Treatment strategies for the edentulous jaw Complete Denture Implant Overdenture Implant Detachable Prosthesis Fixed Prosthesis     #### Treatment Options - Complete Denture - Implant Overdenture - Implant Detachable Prosthesis - Fixed Prosthesis Clinical photo: A set of complete dentures (upper and lower) showing the arrangement of artificial teeth on a gum-colored base, illustrating a treatment strategy for an edentulous jaw. Clinical photo showing the tissue-side (intaglio) surface of a maxillary implant overdenture. The image highlights a central circular metal housing, which serves as the attachment mechanism for connecting the prosthesis to an implant. Clinical photo of the underside of an implant-supported dental prosthesis, showing a metal framework with multiple circular attachment components (likely locator abutments or clips) embedded within the structure. Clinical photo of a full-arch fixed dental prosthesis (bridge) showing an acrylic gingival base and prosthetic teeth with a metal framework containing four screw-access holes for implant attachment. # Lecture 3 Fixed Prosthesis Maxilla  ### Lecture 3 Fixed Prosthesis: Maxilla A composite figure displaying clinical photos of maxillary fixed dental prostheses alongside multiple panoramic radiographs showing various implant configurations and support structures in the jaw. Treatment strategies for the edentulous jaw Treatment strategies for the edentulous jaw # Treatment of Edentulism 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.   *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.* A composite figure consisting of eight panoramic radiographs (X-rays) illustrating various clinical cases of edentulous mandible rehabilitation using dental implants. The images display different implant configurations, including four or five TiUnite implants supporting fixed prostheses in the lower jaw. A composite image displaying eight panoramic dental radiographs (X-rays) that illustrate various configurations of implant-supported prostheses for the treatment of edentulous mandibles and maxillae. The images show different numbers of implants (ranging from four to six or more) and angulations, including tilted anterior implants, supporting fixed full-arch bridges. ## IMMEDIATE LOADING Edentulous Jaws 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 --- #### Timeline and Clinical Milestones - 1991: Single stage surgery and immediate loading (T-033C) - 1994: Routine lower jaw on 4 implants, immediate loading - 1998: Brånemark Novum (T-086) - 2000: Immediate loading maxilla - 2003: Teeth in an hour (NobelGuide) - 2008: Immediate loading of Zygoma implants Sequelae of tooth loss Sequelae of tooth loss # Factors to consider **Initial aesthetic expectation** **Current dentition, prostheses**    - Initial aesthetic expectation - Current dentition, prostheses Clinical photo showing a close-up of the anterior maxillary dentition in occlusion, illustrating the aesthetic appearance and alignment of the teeth. Clinical photo showing the anterior maxillary and mandibular dentition with significant malalignment, crowding, and spacing issues. This image illustrates the 'Current dentition' factor mentioned in the slide text, depicting a case requiring assessment of initial aesthetic expectations. Clinical photo showing a close-up view of a patient's lips and anterior teeth, likely demonstrating the current dentition or prostheses in relation to aesthetic expectations. WHAT ARE THE ISSUES? Facial Aesthetics Left: Before photo—darker teeth, more visible wrinkles, and uneven smile line. Right: After photo—brighter, whiter teeth, smoother skin, and a more defined smile. #### Clinical Evaluation - Left: Before photo—darker teeth, more visible wrinkles, and uneven smile line. - Right: After photo—brighter, whiter teeth, smoother skin, and a more defined smile. # WHAT ARE THE ISSUES? Lip Support Lip support assessment. # Ridge Reduction ## *Facial Support* Evaluation of ridge reduction and facial support. <Ridge Reduction Facial Support> Ridge reduction and facial support. The Face Determination of tooth position within the face #### The Face Determination of tooth position within the face. Where do you want your front teeth? Where do you want your front teeth? What are the issues? **Tooth aesthetics and function**   Key considerations regarding tooth aesthetics and functional requirements. Clinical photo showing the anterior dentition in occlusion with severe malocclusion, including crowding, rotations, and spacing issues. This image illustrates the 'before' state of tooth aesthetics and function as referenced in the slide text. Clinical photo: A close-up, black-and-white view of a patient's full dental arch showing the final result of restorative treatment. The image illustrates 'Tooth aesthetics and function' by displaying a uniform set of teeth with aligned contours and consistent shade, representing the post-treatment state. M-Ah Interocclusal rest space 4mm Dental exposure Mx 2-3mm F,V Vermillion 1mm lingual E Interlabial space occupied by Mx teeth 72% S Mandibular movement Horiz 2mm Interarch space 2mm Fradeani M. Esthetic Analysis: A systematic approach to prosthetic treatment. Quintessence, Illinois. 2004 Spear F, Kokich V, Mathews D. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137:160-169. Pound E. Let “s” be your guide. J Prosthet Dent. 1977;38:482-489.   #### Phonetic and Functional Analysis - **M-Ah** - Interocclusal rest space: 4 mm - Dental exposure (Mx): 2–3 mm - **F, V** - Vermillion border: 1 mm lingual - **E** - Interlabial space occupied by Mx teeth: 72% - **S** - Mandibular movement: Horizontal 2 mm - Interarch space: 2 mm *Fradeani M. Esthetic Analysis: A systematic approach to prosthetic treatment. Quintessence, Illinois. 2004.* *Spear F, Kokich V, Mathews D. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137:160-169.* *Pound E. Let “s” be your guide. J Prosthet Dent. 1977;38:482-489.* This figure is a grayscale clinical photograph showing a close-up lateral view of a patient's lips and anterior teeth in occlusion. It illustrates the vertical relationship between the maxillary incisors and the lower lip, specifically visualizing the dental exposure mentioned in the slide text. Clinical photo: A close-up lateral view of a patient's mouth showing the maxillary teeth and lips. This figure illustrates the concept of dental exposure (labeled Mx 2-3mm) and vermillion display (labeled Vermillion 1mm lingual), as well as the interocclusal rest space (4mm) mentioned in the slide text. # Digital Smile Design Ability to quantify changes to technician More useful for tooth borne pros – limitations with face bow Visualisation of final result Patient communication Coachman C, Calamata M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. Quintessence Dental Technology 2012 #### Clinical Applications - Ability to quantify changes to technician - More useful for tooth-borne prosthetics – limitations with face bow - Visualisation of final result - Patient communication *Coachman C, Calamata M. Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. Quintessence Dental Technology 2012.* Digital Ruler  Digital ruler. Clinical photo: A close-up view of the maxillary anterior teeth overlaid with four vertical rulers marked in millimeters (0-20) and white outlines tracing the gingival margins to measure tooth dimensions. Tooth **Outline**  Tooth outline. Clinical photo of the maxillary anterior teeth showing white, mottled enamel opacities characteristic of dental fluorosis. The image is annotated with white outlines tracing the contours of each tooth. "Real Face Bow"  "Real Face Bow" Photo: A frontal view of a dental cast showing a complete set of upper and lower artificial teeth arranged in occlusion. The teeth are set in a pink wax base on mounted plaster models, illustrating a denture wax-up. Junction between implant and prosthetic tooth determines lip support and phonetic surface The junction between the implant and prosthetic tooth determines lip support and the phonetic surface. # The Face Transfer to radiographic work up and NobelClinician software   #### The Face Transfer to radiographic workup and NobelClinician software. Clinical photo: A black-and-white close-up of a woman's face showing the eye, nose, lips, and cheek. The image serves as a visual header for 'The Face' section. Clinical photo: A black and white intraoral photograph showing a frontal view of a patient's dentition in occlusion, illustrating the final aesthetic result or smile design. The image displays the upper and lower anterior teeth with visible gingival margins and lip retraction. Planning implant placement - Prosthetically driven    Planning implant placement is prosthetically driven. This figure shows a 3D rendered model of the maxilla (upper jaw) with multiple dental implant fixtures virtually placed in various positions. It illustrates the concept of prosthetically driven implant planning, demonstrating how implants are positioned based on the desired final tooth arrangement rather than just available bone volume. A 3D digital rendering of a maxillary dental arch with a transparent overlay of the underlying bone structure, illustrating the concept of prosthetically driven implant placement. The image shows multiple virtual implants positioned at various angles and depths within the jawbone to support a full-arch prosthesis. This figure is a 3D digital rendering or virtual model of the maxilla and mandible, illustrating the concept of prosthetically driven implant planning. It depicts multiple dental implants virtually placed into the jawbone at specific angles and depths to support a future prosthesis. ## **Nobel Clinician Planning - Virtual Surgery** Image 1: "NobelClinician - Danielle Fox" **Treatments** Dental Code (x1! ) Scan Edit CT scan **Software** Scanner Orientation Refine Curve CT Preset Future Images Transfer Locations Slices Panoramic Perpendicular Ok Cancel **Interaction Mode** Brush Save Undo Radio Level / Window Change Workspace Set Focus Screenshot Rulers **Stereo Eval:** ( ) Attach to Core ( ) Attach to Guide (t) Master Model ( ) Treatments ( ) Teeth (7) ( ) Nerves (2) ( ) Teeth (3) ( ) Primelines (2) ( ) Regetration (2) ( ) Space (4) **Use Slices File** #### NobelClinician Planning – Virtual Surgery *NobelClinician - Danielle Fox* ##### Treatments - Dental Code (x1!) - Scan - Edit CT scan ##### Software - Scanner Orientation - Refine Curve - CT Preset - Future Images - Transfer Locations - Slices - Panoramic - Perpendicular - OK / Cancel ##### Interaction Mode - Brush - Save - Undo - Radio - Level / Window - Change Workspace - Set Focus - Screenshot - Rulers ##### Stereo Evaluation - ( ) Attach to Core - ( ) Attach to Guide - (t) Master Model - ( ) Treatments - ( ) Teeth (7) - ( ) Nerves (2) - ( ) Teeth (3) - ( ) Primelines (2) - ( ) Registration (2) - ( ) Space (4) *Use Slices File* NobelConnect - Critical for Complex Interdisciplinary Treatment  - Critical for complex interdisciplinary treatment A schematic network diagram illustrating the 'NobelConnect' system, featuring a central laptop labeled 'Dental professional performing treatment' connected by lines to six surrounding laptops. The peripheral nodes represent different roles in complex interdisciplinary treatment: 'Referring dentist', 'Treatment partners', 'Expert opinion', 'Nobel Biocare', 'Imaging center', and 'Dental technician'. Implant anchorage is then prosthetically directed Implant anchorage is then prosthetically directed.  Clinical photo of a dental bridge prosthesis featuring multiple dark, circular openings on the occlusal surfaces and lingual aspects. Grey arrows originate from a single point to indicate these specific access holes, which are likely for screw retention. # Implant Surgical Pathways | Primary Pathway | Sub-Method / Description | Advanced Options / Materials | | :--- | :--- | :--- | | **Graftless** | **Axial** | Immediate Loading | | | **Tilted** | Anterior sinus<br>posterior sinus<br>pterygoid<br>Zygoma<br>other | | **Grafting** ↓ | Sinus<br>Labial onlay<br>Ridge splitting<br>GBR<br>Interpositional<br>Distraction Osteogenesis<br>LeFort 1<br>Free tissue transfer | **Material Categories:**<br>• Autogenous<br>• Allograft<br>• Xenograft<br>• Synthetic<br>• BMPs<br>• Gene Therapy | | Primary Pathway | Sub-Method / Description | Advanced Options / Materials | | :--- | :--- | :--- | | **Graftless** | **Axial** | Immediate Loading | | | **Tilted** | Anterior sinus<br>posterior sinus<br>pterygoid<br>Zygoma<br>other | | **Grafting** ↓ | Sinus<br>Labial onlay<br>Ridge splitting<br>GBR<br>Interpositional<br>Distraction Osteogenesis<br>LeFort 1<br>Free tissue transfer | **Material Categories:**<br>• Autogenous<br>• Allograft<br>• Xenograft<br>• Synthetic<br>• BMPs<br>• Gene Therapy | # Axial implants no grafting  Radiograph showing a full-arch dental rehabilitation with six axial implants placed in the maxilla (upper jaw) and three axial implants placed in the mandible (lower jaw). The image illustrates the concept of 'Axial implants no grafting' by demonstrating how multiple straight implants can be utilized to support fixed prosthetic bridges without the need for bone augmentation procedures. # 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 | 9yr | 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 | | Cannizzaro et al 2007 | pros | 33 | 202 | Immed loading | Zimmer | 21 | 1 | 100 | 100 |  #### Studies Restoring the Edentulous Maxilla with Fixed Prostheses | Study | Design | Patients | Implants | Surg Proc | System | FDPs | Obs Period | Survival Implants % | Survival FDP % | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Adell et al 1981 | pros | 146 | 981 | Conventional | Branemark | 146 | 9 yr | 81 | 89–96 | | Adell et al 1983 | pros | 73 | 529 | Conventional | Branemark | 73 | 5–10 yr | 82 (5y), 81 (10y) | 100 (5y), 88 (10y) | | Adell