Graftless solutions for the edentulous patient

BDJ Clinician’s Guides Saj Jivraj Editor Graftless Solutions for the Edentulous Patient BDJ Clinician’s Guides More information about this series at http://www.springer.com/series/15753 Saj Jivraj Editor Graftless Solutions for the Edentulous Patient Editor Saj Jivraj Anacapa Dental Art Institute Oxnard, California, USA ISSN 2523-3327    ISSN 2523-3335 (electronic) BDJ Clinician’s Guides ISBN 978-3-319-65857-5    ISBN 978-3-319-65858-2 (eBook) https://doi.org/10.1007/978-3-319-65858-2 Library of Congress Control Number: 2017964316 © Springer International Publishing AG 2018 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword Implant dentistry has evolved tremendously over the last three decades especially for the treatment of the fully edentulous patients In the recent past, implant dentistry, a form of “pre-prosthetic” surgery, included large bone grafting procedures in preparation for the placement of the implants Generally, the implants were placed 6–12 months after the grafting procedures in a 2-stage, delayed load protocol The need to wear a removable prosthesis or at times to abstain from wearing any form of dental prosthesis while the grafts were healing as well as the extended treatment times and the multiple procedures needed prior to the placement of dental implants to support a fixed prosthesis deterred patients from seeking care Today, the “graftless concepts” eliminate the need for grafting and long waiting periods prior to the reconstruction of the edentulous or the patients with “terminal dentition” The ability to remove the patient’s failing dentition, place implants and fabricate a fixed, immediate load prosthesis has changed the manner in which many of our colleagues treat their patients in 2017 The vast body of literature confirming that the graftless approach has the same or at times better long-term outcome as compared to the 2-stage, delayed loading protocols has led to better patient care, higher patient acceptance of treatment while still maintaining long-term success data It is prudent at this point in time to consider why such a change in paradigm and treatment planning has occurred by reviewing the major research and development findings over the last several decades In the 1980s, understanding bone biology and refining the surgical techniques for the preparation of the osteotomy and placement of the implant was the focus in research and development of implant dentistry We were content if osseointegration had occurred and referred the patient for prosthetic reconstruction of the implants regardless of the number, angulation or distribution of the implants In the 1990s we began to understand the limits of functional loads placed on osseointegrated implants Attention to understanding the biomechanical limits of the hardware improved the management of the functional loads placed on implants resulting in more predictable, long-term outcomes In the 2000s, research focused on “graftless concept” using tilted implants as well as distal site anchorage by using the Zygoma implant propelled treatment planning to an unprecedented level The ability to treat a subgroup of patients declared v vi Foreword as “untreatable” with the quad zygoma concept has certainly expanded the services available for the treatment of our patients The authors of this text have outlined the treatment planning, surgical as well as the prosthetic protocols and techniques for the treatment of the edentulous as well as the “terminal dentition” patients They have honoured and highlighted the objectives advocated by Professor PI Branemark which include: • Simplification • Interdisciplinary management • Predictable outcomes • Patient-centred treatment planning Congratulations to the editor, Dr Saj Jivraj, for his leadership in collaborating with experienced clinicians in producing this updated text for the treatment planning of the edentulous patients with a fixed, implant-supported prosthesis “…a decisive factor in patient care is simplification of treatment, which should be based on identifying and utilizing the enormous capacity of existing original anchoring tissues…” Simplification, understanding and appreciating when a treatment option is adequate vs optimal In conjunction with my colleagues Drs Zarrinkelk, Ferro