Full-Arch Implant Rehabilitation [1 ed.] 9780867158090, 2019022458, 9780867158106

Table of contents :
Cover
Half Title Page
Title Page
Library of Congress Cataloging-in-Publication Data
Contents
Preface
Chapter 1: Evolution of the FAIR Protocol
The FAIR Difference
References
Chapter 2: History of Tilted Implants with an Immediate Prosthesis
Tilted Implants and FAIR
Factors Guiding Successful Outcomes
Tilted Implants and Restoration of the Edentulous Maxilla
Position and Angulation of Tilted Implants
Conclusion
References
Chapter 3: Identifying and Evaluating Candidates
Evaluating the FAIR Patient
Treatment Planning
References
Chapter 4: The FAIR Technique and Its Modifications
Surgical Guidelines for Edentulous Arches
FAIR Surgical Guide and Immediate Denture
The FAIR Surgery
Immediate Provisionalization
Conclusion
References
Chapter 5: Treating the Fully Edentulous Maxilla
The FAIR Vision
Preoperative Procedure
FAIR Surgical Procedure
References
Chapter 6: Treating the Fully Edentulous Mandible
FAIR in the Mandible
Preoperative Procedure
FAIR Surgical Procedure
References
Chapter 7: Treating the Partially Edentulous Maxilla
The FAIR Vision
Preoperative Procedure
FAIR Surgical Procedure
References
Chapter 8: Treating the Partially Edentulous Mandible
FAIR in the Mandible: Special Considerations for Partial Edentulism
Preoperative Procedure
FAIR Surgical Procedure
Conclusion
References
Chapter 9: FAIR Prosthetics
Biomechanical Factors
The Provisional Prosthesis
The Definitive Prosthesis
References
Chapter 10: Possible Complications
Complications Unrelated to Prosthesis Fracture
Complications Related to Prosthesis Fracture
Conclusion
References
Back Cover

Citation preview

Arun K. Garg, DMD

1 Evolution of the FAIR Protocol

FU LL- ARCH IMP LA NT R E H A B ILITATI O N

is considered one of the world’s foremost authorities on bone biology, harvesting, and grafting for dental implant surgery. Alongside Dr Robert E. Marx, he pioneered the use of platelet-rich plasma (PRP). He received his dental degree from the University of Florida College of Dentistry in Gainesville, Florida, and completed his residency at the University of Miami Jackson Memorial Hospital in Miami, Florida. He went on to serve for almost two decades as Professor of Surgery in the Division of Oral and Maxillofacial Surgery and as Director of Residency Training at the University of Miami Leonard M. Miller School of Medicine, where he was frequently awarded Faculty Member of the Year by his residents. Dr Garg has published 8 medical textbooks and over 150 journal articles and is currently the president of the International Dental Implant Association. An international lecturer, he also maintains six private practices throughout southern Florida and is the founder of Implant Seminars, a leading dental continuing education company.

Garg

CONTENTS 2 History of Tilted Implants with an Immediate Prosthesis 3 Identifying and Evaluating Candidates 4 The FAIR Technique and Its Modifications 5 Treating the Fully Edentulous Maxilla 6 Treating the Fully Edentulous Mandible 7 Treating the Partially Edentulous Maxilla 8 Treating the Partially Edentulous Mandible 9 FAIR Prosthetics 10 Possible Complications

Arun K. Garg, DMD

FULL-ARCH IMPLANT

The full-arch implant rehabilitation (FAIR) protocol is one of the newest implant therapy innovations to treat the edentulous or nearly edentulous patient. The FAIR prosthesis is immediate, fixed, esthetically pleasing, highly functional, inexpensive, and maintainable, and it can frequently be installed without bone grafting. This book describes how the FAIR protocol works, who it should be used for, and methods to implement it successfully for different patients. The system can be used in both arches and in patients with total or near-total edentulism. Several chapters are devoted to describing step-by-step treatment with detailed clinical photographs documenting every stage from initial assessment to prosthesis delivery. Even those new to fixed denture systems will find the procedures easy to follow and can begin implementing the FAIR approach for their patients.

REHABILITATION

ISBN 978-0-86715-809-0

90000>

9 780867 158090

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Full-Arch Implant Rehabilitation

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FULL-ARCH IMPLANT REHABILITATION Arun K. Garg, DMD Private Practice Limited to Implantology Miami, Florida

Berlin, Barcelona, Chicago, Istanbul, London, Mexico City, Milan, Moscow, Paris, Prague, São Paulo, Seoul, Tokyo, Warsaw

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Library of Congress Cataloging-in-Publication Data Names: Garg, Arun K., 1960- author. Title: Full-arch implant rehabilitation / Arun K. Garg. Description: Berlin ; Chicago : Quintessence Publishing, [2019] | Includes bibliographical references. Identifiers: LCCN 2019022458| ISBN 9780867158090 (paperback) | ISBN 9780867158106 (ebook) Subjects: | MESH: Dental Implantation--methods | Jaw, Edentulous--surgery | Dental Implants | Dental Arch Classification: LCC RK667.I45 | NLM WU 640 | DDC 617.6/93--dc23 LC record available at https://lccn.loc.gov/2019022458

97% © 2019 Quintessence Publishing Co, Inc Quintessence Publishing Co, Inc 411 N Raddant Road Batavia, IL 60510 www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher. Editor: Marieke Zaffron Design: Sue Zubek Production: Kaye Clemens and Christine Cianciosi Printed in China

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CONTENTS Preface vii

1 Evolution of the FAIR Protocol1 The FAIR Difference 3

2 History of Tilted Implants with an Immediate Prosthesis7

Tilted Implants and FAIR 8 Factors Guiding Successful Outcomes 8 Tilted Implants and Restoration of the Edentulous Maxilla 9 Position and Angulation of Tilted Implants 10

3 Identifying and Evaluating Candidates13 Evaluating the FAIR Patient

13

Treatment Planning 17

4 The FAIR Technique and Its Modifications23 Surgical Guidelines for Edentulous Arches 23 FAIR Surgical Guide and Immediate Denture 26 The FAIR Surgery 26 Immediate Provisionalization 28

5 Treating the Fully Edentulous Maxilla33 The FAIR Vision 33 Preoperative Procedure 33 FAIR Surgical Procedure 34

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6 Treating the Fully Edentulous Mandible53 FAIR in the Mandible

53

Preoperative Procedure 54 FAIR Surgical Procedure 54

7 Treating the Partially Edentulous Maxilla71 The FAIR Vision 71 Preoperative Procedure 72 FAIR Surgical Procedure 73

8 Treating the Partially Edentulous Mandible81 FAIR in the Mandible: Special Considerations for Partial Edentulism

81

Preoperative Procedure 83 FAIR Surgical Procedure 83

9 FAIR Prosthetics97 Biomechanical Factors 97 The Provisional Prosthesis 98 The Definitive Prosthesis 100

10 Possible Complications105 Complications Unrelated to Prosthesis Fracture Complications Related to Prosthesis Fracture

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PREFACE

PREFACE The purpose of this book is to explain and illustrate how to treat the edentulous or nearly edentulous patient via a full-arch implant rehabilitation (FAIR) protocol. FAIR is one of the newer innovations in implant therapy to relieve the functional and esthetic misery of a growing worldwide demographic of edentulous patients numbering in the millions. The FAIR protocol offers full-arch prostheses that are immediate, fixed, loaded, esthetically pleasing, highly functional, inexpensive, maintainable, and very reliable. The protocol’s low-morbidity surgical and provisional restoration techniques are accomplished in a single visit with usually only four or five implants, including posterior tilted implants that take advantage of the patient’s available bone, often eliminating the need for bone grafting. The book begins with a two-chapter history of the tremendous progress in dental implantology treatment over the last 40 years, due in large part to advances in digital imaging and materials technology for both implants and prostheses. Subsequent chapters describe the specific methods for choosing and treating patients to restore their full-arch function and esthetics. The text provides a clear, succinct, and authoritative guide to full-arch rehabilitation and as such is ideal for any clinicians incorporating or expanding full-arch restoration modalities into their practice. The case-by-case methodology adds to the uniqueness of the text. A patient-focused approach covers surgical templates and techniques, sterilization, pharmacology, bone biology, complications, and more. Dozens of vivid, digitally mastered artist renderings as well as maxillofacial photography of real patients further enhance the depictions of treatment procedures. Informative tables and charts are also included, many of which depict essential procedural elements for treatment. I hope that the readers also take time to explore the dozens of scholarly resources assembled to support the claims of the text. My further hope is that this text becomes a welcomed companion for any dentists eager to expand their implant knowledge and skills and to advance their careers. My inspiration for writing stems, as always, from my decades-long service as a full-time professor of surgery in the Division of Oral and Maxillofacial Surgery and as director of residency training at the University of Miami Leonard M. Miller School of Medicine. I see FAIR as one of the next logical steps in my career-long focus on bone biology, harvesting, and grafting for dental implant surgery. My humble hope is that this book will have the same global success as several other texts that I’ve written on bone grafting and dental implantology to benefit dental clinicians and patients around the world.

Acknowledgments For their invaluable assistance and work on the patient cases described in this book, I would like to offer special thanks to Renato Rossi, Jr, DMD, MSc, PhD; Maria Del Pilar Rios, DDS, MScD, PhD; and Rosa Ysabel Rios, implant prosthetic specialist.