et al 1990 | pros | 277 | 1789 | Conventional | Branemark | 277 | 5–15 yr | 84 (5y), 78 (15y) | 84 (5y), 78 (15y) | | Carlsson et al 2000 | pros | 13 | 75 | Conventional | Branemark | 13 | 15 yr | 93 | — | | Jemt et al 2002 | pros | 58 | 349 | Conventional | Branemark | 58 | 5 yr | 91 | 93 | | Engfors et al 2004 | retro | 44 | 282 | Conventional | Branemark | 44 | 5 yr | 93 | — | | Jaffin et al 2004 | — | 34 | 236 | Immed loading | Straumann | 34 | 5 yr | 92 | — | | Ortop et al 2004 | pros | 54 | 356 | — | Branemark | 54 | 5 yr | 90 | 95 | | Degidi et al 2005 | retro | 45 | 388 | Immed loading | various | 45 | 5 yr | 98 | — | | Rasmussen et al 2005 | pros | 16 | 91 | Conventional | Astra | 16 | 10 yr | 97 | 100 | | Cannizzaro et al 2007 | pros | 33 | 202 | Immed loading | Zimmer | 21 | 1 yr | 100 | 100 | This figure is a table listing studies on restoring the edentulous maxilla with fixed prostheses using axial implants without grafting. It presents data columns for Study, Design (prospective or retrospective), number of Patients and Implants, Surgical Procedure (Conventional or Immediate loading), Implant System used, number of Fixed Dental Prostheses (FDPs), Observation period, and survival percentages for both Implants and FDPs. Tilted implants no grafting  Tilted implants no grafting This figure consists of a composite of six panoramic radiographs (X-rays) showing various clinical cases of dental implant placement in the maxilla and mandible. The images illustrate the concept of using tilted posterior implants to support full-arch prostheses without the need for bone grafting, as indicated by the slide text. Tilted implants no grafting Maxilla 13 year follow-up 17 year follow-up Mandible 24 year follow-up   #### Follow-up Outcomes - Maxilla: 13-year follow-up and 17-year follow-up - Mandible: 24-year follow-up Panoramic radiograph showing a full-arch dental implant rehabilitation with multiple implants in both the maxilla and mandible, including tilted posterior implants. The image illustrates long-term osseointegration without bone grafting, consistent with the slide text indicating 13 to 24 year follow-ups. Radiograph (panoramic X-ray) showing a full-arch dental rehabilitation with multiple tilted and axial implants supporting fixed prostheses in both the maxilla and mandible, illustrating the long-term stability of 'Tilted implants no grafting' procedures. | 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  #### Clinical Outcomes of Tilted Implants | 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* Table: This table summarizes data from eight studies (ranging from Mattson et al 1999 to Testori et al 2008) regarding implant rehabilitation, detailing columns for Study, Design, Patients, Implants, Surg Proc, System, FDPs, Obs period, Survival Implants %, and Survival FDP %. Studies restoring the edentulous maxilla with fixed prostheses- 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. #### Maxillary Fixed Prostheses Outcomes Studies restoring the edentulous maxilla with fixed prostheses using tilted implants without grafting show: - No significant difference in failure rate or marginal bone levels between axial and tilted implants. *Menini M, Signori A, Tealdo T, Bevilacqua M, Pera F, Ravera G, Pera P. Tilted implants in the immediate loading rehabilitation of the maxilla: a systematic review. J Dent Res. 2012;91(9):821-7.* *Del Fabbro M, Bellini CM, Romeo D, Francetti L. Tilted Implants for the Rehabilitation of Edentulous Jaws: A Systematic Review. Clin Implant Dent Relat Res. 2011* *Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6* *Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011;106(6):359-66.* *Maló P, Araújo Nobre MD, Lopes A, Rodrigues R. Double Full-Arch Versus Single Full-Arch, Four Implant-Supported Rehabilitations: A Retrospective, 5-Year Cohort Study. J Prosthodont. 2015;24(4):263-70.* 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 #### Clinical Advantages - 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   A labelled diagram illustrating a surgical procedure on the anterior maxilla, specifically showing the nasal floor and incisive canal region. The image depicts a vertical osteotomy being performed in the midline with a straight bur, while a second angled bur is positioned to the right, likely indicating the preparation of implant sites or bone grafting access. Clinical photo showing the intraoperative placement of a threaded dental implant fixture into the jawbone. A metal retractor holds back the soft tissue to expose the surgical site, while a surgical driver instrument is engaged with the top of the implant. # 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 statistically significant difference in axial vs. tilted implants *Agliardi E, Panigatti S, Clericò M, Villa C, Malò P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: interim results of a single cohort prospective study. Clin Oral Implants Res. 2010 May; 21(5):459–65.* **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 years prospective single-cohort immediate loading - Implant survival: 98.36% - Marginal bone loss: 0.9 ± 0.7 mm - No difference in axial vs. tilted implants *Agliardi EL, Francetti L, Romeo D, Del Fabbro M. Immediate rehabilitation of the edentulous maxilla: preliminary results of a single-cohort prospective study. Int J Oral Maxillofac Implants. 2009 Sep-Oct;24(5):887-95.* All-on-4 outcomes **Systematic Review** •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 Findings - 13 papers - 4,804 implants, 1,201 prostheses loaded within 48 hours - 99% implant success at 3 years - 99.9% prosthesis success at 3 years - Marginal bone loss: 1.3 ± 0.4 mm at 3 years - No significant difference between axial and tilted implants - Most failures occurred with smokers and patients on bisphosphonate medication - Short-term results *S. B. M. Patzelt, O Bahat, BDS, M. A. Reynolds, J. R. Strub, The All-on-Four Treatment Concept: A Systematic Review. Clin Oral Impl Res 2013* # **All-on-6 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 multicenter immediate loading - 4 axial implants, 2 tilted - Implant survival: 98.8% - Marginal bone loss: 0.9 ± 0.4 mm axial, 0.8 ± 0.5 mm tilted - No difference in axial vs. tilted implants - Prosthesis success rate: 100% *Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL. Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32.* # **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 crestral/marginal bone loss around dental implants. Int J Pros 2012;25:320-322. Members - T Albrektsson, D Buser, S Chen, D Cochran, H De Bruyn, T Jemt, S Koka, M Nevins, L Sennerby, M Simion, T Taylor, A Wennerberg.  #### Multifactorial Reasons for Bone Loss - Cause / effect / association - Early failure - Late failure - Peri-implantitis model - Patient-related factors - Due to inadequate healing initially (lower bone-to-implant contact [BIC] and degree of sustainable osseosufficiency) *Koka S, Zarb G. On osseointegration: The healing adaptation principle in the context of osseosufficiency, osseoseparation and dental implant failure. Int J Pros 2012;25:48-52.