and Yeung, we discuss treatment planning using conventional “analogue” techniques It is appropriate to highlight that the appreciation of “analogue” planning is critical and crucial if the clinician would like to transition using the digital workflow Drs Pikos, Pozzi, Arcurrl and Moy comprehensively present the integration of digital treatment planning into the contemporary implant practice Interdisciplinary management of every patient’s treatment plan resulting in a predictable outcome, which can only be achieved by following documented and evidence-based treatment options Drs Tunkiwala and Kher in collaboration with Mizuno and Torosian discuss the intricacies of the final prosthesis, which was envisioned in the treatment planning stage They underscore the concept of “begin with the end in mind” in their step-bystep discussions of the various stages for the fabrication of the planned definitive prosthesis The ability to prevent as well as manage complications is essential for both the surgical and the restorative care provider Drs Bongard, Powel and Dawood discuss the various techniques and algorithms for the management of complications with the graftless concept Long-term success in treatment planning for the fully edentulous patients is strongly linked to the ability to control the occlusal forces Our colleagues must recognize that recall appointments must be pragmatic Not only should the recall appointment address the patients oral hygiene but documenting the stability of the abutment and the prosthetic screws is absolutely critical “…the continuous cross arch rigid connection of the prosthesis to the implants by ensuring tight abutment and prosthetic screws is essential for long term success…” Foreword vii Drs Moldovan and Jivraj communicate these important considerations in their discussions in the Chapter 16 of this book The time and the passion invested in continuing education and discussions with our colleagues enriches the hearts and minds of all involved in treatment planning and executing the various treatment options for the edentulous patients In the immortal words of PI Branemark, “Listening to the needs and the demands of the patient and executing treatment plans in the best interest of our patients is paramount.” San Francisco, CA, USA Edmond Bedrossian Foreword Dental implants are one of the most significant developments in the treatment of patients who are missing teeth When the method to place and restore these implants was presented to North America at the Toronto Conference more than 30 years ago, a strict protocol was adhered to Over time, researchers and clinicians have taken advantage of better imaging, CAD/CAM technology, newer materials and implant designs to innovate and develop methods of shortening treatment times while obtaining predictable outcomes for patients These methods and materials have been used and reported on by multiple authors and some of these authors have collaborated on this book Collectively they have contributed to this particular method of restoring edentulous patients and elucidated not only the mechanics of placing and restoring implants but more importantly managing atypical situations, patient selection and management of complications Readers of this book will clearly understand a clear treatment protocol that will lead to predictable outcomes for their patients In addition this body of work can help clinicians decide on whether this mode of treatment is suitable for their patients and help them to avoid any complications that may occur This information will also allow the clinician to decide when it is appropriate to refer a patient to more experienced colleagues I have known Dr Jivraj personally for over 15 years and can attest to his dedication to patient care and using a solid evidence base to make treatment decisions Rest assured he has taken the same care in assembling this experienced group of clinicians and teachers to share their experiences and knowledge on this focused subject Winston Chee, D.D.S., F.A.C.P University of Southern California Los Angeles, CA, USA ix Foreword Dr Saj Jivraj has assembled in this textbook a quintessential team of talented worldrenown surgeons and restorative dentists who extensively share their vast knowledge in the latest innovations in Implant Dentistry In order