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1

CHAPTER

Evolution of the FAIR Protocol

T

he full-arch implant rehabilitation (FAIR) protocol is one of the newest innovations in implant therapy to treat the edentulous or nearly edentulous patient. Instead of single implants replacing individual missing teeth, four or five implants are spaced throughout the arch and immediately loaded with a provisional fixed prosthesis. While conventional removable dentures and bone grafting with multiple implants are other options, the latter can take several years and has commensurate high costs. Morever, a number of studies have shown that wearing conventional removable dentures can reduce patients’ quality of life, causing pain and areas of discomfort, chewing and speaking difficulties, slippage, reduced occlusal force, and poor oral sensation. The FAIR dental prosthesis offers many advantages for the dental patient with a fully or partially edentulous arch (Table 1-1). The prosthesis is immediate, fixed, esthetically pleasing, highly functional, inexpensive, and maintainable. Importantly, the FAIR procedure and similar techniques can frequently be performed without bone grafting with exceptional success rates.1–14 Such dental systems are better designed to meet the surgical and restorative needs of more patients with edentulous or partially edentulous arches, because traditional techniques often require extensive bone

grafting. The invasiveness of these procedures deters many patients, and others (particularly elderly patients and those with severe bone loss) may not be good candidates for bone grafting. During the late 1980s and early 1990s, the success rates for immediately loaded implants improved, both for the restoration of individual teeth and the placement of short-span fixed partial dentures.15–20 These developments served to push the envelope toward full-arch replacement, both with and eventually without bone grafting. The mid to late 1990s saw the development of mandibular restoration protocols that attempted to meet the challenges of anatomical placement and a redesigned partial denture architecture in the dense bone of the mandible.21,22 Similar attempts in the softer, more porous maxillary bone were generally unsuccessful because of poor anchorage.23–28 To overcome this challenge, the threading, size, and length of implants were redesigned to condense and thicken bone during placement in soft bone and with sinus elevation and other procedures.29–32 The early 2000s saw significant improvement in the esthetics of fixed prosthodontics, particularly with the introduction of pink ceramic for the gingiva. Retrospective studies of fixed full-arch prostheses in the mandible and

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TABLE 1-1   Advantages and disadvantages of removable dentures, overdentures, and the FAIR approach ADVANTAGES

DISADVANTAGES

Removable dentures

• Relatively inexpensive tooth and gingival replacement • Provides lip support • Easy to remove and clean outside of the mouth

• Uncomfortable • May cause sore spots on gingival tissue • Makes it difficult to eat certain foods • Causes accelerated bone loss • Often requires relining to improve comfort as bone deteriorates • May make speech difficult • May require creams or adhesives to reduce mobility • Approximately 10% functionality compared with natural teeth

Removable overdenture supported by 2 or 4 implants

• Improves stability and functionality to 60% compared with natural teeth • Relatively inexpensive tooth and gingival replacement • Provides lip support • Easy to clean outside of the mouth

• Uncomfortable • May cause sore spots on gingival tissue • Denture must be removed and cleaned outside of the mouth • May still move when chewing or speaking • May require relining to improve fit and comfort as bone deteriorates

FAIR approach

• Improves functionality to 70% compared with natural teeth • Eliminates the need for bone grafting • A provisional partial denture can be provided on the day of surgery, allowing a soft food diet during healing • Replaces roots and teeth • Preserves bone and soft tissue • No decay; 95% success rate over 30 years • Natural-looking esthetics • Allows patients to eat any kinds of foods • Can be cleaned like natural teeth

• Requires healing and restorative time • Involves surgical procedure and anesthesia

zygomatic implants in the maxilla showed how protocols for full-arch dental prostheses had evolved.33–37 For example, when traditional implant surgery and bone grafting for sinus elevation and other procedures are contraindicated in the maxilla due to patient age or other issues with bone density or availability, the longer, nontraditional zygomatic implants can be placed near the dense, more cortical cheek bone (ie, zygoma) in the posterior maxilla (Fig 1-1). This decreases the time needed for the procedure and increases patient comfort.38,39 By about 2010, additional advancements in

implant design and protocols included techniques for extramaxillary anchorage, optimal implant angulation, optional use of cantilevers, and bone reduction (when required).40–45 An earlier treatment option for edentulous patients that reflects the evolution of dental implant technology is the two- or four-implant removable overdenture.46–48 Unlike conventional removable dentures (Fig 1-2), the fixed removable overdenture improves stability and function to approximately 60% that of natural teeth (Fig 1-3) and yet is still relatively inexpensive as a replacement for teeth and

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The FAIR Difference

Fig 1-1  Placing zygomatic implants near the dense, more cortical cheekbone in the posterior maxilla is an example of an early evolution in protocol for full-arch dental prostheses.

Fig 1-2  The conventional denture was a first step in the evolution toward the FAIR protocol.

Fig 1-3  The fixed removable overdenture improves stability and function to approximately 60% that of natural teeth.

gingiva. Additionally, it provides lip support and easy cleaning outside the mouth. Disadvantages include sore spots on the gingiva, some movement when the patient chews and speaks, and the possible need for frequent relining for fit and comfort because of continued bone resorption.

The FAIR Difference In contrast, the FAIR prosthesis and other similar protocols have only two requirements that could be considered disadvantages: a surgical procedure and a short period afterward for healing and restoration. For these relatively minor disadvantages, the FAIR protocol (Fig 1-4) provides 70% of the functionality of natural teeth, requires minimal or

Fig 1-4  The FAIR protocol provides approximately 70% of natural dentition functionality.

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Evolution of the FAIR Protocol

a

b

Fig 1-5  (a) Implants are traditionally placed axially. (b) When using the FAIR technique, the implants are tilted. Note that this also allows for more space in the arch between implants.

a

b

Fig 1-6  Tilting of implants allows the preservation of important anatomical structures: the maxillary sinus in the maxilla (a) and the inferior alveolar nerve in the posterior mandible (b).

no grafting before placement, and serves as a replacement for bone and teeth (preserving both bone and soft tissue). A provisional prosthesis is delivered on the day of surgery, allowing the consumption of soft foods during healing. The definitive prosthesis has a 95% success rate over 30 years with a relatively natural esthetic that also permits virtually no food restrictions. According to the Centers for Disease Control and Prevention, as of 2015, the life expectancy of the average American was almost 79 years. As a result, more patients are seeking a solution to the problem of missing teeth that is not only esthetically pleasing but also cost-effective and highly functional. Doing nothing for the edentulous patient is no longer an option because edentulism negatively impacts overall oral health as well as patient longevity.49,50 Thankfully, there is a relatively simple solution for edentulism that is far superior to traditional dentures and overdentures because an immediately loaded implant-supported full-arch prosthesis is nearly equivalent to natural teeth.51,52

With 70% masticatory function and esthetics, accompanied by very low failure rates, FAIR prostheses have almost the same occlusal force as that of natural dentition.53,54 Traditional implants are placed in the vertical position, like fence posts (Fig 1-5a), but the FAIR technique employs a distally tilted or angled implant for greater stability, like a beach umbrella angled in the sand (Fig 1-5b). Tilted implants preserve important anatomical structures, allowing for longer implants and good cortical bone anchorage (Fig 1-6). Additionally, tilted implants increase spacing between implants, reduce cantilever length, and reduce the need for bone augmentation.32,55–58 The FAIR surgical and provisional restoration techniques are accomplished in a single visit and usually use four or five implants: several axial implants placed anteriorly and two tilted implants placed posteriorly. All implants are later restored with straight and angled multiunit abutments to support a provisional, fixed, immediately loaded, full-arch prosthesis with survival rates between 92% and 100%.59–64

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References

References 1. Misch CE, Degidi M. Five-year prospective study of immediate/ early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system. Clin Implant Dent Relat Res 2003;5:17–28. 2. Motta M, Monsano R, Velloso GR, et al. Guided surgery in esthetic region. J Craniofac Surg 2016;27:e262–e265. 3. Uhlendorf Y, Sartori IA, Melo AC, Uhlendorf J. Changes in lip profile of edentulous patients after placement of maxillary implant-supported fixed prosthesis: Is a wax try-in a reliable diagnostic tool? Int J Oral Maxillofac Implants 2017;32:593–597. 4. Barbosa GA, Bernardes SR, de França DG, das Neves FD, de Mattos Mda G, Ribeiro RF. Stress over implants of one-piece cast frameworks made with different materials. J Craniofac Surg 2016;27:238–241. 5. Zoidis P. The All-on-4 modified polyetheretherketone treatment approach: A clinical report. J Prosthet Dent 2018;119:516–521. 6. Malo P, Rangert B, Dvarsater L. Immediate function of Branemark implants in the esthetic zone: A retrospective clinical study with 6 months to 4 years of follow-up. Clin Implant Dent Relat Res 2000;2:138–146. 7. Malo P, Rangert B, Nobre M. “All-on-Four” immediate-function concept with Branemark System implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent Relat Res 2003;5(suppl 1):2–9. 8. Malo P, Friberg B, Polizzi G, Gualini F, Vighagen T, Rangert B. Immediate and early function of Branemark System implants placed in the esthetic zone: A 1-year prospective clinical multicenter study. Clin Implant Dent Relat Res 2003;5(suppl 1):37–46. 9. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310–320. 10. Malo P, de Araujo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept for completely edentulous maxillae: A clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14(suppl 1):e139–e150. 11. Lopes A, Malo P, de Araujo Nobre M, Sanchez-Fernandez E. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A prospective report on medium- and long-term outcomes. Clin Implant Dent Relat Res 2015;17(suppl 2):e406– e416. 12. Malo P, de Araujo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623. 13. Malo P, Araujo 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;24:263–270. 14. Malo P, de Araujo Nobre M, Lopes A, Ferro A, Gravito I. All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: A 7-year clinical and 5-year radiographic retrospective case series with risk assessment for implant failure and marginal bone level. Clin Implant Dent Relat Res 2015;17(suppl 2):e531–e541. 15. Buser DA, Schroeder A, Sutter F, Lang NP. The new concept of ITI hollow-cylinder and hollow-screw implants: Part 2. Clinical aspects, indications, and early clinical results. Int J Oral Maxillofac Implants 1988;3:173–181.

