Angled implants

1. Dental Implants
Angled (tilted) implants
John Beumer III DDS, MS
Allesandro Pozzi DDS
Division of Advanced Prosthodontics, UCLA
This
program
of
instruc1on
is
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by
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©.
No
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of
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of
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system,
without
prior
permission.

2. Tilted
implants
ª Four
implants
ª Six
implants
ª Pterygoid
implants
ª Zygoma1c
implants

3. Tilted
Implants
–
Edentulous
Maxilla
When
restoring
the
edentulous
maxilla
what
does
this
term
indicate?
ª Posterior
implants
are
1lted
distally
at
about
a
30
degree
angle
and
placed
parallel
to
the
anterior
wall
of
the
maxillary
sinus

4. Tilted
Implants
–
Edentulous
Maxilla
Why
are
they
advantageous
in
the
edentulous
maxilla?
v Longer
implants
in
the
distal
posi1ons
v Improved
primary
stability
v Distal
implants
exit
more
posteriorly
reducing
the
length
of
the
can1lever

5. ª Eliminates
the
need
for
sinus
augmenta1on
ª Eliminates
the
need
for
zygoma1c
implants
ª Enables
fabrica1on
of
an
implant-­‐supported
restora1on
in
many
pa1ents
ª Enables
immediate
loading
in
selected
pa1ents
Tilted
Implants
–
Edentulous
Maxilla

6. Biomechanics
are
favorable
ª More
anterior
–
posterior
(A-­‐
P)
spread
ª Longer
implants
in
the
distal
posi1ons
than
if
placed
axially
ª Shorter
can1levers
required
to
restore
the
posterior
occlusion
A-­‐P
Spread
Tilted
Implants
–
Edentulous
Maxilla
Why
do
they
work?
ª Note
the
difference
between
the
pa1ent’s
right
where
implants
are
angled,
and
the
leV
where
implants
are
placed
axially
Courtesy
Dr.
O.
Jensen

7. Biomechanics
are
favorable
ª Finite
element
analysis
has
shown
that
the
use
of
1lted
implants
is
much
more
favorable
biomechanically
than
using
shorter
implants
with
axial
inclina1ons
(Bevilacqua
et
al,
2010).
Courtesy
Dr.
P.
Pera
Tilted
Implants
–
Edentulous
Maxilla
Why
do
they
work?

8. Success
rates
are
above
90%
(Ma^sson
et
al,
1999;
Krekmanov
et
al,
2000;
Malo
et
al,
2011;
Tealdo
et
al,
2014).
Tealdo
et
al
(2014)
has
the
most
long
term
follow-­‐up
data.
Tilted
Implants
–
Edentulous
Maxilla

9. Three
approaches
ª All
on
four
(Nobel)
ª Only
four
implants
are
placed
ª Angled
abutments
used
to
offset
the
angles
of
the
implants
ª Prosthesis
is
placed
immediately
ª Columbus
bridge
protocol
ª Four
to
six
implants
are
placed
ª Angled
abutments
used
to
offset
the
angles
of
the
implants
ª Prosthesis
is
placed
within
24
hours
ª Co-­‐axis
implants
ª Four
more
implants
are
placed
ª Co-­‐axis
implants
are
used.
Angula1on
correc1on
is
subgingival
and
effected
by
the
angula1on
of
the
implant
plaborm

10. All
on
four
–
Maxilla
(per
Nobel)
Very
specific
defini1on:
Use
of
4
implants
to
support
an
immediately
loaded
fixed
prosthesis
used
to
restore
either
the
edentulous
maxilla
and
mandible

11. All
on
four
(per
Nobel)
ª Computer
guided
treatment
planning
and
and
fully
guided
implant
placement
is
preferred
What
is
computer
guided
treatment
planning
and
surgical
placement?

12. ª Fully
guided
surgery
implies
that
the
surgical
templates
with
their
drill
sleeves
(bushings)
control
the
posi1on,
angula1on,
diameter
as
well
as
the
depth
of
the
implant
osteotomy
sites*
ª The
surgical
template
is
secured
with
bone
screws
or
anchor
pins
All
on
four
(per
Nobel)
*
See
lecture
en1tled
computer
guided
treatment
planning
and
implant
surgery
for
details.
Drill
Sleeves
(Bushings)

13. All
on
four
(per
Nobel)
ª The
prosthesis
is
prepared
prior
to
implant
surgery
and
delivered
immediately
aVer
implant
placement
ª For
immediate
loading
the
implants
must
be
anchored
with
sufficient
primary
stability
to
withstand
occlusal
func1on
ª This
may
require
that
the
apical
por1on
of
the
posterior
implants
engage
the
cor1cal
layers
of
bone
associated
with
the
paranasal
sinus
walls.

