>BMPs</td></tr><tr><td></td><td>Gene Therapy</td></tr></table> #### Implant Surgical Pathways **Graftless** - Axial - Tilted - Immediate loading **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 - ==Implants engaging the zygoma== > [!note] 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. _figures/img_86fd0dea754b8a2a.webp) _figures/img_adae07eb8e949e7b.webp) A panoramic radiograph showing a full-arch implant rehabilitation with multiple axial implants placed in the upper and lower jaws, supporting fixed prostheses. A panoramic radiograph showing full-arch fixed dental prostheses supported by axial implants in both the maxilla and mandible. The image displays multiple vertically placed fixtures with screw-retained prosthetic teeth, illustrating a rehabilitation without bone grafting. Studies restoring the edentulous maxilla with fixed prostheses- Axial Implants no grafting <table> <tr> <th> Study </th> <th> Design </th> <th> Patients </th> <th> Implants </th> <th> Surg Proc </th> <th> System </th> <th> FDPs </th> <th> Obs period </th> <th> Survival Implants% </th> <th> Survival FDP % </th> </tr> <tr> <td> Adell et al 1981 </td> <td> pros </td> <td> 146 </td> <td> 981 </td> <td> Conventional </td> <td> Branemark </td> <td> 146 </td> <td> 9yr </td> <td> 81 </td> <td> 89-96 </td> </tr> <tr> <td> Adell et al 1983 </td> <td> pros </td> <td> 73 </td> <td> 529 </td> <td> Conventional </td> <td> Branemark </td> <td> 73 </td> <td> 5?-10 </td> <td> 82(5y) 81(10y) </td> <td> 100(5y) 88(10y) </td> </tr> <tr> <td> Adell et al 1990 </td> <td> pros </td> <td> 277 </td> <td> 1789 </td> <td> Conventional </td> <td> Branemark </td> <td> 277 </td> <td> 5-15 </td> <td> 84(5y) 78(15y) </td> <td> 84(5y) 78(15y) </td> </tr> <tr> <td> Carlsson et al 2000 </td> <td> pros </td> <td> 13 </td> <td> 75 </td> <td> Conventional </td> <td> Branemark </td> <td> 13 </td> <td> 15 </td> <td> 93 </td> <td> </td> </tr> <tr> <td> Jemt et al 2002 </td> <td> pros </td> <td> 58 </td> <td> 349 </td> <td> Conventional </td> <td> Branemark </td> <td> 58 </td> <td> 5 </td> <td> 91 </td> <td> 93 </td> </tr> <tr> <td> Engfors et al 2004 </td> <td> retro </td> <td> 44 </td> <td> 282 </td> <td> Conventional </td> <td> Branemark </td> <td> 44 </td> <td> 5 </td> <td> 93 </td> <td> </td> </tr> <tr> <td> Jaffin et al 2004 </td> <td> - </td> <td> 34 </td> <td> 236 </td> <td> Immed loading </td> <td> Straumann </td> <td> 34 </td> <td> 5 </td> <td> 92 </td> <td> </td> </tr> <tr> <td> Ortop et al 2004 </td> <td> pros </td> <td> 54 </td> <td> 356 </td> <td> - </td> <td> Branemark </td> <td> 54 </td> <td> 5 </td> <td> 90 </td> <td> 95 </td> </tr> <tr> <td> Degidi et al 2005 </td> <td> retro </td> <td> 45 </td> <td> 388 </td> <td> Immed loading </td> <td> various </td> <td> 45 </td> <td> 5 </td> <td> 98 </td> <td> </td> </tr> <tr> <td> Rasmussen et al 2005 </td> <td> pros </td> <td> 16 </td> <td> 91 </td> <td> Conventional </td> <td> Astra </td> <td> 16 </td> <td> 10 </td> <td> 97 </td> <td> 100 </td> </tr> <tr> <td> Cannizzarro et al 2007 </td> <td> pros </td> <td> 33 </td> <td> 202 </td> <td> Immed loading </td> <td> Zimmerman </td> <td> 21 </td> <td> 1 </td> <td> 100 </td> <td> 100 </td> </tr> </table> _figures/img_6e2cc4e011bc0910.webp) 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 | Table: A data table summarizing clinical studies on restoring the edentulous maxilla with fixed prostheses using axial implants. It lists various studies (e.g., Adell et al, Jemt et al) alongside columns for study design, number of patients and implants, surgical procedures, implant systems used, observation periods, and survival rates for both implants and fixed dental prostheses. _figures/img_9c0595185a81364a.webp) A composite image displaying six panoramic radiographs (OPGs) of patients with full-arch dental rehabilitation. The images demonstrate the placement of multiple endosseous implants in the maxilla and mandible, characterized by distinct axial and tilted posterior fixtures supporting fixed prosthetic bridges. **Tilted implants no grafting** Maxilla 13 year follow-up 17 year follow-up Mandible 24 year follow-up **Superstructure cementation** **Axial CT scan (C1) and Osseous contour details** _figures/img_6d00ec6e9070e701.webp) _figures/img_478d6ac641233ad6.webp) Tilted implants, no grafting: - Maxilla: 13-year follow-up - 17-year follow-up - Mandible: 24-year follow-up *Superstructure cementation* *Axial CT scan (C1) and osseous contour details* > [!note] 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. A panoramic dental radiograph showing a full-arch implant-supported prosthesis in both the maxilla and mandible. The image displays multiple endosseous implants, including tilted posterior fixtures, supporting a continuous row of radiopaque superstructure teeth. A panoramic radiograph displaying a full-arch dental rehabilitation with multiple tilted endosseous implants in both the maxilla and mandible. The image shows the metallic implants and the attached superstructures (prosthetic bars/teeth), illustrating the clinical outcome of the 'tilted implants' treatment mentioned in the slide context. # 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 {%include "_macros.html" %} {%block figure_captions%} {%endblock%} _figures/img_a8d4a6ed684826a9.webp) 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.