to address the ever-increasing magnitude of patients in need of extensive implant treatment, graftless implant solutions must be combined with an in-depth knowledge of surgical and restorative procedures through a rigorous and well-coordinated interdisciplinary approach This textbook displays in an effective and methodical manner the modern foundation for the diagnosis and graftless treatment of edentulous patients with fixed implant-supported prosthetics It provides clear and understandable concepts through basic and advanced implant principles that are required in the initial comprehensive diagnosis and digital workflow all the way through the interdisciplinary teamwork necessary to manage tilted and zygomatic implants, and ultimately produce high-quality full arch implant supported restorations We have greatly benefited over the past years at Augusta University from the great teachings of Dr Jivraj and we trust that this important work will be enjoyed worldwide as a reference textbook in modern implant dentistry Gerard J. Chiche The Dental College of Georgia Augusta, GA, USA xi 420 Fig 17.94  Smile line on presentation is low Fig 17.95  Lateral view demonstrating adequate lip support Fig 17.96 Intra-oral photograph of preoperative presentation S Jivraj and H Zarrinkelk 17  Clinical Patient Presentations 421 Smile line—The patient had a low smile line and this would not pose a problem in hiding the transition zone Contours and emergence—Space creation to develop appropriate contours and emergence was required The existing implant also had to be removed to create a uniform bed into which the implants would be placed Tissue contact—Following extraction of the teeth and creation of adequate restorative space shaping the restorative contours for a convex undersurface is attainable The provisional restorations were to be used to compress the tissue and create a concave tissue surface Occlusion—Occlusion must be addressed in the immediate-load provisional to protect the implants in the weakest quality bone from excessive loads In the definitive restoration occlusion must be organized to distribute the loads over a wide an area as possible 17.5.2 Surgical Evaluation Many patients who are evaluated for full-mouth rehabilitation present with existing dental implants Very often those implants are placed in positions that are appropriate for single tooth or fixed partial appliances Fabrication of an implant-supported fixed denture in a full-arch reconstruction has differing space requirements This may necessitate removing existing implants Our patient presented here was an 85-year-old male with significant past cardiac history He had suffered a myocardial infarction approximately 30 years ago and had undergone cardiac revascularization successfully He was under care of a cardiologist Consultations were made with the patient’s physicians to determine the best method of anaesthesia The patient is an actor and placed a great emphasis on the aesthetic value of his smile He was evaluated by our prosthodontist and conclusion made that repair and replacement of the existing restorations were not viable Clinical evaluation of patient showed many restorations with recurrent caries Patient had a low lip line and long lip 1 mm of gingival show on maximal smiling was noted Gingival tissues were healthy Radiographic evaluation of patient showed long span failing fixed partial dentures in the right and left maxilla There were peri-apical lesions associated with multiple teeth There were also recurrent cervical lesions around most restorative margins He was noted to have large maxillary sinuses The mandible showed sufficient bone in width and height for implant placement The lone implant in the right mandible was well integrated Radiographically the inter-arch space was measured to be 24 mm (Fig. 17.97) 17.5.3 Surgical Treatment Plan Space: The lack of inter-arch space in this case will have to be managed through bone reduction in both maxilla and mandible The existing dental implant in the right mandible will have to be removed to allow reduction of the bone and 422 S Jivraj and H Zarrinkelk Fig 17.97  Panoramic radiograph of patient showing lack of inter-arch space and extensive restorations Fig 17.98  Simulated implant positions based on angled implant concepts showing lack of