14. All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on
Conven1onal
ª Anterior
implants
placed
in
the
lateral-­‐central
interproximal
regions
and
are
parallel
to
one
another
ª Posterior
implant
aligned
parallel
to
the
anterior
wall
of
the
maxillary
sinus
ª Angled
abutments
are
only
necessary
for
the
posterior
implants

15. In
efforts
to
improve
primary
implant
anchorage
two
other
implant
configura1ons
have
been
proposed
(Jensen
et
al,
2015)
M-­‐4
Configura1on
V-­‐4
Configura1on
All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on
Courtesy
Dr.
O.
Jensen

16. M-­‐4
ª Four
implants
placed
at
30
degree
angles
to
miss
nasal
and
sinus
pneuma1zed
cavi1es
in
an
M-­‐shaped
configura1on
when
viewed
on
panoramic
radiography
(Jensen
et
al,
2015).
All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on
Courtesy
Dr.
O.
Jensen

17. ª When
abundant
bone
is
present
M-­‐4
implant
configura1ons
in
pa1ents
provides
excellent
support
of
the
prosthesis
with
20
mm
between
implants.
This
arrangement
requires
li^le
if
any
distal
can1lever.
ª Angled
abutments
are
used
on
all
four
implants
All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on
Courtesy
Dr.
O.
Jensen

18. ª Pa1ent
with
moderate
resorp1on
and
the
recommended
implant
posi1oning
with
the
aim
of
maximizing
A-­‐P
spread
ª Angled
abutments
are
used
on
all
four
implants
ª A-­‐P
spread
may
by
subop1mal
in
these
pa1ents
and
unless
primary
implant
anchorage
is
op1mal,
loading
should
be
delayed
All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on
Courtesy
Dr.
O.
Jensen

19. V-­‐4
ª The
V-­‐4
designa1on
denotes
four
implants
placed
at
30
degree
angles
to
miss
the
sinus
and
nasal
cavi1es
all
converging
toward
the
midline
in
a
V-­‐forma1on
(Jensen
et
al,
2015).
ª Angled
abutments
are
used
on
all
four
implants
All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on

20. (V-­‐4
implant
configura1on
with
trans-­‐sinus
implants)
ª Pa1ents
with
advanced
resorp1on.
There
is
commonly
a
deficiency
of
bone
mass
such
that
posterior
implants
gain
limited
fixa1on
in
a
thin
lateral
nasal
wall.
Anterior
“vomer”
implants
are
usually
well
fixed
in
the
nasal
crest.
ª A
palatal
view
demonstra1ng
implant
anchorage
points.
The
posterior
implants
are
directed
toward
maximal
bone
mass
at
the
lateral
pyriform,
while
the
anterior
implants
are
aimed
toward
the
maximum
available
midline
bone
mass
which
usually
extends
superiorly
into
the
nasal
crest
(V
point).
All
on
Four
–
Maxilla
(per
Nobel)
Posi1on
and
angula1on
Courtesy
Dr.
O.
Jensen

21. All
on
four
–
Maxilla
(per
Nobel)
(V-­‐4
implant
configura1on
with
trans-­‐sinus
implants)
• Under
these
circumstances
delayed
loading
is
recommended
Courtesy
Dr.
O.
Jensen

22. Defini1ve
prostheses
All
on
four
(per
Nobel)
Courtesy
Dr.
M.
Adams
Consists
of
a
fixed
hybrid
prosthesis
ª Resin
denture
teeth
ª Acrylic
resin
ª Metal
substructure
imbedded
within
the
acrylic
resin

23. All
on
four
(per
Nobel)
Defini1ve
prostheses
Consists
of
a
fixed
hybrid
prosthesis
ª Resin
denture
teeth
ª Acrylic
resin
ª Metal
substructure
imbedded
within
the
acrylic
resin
Courtesy
Dr.
M.
Adams

24. All
on
Four
(per
Nobel)
Defini1on:
Use
of
4
implants
to
support
an
immediately
loaded
fixed
prosthesis
used
to
restore
either
the
edentulous
maxilla
and
mandible
Exclusionary
criteria
(Maxilla)
ª Pa1ents
with
significant
parafunc1onal
ac1vity
ª Pa1ents
with
severe
Class
II
or
Class
III
jaw
rela1ons
ª Anchoring
the
surgical
drill
guide
is
difficult
ª Unfavorable
biomechanics
ª Pa1ents
with
opposing
arch
composed
primarily
of
natural
den11on
ª It
is
difficult
to
properly
control
the
occlusion
in
such
pa1ents