* A data table summarizing eight clinical studies (from Mattson et al 1999 to Testori et al 2008) regarding the restoration of edentulous jaws. The columns detail study design, patient and implant counts, surgical procedures (such as immediate loading), implant systems used (e.g., Branemark, 3i), fixed dental prostheses numbers, observation periods, and survival percentages for implants and prostheses. Studies restoring the edentulous maxilla with fixed prosthesis- Tilted implants no grafting **No sig difference in failure rate or** **marginal bone levels between axial** **and tilted implants** Menini M1, 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. 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.* # Tilted implants - 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 - 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.== > [!note] 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. _figures/img_d550e58f035323bf.webp) _figures/img_745203f2d40876c4.webp) A medical illustration showing a cross-section of the maxilla and palate. It depicts two surgical instruments in use: one vertical instrument (likely an implant drill or fixture) positioned at the midline, and a second angled instrument (possibly a probe or syringe tip) approaching from the right side. Clinical endoscopic photo showing a threaded, tubular medical device (likely an esophageal stent or delivery system) positioned within the lumen of a hollow organ. A metal instrument shaft is visible entering from the right side alongside the device. <img>CBCT showing dental implants with sinus lift *CBCT showing dental implants with sinus lift* # All-on-4 outcomes * 20 maxillae 18-42months prospective single cohort immediate loading * Implant survival 100% * Marginal bone loss **0.8 +/- 0.4mm** axial, **0.9 +/- 0.5mm** * No stat 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. - 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.* All-on-4 outcomes • 61 maxillae 1-5yrs prospective single cohort immediate loading • Implant survival 98.36% • Marginal bone loss 0.9+/-0.7mm • 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. - 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 Outcomes **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+/-0.4mm at 3yrs** **No sig diff 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** #### Systematic Review: All-on-4 Outcomes - 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* > [!note] 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 outcomes ##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 +/- 0.4mm axial, 0.8 +/- 0.5mm 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. - 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.* # All-on-6 outcomes - 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 **1.2mm** - 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. - 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 **Multifactorial reasons for bone loss** - 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 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. _figures/img_9b8cb0c46ec0fa95.webp) #### Multifactorial Reasons for Bone Loss - 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 *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. > [!note] 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. > [!example] 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. A radiograph showing multiple dental implants placed in the anterior mandible, with a connecting bar structure visible across the implant heads. The image illustrates the concept of 'star of death' configuration where divergent implant placement leads to mechanical complications and bone loss. <table> <caption> <strong>Patient Risk Factors</strong> </caption> <thead> <tr> <th> <strong>Primary Factors</strong> </th> <th> <strong>Secondary Factors</strong> </th> </tr> </thead> <tbody> <tr> <td> -Opposing Natural Dentition </td> <td> -Smoker </td> </tr> <tr> <td> -Poor Bone Density </td> <td> -Bone </td> </tr> <tr> <td> -Bruxer </td> <td> Volume </td> </tr> <tr> <td> -Male </td> <td> </td> </tr> </tbody> </table> 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. #### Patient Risk Factors | Primary Factors | Secondary Factors | | :--- | :--- | | Opposing natural dentition | Smoker | | Poor bone density | Bone volume | | Bruxer | | | Male | | *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.* - ==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.== # At Risk.. *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. _figures/img_e76b50673816f09c.webp) > 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.* A line graph plots two curves against time (Surgery, 2m, 3m, 1yr) and implant stability. The 'Mechanical' curve starts high at surgery and declines sharply over the first year; the 'Biological' curve starts low and rises to plateau at a high level by one year. # At Risk.. ## Implant Stability | Mechanical | Biological | | :--- | :--- | | **Surgery** | | | 2m | | | 3m | | | 6m | | | 1yr | **100** | Mechanical stability of maxillary bone is **3-4X lower than functional resistance to load** of mandibular bone. Implants are **not as stable cf mandibular bone**. 