posterior maxillary bone and very large sinuses Due to the shape and size of the maxillary sinuses the distal implants would have to be angled more than 45° or positioned too far anteriorly The previously placed mandibular implant requires removal due to anticipated need for bone reduction Fig 17.99  Final simulated implant positions based on zygomatic implant concepts with anterior axial implants Mandibular bone reduction is highlighted Mandible treatment planned according to All-on-4™ treatment concept protocol placement of the implant platform at a more apical position The maxilla bone reduction will be performed with assistance of a tooth-supported surgical guide based on a wax-up of ideal teeth position Spread: The reduction of the maxillary alveolus will make placement of angled implants in the bicuspid regions difficult due to the very large sinuses (Fig. 17.98); therefore, zygomatic implants will be used bilaterally The anterior maxilla retains sufficient bone height and width for placement of axial implants in the incisor region (Fig.  17.99) In the mandible the existing implant will be removed and treated according to the All-on-4™ treatment concept Stability: The patient exhibits sufficient bone volume in the anterior maxilla as well as mandible There are no large defects noted; therefore, under-prepared osteotomies with gradual enlargement of the preparations will be undertaken An aggressively threaded implant design will be utilized 17  Clinical Patient Presentations 423 17.5.4 Surgical Treatment The patient was treated over two consecutive days in an office setting Local anaesthesia supplemented with a very mild sedative technique was utilized on both days All maxillary teeth except those indexed by the surgical stent were removed (Fig. 17.100) Surgical stent was indexed on the remaining maxillary teeth and bone was reduced to allow for at least 16 mm of inter-arch space in the maxillary arch (Fig. 17.101) The remaining teeth were removed and the maxillary arch was reduced to a flat plane (Fig.  17.102) Bilateral zygomatic osteotomies were completed and implants were inserted to appropriate length (Fig. 17.103) Two NobelSpeedy implants were placed in the incisor region of the maxilla (Fig. 17.104) The mandible was treated with a tissue-borne surgical stent Bone reduction was completed and the mandible was treated according to the All-on-4™ treatment concept (Fig. 17.105) All implants in the maxilla and mandible were inserted at torque value of no less than 35 N. Multi-unit abutments were placed and primary closure was achieved Provisional hybrid fixed appliances were fabricated immediately following the surgical phase of treatment and secured to the implants on the day of surgical implant placement (Fig. 17.106) Patient tolerated the anaesthesia and procedure very well and healed uneventfully Final appliances were fabricated 6 months later (Fig. 17.107) Fig 17.100 Anterior maxillary teeth were removed and remaining teeth were used to stabilize a tooth-supported bone reduction stent Fig 17.101 Sufficient dimension of alveolar bone is reduced according to stent to allow for proper restorative space and prosthetic contours 424 S Jivraj and H Zarrinkelk Fig 17.102  A flat plane is created for implant placement Fig 17.103  Position and trajectory of the zygomatic implant osteotomy are noted The optimal position of the implant will place the platform of the zygomatic implant as close to the crest of the residual alveolar ridge and apex of the implant in the thickest portion of the zygomatic bone A window created into the maxillary sinus along the buttress of the zygomatic bone allows for visualization of the sinus and elevation of the Schneiderian membrane Fig 17.104 Final positions of the maxillary implants are shown Emphasis is on creation of the largest A-P spread possible 17  Clinical Patient Presentations 425 Fig 17.105  Position of the mandibular implants Fig 17.106 Radiograph immediately following completion of the surgical phase Fig 17.107 Long-term follow-up radiograph showing stable bone around all of the implants in both maxilla and mandible Healthy sinuses are maintained with zygomatic implants 17.5.5 Prosthodontic Sequence Immediate dentures at the correct vertical dimension were fabricated for a direct pickup procedure Vertical dimension