25. As
men1oned
earlier
the
defini1on
the
“All
on
four”
approach
is
uses
4
implants
to
support
an
immediately
loaded
fixed
prosthesis
used
to
restore
either
the
edentulous
maxilla
and
mandible
What
are
the
prerequisites
for
immediate
loading?*
All
on
Four
(per
Nobel)

26. Immediate
Loading
v For
the
implants
to
become
osseointegrated
they
must
remain
immobilized
during
the
healing
period.
v Therefore
one
of
the
keys
to
successful
immediate
loading
con1nues
to
be
the
effec1veness
of
primary
implant
stability

27. Ini1al
Primary
Stability
(First
day)
Func1on
of:
v Local
bone
quan1ty
and
quality
v Implant
geometry
Tapered
be^er
than
cylindrical
because
you
have
a
be^er
chance
of
maximizing
bone
contact
with
the
internal
and
external
diameters
of
the
implant
v Surgical
procedure
(skill)
Inser1on
torque
–
in
excess
of
45
N/cm
ISQ’s
–
70
and
above
Two
main
factors:
1.
Amount
of
ini1al
bone
contact
2.
Lateral
compression
of
the
osteotomy
site
crea1ng
local
compression
stresses
Courtesy
Dr.
C.
Stanford

28. Immediate
Loading
–
When
Is
it
Feasible?
The
degree
of
ini1al
bone
anchorage
v Skill
of
the
surgeon.
Immediate
loading
is
not
for
beginners
Consider
bicor1cal
stabiliza1on
when
possible
You
must
a^empt
to
engage
the
inner
and
outer
diameter
of
the
implant
with
bone
when
appropriate
Inser1on
torque
–
in
excess
of
45
N/cm
ISQ’s
–
70
and
above
v Volume
and
density
of
the
bone
associated
with
implant
site
Sites
with
dense
trabecular
bone
are
preferred
Longer
implants
are
generally
preferred
Bicor1cal
anchorage
may
be
necessary
Clinical
issues
to
be
considered:

29. Implant
selec1on
ª Tapered,
self
tapping
with
sharply
pitched
threads
Implant
placement
procedure
ª Semi-­‐guided
or
fully
guided
is
preferred
over
free
hand
prepara1on
of
the
osteotomy
site
and
inser1on
of
the
implants
Immediate
loading
All
on
4
per
Nobel
Requirements
for
successful
outcomes

30. Immediate
loading
All
on
4
per
Nobel
Requirements
for
successful
outcomes
Assessment
of
implant
anchorage
ª Torque
values
-­‐
45
N/cm
or
more
ª RFA
values
(resonance
frequency
analysis)
–
70
and
above
ª Don’t
over
torque
for
this
may
impair
the
balance
of
the
biologic
processes
associated
with
osseointegra1on
(O’Sullivan
et
al,
2000;
Bashutski
et
al
2009;
Cha
et
al,
2015)
ª Excessive
levels
of
torque
increases
the
zone
of
dead
and
dying
osteocytes
leading
to
increased
resorp1on
and
a
disrup1on
of
the
balance
of
remodeling
and
repair
mechanisms

31. Characteris1cs
of
the
immediate
load
prosthesis*
ª Rigidity
and
cross
arch
stabiliza1on
ª Passive
fit
ª Minimize
the
can1lever
and
bending
moments
ª Occlusion
ª Clinical
remounts
ª Balanced
ar1cula1on
*
A
successful
outcome
requires
that
the
implants
remain
immobile
(less
than
100
microns
of
movement)
(Maniatopoulos
et
al,
1986;
Szmuckler-­‐Moncler,
2000)
during
the
healing
phase.
Immediate
loading
Requirements
for
successful
outcomes

32. Compliant
pa1ent
ª Manipulate
oral
hygiene
aids
ª Follow
postopera1ve
instruc1ons.
They
include:
ª Liquid
diet
for
the
first
3
weeks
ª Frequent
oral
rinses
with
warm
salt
water
rinses
beginning
24
hours
aVer
surgery.
ª Twice
per
day
oral
rinses
with
chlorhexidine
beginning
4
day
aVer
delivery
and
con1nuing
for
10
days.
ª Mechanical
soV
diet
for
another
3
weeks.
ª Avoid
clenching
and
bruxing
Immediate
loading
Requirements
for
successful
outcomes