* *Zarb G. Implantomania: Prosthodontics at a crossroads. Int J Pros 2012;25:180-185.* *Albrektsson T, Buser D, Sennerby L. On crestral/marginal bone loss around dental implants. Int J Pros 2012;25:320-322.* Members: T Albrektsson, D Buser, S Chen, D Cochran, H De Bruyn, T Jemt, S Koka, M Nevins, L Sennerby, M Simion, T Taylor, A Wennerberg. Radiograph showing four dental implants placed in the maxilla (upper jaw) with a radiopaque bar structure connecting them. The image illustrates the placement of implants relative to anatomical structures such as the nasal cavity and maxillary sinuses, which are visible as dark voids on either side. Patient At Risk.. | | | | :--- | :--- | | **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. #### Patient Risk Stratification | Primary Factors | Secondary Factors | | :--- | :--- | | - Opposing natural dentition<br>- Poor bone density<br>- Bruxer<br>- Male | - Smoker<br>- Bone volume | *Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6.* *Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011;106(6): 359-66.* At Risk.. Implant Stability 74% of failures occurred within 12 months of placement Mechanical Biological Time Surgery 2m 3m 1yr Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6 Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011; 106(6): 359-66.  > 74% of failures occurred within 12 months of placement. #### Failure Modes Over Time - Mechanical stability - Biological stability Timeline milestones: Surgery → 2 months → 3 months → 1 year *Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16;6.* *Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011; 106(6): 359-66.* This line chart illustrates the relationship between Implant Stability (Y-axis) and Time (X-axis) following Surgery. It plots two opposing trends: a "Mechanical" stability curve that starts high at surgery and declines over time, and a "Biological" stability curve that starts low and increases to stabilize around the 3-month mark. **At Risk.** Implant Stability |<br> Time | Mechanical | Surgery 2m 3m 1yr 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.  #### Maxillary Bone Considerations - Timeline / mechanical transition: Surgery → 2 months → 3 months → 1 year - Maxillary bone demonstrates 3–4× lower functional resistance to load; implants are not as stable compared to mandibular bone. *Patzelt, Bahat, Reynolds, Strub. The All-on-Four Treatment Concept: A Systematic Review. CIDRR 2014 16; 6.* *Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: preliminary findings. J Prosthet Dent. 2011; 106(6): 359-66.* This is a line chart illustrating the relationship between Implant Stability (Y-axis) and Time (X-axis, marked from Surgery to 1yr). It depicts two intersecting curves: 'Biological' stability, which starts low at surgery and rises over time to plateau, and 'Mechanical' stability, which starts high at surgery and declines over time. 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, Al disease etc * All-on-4 may not be appropriate for larger arch form and greater load. Chung S, McCullagh A, Irinakas T. Immediate loading in the maxillary arch: evidence-based guidelines to improve success rates: A review. J Oral Implantol. 2011;37:610-21.  #### Factors Contributing to Failure in Immediately Loaded Maxillae - Depending on loading, four implants may be insufficient for complete stability, resulting in lower bone-to-implant contact (BIC) and greater susceptibility to integration breakdown, opportunistic infection, and bone loss. - Risk is exacerbated by patient factors such as smoking, diabetes, IL-1 phenotype, history of periodontitis, and autoimmune disease. - The All-on-4 concept may not be appropriate for larger arch forms and greater functional loads. *Chung S, McCullagh A, Irinakas T. Immediate loading in the maxillary arch: evidence-based guidelines to improve success rates: A review. J Oral Implantol. 2011;37:610-21.* Radiograph: Panoramic X-ray showing four dental implants placed in the maxilla, with two anterior vertical implants and two posterior angled implants. This image illustrates the 'All-on-4' configuration mentioned in the slide text, which discusses how this setup may be insufficient for stability depending on loading conditions. # Management of the Atrophic Maxilla **AUGMENTATION**  Augmentation Radiograph displaying a full-arch implant rehabilitation case. The maxilla shows a fixed prosthesis supported by seven implants, while the mandible exhibits four implants connected by a bar, likely for an overdenture, alongside remaining natural teeth. Iliac Crest grafting   Iliac Crest grafting This labelled diagram illustrates the process of iliac crest grafting, showing the harvesting of bone grafts from the anterior iliac crest (left) and posterior iliac crest (right) and their subsequent placement onto the maxilla (center). The top insets display the shapes of the harvested grafts with dotted lines indicating screw fixation points. An anatomical illustration of the maxilla showing six dental implants placed along the alveolar ridge. In the anterior midline, a bone graft composed of particulate material is depicted filling a defect and being stabilized by two angled fixation screws. 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  - Donor site - Recipient site preparation - Fixation - Implant installation: delayed vs. immediate - Post-graft radiological requirements - Complications > Minimum 1-year treatment plan This figure is a stylized text graphic displaying the words 'Maxillary Bone Graft' in a large, grey, cursive font with a drop shadow. It serves as a decorative title element for the section on maxillary bone graft considerations. Studies restoring 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 | - | | Raghoobar 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 |  | Study | Design | Patients | Implants | Surg Proc | System | Graft material | FDPs | Obs period | Survival Implants (%) | Survival FDP (%) | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Watzek et al. 1998 | retro | 20 | 145 | conventional | Frialit, IMZ | Autogenous | 5 | 1–6 | ~95 | — | | Johansson et al. 1999 | retro | 39 | 131 | immed load | Brånemark | Autogenous HA | 36 | 3 | 75 | 95 | | Wannfors et al. 2000 | RCT | 40 | 150 | immed & conventional | Brånemark | Autogenous | 40 | 1–6 | 84 | — | | Raghoobar et al. 2001 | retro | 75 | 326 | immed & conventional | Brånemark | Autogenous | 27 | 1–10 | 91 | — | | Hallman et al. 2002 | pros | 21 | 67 | conventional | Brånemark | Autogenous, Bio-Oss | 21 | 1 | 82 | — | | Bektor et al. 2004 | retro | 64 | 437 | immed & conventional | Brånemark | Autogenous | 56 | 5–6 | 75 | 100 | This figure is a table summarizing six studies on restoring the edentulous maxilla with fixed prostheses using sinus lift lateral window techniques. It lists data for each study including design type, number of patients and implants, surgical procedure (conventional or immediate load), implant system used, graft material, number of FDPs, observation period, 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, Raghoobar 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 Review Findings - Implant survival more variable in augmented sinuses (36–100%, average ~90%) - Amount of residual bone height is an important prognostic factor - No evidence for the superiority of autogenous bone compared to substitutes - Heterogeneous studies do not allow definitive statements #### References *Graziani, F., Donos, N., Needleman, I., Gabriele, M., and Tonetti, M. (2004). Comparison of implant survival following sinus floor augmentation procedures with implants placed in pristine posterior maxillary bone: a systematic review. Clinical Oral Implants Research, 15, 677–682.