was determined prior to implant placement and a record made Bone reduction guides were fabricated to communicate restorative space required A direct/indirect technique for immediate loading was employed Closed-tray impression copings were placed and impressions made within the intaglio of the denture A bite 426 S Jivraj and H Zarrinkelk Fig 17.108 Undersurface of immediate-load provisional should be convex and highly polished Fig 17.109 Immediate-­ load provisional showing adequate space for acrylic resin titanium prosthesis This is obtained through appropriate planning Fig 17.110  Lateral view of immediate-load provisional demonstrating straight emergence profile registration was made in the centric relation position Vertical dimension, centric relation and occlusal plane were verified The impressions were poured in a low-expansion die stone mounted and processed and finished in the laboratory The prostheses were adjusted to leave a 1 mm space between the prostheses and the tissue Occlusion was adjusted for shimstock hold on anterior teeth and shimstock drag on the posterior teeth Vertical dimension was verified on delivery of the restoration (Figs. 17.108, 17.109 and 17.110) 17  Clinical Patient Presentations 427 Splinted open-tray impressions, jaw relation records and a trial restoration were inserted to verify aesthetics and phonetics The trial restoration was utilized to fabricate a titanium framework using CAD software Computer-aided milling was performed The frameworks were tried in and checked against the putty matrices to ensure sufficient room for acrylic resin and tooth A final try-in was performed on top of the titanium frameworks to verify aesthetics, phonetics, fit and occlusion The wax prosthesis was processed to acrylic resin under heat and pressure using injection-­moulded techniques The prosthesis was delivered adjusting the undersurface to ensure positive pressure Dynamic occlusion was adjusted for canine guidance Static occlusion was adjusted to ensure shimstock hold on canines and premolars, shimstock drag on anterior teeth and no contact on the cantilevers Screws were torqued according to the manufacturer’s instructions and access holes were sealed using Teflon and composite resin A night-time appliance was provided and maintenance instructions were provided (Figs. 17.111, 17.112, 17.113 and 17.114) Fig 17.111  Lateral smile view of definitive acrylic resin titanium prosthesis Fig 17.112  Smile view of definitive acrylic resin titanium prosthesis 428 Fig 17.113  Right lateral of definitive prosthesis in situ Fig 17.114  Left lateral of definitive prosthesis in situ S Jivraj and H Zarrinkelk Index A Acrylic resin bonded to titanium-fixed restorations, 193 bonded/milled to titanium, 197–199 Acrylic resin titanium hybrid framework, 266 CAD/CAM technology, 269–271 design principles, 269 I-/L-shaped design, 270, 271 restoration failure, 270 wrap-around, 270 Acrylic resin titanium prosthesis, 228–239 Ad modum Branemark technique, 144, 155 Aesthetic complications, 323, 324 Aesthetics, speech and facial considerations alveolar bone volume assessment, 245 anthropometry, 244 edentulous jaw treatment, 244 edentulous maxilla and mandible, 248 facial anatomical curvature, 244 intelligible speech production, 252–255 jaw atrophy, consequence of, 249 lip support, 249–252 maxillary incisors, position and form of, 248 orofacial aesthetics, 252 pre- and post-treatment photography, 244 speech adaptation, 257 terminal dentition, 244, 246 three-dimensional imaging, 244 three-dimensional photography, 244, 245 three-dimensional radiographic imaging, 245 three-dimensional stereophotogrammetry, 245 three-dimensional virtual treatment planning software, 245–247 tooth-only prosthesis, 245 All-on-4® guide osteotomy, 107 placement of, 108 All-on-4® protocol, 335, 336, 350 All-on-4® treatment concept, 99, 100 guided surgery, 130–131 implant placement, 128–129 non-guided surgery, 101–129 treatment planning, 100–101 Alveolar atrophy, 22 Alveolar bone volume assessment, aesthetics, 245 Alveolectomy, 36, 245 Angled implants, 333, 335, 341 Anterior tooth position, aesthetics, 248 Anthropometry, 244 B Biologic complications, defined, 322 Bleeding on probing (BOP), 357, 358 Bone reduction, 128 diagnostic steps, 27 guide, 19 protocol stages, 27–32 rationales for, 11, 26 