33. All
on
four
–
Maxilla
(per
Nobel)
Why?
ª The
surgery
is
technique
sensi1ve
ª Requires
bicor1cal
stabiliza1on
in
many
pa1ents
ª Old
technology
and
materials
ª It’s
a
fixed
prosthesis
ª Poor
lip
and
facial
support
ª Speech
and
hygiene
access
are
oVen
incompa1ble
ª Requires
a
great
deal
of
interocclusal
space
ª Esthe1cs
ª Cost
ª Two
prostheses
ª Angled
abutments
are
expensive
ª Beware
of
“one
size
fit
all”
approach
At
UCLA
we
believe
few
pa1ents
are
well
served
with
this
approach
Courtesy
Dr.
M.
Adams

34. All
on
four
-­‐
Maxilla
Issues
of
concern
The
surgery
is
technique
sensi1ve
ª Bicor1cal
stabiliza1on
of
implants
is
oVen
required
ª Trans
sinus
implants
oVen
required
to
achieve
the
desired
amount
of
A-­‐P
spread
ª High
level
of
surgical
skill
required
ª If
you
loose
just
one
implant
you
loose
the
prostheses
Courtesy
Dr.
O.
Jensen

35. All
on
four
–
Maxilla
(per
Nobel)
Issues
of
concern
ª Defini1ve
prosthesis
(Fixed
hybrid
prosthesis)
uses
old
technology
and
materials
ª Denture
teeth
subject
to
wear
and
fracture
ª Acrylic
resin
subject
to
wear
and
oral
contamina1on
Courtesy
Dr.
M.
Adams

36. Issues
of
concern
ª Defini1ve
prosthesis
(Fixed
hybrid
prosthesis)
uses
old
technology
and
materials
ª Denture
teeth
subject
to
wear
and
fracture
ª Acrylic
resin
subject
to
wear
and
oral
contamina1on
All
on
four
–
Maxilla
(per
Nobel)
Courtesy
Dr.
K.
Lyons

37. All
on
four
–
Maxilla
(per
Nobel)
Issues
of
concern
ª Defini1ve
prosthesis
(Fixed
hybrid
prosthesis)
uses
old
technology
and
materials
ª Denture
teeth
subject
to
wear
and
fracture
ª Acrylic
resin
subject
to
wear
and
oral
contamina1on

38. All
on
four
–
Maxilla
(per
Nobel)
Issues
of
concern
ª It’s
a
fixed
prosthesis
ª Poor
lip
and
facial
support
ª Speech
and
hygiene
access
are
oVen
incompa1ble
ª Requires
a
great
deal
of
interocclusal
space
ª If
insufficient
the
prosthesis
may
not
be
able
to
withstand
the
rigors
of
func1on
ª Esthe1cs
–
The
prosthesis
junc1on
is
designed
to
be
superior
to
the
smile
line

39. All
on
four
–
Maxilla
(per
Nobel)
Issues
of
concern
-­‐
Maxilla
ª Esthe1cs
and
lack
of
lip
support
ª Pa^ern
of
resorp1on
following
loss
of
teeth
leads
to
a
pseudo
class
III
jaw
rela1on
ª It
is
not
possible
to
properly
support
the
lip
of
most
such
pa1ents
ª A
denture
flange
is
needed

40. All
on
four
–
Maxilla
(per
Nobel)
Issues
of
concern
ª Hygiene
access
and
speech
ar1cula1on
ª When
you
provide
hygiene
access,
speech
ar1cula1on
is
compromised.
ª When
you
close
the
spaces
used
for
hygiene
access
to
permit
proper
speech
ar1cula1on,
hygiene
is
compromised.
Courtesy
Dr.
M.
Adams

41. All
on
four
–
Maxilla
(per
Nobel)
Issues
of
concern
ª Hygiene
access
and
speech
ar1cula1on
ª When
you
close
the
spaces
used
for
hygiene
access
to
permit
proper
speech
ar1cula1on,
hygiene
is
compromised.
ª Note
the
plaque
that
has
accumulated
on
the
1ssue
side
of
this
“All
on
Four”
prosthesis
Courtesy
Dr.
M.
Adams

42. As
a
result
many
prosthodon1sts
prefer
the
use
of
either
implant
supported
or
implant
assisted
overdentures.
Advantages:
ª Be^er
hygiene
access
ª Be^er
lip
support
ª Be^er
esthe1cs
ª Less
costly
for
the
pa1ent
What
are
the
alterna1ves?