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Evolution of the FAIR Protocol

33. Kinsel RP, Liss M. Retrospective analysis of 56 edentulous dental arches restored with 344 single-stage implants using an immediate loading fixed provisional protocol: Statistical predictors of implant failure. Int J Oral Maxillofac Implants 2007;22:823–830. 34. Eliasson A, Blomqvist F, Wennerberg A, Johansson A. A retrospective analysis of early and delayed loading of full-arch mandibular prostheses using three different implant systems: Clinical results with up to 5 years of loading. Clin Implant Dent Relat Res 2009;11:134–148. 35. Fortin Y. Placement of zygomatic implants into the malar prominence of the maxillary bone for apical fixation: A clinical report of 5 to 13 years. Int J Oral Maxillofac Implants 2017;32:633–641. 36. Fortin Y, Sullivan RM. Terminal posterior tilted implants planned as a sinus graft alternative for fixed full-arch implant-supported maxillary restoration: A case series with 10- to 19-year results on 44 consecutive patients presenting for routine maintenance. Clin Implant Dent Relat Res 2017;19:56–68. 37. Pi Urgell J, Revilla Gutiérrez V, Gay Escoda CG. Rehabilitation of atrophic maxilla: A review of 101 zygomatic implants. Med Oral Patol Oral Cir Bucal 2008;13:e363–e370. 38. Chow J, Wat P, Hui E, Lee P, Li W. A new method to eliminate the risk of maxillary sinusitis with zygomatic implants. Int J Oral Maxillofac Implants 2010;25:1233–1240. 39. Atalay B, Doganay � Ö, Saraçoglu � BK, Bultan Ö, Hafiz G. Clinical evaluation of zygomatic implant-supported fixed and removable prosthesis. J Craniofac Surg 2017;28:185–189. 40. Lifshitz AB, Muñoz M. Evaluation of the stability of self-drilling mini-implants for maxillary anchorage under immediate loading. World J Orthod 2010;11:352–356. 41. Harirforoush R, Arzanpour S, Chehroudi B. The effects of implant angulation on the resonance frequency of a dental implant. Med Eng Phys 2014;36:1024–1032. 42. Alencar SM, Nogueira LB, Leal de Moura W, et al. FEA of peri-implant stresses in fixed partial denture prostheses with cantilevers. J Prosthodont 2017;26:150–155. 43. Sheridan RA, Decker AM, Plonka AB, Wang HL. The role of occlusion in implant therapy: A comprehensive updated review. Implant Dent 2016;25:829–838. 44. Romanos GE, Gupta B, Gaertner K, Nentwig GH. Distal cantilever in full-arch prostheses and immediate loading: A retrospective clinical study. Int J Oral Maxillofac Implants 2014;29:427–431. 45. Tischler M, Ganz SD, Patch C. An ideal full-arch tooth replacement option: CAD/CAM zirconia screw-retained implant bridge. Dent Today 2013;32(5):98–102. 46. Galindo DF. The implant-supported milled-bar mandibular overdenture. J Prosthodont 2001;10:46–51. 47. Chee WW. Treatment planning: Implant-supported partial overdentures. J Calif Dent Assoc 2005;33:313–316. 48. Shetty PP, Gangaiah M, Chowdhary R. Hidden overdenture bar in fixed implant-retained hybrid prosthesis: Report of a novel technique. J Contemp Dent Pract 2016;17:780–782. 49. Emami E, de Souza RF, Kabawat M, Feine JS. The impact of edentulism on oral and general health. Int J Dent 2013;2013:498–305.

50. Gil-Montoya JA, de Mello AL, Barrios R, Gonzalez-Moles MA, Bravo M. Oral health in the elderly patient and its impact on general well-being: A nonsystematic review. Clin Interv Aging 2015;10:461– 467. 51. Dellavia C, Rosati R, Del Fabbro M, Pellegrini G. Functional jaw muscle assessment in patients with a full fixed prosthesis on a limited number of implants: A review of the literature. Eur J Oral Implantol 2014;7(suppl 2):S155–S169. 52. Rosenbaum N. Full-arch implant-retained prosthetics in general dental practice. Dent Update 2012;39:108–116. 53. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP. Implant loading protocols for edentulous patients with fixed prostheses: A systematic review and meta-analysis. Int J Oral Maxillofac Implants 2014;29(suppl):256–270. 54. Balshi TJ, Wolfinger GJ, Slauch RW, Balshi SF. A retrospective analysis of 800 Brånemark System implants following the All-on-Four protocol. J Prosthodont 2014;23:83–88. 55. Malhotra AO, Padmanabhan TV, Mohamed K, Natarajan S, Elavia U. Load transfer in tilted implants with varying cantilever lengths in an All-on-Four situation. Aust Dent J 2012;57:440–445. 56. Krennmair G, Seemann R, Weinländer M, Krennmair S, Piehslinger E. Clinical outcome and peri-implant findings of four-implant-supported distal cantilevered fixed mandibular prostheses: Five-year results. Int J Oral Maxillofac Implants 2013;28:831–840. 57. Drago C. Frequency and type of prosthetic complications associated with interim, immediately loaded full-arch prostheses: A 2-year retrospective chart review. J Prosthodont 2016;25:433–439. 58. Spinelli D, Ottria L, DE Vico G, Bollero R, Barlattani A, Bollero P. Full rehabilitation with Nobel Clinician and Procera Implant Bridge: Case report. Oral Implantol (Rome) 2013;6:25–36. 59. Kwon T, Bain PA, Levin L. Systematic review of short- (5-10 years) and long-term (10 years or more) survival and success of full-arch fixed dental hybrid prostheses and supporting implants. J Dent 2014;42:1228–1241. 60. Francetti L, Rodolfi A, Barbaro B, Taschieri S, Cavalli N, Corbella S. Implant success rates in full-arch rehabilitations supported by upright and tilted implants: A retrospective investigation with up to five years of follow-up. J Periodontal Implant Sci 2015;45:210–215. 61. Krennmair S, Weinländer M, Malek M, Forstner T, Krennmair G, Stimmelmayr M. Mandibular full-arch fixed prostheses supported on 4 implants with either axial or tilted distal implants: A 3-year prospective study. Clin Implant Dent Relat Res 2016;18:1119–1133. 62. Ayub KV, Ayub EA, Lins do Valle A, Bonfante G, Pegoraro T, Fernando L. Seven-year follow-up of full-arch prostheses supported by four implants: A prospective study. Int J Oral Maxillofac Implants 2017;32:1351–1358. 63. Testori T, Galli F, Fumagalli L, et al. Assessment of long-term survival of immediately loaded tilted implants supporting a maxillary full-arch fixed prosthesis. Int J Oral Maxillofac Implants 2017;32:904–911. 64. Lopes A, Maló P, de Araújo Nobre M, Sánchez-Fernández E, Gravito I. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A retrospective report on the 7-years clinical and 5-years radiographic outcomes. Clin Implant Dent Relat Res 2017;19:233–244.

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History of Tilted Implants with an Immediate Prosthesis

W

hile tilted implants are a relatively recent advancement for the restoration of edentulous arches, the benefits of using tilted implants are clear: • An increased osseointegration surface area due to the increase in implant length • Greater primary stability resulting from the ability of the implant to potentially anchor in multiple bicortical bone layers • Reduction of cantilever forces via distal placement and improved distribution across the arch (Fig 2-1) • Elimination or minimization of the need for traditional bone grafting, resulting in reduced morbidity

The development of a protocol for using tilted implants has a relatively long history. One of the first cases in this evolution was a prospective study with a 10-year follow-up that described placing a fixed restoration on immediately loaded Brånemark implants in an edentulous mandible.1 In this study, three implants were less than optimally placed and loaded provisionally, while the remainder were submerged and allowed to integrate. Once the unloaded implants had integrated, the loaded implants were scheduled to be removed. Unexpectedly, most of the loaded implants had integrated as well. Nearly 10 years later, similar results were reported in fully edentulous maxillae and mandibles. In this study, a variety of immediately loaded rigidly splinted implants were used, and some were provisionally loaded, while others were allowed to integrate before final loading.2 Around the same time, another 10-year retrospective study was published.3 This study compared successful delayed-loaded arches in which either four or six implants, 7 mm and 10 mm long, had

CHAPTER

Cantilever length AP spread

Fig 2-1 Cantilever length should not exceed twice the anteroposterior (AP) spread or a maximum of 20 mm.

been placed.3 A similar series of unexpected consequences were reported in a study that involved short implants and osseointegration of implants that were supposed to be sacrificed after provisionalization; in this study, the short implants proved remarkably resilient after immediate loading as revealed by light microscopy analysis.4 The final piece in the synergistic puzzle is a study performed in the early 2000s involving the Marius bridge (Cycad). This is a full-arch removable restoration for fully edentulous maxillae that provides lip support as well as improved speech. By using longer, tilted implants, there is no need for sinus elevation or other bone grafting to achieve optimal anchorage in the bone to support the prosthesis.5 These cases culminated in a study that introduced the optimal use of two tilted and two axial implants with immediate loading in the edentulous maxilla: a four-implant, full-arch restoration treatment.6

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to using a tilted implant for a cantilever partial denture or the restoration of a single tooth.

Factors Guiding Successful Outcomes

Fig 2-2  An angled multiunit abutment on a tilted implant can be used to bring the prosthetic reconstruction in line for the prosthesis-retaining screws.

A successful outcome requires implants to remain immobile during healing, so a number of factors affect the success of immediate loading. Essential components of such an outcome include initial primary stability, optimal implant anchorage, a rigid prosthesis, and a cooperative patient. Primary stability

Tilted Implants and FAIR Full-arch implant rehabilitation (FAIR) procedures successfully restore edentulous and partially edentulous arches by exploiting the surgical and prosthetic advantages of placing distal tilted implants. Because tilted implants reduce cantilever length, they are an effective way to treat edentulous arches via the FAIR approach, making immediate fixed prostheses possible. However, tilted implants should be carefully placed anterior to the maxillary sinus to avoid tearing or rupture of the sinus membrane.7–9 Additionally, the literature confirms that tilted implants do not increase bone resorption.10,11 A number of general recommendations concerning the placement of tilted implants have been documented.12 For example, the best bone quality for placing these implants is D1 and D2 bone. D1 bone is commonly located in the anterior mandible, and D2 bone is commonly found in the anterior maxilla as well as throughout the mandible. Planning and preparation for placement of implants should include three-dimensional (3D) technology and guidance, and a single 3D plane should govern angulations between implants to make prosthetic restoration as simple as possible. Additionally, angulation of implants should ideally not exceed a maximum of 30 degrees because bite and occlusal forces are higher with increased angulation, both for the bone-to-implant interface and the implant-to-abutment interface (Fig 2-2). Finally, implant splinting is preferable

Initial primary stability is a product of several factors, including quality and quantity of local bone, implant geometry, and implant shape. Tapered, self-tapping implants create optimal bone contact based on the diameter of the implant—both internally and externally—due to sharply pitched threads. Initial implant stability is also affected by implant pitch (a wide, deep pitch is the preference), surgical procedure and surgical skill, torque exceeding 45 Ncm during implant insertion, and an implant stability quotient of 70 or higher. Implant anchorage Implant anchorage should include torque values between 45 and 70 Ncm. Additionally, values of resonance frequency analyses should register at 70 or above. The clinician should be certain not to overtorque (ie, > 70 Ncm) because it can disrupt essential biologic processes taking place between the bone and the implant, and these are required for effective osseointegration.13 For example, too much torque can widen the area of damaged osteocytes, increasing resorption and disrupting bone remodeling and repair.14–16 Prosthesis The prosthesis used for immediate loading of the implants is characterized by a rigid, cross-arch stability. The fit is passive, with a minimum of cantilever and bend. Occlusion is governed by clinical remounts and balanced articulation.17–19 Provisional prostheses are generally composed of acrylic resin material, and the terms high-density and resin-based

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Tilted Implants and Restoration of the Edentulous Maxilla

V point

Fig 2-3  A palatal view demonstrating implant anchorage points. The posterior implants are directed toward maximal bone mass at the lateral piriform rim, while the anterior implants are aimed toward the maximal bone mass anteriorly. Depending on the situation, this may be at the nasal floor, at the lateral piriform, or at the midline, which usually extends superiorly into the nasal crest (V point).