* *Pjetursson, B. E., Tan, W. C., Zwahlen, M., and Lang, N. P. (2008). A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Journal of Clinical Periodontology, 35(8 Suppl), 216–240.* *Nkenke, E., and Stelzle, F. (2009). Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review. Clinical Oral Implants Research, 20(Suppl 4), 124–133.* *Rickert, D., Slater, J. J., Meijer, H. J., Vissink, A., and Raghoobar, G. M. (2012). Maxillary sinus lift with solely autogenous bone compared to a combination of autogenous bone and growth factors or (solely) bone substitutes. A systematic review. International Journal of Oral and Maxillofacial Surgery, 41(2), 160–167.* Zygoma Implants Zygoma Implants Studies restoring the edentulous maxilla with fixed prostheses- Zyoma 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 | - | | Beccctor et al 2005 | Retro | 16 | 31 | conventional | Branemark | 16 | 1-6 | 90 | - | | Ajlgren et al 2006 | Pros | 13 | 25 | conventional | Branemark | 4 | 1-4 | 100 | - | | Bredrossian et al 2006 | Pros | 14 | 28 | immed loading | Branemark | 14 | 1-4 | 100 | 100 | | Farzad et al 2006 | Pros | 11 | 22 | conventional | Branemark | 11 | 1-4 | 100 | - | | Davo et al 2007 | Retro | 18 | 36 | immed loading | Branemark | 18 | 1 | 100 | 100 | | Duarte et al 2007 | Pros | 12 | 48 | immed loading | Branemark | 12 | 2.5 | 96 | - | | Penarrocha et al 2007 | Retro | 21 | 40 | conventional | Branemark | 21 | 1-4 | 100 | - | | Bredrossian et al 2010 | Pros | 36 | 74 | conv/immed | Branemark | 36 | 7 | 97.3 | 100 | | Miglioranca et al 2012 | Pros | 25 | 40 | immed loading | Branemark | 25 | 8 | 97.5 | 95.2 | | Aparicio et al 2014 | Retro | 22 | 41 | conventional | Branemark | 22 | 10 | 97.7 | 100 | | Davo et al 2013 | Pros | 42 | 69 | immed loading | Branemark | 37 | 5 | 98.5 | 100 | | Malo et al 2014 | Retro | 39 | 92 | immed loading | Branemark | 39 | 5 | 98.8 | 100 | | Davo et al 2015 | Pros | 14 | 64 | immed loading | Branemark | 14 | 5 | 100 | 100 |  #### Clinical Studies: Edentulous Maxilla Restored with Fixed Prostheses and Zygomatic 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 | - | | Beccctor et al 2005 | Retro | 16 | 31 | conventional | Branemark | 16 | 1-6 | 90 | - | | Ajlgren et al 2006 | Pros | 13 | 25 | conventional | Branemark | 4 | 1-4 | 100 | - | | Bredrossian et al 2006 | Pros | 14 | 28 | immed loading | Branemark | 14 | 1-4 | 100 | 100 | | Farzad et al 2006 | Pros | 11 | 22 | conventional | Branemark | 11 | 1-4 | 100 | - | | Davo et al 2007 | Retro | 18 | 36 | immed loading | Branemark | 18 | 1 | 100 | 100 | | Duarte et al 2007 | Pros | 12 | 48 | immed loading | Branemark | 12 | 2.5 | 96 | - | | Penarrocha et al 2007 | Retro | 21 | 40 | conventional | Branemark | 21 | 1-4 | 100 | - | | Bredrossian et al 2010 | Pros | 36 | 74 | conv/immed | Branemark | 36 | 7 | 97.3 | 100 | | Miglioranca et al 2012 | Pros | 25 | 40 | immed loading | Branemark | 25 | 8 | 97.5 | 95.2 | | Aparicio et al 2014 | Retro | 22 | 41 | conventional | Branemark | 22 | 10 | 97.7 | 100 | | Davo et al 2013 | Pros | 42 | 69 | immed loading | Branemark | 37 | 5 | 98.5 | 100 | | Malo et al 2014 | Retro | 39 | 92 | immed loading | Branemark | 39 | 5 | 98.8 | 100 | | Davo et al 2015 | Pros | 14 | 64 | immed loading | Branemark | 14 | 5 | 100 | 100 | This figure is a table summarizing multiple studies on restoring the edentulous maxilla with fixed prostheses using Zygoma implants. It lists specific data points for each study, including the design type (Prospective or Retrospective), number of patients and implants, surgical procedure (conventional or immediate loading), implant system used, observation period in years, and survival rates for both implants and FDPs. Zygomatic Implants 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.  - 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.* This figure is a 3D reconstruction or radiographic image showing multiple dental implants placed in the maxilla. It specifically illustrates two long, angled zygomatic implants extending superiorly into the zygomatic bone (cheekbone) alongside shorter standard implants in the anterior region, visualizing the anchorage method discussed in the context of survival rates. # 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. ^]  - 25 articles - Overall survival rate 97.8% (1,541 ZI, 33 failures) - Failure generally in the first year due to infection and sinusitis *Goiato MC, Pellizzer EP, Moreno A, Gennari-Filho H, Dos Santos DM, Santiago JF Jr, Dos Santos EG. Implants in the zygomatic bone for maxillary prosthetic rehabilitation: a systematic review. Int J Oral Maxillofac Surg. 2014;43:748-757. Review.* This figure is a 3D reconstructed radiographic image (likely from a CT scan) illustrating zygomatic implants in the maxillary bone for prosthetic rehabilitation. It shows two long, angled zygomatic implants extending superiorly into the zygomatic arch alongside shorter anterior dental implants anchored in the maxilla. # 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.  - 16 patients: - All satisfied; 50% with some complaints (50% prosthesis, 38% implants) - 22 patients: - 84% satisfaction above 80% (32% had 100% satisfaction) - Satisfaction (high) approaching the general population *Sartori et al Evaluation of Patients Rehabilitated with Zygomatic Fixtures. J Oral Maxillofac Surg 2012;70:314-9.* *Aparicio et al The Long Term Use of Zygomatic Implants: A 10 Year Clinical and Radiographic Report. Clin Impl Dent Relat Res 2012* *Wang F, Monje A, Lin GH, Wu Y, Monje F, Wang HL, Davó R. Reliability of four zygomatic implant-supported prostheses for the rehabilitation of the atrophic maxilla: A systematic review IJOMI 2015;30:293-298.