100 80 60 40 20 0 | | | | :--- | :--- | | Surgery | Time | | **Mechanical** | | | **Biological** | | Maxillary bone type 3-4X 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. _figures/img_904096e614bf5d7a.webp) #### Implant Stability | 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**. 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.* > [!note] 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. A line graph titled 'Implant Stability' plots the progression of two stability types over time. The x-axis marks intervals from 'Surgery' to '1yr', while the y-axis shows a scale from 0 to 100. Two intersecting lines illustrate that 'Mechanical' stability decreases sharply after surgery, whereas 'Biological' stability increases over the same period. # Implant Failure * 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 pt factors eg 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. _figures/img_524bf86eafdc5dc1.webp) - 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.* Radiograph: This panoramic X-ray image displays four dental implants placed in the maxillary arch, illustrating an 'All-on-4' configuration where the two posterior implants are angled distally. The radiopaque fixtures are clearly visible embedded within the jawbone, supporting the slide's discussion on implant stability and loading. ## Management of the Atrophic Maxilla ### Augmentation _figures/img_954616f6529b36f9.webp) #### Augmentation Panoramic dental radiograph showing a full-arch implant-supported prosthesis in the maxilla (upper jaw) and multiple implants with a connecting bar in the mandible (lower jaw). The image demonstrates bone grafting materials or sinus lift procedures evident as radiopaque areas surrounding the upper implants. Iliac Crest grafting _figures/img_453495d831e811fa.webp) _figures/img_c4ce68fdf947004c.webp) Iliac Crest grafting This schematic diagram illustrates the harvesting and application of bone grafts from the iliac crest. It depicts a lateral view of the pelvis with an arrow showing the removal of a curved cortical bone segment, which is then shown being fixed across the midline of the anterior maxilla using screws. This schematic illustration depicts the anterior maxilla featuring six dental implants placed in the alveolar ridge. In the central region between the implants, a bone graft with a honeycomb-like trabecular texture is shown stabilized by two crossed screws, visually representing the concept of iliac crest grafting to reconstruct the jawbone. # Maxillary Bone Graft ## Considerations - Donor site - Recipient site preparation - Fixation - Implant installation delayed -vs- immediate - Post graft radiological requirements - Complications **MINIMUM 1 YEAR TREATMENT PLAN** _figures/img_9d2f092a24755ca1.webp) #### Maxillary Bone Graft Considerations - Donor site - Recipient site preparation - Fixation - Implant installation delayed vs immediate - Post graft radiological requirements - Complications > MINIMUM 1 YEAR TREATMENT PLAN - ==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.== > [!note] 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. A decorative text graphic displaying the words "Maxillary Bone Graft" in a stylized, grey cursive font with a drop shadow effect. This element serves as an ornamental title banner rather than an instructional diagram or clinical image. <span style="white-space: pre-wrap"> Studis restering the edentulous maxilla with fixed protheses- 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, BiOss | 21 | 1 | 82 | - | | Bektor et al 2004 | retro | 64 | 437 | immed & conventional | Branemark | Autogenous | 56 | 5-6 | 75 | 100 | </span> _figures/img_a321de06509397f3.webp) 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 | > [!example] 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. A data table summarizing six clinical studies (Watzek et al 1998 to Bektor et al 2004) regarding the restoration of edentulous maxillas with fixed prostheses and sinus lifts. The columns detail study design, patient counts, implant numbers, surgical procedures, implant systems used, graft materials, number of fixed dental prostheses (FDPs), observation periods, and survival rates for both implants and FDPs. Systematic Reviews of Studies restoring the edentulous maxilla with fixed prostheses Sinus Lift Lateral Window - Implant survival more variable in augmented sinuses (36-100% *Av ~90%*) - Amount of residual bone height important prognostic factor - No evidence for the superiority of Autogenous bone compared to substitutes - Heterogenous 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 BE1, 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 D1, 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. 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.