43. Alterna1ve
treatment
Overdenture
Implant
assisted
design
ª Combined
implant
and
soV
1ssue
support
ª Resilient
a^achments
posteriorly

44. Alterna1ve
Treatment
Overdenture
Implant
supported
design
ª Support
derived
from
implants
ª Milled
bar
with
a^achments

45. All
on
four
–
Maxilla
(per
Nobel)
Addi1onal
issues
of
concern
ª Interocclusal
space
ª 15-­‐17mm
ª Smile
line
ª Many
clinicians
using
the
“All
on
four”
approach
advise
placing
the
junc1on
between
the
prosthesis
and
the
mucosa
above
the
lip
line
during
a
high
smile
ª This
may
require
removal
of
excessive
amounts
of
bone
Courtesy
Dr.
S.
Lewis
Courtesy
Dr.
P.
Pera

46. All
on
four
–
Maxilla
(per
Nobel)
Addi1onal
issues
of
concern
ª Interocclusal
space
ª 15-­‐17mm
ª Smile
line
ª Because
of
the
design
of
the
prosthesis,
addi1onal
reduc1on
of
bone
is
required
if
the
smile
line
is
high.
One
mm
of
addi1onal
bone
reduc1on
necessary
for
every
mm
the
smile
line
is
above
the
CEJ
Courtesy
Dr.
S.
Lewis
Courtesy
Dr.
P.
Pera

47. All
on
four
–
Maxilla
(per
Nobel)
Addi1onal
issues
of
concern
ª Interocclusal
space
ª 15-­‐17mm
ª Smile
line
ª We
feel
that
there
are
other
alterna1ves
which
be^er
serve
the
pa1ent
(i.e.
the
Columbus
bridge
protocol
and
delayed
loading
using
metal-­‐ceramic
or
a
monolithic
zirconia
prosthesis)
Courtesy
Dr.
S.
Lewis
Courtesy
Dr.
P.
Pera

48. Addi1onal
issues
of
concern
ª Interocclusal
space
ª Fracture
of
the
prosthesis
may
occuer
when
there
is
insufficient
interocclusal
space
to
fabricate
a
prosthesis
of
sufficient
bulk
to
withstand
occlusal
func1on.
All
on
four
–
Maxilla
(per
Nobel)

49. All
on
4
concept
–
Edentulous
Maxilla
Overdentures
may
be
preferred
Advantages
ª Implant
supported
ª Be^er
esthe1cs
ª Lip
support
provided
by
a
denture
flange
ª Be^er
speech
ar1cula1on
ª Be^er
hygiene
access

50. What
about
the
use
of
1lted
implants
in
the
edentulous
mandible?
May
be
necessary
when
an
appropriate
anterior
–
posterior
(A-­‐P)
spread
cannot
be
obtained
using
axial
inclina1ons.

51. What
is
the
minimal
A-­‐P
spread
necessary
to
fabricate
a
fixed
prosthesis
for
the
edentulous
mandible?
ª Length
of
implants
ª Minimum
length
-­‐
7
mm
ª Number
of
implants
ª Minimum
number
-­‐
4
ª A-­‐P
Spread
ª Minimum
amount
–
1
cm
(A-­‐P
spread)
(A-­‐P
spread)

52. Anterior
–
Posterior
Spread
and
the
length
of
the
can1lever
extension
A-­‐P
Spread
(1
cm
or
more)
ª Can1lever
length
should
not
exceed
2
1mes
the
A-­‐P
spread
or
a
maximum
of
20
mm.
ª When
A-­‐P
spread
is
less
than
1
cm
it
may
not
be
possible
to
restore
the
posterior
den11on
because
of
limits
of
the
can1lever
Can9lever
Length
What
is
the
minimal
A-­‐P
spread
in
combina1on
with
the
length
of
the
can1lever,
necessary
to
fabricate
a
fixed
prosthesis
for
the
edentulous
mandible?

53. Anterior – Posterior Spread
A-P Spread
(1 cm or more)
Cantilever length should not
exceed 2 times the A-P spread.
CantileverLength
What
is
the
minimal
A-­‐P
spread
in
combina1on
with
the
length
of
the
can1lever,
necessary
to
fabricate
a
fixed
prosthesis
for
the
edentulous
mandible?

54. Consequences
of
insufficient
A-­‐P
spread
and
excessive
can1lever
length
Result
ª Mechanical
failures
ª Implant
overload
In
this
pa1ent
the
result
was
recurrent
fractures
of
the
prosthesis
retaining
screws
(arrows).