* This figure is a lateral radiograph showing the placement of zygomatic implants in the maxilla. It depicts two long, angled fixtures extending into the zygomatic bone (cheekbone) alongside shorter anterior dental implants, illustrating the surgical support structure for the rehabilitated maxilla mentioned in the study titles. **Treatment Planning Guidelines** Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study IJOMI 2010:25; 1213-1221  *Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: A 7-year prospective study IJOMI 2010:25; 1213-1221* A panoramic radiograph of the maxilla overlaid with colored circles and labels indicating specific anatomical regions for implant placement. The figure illustrates 'Treatment Planning Guidelines' by demarcating three distinct areas: Zone 1 is located in the central midline region, while two instances of Zone 2 are positioned laterally to the center, and two instances of Zone 3 are located in the most lateral posterior 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   - 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 showing six traditional axial implants placed in the maxilla supporting a full-arch prosthesis, illustrating the slide text 'Zones 1,2 &3 - Traditional Axial implants'. This figure displays three distinct 3D renderings of dental implant screws, illustrating different thread designs and apical geometries (such as the self-tapping flutes on the left). The implants are shown in a vertical orientation with reflections below them. 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    - 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* Radiograph showing the placement of multiple dental implants in the maxilla, including two long, angled zygomatic implants extending into the cheekbone and four shorter, vertical traditional implants in the anterior region. The image illustrates a full-arch fixed prosthesis supported by this combination of implant types. Radiograph (X-ray) of the maxilla illustrating the 'zygoma concept' for rehabilitation, featuring four dental implants: two traditional axial implants in the anterior region and two tilted zygomatic implants extending into the zygomatic bone. Figure showing three different dental implant fixtures with varying thread designs and head configurations, illustrating the hardware used for traditional axial and tilted implants as referenced in the treatment planning guidelines. 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  - 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 demonstrating the rehabilitation of an edentulous maxilla using the zygoma concept, featuring four traditional axial implants in the central region and two long, angled zygomatic implants on the lateral sides. The implants are connected by a radiopaque prosthetic superstructure. 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  - 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* This is a panoramic radiograph illustrating the 'Quad Zygoma' concept for rehabilitating an edentulous maxilla with insufficient bone. It shows four long dental implants placed bilaterally, angling upward from the anterior alveolar ridge into the zygomatic bones to provide anchorage. Zone 3 Zone 2 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.  #### Maxillary Zone Distribution - Zone 3 - Zone 2 - Zone 1 *Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T. Fixed-prosthetic implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method. J Oral Maxillofac Surg. 2008;66(1):112-22.* This figure is a panoramic radiograph of the maxilla overlaid with a diagram illustrating dental implant placement. It displays four implants positioned within color-coded regions labeled Zone 1 (central anterior), Zone 2 (lateral anterior), and Zone 3 (posterior), showing how ridge reduction affects the available bone height and the anteroposterior (AP) spread of the implants. # Ridge reduction affects implant length and AP spread  Ridge reduction affects implant length and AP spread. This figure is a panoramic radiograph of an edentulous maxilla overlaid with a diagram illustrating the placement of four dental implants. The image defines three anatomical regions for implant planning, labeled as 'Zone 1' (central incisor area), 'Zone 2' (canine/premolar areas), and 'Zone 3' (posterior molar/tuberosity areas). A white line traces the alveolar ridge contour to demonstrate how ridge reduction affects the available bone height and AP spread. # Ridge reduction affects implant length and AP spread Maló P, Nobre Md, Lopes A. Immediate loading of 'All-on-4' maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol. 2013;6(3):273-83.  Ridge reduction affects implant length and AP spread. *Maló P, Nobre Md, Lopes A. Immediate loading of 'All-on-4' maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol. 2013;6(3):273-83.* This figure is a panoramic radiograph of a maxilla overlaid with a diagram of four dental implants and color-coded regions. It illustrates the 'All-on-4' surgical technique, with labels identifying 'Zone 1' as the anterior region with two vertical implants and 'Zone 2' and 'Zone 3' as the posterior regions containing tilted implants. Zone 1 Zone 2 Zone 3 Zone 2 Zone 3 Goiato MC, Pellizzer EP, Moreno A, Gennari-Filho H, dos Santos DM, Santiago JF Jr, dos Santos EG. Implants in the zygomatic bone for maxillary prosthetic rehabilitation: a systematic review. Int J Oral Maxillofac Surg. 2014;43(6):748-57.  - Zone 1 - Zone 2 - Zone 3 - Zone 2 - Zone 3 *Goiato MC, Pellizzer EP, Moreno A, Gennari-Filho H, dos Santos DM, Santiago JF Jr, dos Santos EG. Implants in the zygomatic bone for maxillary prosthetic rehabilitation: a systematic review. Int J Oral Maxillofac Surg. 2014;43(6):748-57.* A labelled diagram overlaid on a panoramic radiograph illustrating the placement of dental implants in the maxilla. The image defines specific anatomical regions with text labels: Zone 1 (central), Zone 2 (lateral to center), and Zone 3 (distal/zygomatic). It visually demonstrates how ridge reduction affects implant length and anteroposterior spread by showing implants of varying lengths and angulations within these zones. # Home Care ## *Patient Aids*   ### Patient Aids Clinical photo of a Waterpik oral irrigator unit with its storage lid open, revealing the reservoir, control dials for pressure settings (2-10), and a variety of interchangeable tips stored in the top compartment. A clinical photo of an Oral-B home care station featuring two handheld devices: a standard electric toothbrush on the left and an OxyJet oral irrigator on the right. The base unit includes a central translucent water reservoir with volume markings, an 'air filter' button, and a control dial labeled '1'. C L E A N S I B I L I T Y Convex tissue fitting surface Centrix ® Box A from Centrix.com. Point of clinical excellence®  ### Cleansibility - Convex tissue fitting surface *Centrix® – Point of clinical excellence® (Centrix.com)* Clinical photo of a dental prosthesis, likely an overdenture or implant-supported bridge, featuring a metal framework with four visible cylindrical attachments. The image illustrates the concept of "CLEANSIBILITY" mentioned in the slide text by showing the