* ### Studies restoring the edentulous maxilla with fixed prostheses- Zygoma implants | 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 | _figures/img_3840874f84f0544e.webp) #### Studies Restoring the Edentulous Maxilla with Fixed Prostheses — Zygoma Implants | 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 | > [!note] 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. A data table summarizing clinical studies on restoring the edentulous maxilla with fixed prostheses using zygoma implants. The columns list the study citation, design type (Prospective or Retrospective), number of patients, number of zygomatic implants, surgical procedure (conventional or immediate loading), implant system used, number of fixed dental prostheses (FDPs), observation period in years, and survival percentages for both implants and FDPs. # Systematic reviews - 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. _figures/img_a7ba764f9fd192e3.webp) #### Systematic Reviews - 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.* A lateral radiograph (X-ray) showing a prosthetic rehabilitation with multiple dental implants. The image displays two long, angled zygomatic fixtures extending superiorly into the upper facial skeleton, alongside several shorter vertical implants in the maxillary region, all connected to a prosthetic framework. # Systematic reviews • 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. _figures/img_7ce192eb2208abfd.webp) #### Systematic Reviews - 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.* A 3D reconstructed radiographic image (likely from a CBCT scan) showing multiple dental implants anchored in the maxilla and extending superiorly into the zygomatic bone. Satisfaction Studies * 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. _figures/img_4857d88a6511768d.webp) #### Satisfaction Studies - 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.* > [!note] 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. A lateral radiograph showing multiple long, angled metallic implants (zygomatic fixtures) extending superiorly into the facial skeleton, connected to a prosthetic framework in the maxillary region. Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study IJOMI 2010:25; 1213-1221 _figures/img_e8d43c4f9d061e76.webp) *Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study. IJOMI 2010;25:1213-1221.* This diagram overlays colored circular zones on a frontal radiograph of the skull to illustrate treatment planning guidelines. The image displays five labeled regions: a central yellow circle marked 'Zone 1', flanked by two purple circles marked 'Zone 2', and two outer blue circles marked 'Zone 3'. These zones are arranged symmetrically across the midface area, corresponding to the zygomatic bone regions. Treatment Planning Guidelines 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 _figures/img_2ba6052ed5ce7d6a.webp) #### Treatment Planning Guidelines 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.* Radiograph: A panoramic dental X-ray showing a full-arch fixed prosthesis supported by six axial implants in the maxilla. The image illustrates the treatment planning guidelines for traditional axial implants, with the prosthetic teeth and implant fixtures clearly visible against the bone structure. # Treatment Planning Guidelines ## 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 _figures/img_155a3375a23c20bd.webp) _figures/img_d8e311b68fb3191e.webp) _figures/img_8a55c10d29cc114e.webp) #### Treatment Planning Guidelines 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.* A panoramic radiograph showing a full-arch maxillary prosthesis supported by six dental implants. The image illustrates the placement of traditional axial implants in the central region and tilted implants in the posterior regions (Zones 1 and 2) to support the restoration. Radiograph: A panoramic dental X-ray of the maxilla showing four implants supporting a fixed prosthetic bridge. The image displays two central vertical implants and two lateral implants placed at an oblique angle, illustrating a treatment plan combining axial and tilted implant placement. A studio product rendering showing three distinct dental implant fixtures side-by-side against a white background with reflections. The implants feature different thread geometries and connection interfaces, including internal hex and conical designs. # Treatment Planning Guidelines 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 _figures/img_3fa12baec694dcd3.webp) #### Treatment Planning Guidelines 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.* Radiograph: A panoramic X-ray showing a full-arch prosthetic rehabilitation supported by multiple implants, including four central vertical fixtures and two long lateral zygomatic implants anchored in the upper jaw structure. # Treatment Planning Guidelines ## 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 _figures/img_4afb5d33837e8fa4.webp) #### Treatment Planning Guidelines 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.