Fig 2-4  Posterior implants are tilted distally at about a 30-degree angle and placed parallel to the anterior wall of the maxillary sinuses. The two anterior implants can be straight (axially placed) or slightly tilted as necessary.

are often used as part of their description. Definitive prostheses are often constructed with the application of computer-aided design/computer-assisted manufacturing (CAD/CAM) technologies. Patient cooperation A cooperative patient is essential for successful outcomes. The patient must learn to properly use oral hygiene aids and strictly follow instructions for postoperative care. For example, a liquid diet must be maintained for the first 3 weeks after the procedure, followed by a diet of soft foods for an additional 3 weeks. Clenching and bruxing must be avoided. The patient should begin performing frequent mouth rinses with warm salt water 24 hours after the procedure. Additionally, on day 4 postsurgery, the patient should begin a 10-day process of twice daily oral rinses with chlorhexidine.20–22

Tilted Implants and Restoration of the Edentulous Maxilla In the edentulous maxilla, the posterior, distally tilted implants should be placed at approximately a 30-degree angle, parallel to the anterior wall of the maxillary sinus.

The clinician can place the apex of the tilted implant in the lateral piriform rim, an area of bone that is both relatively dense and nonresorptive. Two implants are placed vertically in the anterior maxilla, although they can also be tilted slightly (Figs 2-3 and 2-4). In most clinical situations, an implant-supported restoration can be fabricated, and immediate loading is possible for select patients. Pterygoid and zygomatic implants Three basic types of angled implants can be placed in the severely compromised edentulous maxilla: pterygoid, zygomatic, and standard tilted implants. The use of pterygoid implants was first described in the late 1970s as an option for restoring function in bone-compromised arches.23 More recent developments occurred in the early and late 1990s and then in the 2000s.24–27 These implants are used to improve the pattern of implant distribution, the anteroposterior (AP) spread, and the biomechanics, and they have a success rate of nearly 91%.28 However, their use has decreased because more predictable techniques are often available, and zygomatic implants are another strong option. Zygomatic implants are used in cases where there is insufficient bone in the alveolar crest or palatal area to support implant placement. Zygomatic implants were first

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History of Tilted Implants with an Immediate Prosthesis

20 mm

20 mm

20 mm

15 mm

10–15 mm

15 mm

Fig 2-5  When abundant bone is present, M-4 implant configurations provide excellent support of the prosthesis with 20 mm between implants.

Fig 2-6  The V-4 pattern also uses four implants with complementary tilted abutments. Implants are placed at 30-degree angles so they form a V shape toward the midline.

envisioned and developed in the 1990s and should be used only in maxillae that are severely resorbed.29–32 Despite their success, there are a number of disadvantages associated with pterygoid and zygomatic implants, including the complexity of the surgery, graft site morbidity, postoperative patient discomfort, and some unpredictability of outcomes.33–35 These have led many clinicians to favor the placement of standard-sized tilted implants parallel to the mental foramen, inferior alveolar nerve, and anterior wall of the maxillary sinus as a more reliable, traditional approach for a full-arch prosthesis.5,36,37 Tilted implants can be used to avoid the anterior loop of the inferior alveolar nerve. Additionally, the use of these implants helps to shorten the distal cantilever. Like pterygoid implants, tilted implants are used to improve the pattern of implant distribution and the AP spread as well as biomechanics. Importantly, these implants can help reduce the risks of both biologic and mechanical failures.

prosthesis support is superb, seldom requiring any distal cantilever. All four implants are designed to receive tilted abutments. In the M-4 pattern, the clinician places the implants in an M-shaped configuration at 30-degree angles, avoiding nasal and pneumatized sinus cavities; the pattern is easily delineated on panoramic radiographs. Moderate resorption of maxillary bone requires the positioning of implants to maximize AP coverage, but because the coverage may not be sufficient, delayed loading may be required if primary implant anchorage is suboptimal.

Position and Angulation of Tilted Implants M-4 configuration In addition to the implant placement configurations now being used by most clinicians, at least two other patterns can improve the primary anchorage of implants: M-4 and V-4 configurations.38,39 The M-4 pattern (Fig 2-5) is best employed in patients with plenty of available bone in the maxilla. With a distance of 20 mm between implants,

V-4 configuration The V-4 pattern (Fig 2-6) also uses four implants with complementary tilted abutments. The clinician places the implants at 30-degree angles (again, to avoid the sinus and nasal cavities), creating a V-formation toward the midline. This configuration is recommended for patients whose maxillae exhibit advanced bone resorption. A thin lateral nasal wall precludes optimal fixation of posterior implants due to the scarcity of bone mass. In such cases, the clinician can target the nasal crest to securely fix anterior vomer implants, which enables a palatal view of the points of implant anchorage. The posterior implants must be placed at the abundant bone mass of the lateral piriform. In contrast, the anterior implants are placed in the maximal bone mass at the midline, usually extending superiorly into the nasal crest V-point (see Fig 2-4). Delayed loading of the implants is preferred in these circumstances, and some sinus grafting may be required.

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References

Conclusion The discovery that dental implants could be successfully loaded immediately after placement in the edentulous maxilla and mandible to support a fixed full-arch prosthesis initiated a significant change in the quest for restoring appearance and function for thousands of edentulous or nearly edentulous patients. The FAIR protocol enables an ever-growing segment of the aging and infirm population of dental patients to avoid complex techniques with high morbidity and still regain dental function and appearance.

References 1. Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 2000;15:405–414. 2. Lee SP, Paik KS, Kim MK. Anatomical study of the pyramidal process of the palatine bone in relation to implant placement in the posterior maxilla. J Oral Rehabil 2001;28:125–132. 3. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and Periotest study. Clin Implant Dent Relat Res 2001;3:39–49. 4. Raviv E, Turcotte A, Harel-Raviv M. Short dental implants in reduced alveolar bone height. Quintessence Int 2010;41:575–579. 5. Balleri P, Ferrari M, Veltri M. One-year outcome of implants strategically placed in the retrocanine bone triangle. Clin Implant Dent Relat Res 2010;12:324–330. 6. Agliardi E, Clericò M, Ciancio P, Massironi D. Immediate loading of full-arch fixed prostheses supported by axial and tilted implants for the treatment of edentulous atrophic mandibles. Quintessence Int 2010;41:285–293. 7. Bedrossian E. Rescue implant concept: The expanded use of the zygoma implant in the graftless solutions. Dent Clin North Am 2011;55:745–777. 8. Fortin T, Camby E, Alik M, Isidori M, Bouchet H. Panoramic images versus three-dimensional planning software for oral implant planning in atrophied posterior maxillary: A clinical radiological study. Clin Implant Dent Relat Res 2013;15:198–204. 9. Peñarrocha Diago M, Maestre Ferrín L, Peñarrocha Oltra D, Canullo L, Calvo Guirado JL, Peñarrocha Diago M. Tilted implants for the restoration of posterior mandibles with horizontal atrophy: An alternative treatment. J Oral Maxillofac Surg 2013;71:856–864. 10. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310–320. 11. Malo P, de Araujo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept: A clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14:e139–e150. 12. Lopes A, Malo P, de Araujo Nobre M, Sanchez-Fernandez E. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A prospective report on medium- and long-term outcomes. Clin Implant Dent Relat Res 2015;17:e406–e416.

13. Malo P, de Araujo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623. 14. Malo P, Araujo 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;24:263–270. 15. Malo P, de Araujo Nobre M, Lopes A, Ferro A, Gravito I. All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: A 7-year clinical and 5-year radiographic retrospective case series with risk assessment for implant failure and marginal bone level. Clin Implant Dent Relat Res 2015;17:e531–e541. 16. Ali SA, Karthigeyan S, Deivanai M, Kumar A. Implant rehabilitation for atrophic maxilla: A review. J Indian Prosthodont Soc 2014;14:196– 207. 17. Rangert B, Jemt T, Jörneus L. Forces and moments on Branemark implants. Int J Oral Maxillofac Implants 1989;4:241–247. 18. Zurdo J, Romão C, Wennström JL. Survival and complication rates of implant-supported fixed partial dentures with cantilevers: A systematic review. Clin Oral Implants Res 2009;20(suppl 4):59–66. 19. Salvi GE, Brägger U. Mechanical and technical risks in implant therapy. Int J Oral Maxillofac Implants 2009;24(suppl):69–85. 20. Block MS, Haggerty CJ, Fisher GR. Nongrafting implant options for restoration of the edentulous maxilla. J Oral Maxillofac Surg 2009;67:872–881. 21. Ata-Ali J, Peñarrocha-Oltra D, Candel-Marti E, Peñarrocha-Diago M. Oral rehabilitation with tilted dental implants: A metaanalysis. Med Oral Patol Oral Cir Bucal 2012;17:e582–e587. 22. Agliardi EL, Romeo D, Panigatti S, de Araújo Nobre M, Maló P. Immediate full-arch rehabilitation of the severely atrophic maxilla supported by zygomatic implants: A prospective clinical study with minimum follow-up of 6 years. Int J Oral Maxillofac Surg 2017;46:1592–1599. 23. Schnitman PA, Wohrle PS, Rubenstein JE. Immediate fixed interim prostheses supported by two-stage threaded implants: Methodology and results. J Oral Implantol 1990;16:96–105. 24. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: Ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants 1997;12:319–324. 25. Brånemark PI, Svensson B, van Steenberghe D. Ten-year survival rates of fixed prostheses on four or six implants ad modum Brånemark in full edentulism. Clin Oral Implants Res 1995;6:227–231. 26. Sendax VI. Mini-implants as adjuncts for transitional prostheses. Dent Implantol Update 1996;7:12–15. 27. Fortin Y, Sullivan RM, Rangert BR. The Marius implant bridge: surgical and prosthetic rehabilitation for the completely edentulous upper jaw with moderate to severe resorption: A 5-year retrospective clinical study. Clin Implant Dent Relat Res 2002;4:69–77. 28. Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: A 1-year retrospective clinical study. Clin Implant Dent Relat Res 2005;7(suppl 1):S88–S94. 29. Testori T, Mandelli F, Mantovani M, Taschieri S, Weinstein RL, Del Fabbro M. Tilted trans-sinus implants for the treatment of maxillary atrophy: Case series of 35 consecutive patients. J Oral Maxillofac Surg 2013;71:1187–1194. 30. Agliardi EL, Romeo D, Wenger A, Gastaldi G, Gherlone E. Immediate rehabilitation of the posterior maxilla with extensive sinus pneumatization with one axial and one trans-sinus tilted implant: A 3-year clinical report and a classification. J Prosthet Dent 2015;113:163–168.