smooth, convex tissue-fitting surface of the appliance designed for hygiene. The image contains no OCR-detectable text (e.g., numbers, labels, captions printed on the slide or figure). The provided “PDF Text: 74” is likely an external reference (e.g., figure number from source document) and not visible in the image itself. Per instructions, we transcribe only text present on the page — which here is none aside from the implicit figure context captured via tags and output NOTHING ELSE. And since there is no actual transcribable text (only the image content), we output ONLY the <img> tag as required. Additionally, for the captioning JSON: There is no verbatim on-screen caption text associated with BOX_A — no diagnosis, no title, no label printed near the image. Therefore, the caption field must be empty. ---  Clinical photo: Two grayscale images of a dental prosthesis framework showing multiple embedded metallic attachment housings. The left image displays the full U-shaped arch with visible anterior teeth, while the right image provides a close-up view of the textured internal surface and circular metal components. Both Jaws **DEFINITIVE BRIDGE OPTIONS** * Mandible - acrylic resin * Maxilla -more wear resistant - ceramic if possible  #### Considerations by Arch - Mandible: Acrylic resin - Maxilla: More wear resistant — ceramic if possible Clinical photo showing a frontal view of a complete set of teeth in occlusion, illustrating the 'Both Jaws' definitive bridge options. The image displays the maxillary and mandibular arches, corresponding to the slide text's discussion of using acrylic resin for the mandible and wear-resistant ceramic for the maxilla. # MAXILLARY BRIDGE OPTIONS 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 Need occlusal splint  #### Procera Titanium Hybrid with Acrylic Teeth - Maintenance is medium, but relatively easy to fix - Retread required every 5–7 years for wear - Staining around margins - Acrylic resin fractures - Tooth fractures - Need occlusal splint Clinical photo showing the intaglio (underside) view of a Procera Titanium hybrid dental bridge, revealing the exposed metal framework and screw access channels beneath the acrylic resin teeth. Severe Bruxism Torsello F, di Torresanto VM, Ercoli C, Cordaro L. Evaluation of the marginal precision of one-piece complete arch titanium frameworks fabricated using five different methods for implant-supported restorations. Clin Oral Implants Res. 2008;19(8):772-9. Hjalmarsson L, Örtorp A, Smedberg JI, Jemt T. Precision of fit to implants: a comparison of Cresco™ and Procera® implant bridge frameworks. Clin Implant Dent Relat Res. 2010;12(4):271-80.  Severe Bruxism *Torsello F, di Torresanto VM, Ercoli C, Cordaro L. Evaluation of the marginal precision of one-piece complete arch titanium frameworks fabricated using five different methods for implant-supported restorations. Clin Oral Implants Res. 2008;19(8):772-9.* *Hjalmarsson L, Örtorp A, Smedberg JI, Jemt T. Precision of fit to implants: a comparison of Cresco™ and Procera® implant bridge frameworks. Clin Implant Dent Relat Res. 2010;12(4):271-80.* Clinical photo: An intraoral occlusal view of a maxillary arch showing a metal-ceramic fixed dental prosthesis (bridge) with exposed metal occlusal surfaces on the posterior teeth and anterior guidance areas, likely illustrating a restoration designed for severe bruxism. # Maxillary Bridge Options ### PFM - Gold cemented framework Gold prices are getting crazy - US$11K for this one! Maintenance low but expensive and difficult to fix   #### PFM – Gold Cemented Framework - Gold prices are getting crazy — US$11K for this one! - Maintenance is low, but expensive and difficult to fix Clinical photo showing a frontal view of a patient's maxillary anterior teeth, illustrating the aesthetic result of a porcelain-fused-to-metal (PFM) bridge mentioned in the slide text. Clinical photo showing the intaglio (tissue) surface of a maxillary implant-supported fixed dental prosthesis. The image displays the exposed metal framework and screw access channels for the implants, illustrating the 'PFM - Gold cemented framework' option mentioned in the slide text. # MAXILLARY ## BRIDGE OPTIONS **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)**    #### PFM – CrCo Framework - CAD/CAM framework: low cost, can have reasonable fit - Maintenance: low, but expensive and difficult to fix - Gingival replacement: - Composite (marginal staining) - Porcelain (aesthetics getting better) Clinical photo of a maxillary dental bridge prosthesis featuring a pink gingival replacement base and white teeth, illustrating the aesthetic outcome of the restoration mentioned in the slide text. This is a clinical photo showing a maxillary dental bridge framework seated on a cast model. The image displays metal abutments supporting the prosthetic teeth, illustrating the fit and structure of the restoration discussed in the context of PFM or CadCam options. Clinical photo of a maxillary dental bridge prosthesis, illustrating the concept of gingival replacement where pink material simulates gum tissue alongside white prosthetic teeth. 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   #### PFM – Porcelain Fused to Titanium - CAD/CAM Procera framework: low cost, excellent fit - Maintenance: low, but expensive and difficult to fix - Aesthetics of titanium porcelain: ordinary Radiograph: Panoramic X-ray showing a maxillary bridge supported by six dental implants and a mandibular bar-retained overdenture supported by three implants. The image illustrates the radiographic appearance of implant-supported prostheses, specifically the titanium framework mentioned in the slide text. Clinical photo showing a frontal view of a maxillary porcelain-fused-to-metal (PFM) bridge in occlusion with the mandibular dentition. The image illustrates the aesthetic appearance of the prosthesis and reveals the underlying metal framework of the lower restoration. <table> <tr> <th>Material Type</th> <th>Examples</th> <th>Flexural Strength (~Mpa)</th> </tr> <tr> <td>Feldspathic</td> <td>veneering porcelain, veneers</td> <td>90</td> </tr> <tr> <td>Pressable ceramics</td> <td>Empress, Cergo, Optimal</td> <td>150</td> </tr> <tr> <td>Indirect composites</td> <td>Belleglass, Critobal</td> <td>200</td> </tr> <tr> <td>Pressable Lithium disilicate</td> <td>Empr.2, e-Max</td> <td>300</td> </tr> <tr> <td>Glass infiltrated ceramics</td> <td>In-Ceram Alum.</td> <td>400</td> </tr> <tr> <td>Alumina</td> <td>Procera</td> <td>650</td> </tr> <tr> <td>(Y-TPZ) Zirconia</td> <td>Procera, Lava, Allzirkon</td> <td>1200</td> </tr> </table> | Material Type | Examples | Flexural Strength (~MPa) | | --- | --- | --- | | Feldspathic | Veneering porcelain, veneers | 90 | | Pressable ceramics | Empress, Cergo, Optimal | 150 | | Indirect composites | Belleglass, Cristobal | 200 | | Pressable Lithium disilicate | Empr.2, e.max | 300 | | Glass infiltrated ceramics | In-Ceram Alum. | 400 | | Alumina | Procera | 650 | | (Y-TZP) Zirconia | Procera, Lava, Allzirkon | 1200 | FLEXURAL STRENGTH [presenting a slide showing flexural strength of the current dental materials] *Flexural strength of current dental materials.