* > [!note] 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. A panoramic radiograph showing four long, angled implants anchored in the upper jaw and connected by a horizontal bar. This configuration illustrates a fixed prosthetic rehabilitation for an edentulous maxilla. The text provided in the PDF is encoded garbage data/letters which appears to be meaningless and corrupted. It contains abbreviations that do not form coherent sentences or match the content of the image. The image is a diagram illustrating dental implants. The text on it is centrally located in the "FIGURE" area described on the instructions. Therefore, per the **FIGURE/IMAGE RULES** (specifically: "If the text on the page only makes sense in the context of a figure... treat the whole page as a figure"), I will output the OCR of the diagram as an `<img>` tag, as the OCR garbage cannot be separated from the relevant figure content. Ridge reduction affects implant length and AP spread 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. _figures/img_ee0a663b73b6cb99.webp) 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.* A radiograph of the maxilla overlaid with a schematic diagram showing four dental implants placed at varying angles and depths. The image is annotated with white contour lines representing bone structure and color-coded circles labeled 'Zone 1' (yellow, central), 'Zone 2' (purple, intermediate), and 'Zone 3' (blue, lateral) to illustrate spatial relationships relative to the implants. <p style="text-align:center; font-size: 8pt;">&nbsp;</p> <div style="text-align:center; font-size: 8pt;">&nbsp;</div> <center><b>Ridge reduction affects implant length and AP spread</b></center> <br> <div align="center" style="font-size: 6pt;"> Zone 3 &nbsp; Zone 2 &nbsp; Zone 1 &nbsp; Zone 2 &nbsp; Zone 3 </div> <br> 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. _figures/img_ef43ecb7dfdf1d4e.webp) 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.* A schematic diagram overlaid on a panoramic radiograph illustrates the placement of four dental implants within the edentulous maxilla. The image uses color-coded circles and white outlines to delineate three distinct anatomical regions, labeled Zone 1 (central), Zone 2 (paramedian), and Zone 3 (posterior), showing how implant angulation and position relate to these zones. Ridge reduction affects implant length and AP spread 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. _figures/img_f56b3dda4843744d.webp) 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.* A panoramic radiograph overlaid with a schematic diagram of four dental implants and color-coded anatomical zones. The image illustrates the placement of tilted implants in Zone 3 and vertical implants in Zone 1, with Zone 2 representing the intermediate regions. # Ridge reduction affects implant length and AP spread | Line | | :--- | | 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. _figures/img_1490937ec343509b.webp) 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.* > [!note] 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. A radiographic image overlaid with a schematic diagram of five dental implants, illustrating the classification of implant placement sites. The implants are grouped into three labelled regions: Zone 1 (central vertical implants), Zone 2 (intermediate angled implants), and Zone 3 (most posterior highly angled implants). White contour lines trace the maxillary sinus floor and alveolar ridge to show how implant length and angulation vary across these zones. # Home Care Patient Aids _figures/img_61afb9cb5d824861.webp) _figures/img_2553b3b20f026b75.webp) Home Care Patient Aids > [!note] 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. A product photograph showing a Waterpik oral irrigator device. The unit features a water reservoir, control dial, and handle with a tip inserted, while the open top lid reveals storage for multiple replacement tips. A product photograph showing two Oral-B electric toothbrush handles docked on a charging and sanitizing station. The unit features a central translucent container, an 'air filter' button, and branding for the 'OxyJet' model. # C L E A N S I B I L I T Y ## Convex tissue fitting surface 73 _figures/img_7e40fbf301fcbba6.webp) Cleansibility - Convex tissue fitting surface - ==A convex surface allows a water jet to pass along and clean the entire tissue-fitting area== Clinical photo: An intraoral view of a fixed dental prosthesis featuring a metal framework with four abutment cylinders, set within a U-shaped denture base. The image illustrates the tissue-fitting surface area relevant to cleanability. _figures/img_36239cec7f772e90.webp) A composite clinical photograph showing a horseshoe-shaped dental framework fitted onto a model of an edentulous arch. The left panel displays the full U-shaped metal bar with multiple circular housings embedded in resin, while the right panel provides a close-up view of these cylindrical components. # DEFINITIVE BRIDGE OPTIONS ## Both Jaws * Mandible - acrylic resin * Maxilla - more wear resistant – ceramic if possible _figures/img_a261f40e0509e1fb.webp) Definitive Bridge Options — Both Jaws - Mandible — acrylic resin - Maxilla — more wear resistant - Ceramic if possible > [!note] 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. Clinical photo showing a frontal intraoral view of complete dentures in