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31. Tallarico M, Better H, De Riu G, Meloni SM. A novel implant system dedicate to hydraulic Schneiderian membrane elevation and simultaneously bone graft augmentation: An up-to 45 months retrospective clinical study. J Craniomaxillofac Surg 2016;44:1089–1094. 32. Queridinha BM, Almeida RF, Felino A, de Araújo Nobre M, Maló P. Partial rehabilitation with distally tilted and straight implants in the posterior maxilla with immediate loading protocol: A retrospective cohort study with 5-year follow-up. Int J Oral Maxillofac Implants 2016;31:891–899. 33. Casar-Espinosa JC, Castillo-Oyagüe R, Serrera-Figallo MÁ, et al. Combination of straight and tilted implants for supporting screw-retained dental prostheses in atrophic posterior maxillae: A 2-year prospective study. J Dent 2017;63:85–93. 34. Asawa N, Bulbule N, Kakade D, Shah R. Angulated implants: An alternative to bone augmentation and sinus lift procedure: Systematic review. J Clin Diagn Res 2015;9:ZE10–ZE13.

35. Insua A, Monje A, Wang HL, Miron RJ. Basis of bone metabolism around dental implants during osseointegration and peri-implant bone loss. J Biomed Mater Res A 2017;105:2075–2089. 36. Bidgoli M, Soheilifar S, Faradmal J, Soheilifar S. High insertion torque and peri-implant bone loss: Is there a relationship? J Long Term Eff Med Implants 2015;25:209–213. 37. Glibert M, De Bruyn H, Östman PO. Six-year radiographic, clinical, and soft tissue outcomes of immediately loaded, straight-walled, platform-switched, titanium-alloy implants with nanosurface topography. Int J Oral Maxillofac Implants 2016;31:167–171. 38. Berardini M, Trisi P, Sinjari B, Rutjes AW, Caputi S. The effects of high insertion torque versus low insertion torque on marginal bone resorption and implant failure rates: A systematic review with meta-analyses. Implant Dent 2016;25:532–540. 39. Bressan E, Grusovin MG, D’Avenia F, et al. The influence of repeated abutment changes on peri-implant tissue stability: 3-year post-loading results from a multicentre randomised controlled trial. Eur J Oral Implantol 2017;10:373–390.

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CHAPTER

Identifying and Evaluating Candidates

T

here are a number of psychosocial considerations for dental patients with edentulous or nearly edentulous arches.1 Patients who have complete or partial dentures are often embarrassed because of perceived esthetic shortcomings, and they may suffer from functional discomfort and compromised denture retention accompanied by difficulty speaking and chewing. Although there are denture adhesive applications to combat these esthetic and functional problems, many denture patients consider their use a personal and social burden.2–6 Full-arch implant rehabilitation (FAIR) prostheses can provide these patients with the functional and esthetic alternatives they seek, including quality-of-life enhancements of increased personal well-being and self-esteem. FAIR patients generally range in age from the mid-50s to mid-80s and have as many as eight functioning teeth that may suffer from moderate to advanced periodontal disease. These patients can expect predictable restoration with up to 70% of the esthetics and functionality of their natural teeth7–10 (Box 3-1). However, many candidates assume they will achieve 100% of their natural function, and this is why it is very important to be as explicit as possible from the beginning. Patient concerns about quality of esthetics and function often extend to questions concerning the quality of FAIR materials (eg, the brand of the implant system, the material used for the definitive prosthesis, etc). The clinician should indulge this curiosity because it may save future time and expenses, especially if the patient makes assumptions based on incomplete information. Many elderly patients—and even many middle-aged candidates for the FAIR procedure—have concerns that center on timing, such as the practicality of wearing a

BOX 3-1

Relative esthetic and functional capacity

Natural teeth

100%

Fixed implant partial denture

90%

FAIR technique

70%

Implant-supported overdenture

55%

Maxillary denture

30%

Mandibular denture

10%

No teeth, no denture

0%

removable denture for up to 1 year between tooth extraction and delivery of the definitive prostheses. However, in the FAIR case, which employs a transitional screw-in prosthesis, there is always a fixed prosthesis in place even during the implant osseointegration period, limiting or eliminating the need to wear a removable denture during the treatment phase.11–12

Evaluating the FAIR Patient The clinician should thoroughly evaluate the patient before choosing an appropriate treatment protocol4–7 (Fig 3-1). Evaluations should include the patient’s medical history and how his or her overall condition might affect expected outcomes from the surgical treatment. The patient’s dental history must include any history of dental failure due to periodontal disease or other conditions such as clenching or bruxing. A panoramic radiographic should be included in the initial records to help determine if a full-mouth periapical

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Identifying and Evaluating Candidates

Medical history, chief complaint, and patient expectations Note any conditions that might affect the patient’s treatment outcome or their suitability for a surgical procedure. The patient’s expectations should also be discussed and recorded.

Intraoral and extraoral examination For patients with remaining teeth, the oral examination is always based on periodontal findings and the disease status of the remaining teeth and soft tissue.

Dental history Understand the patient’s expectations and history with dental failure (eg, periodontal disease) as well as habits including clenching and bruxing.

Radiographic analysis Initial radiographic evaluation can be done with the help of a panoramic radiograph. The practitioner can then decide if other methods are needed, such as a full-mouth periapical series, a cone beam computed tomography (CBCT) scan, or medical CT scan.

Fig 3-1 A thorough evaluation is necessary to choose the right treatment and to establish a predictable treatment outcome.

series, a computed tomography (CT) scan, or a cone beam CT (CBCT) analysis is required. History, complaint, and expectations The answers a patient gives to several important treatment planning questions can provide the clinical team with information that is vital to a successful treatment outcome13 (Box 3-2). Specifically, patients should be asked to describe any type of discomfort or pain associated with their use of a full or partial denture. They can also be asked about their experience sleeping while wearing dentures, if they notice a burning sensation in the mouth, or if the denture produces sore spots in the mouth. Regarding esthetics, patients should explain any changes they have noticed in their facial appearance and indicate whether they are happy with their appearance and confident when smiling. They should be encouraged to explain any concerns they have about signs of aging resulting from wearing their denture. Functional questions should address their experiences eating and speaking comfortably without pain or looseness of the denture.13,14 Patients should be asked how they feel about using denture adhesives and the history and frequency of any past use. Can the patient easily eat dry

foods, such as granola bars? Do they ever notice dryness of the mouth or lips? Do the patient’s lips ever stick together?15 Patients should explain whether chewing challenges limit the types of foods they can eat, if they require special food preparation, and whether they feel that they can generally eat the foods they like without interference from the denture.16 Dental history The clinician should inquire about the patient’s dental history relative to the use of dentures, including the reasons for tooth loss (eg, periodontal disease, destructive function, dental caries), how long they have been wearing dentures, the last time their current dentures were relined or adjusted, and if they used a removable partial denture before acquiring a full denture.17 The FAIR patient’s current esthetics (eg, smile line) and function (eg, vertical occlusal dimension) are crucial determinants for treatment.18 Necessary preoperative correctives may be required to address poor-fitting dentures, limited interocclusal space, incorrect bite, and insufficient space for a prosthesis. The ideal candidate for the FAIR protocol has eight teeth or fewer per arch, moderate to advanced

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BOX 3-2

Treatment planning questions

Comfort • Please describe any type of discomfort or awareness of pain associated with your denture or partial denture. • What is your experience sleeping with dentures in your mouth? • Do you notice a burning sensation in your mouth? Please explain. • Do you currently have sore spots from your denture? Please explain. Esthetics • Have you noticed changes in the appearance of your face? Please explain. • Are you happy with the appearance of your teeth? Please explain. • Are you confident with your smile? Please explain. • Are you concerned with signs of aging (appearance of face)? Please explain. • Do you have sores at the corners of your mouth? Please explain. Function: Chewing and speaking • Can you eat and speak comfortably without pain or looseness of the denture? Please explain.

periodontal disease, cost concerns (eg, no wish for a crown, partial denture, or graft), and a desire for a same-day fixed provisional restoration (Figs 3-2 and 3-3). Examinations The clinician should perform intraoral and extraoral examinations. The condition of remaining teeth, the existence of caries, the patient’s occlusion (and discrepancies in occlusion), and any tooth migration should be carefully evaluated and documented.19 Patients with remaining teeth should be examined based on periodontal findings and disease status of both teeth and soft tissue. Patients with partial or complete edentulism should be evaluated for general and specific soft tissue conditions.20 Photographic evaluation should include the following views: • Full face and reposed lips with and without denture or partial denture

• Do you use denture adhesives? Occasional or routine? What is your attitude toward adhesives? Please explain. • Can you easily eat dry foods (for example, a granola bar)? Please explain. • Do you ever notice dryness of your mouth, including your lips? Please explain. • Do you ever feel like your lips stick together? Please explain. • What food limitations have you experienced because of chewing challenges? Do you have any special requirements for food preparation? • Can you eat what you would like to eat? Please explain. Dental history • When was your last reline or adjustment of this denture? • How long have you been using dentures? How long have you been using this particular denture? • Did you use a removable partial denture before obtaining your complete denture? Please explain. • What was the reason for tooth loss?

• Full face smiling with and without denture or partial denture • Lips retracted and teeth apart with and without denture or partial denture • Lips retracted and teeth together: frontal, right, and left • Lateral full face • Lateral smile • Intraoral alveolar ridge without denture • Occlusal and intaglio aspects without denture Esthetic and phonetic components of the case evaluation should include nasolabial angle, facial midline, occlusal plane, lips (support, size, and dynamics), tooth display at rest and when speaking, smile line, and transition zone.21 For both edentulous and partially edentulous patients, a base plate and bite rim can be used to capture the vertical dimension of occlusion (ie, the relationship of the mandible and maxilla with the teeth at maximal intercuspation).