* M A X I L L A R Y B R I D G E O P T I O N S eMax ceramic crowns layered anteriorly, monolithic posteriorly (300MPa vs 90MPa veneering porcelain) Need occlusal splint 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   #### e.max Ceramic Crowns - Layered anteriorly, monolithic posteriorly (300 MPa vs 90 MPa veneering porcelain) - Need occlusal splint - No gold component in Procera framework and no difference in cost for size of framework - Maintenance is low and generally just replacement of one crown - Gingival replacement: composite (marginal staining) — can be retreaded relatively easily Clinical photo showing a close-up view of maxillary anterior dental crowns and the adjacent gingival tissue, illustrating the aesthetic outcome of the eMax ceramic bridge options mentioned in the slide text. Clinical photo showing a disassembled maxillary bridge framework alongside individual ceramic crowns. The image illustrates the concept of maintenance and repair mentioned in the text, where low maintenance allows for the replacement of a single crown rather than the entire prosthesis. F L E X U R A L S T R E N G T H **Current Dental Materials** | Material Type | Flexural Strength (~Mpa) | |------------------------------------------|---------------------------| | Feldspathic - eg veneering porcelain, veneers | ~90 | | Pressable ceramics - eg: Empress, Cergo, Optimal | ~150 | | Indirect composites – eg: Belleglass, Critobal | ~200 | | Pressable Lithium disilicate – eg: Empr.2, e-Max | ~300 | | Glass infiltrated ceramics – eg: In-Ceram Alum. | ~400 | | Alumina – Procera | ~650 | | (Y-TPZ) Zirconia – eg: Procera, Lava, Allzirkon | ~1200 | #### Current Dental Materials | Material Type | Flexural Strength (~MPa) | | --- | --- | | Feldspathic (e.g., veneering porcelain, veneers) | ~90 | | Pressable ceramics (e.g., Empress, Cergo, Optimal) | ~150 | | Indirect composites (e.g., Belleglass, Cristobal) | ~200 | | Pressable lithium disilicate (e.g., Empr.2, e.max) | ~300 | | Glass infiltrated ceramics (e.g., In-Ceram Alum.) | ~400 | | Alumina (Procera) | ~650 | | (Y-TZP) Zirconia (e.g., Procera, Lava, Allzirkon) | ~1200 | M A X I L L A R Y B R I D G E O P T I O N S **## 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  #### Full Zirconia - Massive downside if framework fractures - Industrial fabrication essential - Need highly experienced technician → Need occlusal splint - Attention to detail - More long-term clinical research required This photo displays a four-unit full zirconia dental bridge against a black background, showing the facial surface of the prosthetic teeth and two cylindrical connection structures at the top. It serves as a visual example of the 'Full Zirconia' maxillary bridge option listed in the slide text. Maxillary Bridge Options **Ti CAD CAM framework/ Stained Monolithic Zirconia segments** Titanium CAD/CAM framework / Stained monolithic zirconia segments # 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  #### Follow-Up Schedule - Weekly for first 4 weeks, then every 6 weeks until 6 months - Then every 3–6 months according to need #### Radiographic Protocol - OPG radiographs at bridge placement, 6 months, then yearly for 5 years - Then every 2–3 years depending on history Radiograph: Panoramic X-ray (OPG) showing the maxilla and mandible with extensive dental implant restorations, including multiple angled implants in the upper jaw supporting a fixed bridge and four vertical implants in the lower jaw. OUR PREFERENCES No Pre-implant Grafting Utilize available native bone  - No pre-implant grafting - Utilize available native bone Clinical photo: An intraoperative view showing dental implants placed in the posterior jaw, illustrating the concept of utilizing available native bone without pre-implant grafting. The image displays two threaded implants inserted into a sinus cavity (sinus lift) and other implant fixtures with abutments in the anterior region. OUR P R E F E R E N C E S Immediate Loading Rigid prosthesis Cross arch splinting   - Immediate loading - Rigid prosthesis - Cross arch splinting Clinical photo: A black-and-white photograph showing a full-arch dental prosthesis (upper) positioned over a model or jaw containing visible dental implants (lower). This image illustrates the concept of 'Immediate Loading' and a 'Rigid prosthesis' mentioned in the slide text, demonstrating how the prosthetic teeth are connected across the arch. Clinical photo of a full-arch rigid dental prosthesis, illustrating the concept of immediate loading with cross-arch splinting mentioned in the slide text. The image displays an upper denture bridge featuring artificial teeth and gingival material, with visible metallic abutment interfaces on the occlusal surface for attachment to implants. **OUR PREFERENCES** Prosthetic replacement of soft tissue and facial support  Prosthetic replacement of soft tissue and facial support A grayscale medical imaging scan (likely a CT or radiograph) showing a frontal view of a human skull. The image illustrates the craniofacial structure, including the cranium, orbits, nasal cavity, and mandible, relevant to the slide's topic of prosthetic replacement of soft tissue and facial support. # P A T I E N T B E N E F I T S * **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** #### 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 **C**LINICIAN BENEFITS Increased Predictability & Safety Reduction in Interim Management Predictable Prosthetic Outcome #### Clinician Benefits - Increased predictability & safety - Reduction in interim management - Predictable prosthetic outcome ASSOCIATED BRÅNEMARK OSSEOINTEGRATION CENTER PERTH # Thank you! THE UNIVERSITY OF WESTERN AUSTRALIA glenliddelow@gmail.com www.branemarkcentre.com.au B R Å N E M A R K C E N T R E P E R T H , A U S T R A L I A ### Thank you! #### Affiliations - Associated Brånemark Osseointegration Center, Perth, Australia - The University of Western Australia #### Contact Information - Email: glenliddelow@gmail.com - Website: www.branemarkcentre.com.au [^1]: Original PDF page 1: [[No obsidian-L7 Dental School Maxilla fixed notes.pdf#page=1|No obsidian-L7 Dental School Maxilla fixed notes, p.1]] [^2]: Original PDF page 2: [[No obsidian-L7 Dental School Maxilla fixed notes.pdf#page=2|No obsidian-L7 Dental School Maxilla fixed notes, p.2]] [^3]: Original PDF page 3: [[No obsidian-L7 Dental School Maxilla fixed notes.pdf#page=3|No obsidian-L7 Dental School Maxilla fixed notes, p.3]] [^4]: Original PDF page 4: [[No obsidian-L7 Dental School Maxilla fixed notes.pdf#page=4|No obsidian-L7 Dental School Maxilla fixed notes, p.4]] [^5]: Original PDF page 5: [[No obsidian-L7 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