occlusion. The image illustrates the arrangement of maxillary and mandibular teeth, consistent with the slide's topic of definitive bridge options and material selection. MAXILLARY BRIDGE OPTIONS **Need** occlusal splint Procera Titanium hybrid with acrylic teeth Maintenance medium but relatively easy to fix Retread 5-7 years for wear Staining around margins Acrylic resin fractures Tooth fractures _figures/img_c87b21e394ce8ae1.webp) #### Procera Titanium Hybrid with Acrylic Teeth Need occlusal splint. - Maintenance medium but relatively easy to fix - Retread 5–7 years for wear - Staining around margins - Acrylic resin fractures - Tooth fractures Clinical photograph showing the intaglio (tissue-facing) view of a maxillary dental prosthesis, featuring a polished metal framework with acrylic teeth attached. The image illustrates the internal structure of a titanium hybrid bridge option. 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. _figures/img_3887e3f83a8fc865.webp) *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.* > [!note] 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. A clinical photograph showing a maxillary dental arch with a complete metal framework in place. The image displays the internal surface of the framework, including screw access holes and connector bars, seated over the palatal tissue. M A X I L L A R Y B R I D G E O P T I O N S **PFM - Gold cemented framework** Gold prices are getting crazy - US$11K for this one! Maintenance low but expensive and difficult to fix _figures/img_2b7b8d40c01b8b73.webp) _figures/img_924397a1953f73fa.webp) #### PFM — Gold Cemented Framework Gold prices are getting crazy — US$11K for this one! Maintenance low but expensive and difficult to fix. > [!note] 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. Clinical photo: A close-up, black-and-white intraoral view of the upper anterior teeth. The image displays a row of maxillary incisors and canines with significant specular highlights on the enamel surfaces. A clinical photograph showing the intaglio (tissue-facing) surface of a dental prosthesis, revealing multiple metallic screw access holes and circular abutment housings within the framework. **MAXILLARY BRIDGE OPTIONS** **Need occlusal splint** **PFM - CrCo framework** **CadCam framework -low cost, can have reasonable fit** **Maintenance low but expensive and difficult to fix** **Gingival replacement - composite (marginal staining), porcelain (aesthetics getting better)** _figures/img_1c31e4a665bd0164.webp) _figures/img_2de93e82c58037fb.webp) _figures/img_86d5509034ea0c4d.webp) #### PFM — CrCo Framework - 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) Clinical photograph of a maxillary dental prosthesis viewed from the palatal aspect, showing a continuous bridge framework with attached artificial teeth and metallic abutment connections visible at the posterior ends. Clinical photo: A close-up view of a dental implant abutment and crown preparation in the posterior maxilla, with a metal instrument visible on the left side. Clinical photo: A close-up view of a fixed dental prosthesis, likely a bridge or implant-supported restoration. The image shows multiple artificial teeth (pontics) connected together, with visible metal framework components emerging from the gingival area. # M A X I L L A R Y # B R I D G E O P T I O N S **PFM - Porcelian fused to titanium** CadCam Procera framework -low cost, Excellent fit Maintenance low but expensive and difficult to fix Aesthetics of Ti Porcelain ordinary _figures/img_3f12b5012c85de15.webp) _figures/img_327a944c0ce292a5.webp) #### PFM — Porcelain Fused to Titanium - CadCam Procera framework — low cost, excellent fit - Maintenance low but expensive and difficult to fix - Aesthetics of Ti porcelain ordinary A panoramic radiograph showing a full-arch maxillary implant-supported prosthesis with multiple vertical implants and abutments, positioned above a mandibular framework supported by three implants. Clinical photo showing a full-arch fixed dental prosthesis (likely a PFM bridge) in place. The image displays the upper teeth with porcelain crowns and reveals a dark metallic framework or substructure along the lower edge of the restoration. | **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, Allzirron | ~1200 Mpa| **FLEXURAL STRENGTH** **CURRENT DENTAL MATERIALS** 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 | <details> <summary><b>FLEXURAL STRENGTH</b></summary> <br> Current Dental Materials <br> </details> | Material | Examples | Flexural Strength | | :--- | :--- | :--- | | Feldspathic | eg veneering porcelain, veneers | ~90Mpa | | Pressable ceramics | eg: Empress, Cergo, Optimal | ~150Mpa | | Indirect composites | eg: Belleglass, Critobal | ~200Mpa | | Pressable Lithium disilicate | eg: Empr.2, e-Max | ~300Mpa | | Glass infiltrated ceramics | eg: In-Ceram Alum. | ~400Mpa | | Alumina | Procera | ~650Mpa | | (Y-TPZ) Zirconia | eg: Procera, Lava, Allzirkon | ~1200Mpa | 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, Allzirkon | ~1200 MPa | --- # MAXILLARY BRIDGE OPTIONS **eMax** ceramic crowns layered anteriorly, monolithic posteriorly (300MPa