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b

a

c

Fig 3-2 (a to c) A partially edentulous patient with 0 to 8 teeth in the maxilla and moderate to advanced periodontal bone loss is the ideal candidate for maxillary FAIR treatment.

b

a

c

Fig 3-3 (a to c) This patient is fully edentulous in the maxilla and is also an ideal candidate for FAIR treatment.

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Fig 3-4 A three-dimensional STL model from the CT scan is extremely helpful in treatment planning for the surgery.

a

c

b

d

Fig 3-5 Four broad categories of ideal FAIR candidates. (a) Partially edentulous maxilla. (b) Fully edentulous maxilla. (c) Partially edentulous mandible. (d) Fully edentulous mandible.

Radiographic analysis Patients should be evaluated for availability and quantity of bone to maximize the possibility of immediate function of the prosthesis.22 The availability of both hard tissue and soft tissue is what determines the type of definitive prosthesis that will be placed. CT scans are used to plan the treatment and to design the case, including possible use of a three-dimensional stereolithographic (STL) model (Fig 3-4).

Treatment Planning Case classification FAIR cases fall into four broad categories (Fig 3-5): the fully or partially edentulous maxilla and the fully or partially edentulous mandible. Each of these cases requires a different perioperative approach. For example, maxillary cases require surgical avoidance of the sinus and engagement of the sinus wall, whereas mandibular cases require avoidance of the mental foramen. In partially edentulous cases, measurements are based on adjacent

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> 20 mm 18–20 mm 15–17 mm 12–14 mm 11 mm

Fixed prosthesis zone: 11 mm Crown and root fixed prosthesis zone: 12–14 mm FAIR prosthesis zone: 15–17 mm Overdenture prosthesis zone: 18–20 mm Bar overdenture prosthesis zone: > 20 mm

Fig 3-6 The optimal prosthetic options based on distance from bone to the incisal edge of the final intended restorations.

teeth; in fully edentulous cases, they are based on the patient’s denture. Fully edentulous cases may or may not require bone removal or a blood draw for employment of platelet-rich plasma therapies, but partially edentulous cases will involve both as well as bone grafts and the use of different socket-debriding burs. Measurements Distance to bone In a partially edentulous maxillary case, the right central incisor may be missing and the left present, so a periapical radiograph will be needed to measure from the incisal edge of the left central incisor up to the bone. However, in a fully edentulous maxilla, this measurement must be made with the denture in place and taken from the incisal edge of the denture teeth up to the bone on the CT scan or panoramic radiograph. The recommended treatment option will vary depending on the measurement (Fig 3-6). If the measurement is 11 mm, a normal crown can be placed at the right incisor site, but if it is 15 mm, the crown will most likely include pink or root-colored porcelain. Depending on the esthetics, a partial denture may

be a better option than an implant. If the measurement from incisal edge to bone is 15 to 17 mm as determined by the clinician’s examination of a periapical or panoramic radiograph (accounting for magnification) or CT scan, then a hybrid prosthesis is required due to the lack of available gingival tissue. This is the most appropriate candidate for the FAIR procedure. If the measurement is 18 to 20 mm, the patient requires an overdenture. A measurement greater than 20 mm from the incisal edge of the denture to the bone probably requires a bar overdenture. These measurement variables require the clinician to decide which of the five restorative options best suits the patient’s needs. Insufficient bone may prohibit a FAIR solution and instead call for an overdenture or zygomatic implants. An abundance of bone may also preclude a FAIR procedure and call instead for a traditional fixed prosthesis solution. Occasionally, bone grafts that increase vertical bone height can “upgrade” a patient from a more complex restoration to a simpler restoration. For the most common partially edentulous cases, the clinician hopes for an ideal measurement of 15 mm from the incisal edge of a nonsupererupted tooth to the bone. If the measurement is 13 to 14 mm, bone grinding is required to reach 15

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a

b

Fig 3-7 (a) This case is successful because the transition line (green dotted line) is apical to the smile line (red dotted line). (b) If the transition line is coronal to the smile line, it is a an esthetic failure.

mm. The 15-mm measurement should not only provide the strength needed for the definitive prosthesis but also hide the transition line from the acrylic to the gingiva. Smile and lip line For patients with high smile lines, a measurement of 17 to 18 mm is preferred to conceal the transitional line from the prosthesis to the patient’s gingiva. Conversely, patients with a low smile line may require a measurement of only 15 mm. Less distance than that, however, can compromise the strength of the prosthesis. The 15 to 17–mm protocol combines optimal esthetics with technologically sound function based on the length of the implants and the type of bone in which they are placed. Evaluating the smile line and the transition line of the prosthesis can help in establishing potential esthetic considerations. The transition line must be apical to the smile line for an esthetic outcome (Fig 3-7a). If the transition line is coronal to the smile line, the outcome is unesthetic (Fig 3-7b). Bone volume and density Bone volume can be evaluated with a CT scan and radiographs to help determine the implant and restoration

options. Bone resorption is designated as mild, moderate, or severe23,24 (Figs 3-8 and 3-9). Additionally, accurate records must be made to assess the condition of the oral mucosa; alveolar ridges; and facial, cheek, and lip support, including contours. The clinician should take impressions of both arches and a bite registration, including the palate and vestibules in the maxilla and the retromolar pads in the mandible. Model evaluation Incisal/bone measurements to determine bone removal can be made based on existing teeth. Use palatal references in the maxilla and the retromolar pad in the mandible to obtain proper seating measurements. Another method is to obtain a bite registration by using the immediate prosthesis from the laboratory in conjunction with bite registration materials once remaining teeth have been extracted. This type of immediate occlusal guide can be used to verify the measurements obtained by more traditional methods. A midline deviation of up to 4 mm is not a concern esthetically, but in cases where the deviation may be greater, the occlusal guide can help the clinician avoid complications. The guide can also be used to confirm the proper vertical dimension.

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No resorption

d

c

Mild resorption

f

e

Moderate resorption

h

g

Advanced resorption

Fig 3-8 Bone resorption severity in the maxilla. (a and b) No resorption. (c and d) Mild resorption. (e and f) Moderate resorption. (g and h) Advanced resorption. Red dotted box indicates optimal amounts of resorption for the FAIR procedure.

b

a

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No resorption

d

c

Mild resorption

f

e

Moderate resorption

h

g

Advanced resorption

Fig 3-9 Bone resorption severity in the mandible. (a and b) No resorption. (c and d) Mild resorption. (e and f) Moderate resorption. (g and h) Advanced resorption. Red dotted box indicates optimal amounts of resorption for the FAIR procedure.

b

a

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References 1. Allen PF, McMillan AS. A review of the functional and psychosocial outcomes of edentulousness treated with complete replacement dentures. J Can Dent Assoc 2003;69:662. 2. Leles CR, Ferreira NP, Vieira AH, Campos AC, Silva ET. Factors influencing edentulous patients’ preferences for prosthodontic treatment. J Oral Rehabil 2011;38:333–339. 3. Heath MR. The effect of maximum biting force and bone loss upon masticatory function and dietary selection of the elderly. Int Dent J 1982;32:345–356. 4. Wolff A, Gadre A, Begleiter A, Moskona D, Cardash H. Correlation between patient satisfaction with complete dentures and denture quality, oral condition, and flow rate of submandibular/sublingual salivary glands. Int J Prosthodont 2003;16:45–48. 5. Chierici G, Lawson L. Clinical speech considerations in prosthodontics: Perspectives of the prosthodontist and speech pathologist. J Prosthet Dent 1973;29:29–39. 6. Reissmann DR, Dard M, Lamprecht R, Struppek J, Heydecke G. Oral health-related quality of life in subjects with implant-supported prostheses: A systematic review. J Dent 2017;65:22–40. 7. Dellavia C, Rosati R, Del Fabbro M, Pellegrini G. Functional jaw muscle assessment in patients with a full fixed prosthesis on a limited number of implants: A review of the literature. Eur J Oral Implantol 2014;7(suppl 2):S155–S169. 8. Rosenbaum N. Full-arch implant-retained prosthetics in general dental practice. Dent Update 2012;39:108–116. 9. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP. Implant loading protocols for edentulous patients with fixed prostheses: A systematic review and meta-analysis. Int J Oral Maxillofac Implants 2014;29(suppl):256–270. 10. Balshi TJ, Wolfinger GJ, Slauch RW, Balshi SF. A retrospective analysis of 800 Brånemark System implants following the All-on-Four protocol. J Prosthodont 2014;23:83–88. 11. Misch CM. Immediate loading of definitive implants in the edentulous mandible using a fixed provisional prosthesis: The denture conversion technique. J Oral Maxillofac Surg 2004;62(9 suppl 2):106–115. 12. Cibirka RM, Linebaugh ML. The fixed/detachable implant provisional prosthesis. J Prosthodont 1997;6:149–152.

13. Sclar AG, Cardenas JD, Von Haussen U. Diagnostically driven planning and execution of an All-on-4 treatment concept. Compend Contin Educ Dent 2015;36:332–338. 14. 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;66:112–122. 15. Uhlendorf Y, Sartori IA, Melo AC, Uhlendorf J. Changes in lip profile of edentulous patients after placement of maxillary implant-supported fixed prosthesis: Is a wax try-in a reliable diagnostic tool? Int J Oral Maxillofac Implants 2017;32:593–597. 16. Allen F, McMillan A. Food selection and perceptions of chewing ability following provision of implant and conventional prostheses in complete denture wearers. Clin Oral Implants Res 2002;13:320–326. 17. Koper A. The initial interview with complete denture patients: Its structure and strategy. J Prosthet Dent 1970;23:590–597. 18. Sheridan RA, Decker AM, Plonka AB, Wang HL. The role of occlusion in implant therapy: A comprehensive updated review. Implant Dent 2016;25:829–838. 19. Palla S. Occlusal considerations in complete dentures. In McNeil C (ed). Science and Practice of Occlusion. Chicago: Quintessence, 1997:457–467. 20. McGarry TJ, Nimmo A, Skiba JF, Ahlstom RH, Smith CR, Koumjian JH. Classification system for complete edentulism. The American College of Prosthodontics. J Prosthodont 1999;8:27–39. 21. Rosenlicht JL, Ward JA, Krauser JT. Immediate loading of dental implants In: Babbush CA, Hahn JA, Krauser JT, Rosenlicht JL (eds). Dental Implants: The Art and Science, ed 2. St Louis: Saunders, 2010:340–354. 22. Maló P, de Araújo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623. 23. Chugh T, Jain AK, Jaiswal RK, Mehrotra P, Mehrotra R. Bone density and its importance in orthodontics. J Oral Biol Craniofac Res 2013;3:92–97. 24. Parel SM, Phillips WR. A risk assessment treatment planning protocol for the four implant immediately loaded maxilla: Preliminary findings. J Prosthet Dent 2011;106:359–366.