with rongeur, 106 with round bur, 107 types of, 27 Bone-supported surgical template, 53 Bone-to-implant contact (BIC), 137 C Cantilevers, prosthesis, 195, 196 Ceramic chipping, 59 Ceramic-based restorations, space ­requirements for, Chlorhexidine solution irrigation, 357 Cobalt chromium, 200, 201 Composite defect, 18 © Springer International Publishing AG 2018 S Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides, https://doi.org/10.1007/978-3-319-65858-2 429 430 Computer-aided design/computer-aided manufacturing (CAD-CAM) zirconia, 59 Computer-guided implant surgery, 62 Cross-arch splinting, 78 Cumulative survival rate (CSR), 135 D Decision-making parameters, Definitive prostheses, 58–61 Definitive prosthodontic phase, of ­implant-­supported prostheses, 329 Dental implant maintenance, 355 home care, 356–358 in-office dental implant management, 356–359 plaque accumulation and removal, 362 record keeping, 359–362 Dentoalveolar compensation, 26 Digital smile design protocol, 248 simulation, 246 Double-arch zirconia restoration, 229 Double-scan technique, 47–48 Drilling protocol, 56–57 E Edentulism, 15 routine treatment for, Edentulous jaw treatment, 244 Edentulous maxillae, anatomy, 70, 134 Edentulous patient diagnosis, 16 treatment planning, 16 Extramaxillary approach, 347 Extra-oral complication, 350 Extra-sinus placement, 139, 143 F Facial anatomical curvature, aesthetics, 244–245 Failing dentition, 419, 421–425 case study, 419 bilateral zygomatic osteotomies, 423, 424 bone reduction, 423 clinical observation, 419 long-term follow-up, 425 NobelSpeedy implants, 423, 424 prosthodontic diagnosis, 419 prosthodontic sequence, 425 surgical evaluation, 421 Index surgical stent, 423 surgical treatment plan, 421–422 Fixed prostheses contour, speech and facial aesthetic considerations alveolar bone volume assessment, 245 anthropometry, 244 edentulous jaw treatment, 244 edentulous maxilla and mandible, 248 facial anatomical curvature, 244 intelligible speech production, 252–255 jaw atrophy, consequence of, 249 lip support, 249–252 maxillary incisors, position and form of, 248–249 orofacial aesthetics, 252 pre- and post-treatment photography, 244 speech adaptation, 257 terminal dentition, 244, 246 three-dimensional imaging, 244 three-dimensional photography, 244, 245 three-dimensional radiographic imaging, 245 three-dimensional stereophotogrammetry, 245 three-dimensional virtual treatment planning software, 245–247 tooth-only prosthesis, 245 Flapless surgery, 63 Flapless vs with flap surgical technique, 55, 56 Full-arch fixed implant-supported prostheses, 321 complications (see Prosthetic complications) definitive prosthodontic phase, 329–330 digital planning, 328 maintenance phase, 329–331 misconceptions of, 321 surgical procedure, 327 transitional prosthodontic phase, 327–329 Full-arch implant treatment, 343 Full-arch implant-supported restoration, 190–209, 215, 264–271, 287–290, 369, 371–379, 381 acrylic resin titanium hybrid framework, 266–271 case study anaesthesia modality, 369 antibiotic medication, 376 clinical and radiographic data, 369 clinical examination, 369 contours and emergence, 376 incisal edge position, 373 lip support, 373 mandibular implants, 378 Index NobelSpeedy implants, 377 occlusion, 376 patients medical status and history, 369 prosthetic evaluation, 373–376 prosthodontic sequence, 379 radiographic evaluation, 369, 371 restorative space, 373 smile line, 376 surgical procedure, 376–379 surgical treatment plan, 372 tissue contact, 376 vertical dimension, 379 wax trial prosthesis, 379, 381 zygomatic implant, 373, 377, 378 fabrication design considerations, 190 acrylic resin, bonded/milled to titanium, 196–200 aesthetic demands, 193–195 aesthetics, 290 cantilevers, 195, 196 connector size, 289 ease of fabrication, 287 ease of fabrication and passivity, 195–197 implant/abutment interface, 288–289 inadequate restorative space, 190–193 milled cobalt chromium, 200, 201 nature of opposing dentition, 193, 194 occlusion/wear, 289 passivity of framework, 288 PEEK, 197–200 restorative space, 287 screw access trajectory, 190–193 screw-retained restoration, 290 veneering porcelain, 290 Zirconia, 200–209 laboratory fabrication process, 271–287, 291–318 metal ceramics (see Metal ceramic restorations) PEEK, 264–265 laboratory fabrication process, 264–271 