vs 90MPa 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 _figures/img_d5feb5749910c358.webp) _figures/img_389359b2c2801596.webp) #### eMax Ceramic Crowns - 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 > [!note] 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. A close-up clinical photograph of the maxillary anterior teeth, showing a bridge restoration with glossy ceramic crowns and pink gingival material replacing the gum tissue. A clinical photograph showing a complete arch of dental crowns attached to a metal framework on the right, with several individual ceramic crown components displayed separately on the left. The image illustrates the modular construction of a fixed prosthesis, highlighting the distinction between the structural framework and the replaceable crown units. # FLEXURAL STRENGTH ### *Current Dental Materials* <table> <tbody> <tr> <td>Feldspathic - eg veneering porcelain, veneers</td> <td>~90Mpa</td> </tr> <tr> <td>Pressable ceramics - eg: Empress, Cergo, Optimal</td> <td>~150Mpa</td> </tr> <tr> <td>Indirect composites – eg: Belleglass, Critobal</td> <td>~200Mpa</td> </tr> <tr> <td>Pressable Lithium disilicate – eg: Empr.2, e-Max</td> <td>~300Mpa</td> </tr> <tr> <td>Glass infiltrated ceramics – eg: In-Ceram Alum.</td> <td>~400Mpa</td> </tr> <tr> <td>Alumina – Procera</td> <td>~650Mpa</td> </tr> <tr> <td>(Y-TPZ) Zirconia – eg: Procera, Lava, Allzirkon</td> <td>~1200Mpa</td> </tr> </tbody> </table> Flexural Strength — *Current Dental 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 | > [!note] 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. # **Maxillary Bridge Options** **Full Zirconia** * Massive downside if framework fracture * Industrial fabrication essential * Need highly experienced technician -> **Need occlusal splint** * Attention to detail * More long term clinical research required _figures/img_25ff5774b3eac6c0.webp) #### Full Zirconia - Massive downside if framework fracture - Industrial fabrication essential - Need highly experienced technician → need occlusal splint - Attention to detail - More long term clinical research required Clinical photograph showing a four-unit implant-supported dental bridge with two abutment screws visible at the top, illustrating the full zirconia framework discussed in the slide. # Maxillary Bridge Options ## Ti CAD CAM framework/ Stained Monolithic Zirconia segments _figures/img_446e728364145896.webp) Ti CAD CAM framework / stained monolithic zirconia segments > [!note] 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. A studio photograph of a disassembled dental prosthesis, showing a titanium framework with attached anterior teeth at the top and three separate monolithic zirconia segments (anterior and two posterior) arranged below. * **MAINTENANCE PROTOCOL** * Follow-up weekly for first 4 weeks then 6 weekly until 6 months * Then 3-6 mthly according to need * OPG Radiographs at bridge placement, 6 mths, then yearly for 5 years * Then every 2-3 years depending on history _figures/img_138966f193d0d452.webp) - 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 > [!note] 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. > [!note] 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. Radiograph: A panoramic dental X-ray (OPG) showing a full-arch implant-supported prosthesis in both the maxilla and mandible. The image displays multiple dental implants with abutments supporting fixed bridges, consistent with the monitoring protocol described on the slide. OUR PREFERENCES No Pre-implant Grafting Utilize available native bone _figures/img_9c5a1632cb665b86.webp) **No Pre-implant Grafting** - Utilize available native bone Clinical photograph showing dental implants placed in the jawbone, with exposed threaded implant fixtures and healing abutments. Our Preferences Cross arch splinting <Rigid prosthesis shows cross arch splinting> _figures/img_7e593880212c970b.webp) _figures/img_89aeb0ad1df68798.webp) Cross arch splinting *Rigid prosthesis shows cross arch splinting* A clinical photograph showing an occlusal view of a rigid dental prosthesis positioned over implant abutments. The full-arch restoration demonstrates the concept of cross-arch splinting, where the teeth are connected into a single unit to provide stability for immediate loading. A close-up photograph of a rigid dental prosthesis, likely an implant-supported bridge or denture. The image displays a row of artificial teeth attached to a base, with visible metallic circular abutments on the underside used for securing the device. # OUR PREFERENCES Prosthetic replacement of soft tissue and facial support _figures/img_c3cf41b6bed9db22.webp) Prosthetic replacement of soft tissue and facial support A grayscale 3D surface rendering of a human face, showing the facial contours and features. **PATIENT BENEFITS** 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 **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 BENEFITS * Increased Predictability & Safety * Reduction in Interim Management * Predictable Prosthetic Outcome - Increased Predictability & Safety - Reduction in Interim Management - Predictable Prosthetic