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T

he full-arch implant rehabilitation (FAIR) offers edentulous patients the opportunity to have a full-arch fixed restoration even if their bone levels are insufficient and of very poor quality. With FAIR, this can be done without the complex surgeries, high morbidity rates, and extensive treatment costs that often accompany bone regeneration and grafting. Additionally, many patients can benefit from the FAIR protocol because it restores both esthetics and function, not only with high success rates but also in a relatively short period. These patients may include elderly patients who previously were not candidates for maxillary reconstruction with bone grafting. Therefore, in many respects, the FAIR protocol represents the culmination of decades of implant-driven full-arch rehabilitation practices that have restored thousands of edentulous or nearly edentulous patients to almost natural dental appearance and function.1–19 Importantly, FAIR and similar protocols accomplish their goals with methods no more complex than those used to place traditional implants—but in less time, at a lower cost, and with less morbidity for a growing number of previously untreatable patients20–22 (Box 4-1).

Surgical Guidelines for Edentulous Arches The FAIR standard surgical protocol requires the placement of two to three implants in the traditional axial positions with zero or minimal angulation and two tilted posterior implants angled approximately 30 degrees distally to avoid anatomical barriers such as the maxillary sinus floor in the maxilla and the mental nerve in the mandible (Fig 4-1). In the

BOX 4-1

CHAPTER

The basic concepts of FAIR

• The use of tilted posterior implants to overcome bony deficits or avoid vital anatomical structures • Four to six dental implants to support a full-arch fixed prosthesis • Immediate loading when possible • Single-day treatment for extractions, implant placement, and possible provisionalization with a fixed prosthesis

edentulous maxilla, the tilted implants closely parallel the maxillary anterior sinus wall. Therefore, the implant surgeon must be thoroughly acquainted with the lateral piriform rim, the nasal floor, the incisive nerve and foramen, the anterior wall of the sinus, the crestal width, and the midline.23–27 For the FAIR protocol, the crestal bone ridge of the edentulous maxilla from canine to canine must be at least 4 mm wide and 10 mm high (Fig 4-2a). In contrast, the implants for mandibular rehabilitation follow the anterior loop of the mental nerve.28–31 The clinician should take great care to not only identify the mental foramen but also to have an idea of the path of the anterior loop of the mental nerve. In most patients with edentulous mandibles, the mandibular symphysis (ie, the bone located between the canines) is present for dental implant placement. Anatomically, the bone ridge in the interforaminal region must be at least 4 mm wide and 8 mm high to receive the tilted implants (Fig 4-2b). It is important to note that while immediate provisionalization of both arches is the goal of the FAIR protocol, the

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a

b

Fig 4-1 The FAIR protocol includes two implants in the traditional axial position and two tilted posterior implants angled 30 degrees distally to avoid anatomical barriers such as the maxillary sinus floor (a) and the mental nerve (b).

10-mm height

8-mm height

4-mm width

a

4-mm width b

Fig 4-2 (a) Crestal bone ridge of the maxilla from canine to canine must be at least 4 mm wide and ≥ 10 mm high. (b) Bone ridge in the interforaminal region of the mandible must be at least 4 mm wide and ≥ 8 mm high to receive the tilted implants.

clinician must consider each case carefully (Fig 4-3). For example, if the torque necessary to tighten the implants for immediate functioning is not reached, then an alternate loading protocol may have to be followed. Such a protocol could, for example, require traditional delayed loading of the provisional and definitive prostheses to ensure survival of the implants and treatment success.32–36 Implant positioning in the maxilla In the maxilla, the posterior implants are placed first, followed by the anterior implants. Bilateral releasing incisions are made buccally in the first molar area of the maxilla to raise a mucoperiosteal flap along the crest of the ridge. While the clinician can determine the precise location of the anterior wall of the sinus by using a round bur to create a small window in the anterior wall of the sinus cavity, the current protocol suggests establishing this landmark instead via

elevation of the nasal floor to determine the position of the lateral piriform rim. The clinician can shift the position of a posterior implant by tilting it approximately 30 degrees, following the anterior sinus wall. This shift causes an otherwise vertically placed implant in the canine/first premolar region to become a tilted implant in the second premolar/ first molar region. The inclination is then corrected when a 30-degree angulated abutment is placed on the tilted implant. In contrast, the anterior implants for maxillary rehabilitation are usually placed in the sites of the lateral or central incisors. The clinician orients the anterior implants by attaching guide pins and aligning them using a clear denture duplicate template fabricated from the immediate denture. The apices of the tilted posterior implants typically extend to the canine region, so the positions of the anterior implants must be carefully selected to avoid any conflict.

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Surgical Guidelines for Edentulous Arches

a

No bone available

b

Bone available until lateral incisors

c

Bone available until first premolar

d

Bone available until second premolar

e

Bone available until first molar

f

Good bone volume

Fig 4-3 (a to f) The chosen protocol will depend on the patient’s clinical situation.

Implant positioning in the mandible In the mandible, the anterior implants are placed first, followed by the posterior implants. A crestal incision is made from first molar to first molar to raise a mucoperiosteal flap in the mandible. To allow proper flap reflection and easy identification of the mental nerve without damaging it, a vertical releasing incision approximately 7 mm long should be made in the midline. This placement is especially important when the clinician encounters superficial mental foramina, as is usually the case with an extremely resorbed mandible. The two distal implants are placed at a 30-degree angle distally relative to the occlusal plane just anterior to the

foramina and the anterior loops of the mental nerve. When placed properly, the posterior implants, which should be approximately 4 mm in diameter, usually surface at the site of the second premolar. The anatomy of the jaw guides the placement of the additional two anterior implants; they are tilted posteriorly in a severely resorbed arch. Both the posterior and anterior implants require complementary angulated multiunit abutments. For the anterior implants, the angle of the abutments is generally between 0 and 17 degrees; however, for the posterior implants, the angle is generally 30 degrees. The clinician chooses these abutment angulations to help ensure an occlusal or lingual location for the access holes of the prosthetic screws. The

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Fig 4-4 Prefabricated denture with bite registration.

clinician should also ensure that the height of the platform on the four abutments is the same to yield a prosthesis that not only facilitates hygiene but also is mechanically correct.

FAIR Surgical Guide and Immediate Denture The process of creating an immediate denture for the patient undergoing total-arch rehabilitation involves several steps.37–39 First, the dental laboratory creates a wax try-in denture derived from the patient’s dental arch impression and bite registration. The wax try-in denture helps to confirm the vertical dimension of the arch, esthetics and phonetics, and facial support. During this phase of the procedure, the clinician makes any necessary modifications and other improvements to the denture (Fig 4-4). Production of the immediate denture by the dental laboratory follows the modifications made to the wax try-in denture; the process includes remounting and equilibration, cross mounting, occlusal guide and bite registration, duplicating the denture in clear acrylic, making a lingual trough in the clear denture duplicate to create a surgical template, adding angulation markings for the posterior implants on the template if desired, and marking the template with the necessary degree of ridge reduction. The clinician should rely on established tilted implant concept brands for their armamentarium, such as Zimmer, Nobel Biocare, ImplantVision, or Astra EV. The ImplantVision system uses multiunit abutments, combining both straight and angled components. For four to six implants, a

good assortment of abutments includes six of each of the following: 30-degree, 18-degree, 9-degree, and 0-degree. Additional tools for a converted denture prosthesis include titanium sleeves and retaining screws, analogs (recyclable), direction indicators, a positioning guide for the clear denture duplicate template, and a prosthetic torque wrench.

The FAIR Surgery Prior to surgery, the clinician must measure and mark the vertical dimension of occlusion. To preserve the patient’s actual vertical dimension, the clinician places the implants using the immediate clear denture duplicate template as a guide. Before the patient’s teeth are extracted, the surgical specialist must mark the chin and nose of the patient to measure the distance between these two anatomical features while in occlusion (Fig 4-5). Small dot marks can be made on the nose and chin and measured with a ruler to obtain the correct vertical dimension. This measurement can be considered a safeguard measurement of the vertical dimension of occlusion in case seating of the prostheses using the retromolar pad and the palate reveals a grossly obvious disproportion. If both arches are being treated simultaneously, 22 to 26 mm of interarch space is required. If a single arch is being treated, 15 to 17 mm of space is required for the given arch. Once anesthesia has been administered, flaps are reflected, and any remaining teeth are extracted (Fig 4-6). The clinician can then begin leveling and reducing the alveolar bone in preparation for implants (Fig 4-7). Ridge

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The FAIR Surgery

Fig 4-6 Any remaining teeth are extracted.

Fig 4-5 Marking the nose and chin to measure vertical dimension.

a

Fig 4-7 Irregularities in the alveolar bone are leveled in preparation for implants.

b

Fig 4-8 (a and b) Ridge-contouring burs of various sizes.

reduction should be accomplished to remove any irregularities and create the appropriate vertical dimension of occlusion. Generally, aggressive grinding of bone should be avoided to maintain at least some cortical bone at the crest (and not just cancellous bone). Implant threads should not be exposed, so at least 8 mm of bone width in a buccolingual dimension must be maintained at the crest (4 mm for the implant width and 2 mm each for the lingual and buccal aspects). The clinician can mark the clear denture duplicate template flange at 15 mm from the incisal edge

to create a guide for the ridge reduction. An even easier method is to cut the flange exactly to 15 mm: Take the clear denture duplicate template and cut it from first premolar to first premolar at 15 mm above the incisal edge. The bone is then cut to the flange. To create a broad shelf to facilitate implant placement, a specialized bur is used like that normally used for grinding dentures but adapted to easily produce a convex surface (Fig 4-8). This method for bone contouring is superior to the use of a piezoelectric drill or a reciprocating saw. The

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Fig 4-9 The clear denture duplicate template and the angled direction indicators are used to confirm proper implant angulation.