two-piece occlusal rim, 262–264, 284 (see Zirconia) Functional complications, 323, 324 Functional endoscopic sinus surgery (FESS), 347 G Gingival display, Graftless implant reconstruction for advanced atrophy, 333 failing implant removal, 338–340 431 implant failure, 335–338 implant removal, 340 maxillary sinus-related complications, 347 planning and patient selection, 353 rescue implants, 340–342 3D imaging with cone beam computed tomography, 335 zygomatic implants, 342 Guided implant surgery, 63 H Haphazard bone reduction, 11 Healing caps, 117 High-performance polymers, see PEEK I Immediate loading axial vs tilted Implants, 91–93 classification, 86 clinical methods, 161–183 definition, 86, 159 delaying insertion, 160 direct technique, 161–170 direct-indirect technique, 176–183 elements, 88 fabrication and insertion method, 160 factors in, 86–87 indirect technique, 183 occlusion, 88–91 optimal number, 91–92 patient selection, 160 requirements, 88, 160, 161 restorative considerations, 161 surgical considerations, 160 vertical cantilever height, 92–93 Implant planning software, 104, 105 Implant rehabilitation, fixed vs removable, Implants, 190 full-arch fixed implant (see Full-arch implant-supported restorations) Implant-supported over-dentures, 193 Inflammation, 324 Intelligible speech production, 252–255 Interdental cleaning tools, 357 Interim prostheses, 57–58 J Jaw atrophy, consequence of, 249 Index 432 K Keratinized tissue assessment, 358, 359 L Lip prominence, 248 Lip support, 6–9, 248–252 and smile line evaluation, 103 Listerine mouthwash, 357 M Maintenance phase, of implant-supported prostheses, 330 Mandible, incision on, 106 Mandibular full-arch fixed implant-supported prostheses, 322 Mandibular incisal edge, Maxilla incision on, 105 zones of, 136 and zygoma bones, 135 Maxillary full-arch fixed implant-supported prostheses, 322 Maxillary incisal-edge position, Maxillary incisors position, aesthetics, 248 Maxillary sinus-related complications, 347 Metal ceramic restorations, 215–219, 221, 222, 228–232 bisque trial, 225–226 chlorhexidine gel, 226 framwork trial, 221–225 impression procedure, 215 abutment-level approach, 215, 216 acrylic jigs, 218, 219 autopolymerizing resin, 218 closed tray/indirect transfer technique, 216, 217 implant-level approach, 215, 217 restorative space requirements, 215 soft-tissue collar height, 215 verification jigs, 221, 222 impression procedure open-tray impressions, 217 open-tray/direct pickup technique, 216, 218 interocclusal records, 219 post-operative instructions and follow-up, 228–232 interdental brushes, 228 oral prophylaxis, 228 zirconia-based, 228–232 prosthetic treatment sequence, 214 screw-retained restorations, 226, 227 second interocclusal record, 221–225 Metal-acrylic prostheses, 322, 330 Milling and rapid prototyping, 29 Monolithic full-arch restorations, 228 Monolithic full-contour zirconia-fixed restorations, 193 Mucosa-supported surgical template, 53 N NobelClinician®, 245, 246, 249 NobelGuide®, 249 Non-engaging abutments, 59 nSequence® Guided Prosthetics™, 29 O Occlusal management, 32 Occlusal refinement, objective of, 239 Occlusal stresses, 80 Occlusal vertical dimension (OVD), 325 Occlusion, 12, 13 Occlusion vertical dimension, 105 Oral irrigators, 357, 358 Orofacial aesthetics, 252 Orthopantomography and CBCT before surgery, 101, 102 os zygomaticus microstructure, 71 morphology, 71 P Patient-specific anatomical reconstruction and image fusion (PSARIF), 28 Peri-implant vs periodontal attachment, 356 Peri-implantitis defined, 356 failure factors, 356 Periodontal vs peri-implant attachment, 356 Phonetics, 324 Pickup impression, extraoral conversion, 183 Plaque control procedures, professionally administered, 358 Plumping of flanges, 248 PMMA bridge provisional, 31 with refinement, 31 to temporary cylinders, 30 PMMA hybrid prosthesis, 40 Polyether etherketone (PEEK), 200, 264–269 laboratory fabrication process anatomical implant substructures, 265 design considerations, 265–269 implant bars, 265 Index Polymers, 265 PEEK, 200, 264 laboratory fabrication process, 265 Porcelain fused to metal/zirconia-fixed restorations, 193 Prosthesis, 190–202, 244 fabrication design considerations acrylic resin, bonded/milled to titanium, 197–199 aesthetic demands, 195 cantilevers, 195, 196 ease of fabrication and passivity, 