55. Insufficient
A-­‐P
spread
combined
with
excessive
can1lever
length
(34
mm
on
the
leV
side
and
26
mm
on
the
right
side)
Result:
ª Mechanical
failure
-­‐
Implant
fracture
ª Implant
overload
and
loss
of
bone
anchoring
the
implant
In
this
pa1ent
a
combina1on
of
excessive
can1lever
length
and
insufficient
A-­‐P
spread
lead
to
implant
overload
and
a
resorp1ve
remodeling
response
of
the
adjacent
bone
and
implant
fracture.
Consequences
of
insufficient
A-­‐P
spread
and
excessive
can1lever
length

56. Implant
Overload
and
Bone
Resorp1on
Mechanisms
of
Implant
Failure
v Excessive
occlusal
loads
v Resul1ng
microdamage
(fractures,
cracks,
and
delamina1ons
[arrows])
v Resorp1on
remodeling
response
of
bone
is
provoked
v Increased
porosity
of
bone
in
the
interface
zone
secondary
to
remodeling
v Vicious
cycle
of
con1nued
loading,
more
micro-­‐damage,
more
porosity
un1l
failure
(Howshaw
et
al,
1995;
Brunski
et
al,
2000;
Myata
et
al,
2002;
Myamoto
et
al,
2008;
Nagasawa
et
al,
2013
)

57. Biomechanics
and
A-­‐P
spread
–
Case
report
ª Six
implants
have
have
been
placed,
A-­‐P
spread
is
only
about
5
mm.
The
can1lever
extension
must
be
limited
to
10
mm
and
this
is
insufficient
to
restore
the
posterior
den11on
with
a
fixed
prosthesis.
ª What
would
have
a
be^er
op1on
for
this
pa1ent?

58. Biomechanics
and
A-­‐P
spread
–
Case
report
Either
ª Tilted
implants
with
four
implants
and
a
fixed
prosthesis
ª Placement
of
two
implants
and
an
overdenture

59. Tilted
implants
–
Mandible
Pa1ent
selec1on
ª Pa1ents
with
square
arch
forms
ª Pa1ents
demonstra1ng
an
anterior
loop
of
the
mental
nerve
ª This
technique
will
improve
implant
distribu1on
pa^ern
(increase
the
A-­‐P
spread)
for
more
favorable
biomechanics

60. Tilted
implants
–
Mandible
Uses
and
advantages
ª Square
arch
forms
ª Avoid
the
anterior
loop
of
the
inferior
alveolar
nerve
ª Shortens
the
can1lever
ª Minimizes
the
risk
of
biologic
and
mechanical
failures

61. ª Anterior
implants
should
be
placed
in
the
lateral
incisor
posi1ons
ª Note
the
posi1on
of
these
anterior
implants
Tilted
implants
–
Mandible
Posi1oning
of
implants
Courtesy
Dr.
N.
Barakat

62. In
pa1ents
with
a
Cawood
Class
V
or
VI
mandible
there
is
li^le
addi1onal
benefit
from
1pping
the
posterior
implants
Treatment of the
rely Resorbed Mandible
ferior
rows)
e of the
Under
these
circumstances
it
is
best
to
place
two
implants
and
make
an
overdenture
Tilted
implants
–
Mandible

63. Exclusionary
criteria
ª Cawood
Class
V
or
VI
mandible
ª Tipping
the
posterior
implant
posterior
is
only
valuable
when
there
is
at
least
3-­‐4
mm
of
bone
over
the
nerve
Tilted
implants
–
Mandible
Courtesy
Dr.
O.
Jensen

64. ª Computer
guided
treatment
planning
and
implant
placement
preferred
ª The
prosthesis
may
be
delivered
immediately
if
op1mal
anchorage
is
achieved
Tilted
implants
–
Mandible

65. The
Columbus
Bridge
Use
of
angled
implants
to
restore
the
edentulous
maxilla
ª Only
select
group
of
pa1ent
qualify
ª Pa1ents
with
favorable
jaw
rela1ons
and
bone
contours
are
preferred.
Those
with
pseudo
class
III
jaw
rela1ons
are
not
considered
good
candidates
ª Prosthe1c
volume
and
smile
line
is
carefully
evaluated
ª 4-­‐6
implants
are
placed
ª Pterygoid
implants
used
when
necessary

66. The
Columbus
Bridge
Use
of
angled
implants
to
restore
the
edentulous
maxilla
Surgical
protocol
ª Tapered,
self
taping
implants
with
external
hex
used
ª Anterior
implants
placed
in
tooth
posi1ons
ª Implants
of
at
least
13
mm
in
length
are
desired
ª Implants
placed
with
free
hand
drilling
with
the
aid
of
a
surgical
template
ª Implant
inser1on
torque
should
exceed
40
N/cm
ª Angled,
conical
abutments
are
used
in
the
posterior
posi1ons
ª No
bone
regenera1ve
techniques
used
Courtesy
Dr.
P.
Pera