Outcome > [!note] 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. # The University of Western Australia ## ERADICATION OF PATHOLOGY # Thank you! **glenliddelow@gmail.com** **www.branemarkcentre.com.au** **BRÅNEMARK CENTRE** **PERTH, AUSTRALIA** _figures/img_f15c9528e8643915.webp) *Eradication of Pathology* Thank you! - glenliddelow@gmail.com - www.branemarkcentre.com.au BRÅNEMARK CENTRE, PERTH, AUSTRALIA The image displays the coat of arms of The University of Western Australia, featuring a shield with an open book at the top and a black swan within a diamond shape below. A ribbon banner beneath the shield bears the motto 'SEEK WISDOM'. ## 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 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. _cases_attachments/slide_p11_4dcd77d2d2d3f6d2.webp) ### 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. _cases_attachments/img_6d00ec6e9070e701.webp) _cases_attachments/img_478d6ac641233ad6.webp) _cases_attachments/slide_p38_c4b01accfdd502f5.webp) ### 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 FP2 prosthesis and facial aesthetics evaluation # WHAT ARE THE ISSUES? Lip Support Before and after dental smile comparison Superstructure cementation A panoramic dental radiograph showing a full-arch implant-supported prosthesis in both the maxilla and mandible. The image displays multiple endosseous implants, including tilted posterior fixtures, supporting a continuous row of radiopaque superstructure teeth. Axial CT scan (C1) and Osseous contour details A panoramic radiograph displaying a full-arch dental rehabilitation with multiple tilted endosseous implants in both the maxilla and mandible. The image shows the metallic implants and the attached superstructures (prosthetic bars/teeth), illustrating the clinical outcome of the 'tilted implants' treatment mentioned in the slide context. # Studies restoring the edentulous maxilla with fixed prostheses - Tilted implants no grafting | Study | Design | Patients | Implants | Surg Proc | System | FDPs | Obs period | Survival Implants% | Su ## 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. ## 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. _cases_attachments/img_c87b21e394ce8ae1.webp) _cases_attachments/img_3887e3f83a8fc865.webp) _cases_attachments/img_327a944c0ce292a5.webp) ### 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. Case: Female patient with severe maxillary atrophy treated with semi-guided zygomatic implants Clinical photograph showing the intaglio (tissue-facing) view of a maxillary dental prosthesis, featuring a polished metal framework with acrylic teeth attached. The image illustrates the internal structure of a titanium hybrid bridge option. A clinical photograph showing a maxillary dental arch with a complete metal framework in place. The image displays the internal surface of the framework, including screw access holes and connector bars, seated over the palatal tissue. Clinical photo showing a full-arch fixed dental prosthesis (likely a PFM bridge) in place. The image displays the upper teeth with porcelain crowns and reveals a dark metallic framework or substructure along the lower edge of the restoration. [^1]: Original PDF page 1: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=1|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.1]] [^2]: Original PDF page 2: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=2|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.2]] [^3]: Original PDF page 3: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=3|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.3]] [^4]: Original PDF page 4: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=4|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.4]] [^5]: Original PDF page 5: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=5|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.5]] [^6]: Original PDF page 6: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=6|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.6]] [^7]: Original PDF page 7: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=7|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.7]] [^8]: Original PDF page 8: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=8|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.8]] [^9]: Original PDF page 9: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=9|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.9]] [^10]: Original PDF page 10: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=10|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.10]] [^11]: Original PDF page 11: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=11|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.11]] [^12]: Original PDF page 12: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=12|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.12]] [^13]: Original PDF page 13: [[L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes_compressed (1).pdf#page=13|L7 Management of edentulism and the terminal dentitionl Maxilla fixed notes compressed (1), p.13]] [^14]: 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