196 inadequate restorative space, 193 milled cobalt chromium, 200, 201 nature of opposing dentition, 193, 194 PEEK, 200 screw access trajectory, 190–192 Zirconia, 202 fixed (see Fixed prostheses contour, speech and facial aesthetic considerations) Prosthesis-related biological complications, 324 Prosthetic complications, 325 centric relation, 326 definition, 322 diagnostic phase iatrogenic, 325 occlusal vertical dimension and restorative space, 325 lip support, 326 transition zone, 325–326 Prosthetic maintenance complications, 363–365 post-delivery instructions, 365 restoration design, 362 screw replacement, 364 Prosthetic screw loosening, 323 Provisional prosthesis, 335 Pulsated oral irrigators, 357 Q Quad zygoma concept, 70 R Refractory peri-implant problems, 341, 345 Rehabilitation procedure, 103 Rescue concept, 135 Restoration fracture, resin- based, Restorative space, full-arch fixed implant, 193 433 S Screw access trajectory, 190–192 Screw-retained restoration, 359 Self-performed oral hygiene practices, 357 Sheffield test, 225, 229 Short implants, 333, 335 Sinus lift consensus conference, 134 Smile line and lip length, 9–10 Smiling CBCT scan technique, 62 Smiling scan, 50–53 Soft-tissue hyperplasia, 324 Software-driven interdisciplinary virtual workup, 28–29 Speech adaptation, 257 Stereolithographic surgical templates, 56 Stereolithography (STL), 50 Structural complications, 323 T Temporary titanium cylinders, 153 Terminal dentition, 244, 382–401, 405, 407–419 case study, 392 alveoloplasty, 390 anaesthesia, 388 bone reduction, 389 clinical examination, 382, 386 contours and emergence, 384 incisal edge position, 384, 385 initial patient presentation, 382, 383 lip support, 384, 385 mandibular provisional prosthesis, 390 occlusion, 384 osteotomies, 389 prosthetic treatment plan, 391–393 radiographic exam, 386 restorative space, 384 smile line, 384, 385 surgical evaluation, 386 surgical treatment plan, 387–388 tissue contact, 384 zygomatic implant, 389 digital smile design simulation, 246 fixed implant-supported restorations, 394 class III malocclusion, 397 contours and emergence, 395 graft-less option, 394 incisal edge position, 395 lip support, 395 occlusion, 396 orthodontics and orthognathic surgery, 394 prosthetic treatment plan, 401 Index 434 Terminal dentition (cont.) restorative space, 395 smile line, 395 staged implant placement and fabrication, 394 surgical evaluation, 396 surgical treatment plan, 398–401 tissue contact, 395 implant-supported restorations using graft-less protocol clinical evaluation, 407 diagnostic perspective, 405 prosthodontic sequence, 415–419 radiographic examination, 408 surgical treatment plan, 408–415 3D implant planning software programs, 63 Tissue contact, 11, 12 Tooth-only defect, 18 Tooth-only prosthesis, 245 Tooth-supported surgical template, 53 Transition line, defined, 136 Transitional prosthodontic phase, of implant-­ supported prostheses, 327 Transmucosal portion, 154 T-scan, 330 V Vitamin D deficiency, 359–360 von Mises stress, 80 W Wax tooth try-in, 236 Z ZAGA classification, 75 Zirconia, 200–202, 284 hybrid designs, with individual ceramic crowns, 207, 208 minimally layered, 203–206 monolithic, 202, 203 Zirconia-based full-arch restorations, 228 Zygomatic implant, 135, 353 anterior-posterior (AP) distribution, 71 apical infection, 347–351 deformation under function, 137–139 failure and, 340–346 patient selection, 135 postoperative care, 154–155 preoperative considerations, 139–141 primary load-bearing bone under function, 137–138 prosthetic conversion technique, 151–154 quad-cortical stabilization, 135 radiographic evaluation, 136–137 surgical options, 141–142 surgical protocol, 142–151 trajectory of, 72–76, 141 use, 135 ... prosthesis deterred patients from seeking care Today, the ? ?graftless concepts” eliminate the need for grafting and long waiting periods prior to the reconstruction of the edentulous or the patients... options for the edentulous patients In the immortal words of PI Branemark, “Listening to the needs and the demands of the patient and executing treatment plans in the best interest of our patients... the minimum long enough to reach from the bicuspid region to the piriform rim In the mandible the distal implant is positioned with the platform above the mental foramen and tilted to avoid the