67. The
Columbus
Bridge
Use
of
angled
implants
to
restore
the
edentulous
maxilla
ª Impressions
made
immediately
following
implant
placement
ª Metal
framework
waxed
and
cast
based
on
a
diagnos1c
wax-­‐up/
trial
denture
set
up
ª It
must
be
sufficiently
rigid
to
resist
bending
ª Rigid
gold
or
palladium
alloys
are
used
ª The
prosthesis
is
designed
without
can1levers
ª The
func1onal
and
esthe1c
surfaces
of
the
provisional
are
restored
with
denture
teeth
and
acrylic
resin
ª Prosthesis
is
screw
retained
ª Prosthesis
delivered
within
24
hours
of
implant
placement
ª Defini1ve
prosthesis
fabricated
4
months
following
implant
surgery
Prosthodon1c
protocol

68. The
Columbus
Bridge
(A
variant
of
the
all
on
four
concept)
Provisional
is
delivered
within
24
hours
and
is
resin
with
a
metal
substructure
Courtesy
Dr.
P.
Pera

69. Finished
prosthesis.
Usually
the
provisional
is
replaced
during
the
first
year.
The
Columbus
Bridge
(A
variant
of
the
all
on
four
concept)
Delivery
One
year
later
Courtesy
Dr.
P.
Pera

70. Courtesy
Dr.
D.
Howes
Subcrestal
vs
supracrestal
angula1on
correc1on
However,
surgical
placement
is
more
demanding
Co-­‐axis
implants
ª Co-­‐axis
implants
are
used
ª Two
prostheses
$825
/
angled
abutment
Subcrestal
is
preferred

71. Advantages
of
Coaxis
implant
ª Less
cost
ª Screw
retained
ª Prosthodon1c
and
technical
simplicity
ª Standard
prosthe1c
componentry
Courtesy
Dr.
D.
Howes
Subcrestal
vs
supracrestal
angula1on
correc1on
Angled
abutments
vs
Coaxis
implants
However,
surgical
placement
is
more
demanding
Co-­‐axis
implants

72. Data
–
Tilted
implants
and
immediate
loading
Courtesy
Dr.
P.
Pera)
Retrospec1ve
studies
published
during
the
last
several
years
and
recent
literature
reviews
(Papaspyridakos
et
al,
2014,
Gallucci
et
al,
2014)
appear
to
indicate
that
immediate
load
prostheses
can
be
employed
with
success
in
the
edentulous
maxilla.
However
the
report
of
Tealdo
and
colleagues
(2014)
is
perhaps
the
most
revealing.

73. ª The
pa1ents
were
divided
into
two
groups
–
an
immediate
load
group
(34
pa1ents)(prosthesis
delivered
within
24
hours)
and
a
delayed
loading
group
(15
pa1ents)
(prosthesis
delivered
an
average
of
8.75
months
aVer
implant
placement).
The
groups
were
unmatched.
ª All
implants
used
in
the
study
had
acid
etched
surfaces,
were
4
mm
in
diameter
and
at
least
10
mm
in
length.
Straight
walled
implants
were
placed
into
healed
edentulous
sites
and
tapered
implants
placed
into
extrac1on
sites.
ª Four
to
six
implants
were
placed
in
the
immediate
load
group,
the
distal
implants
were
1lted
distally
and
all
implants
achieved
inser1on
torques
of
at
least
40
Ncm.
Data
–
Tilted
implants
and
immediate
loading
Courtesy
Dr.
P.
Pera)

74. ª The
prostheses
for
the
immediate
load
pa1ents
were
designed
without
distal
can1levers,
customized
metal
frameworks
were
fabricated
of
palladium
alloy,
occlusal
surfaces
were
restored
with
resin,
and
the
occlusal
scheme
used
was
group
func1on.
ª Reproducible
periapical
radiographs
using
customized
film
holders
were
obtained
at
delivery
and
at
subsequent
12
month
intervals
in
order
to
assess
bone
levels
around
the
implants.
ª The
cumula1ve
implant
survival
rate
was
93.9%
for
the
immediate
load
group
and
95.9%
for
the
delayed
load
group.
No
pa1ent
lost
more
than
one
implant.
In
both
groups,
almost
all
of
the
implant
losses
were
within
12
months
of
implant
placement.
Data
–
Tilted
implants
and
immediate
loading
Courtesy
Dr.
P.
Pera)

75. ª All
original
fixed
prostheses
remained
in
func1on
but
several
required
altera1ons
or
repairs,
most
secondary
to
fractures
associated
with
the
resin
veneers.
However
there
were
no
fractures
associated
with
the
metal
frameworks.
ª Mean
bone
loss
around
implants
was
greater
for
the
delayed
group
than
for
the
immediate
load
group.
Data
–
Tilted
implants
and
immediate
loading
Courtesy
Dr.
P.
Pera)

76. All
on
6
with
Pterygoid
Implants
Preferred
when
opposing
mandible
is
dentate

77. With
guided
workup
and
surgical
procedures
the
prosthesis
can
be
designed
and
fabricated
prior
to
implant
placement
All
on
6
with
Pterygoid
Implants

78. ª Avoids
sinus
augmenta1on
ª Improves
implant
distribu1on
pa^erns,
A-­‐P
spread
and
biomechanics
ª Preferred
if
immediate
loading
is
considered
ª Success
rates
of
pterygoid
implants
close
to
90%
(Candel
et
al,
2012)
All
on
6
with
Pterygoid
Implants

79. ª Used
to
provide
posterior
support
in
full
arch
and
posterior
quadrant
prostheses
ª Success
rates
close
to
90%
(Candel
et
al,
2012)
All
on
6
with
Pterygoid
Implants

80. All
on
6
with
Pterygoid
Implants

81. All
on
6
with
Pterygoid
Implants
ª Framework
is
made
of
monolithic
zirconia
ª Crowns
are
made
of
lithium
disilicate
and
cemented
to
the
framework

82. Tilted
implants
-­‐
Posterior
quadrants
ª An
alterna1ve
to
sinus
augmenta1on
ª Computer
guided
treatment
planning
and
implant
placement
is
preferred

83. Tilted
implants
-­‐
Posterior
quadrants
• Anterior
guidance
provided
by
natural
den11on

84. Pterygoid
implants
ª Combina1on
of
1lted
and
pterygoid
implant
ª Longer
implants
ª Improved
biomechanics
ª Eliminates
the
need
for
sinus
augmenta1on

85. Pterygoid
implants
If
fully
guided
surgery
is
used,
abutments
can
be
chosen
or
milled
prior
to
surgical
placement

86. Pterygoid
implants
ª Implants
placed
with
the
aid
of
a
surgical
template
ª Semi-­‐guided
surgical
placement
was
employed

87. Pterygoid
implants
ª Combina1on
of
1lted
implant
and
a
pterygoid
implant
ª Eliminates
the
need
for
sinus
augmenta1on
ª Occlusion
is
anterior
guidance

88. Zygoma1c
implants
ª Introduced
by
Branemark
in
the
late
1980’s
ª Pa1ents
with
moderately
resorbed
maxillae
ª Designed
to
be
used
in
concert
with
2-­‐4
implants
placed
in
the
anterior
maxilla
ª Success
rates
have
been
very
high
in
conven1onal
pa1ents
(Branemark,
2004;
Aparicio
et
al,
2006;
Bedrossian
et
al,
2006;
Kahnberg
et
al,
2007;
Bedrossian
et
al,
2012).

89. Zygoma1c
implants
Complica1ons
–
rare
but
significant
ª Oral
antral
fistula
ª Postopera1ve
maxillary
sinusi1s
ª Peri-­‐orbital
hematoma
ª Facial
swelling
ª Penetra1on
of
the
orbit

90. Zygoma1c
implants
No
longer
recommended
for
pa1ents
with
an
intact
palate
ª Distor1on
of
palatal
contours
Other
op1ons
available
that
are
more
effec1ve.
ª Tilted
implants
ª Pterygoid
implants
ª Sinus
augmenta1on

91. Zygoma1c
implants
ª Pa1ent
was
allergic
to
acrylic
resin
ª Zygoma1c
implants
used
to
avoid
sinus
augmenta1on
ª Zygoma1c
implants
did
not
alter
the
contours
of
the
restora1on
or
impair
the
tongue
space

92. Zygoma1c
implants
Used
for
pa1ents
with
major
defects
of
the
hard
palate
ª Useful
for
incomplete
repaired
cleV
lip
and
palate
pa1ents
ª Edentulous
maxillectomy
pa1ents
with
large
defects
ª Success
rates
have
been
good
(Schmidt
et
al,
2004;
Schmidt,
2007)
Courtesy
A.
Sharma

93. Zygoma1c
implants
Issues
ª Radia1on
effects
ª Hygiene
access
ª Long
term
survivabilty
Best
suited
for
total
palatectomy
defects
Courtesy
A.
Sharma

94. Zygoma1c
implants
Prosthodon1c
issues
ª Two
implants
per
side
ª Splint
all
implants
together
ª Implant
supported
vs
implant
assisted
design
depends
on
implant
distribu1on
pa^ern
Best
suited
for
total
palatectomy
defects
Courtesy
A.
Sharma

95. v Visit
ffofr.org
for
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Prosthodon1cs
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