Fig 4-10 Placing multiunit abutments. The abutments should be only hand-tightened at first.

adapted bur has a latch attachment to fit the implant motor, but it is long enough to fit in a straight attachment similar to the kind used for creating sinus windows. The bur should be run at 2,000 rpm. The clinician should complete one arch at a time to avoid losing the vertical dimension. If both dental arches are being rehabilitated, the maxilla should be provisionalized with its denture first, using the palate for guidance in the maxillary denture. However, in the mandible, the clinician should use the retromolar pad and bite registration as guides. The implants should be equally distributed and tilted to avoid the maxillary sinus in the maxilla and the mental nerve in the mandible. To load the implants provisionally with the patient’s immediate denture, 45 Ncm of torque must be achieved for the implants to reach initial stability. Tilting the implants at placement involves a number of factors, including bone availability and the increased amount of cantilever obtainable via angulation. The clinician should remember that a tilted implant better supports cantilevers. When less bone is available, longer tilted implants can usually be used. Tilting also allows for avoidance of the mental foramen and the anterior loop of the mental nerve in the mandible as revealed in computed tomography (CT) scans. Occasionally bone augmentation may be necessary,

such as a sinus elevation in the maxilla or grafting above the inferior alveolar nerve in the mandible. The trough of the clear surgical template is used after implants are placed in conjunction with direction indicators placed on the implants to confirm proper angulation (Fig 4-9). Repositioning the implants may be necessary if the trough does not align with the direction indicators. The direction indicators must not be too far facially because this can be a concern for the esthetics of the prosthesis.

Immediate Provisionalization Once the implants are placed, the next step in the process is to attach the multiunit abutments. Initially, the abutments should be only hand-tightened (Fig 4-10), and the clinician should confirm proper seating via radiography. Once the proper seating of the abutments has been verified radiographically, the clinician can torque the tilted abutments to 15 Ncm and the straight abutments to 35 Ncm. Prior to suturing, multiunit healing caps can be attached to the multiunit abutments. At this point, holes or apertures will be drilled in the immediate prosthesis for the prosthetic abutments. There

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Immediate Provisionalization

Fig 4-11 Bite registration material is applied to the intaglio surface of the denture.

a

Fig 4-12 Holes are drilled in the locations of the ambutments.

b

Fig 4-13 (a) Titanium sleeves are attached to the abutments. (b) The titanium sleeves should fit passively through the holes drilled in the denture.

are two options to register the proper location of the apertures: vacuforming or bite registration material (eg, Futar, Kettenbach). If the vacuforming option is chosen, the vacuformed denture duplicate is placed in the patient’s mouth and used to mark the four implant points. The vacuform retainer can then be used as a guide to drill the apertures for the implant copings. If the bite registration method is chosen, bite registration material is applied to the intaglio surface of the denture (Fig 4-11). The denture is placed, using the palate (in the maxilla) or retromolar pad (in the mandible) to seal the denture and create marks in the

bite registration material in the implant multiunit abutment locations. After the aperture locations are marked on the prosthesis, the holes are cut with a drill, and impression material is removed (Fig 4-12). Titanium sleeves are attached to the abutments and should protrude through the holes in the prosthesis to confirm the ability to attach them to the prosthesis (Fig 4-13). The next step is to convert the denture to a fixed denture. Rubber dam should be used to protect the implants and the patient. Light-body impression material, GI-Mask (Coltene),

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a

b

Fig 4-14 (a) MucoHard Acrylic (Parkell) and GI-Mask with the appropriate-size tips on each. (b) GI-Mask should be placed in the top of the cylinders to prevent acrylic from entering.

Fig 4-15 MucoHard being applied around the multiunit cylinders.

Fig 4-16 A portable, rechargeable laboratory motor makes trimming the prosthesis in the operating room convenient.

wax, or polytetrafluoroethylene (PTFE) tape should be placed in the top of the titanium sleeves to prevent the acrylic from entering (Fig 4-14). To accomplish the acrylic pickup of the titanium sleeves, a cold-curing (exothermic polymer) acrylic, such as MucoHard (Parkell), is used at a thin consistency to infiltrate the undercuts of the titanium sleeves (Fig 4-15). After bonding is complete, a permanent marker can be used to indicate the height to which the titanium sleeves should be cut. The titanium sleeves are unscrewed and cut with a portable, rechargeable laboratory motor with an appropriate bur (Fig 4-16). If there are any resulting metal filings from cutting the titanium sleeve, they must be removed. The modified denture in now cut distal to the titanium sleeve. A disk can be used for larger cuts, and a

diamond bur can be used for more finessed cuts. Prosthesis cantilever distance should be equal to the dimension of one-half to one tooth (Fig 4-17). Less cantilever can fracture the prosthesis near the titanium sleeve, and more cantilever can overstress the implants. The intaglio surface of the provisional prosthesis is then adjusted by adding or subtracting acrylic as necessary. The surface is polished, with any sharp edges or angles removed (Fig 4-18). The prosthesis is then screwed into the multiunit abutments with a driver and torqued to 15 Ncm. The holes in the titanium sleeves for the provisional fixed prosthesis are filled with a composite resin such as Fermit (Ivoclar Vivadent), and the occlusion is checked for evenness and balance. There should be zero occlusion distal to the last titanium sleeve.

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References

Fig 4-17 Trimming the palate, borders, and flanges and removing any excessive distal cantilevers.

Fig 4-18 An ovate or flat contour should be created to facilitate the oral hygiene and maintenance of the provisional prosthesis.

Conclusion

6. Agliardi E, Clericò M, Ciancio P, Massironi D. Immediate loading of full-arch fixed prostheses supported by axial and tilted implants for the treatment of edentulous atrophic mandibles. Quintessence Int 2010;41:285–293. 7. Bedrossian E. Rescue implant concept: The expanded use of the zygoma implant in the graftless solutions. Dent Clin North Am 2011;55:745–777. 8. Fortin T, Camby E, Alik M, Isidori M, Bouchet H. Panoramic images versus three-dimensional planning software for oral implant planning in atrophied posterior maxillary: A clinical radiological study. Clin Implant Dent Relat Res 2013;15:198–204. 9. Peñarrocha Diago M, Maestre Ferrín L, Peñarrocha Oltra D, Canullo L, Calvo Guirado JL, Peñarrocha Diago M. Tilted implants for the restoration of posterior mandibles with horizontal atrophy: An alternative treatment. J Oral Maxillofac Surg 2013;71:856–864. 10. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310–320. 11. Malo P, de Araujo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept: A clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14:e139–e150. 12. Lopes A, Malo P, de Araujo Nobre M, Sanchez-Fernandez E. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A prospective report on medium- and long-term outcomes. Clin Implant Dent Relat Res 2015;17:e406–e416. 13. Malo P, de Araujo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623. 14. Malo P, Araujo 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;24:263–270. 15. Malo P, de Araujo Nobre M, Lopes A, Ferro A, Gravito I. All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: A 7-year clinical and 5-year radiographic retrospective case series with risk assessment for implant failure and marginal bone level. Clin Implant Dent Relat Res 2015;17:e531–e541.

The FAIR protocol provides a step-by-step procedure for restoring the edentulous maxilla and mandible to nearly natural esthetics and function. The protocol represents 30 years of clinical evolution, showing how implant-driven full-arch rehabilitation practices can provide edentulous or nearly edentulous patients with the dental appearance and function they increasingly demand. The FAIR approach provides fixed rehabilitation of the entire arch without the complex surgeries, high morbidity rates, high costs, and lengthy perioperative treatments traditionally associated with bone regeneration and grafting procedures.

References 1. Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants 2000;15:405–414. 2. Lee SP, Paik KS, Kim MK. Anatomical study of the pyramidal process of the palatine bone in relation to implant placement in the posterior maxilla. J Oral Rehabil 2001;28:125–132. 3. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, and periotest study. Clin Implant Dent Relat Res 2001;3:39–49. 4. Raviv E, Turcotte A, Harel-Raviv M. Short dental implants in reduced alveolar bone height. Quintessence Int 2010;41:575–579. 5. Balleri P, Ferrari M, Veltri M. One-year outcome of implants strategically placed in the retrocanine bone triangle. Clin Implant Dent Relat Res 2010;12:324–330.

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16. Ali SA, Karthigeyan S, Deivanai M, Kumar A. Implant rehabilitation for atrophic maxilla: A review. J Indian Prosthodont Soc 2014;14:196– 207. 17. Rangert B, Jemt T, Jörneus L. Forces and moments on Branemark implants. Int J Oral Maxillofac Implants 1989;4:241–247. 18. Zurdo J, Romão C, Wennström JL. Survival and complication rates of implant-supported fixed partial dentures with cantilevers: A systematic review. Clin Oral Implants Res 2009;20(suppl 4):59–66. 19. Salvi GE, Brägger U. Mechanical and technical risks in implant therapy. Int J Oral Maxillofac Implants 2009;24(suppl):69–85. 20. Block MS, Haggerty CJ, Fisher GR. Nongrafting implant options for restoration of the edentulous maxilla. J Oral Maxillofac Surg 2009;67:872–881. 21. Ata-Ali J, Peñarrocha-Oltra D, Candel-Marti E, Peñarrocha-Diago M. Oral rehabilitation with tilted dental implants: A metaanalysis. Med Oral Patol Oral Cir Bucal 2012;17:e582–e587. 22. Agliardi EL, Romeo D, Panigatti S, de Araújo Nobre M, Maló P. Immediate full-arch rehabilitation of the severely atrophic maxilla supported by zygomatic implants: A prospective clinical study with minimum follow-up of 6 years. Int J Oral Maxillofac Surg 2017;46:1592–1599. 23. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: Anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19(suppl):43–61. 24. Tolstunov L. Implant zones of the jaws: Implant location and related success rate. J Oral Implantol 2007;33:211–220. 25. Morand M, Irinakis T. The challenge of implant therapy in the posterior maxilla: Providing a rationale for the use of short implants. J Oral Implantol 2007;33:257–266. 26. Greenstein G, Cavallaro J, Tarnow D. Practical application of anatomy for the dental implant surgeon. J Periodontol 2008;79:1833–1846. 27. Boeddinghaus R, Whyte A. Trends in maxillofacial imaging. Clin Radiol 2018;73:4–18. 28. Greenstein G, Tarnow D. The mental foramen and nerve: Clinical and anatomical factors related to dental implant placement: A literature review. J Periodontol 2006;77:1933–1943.

29. Froum S, Casanova L, Byrne S, Cho SC. Risk assessment before extraction for immediate implant placement in the posterior mandible: A computerized tomographic scan study. J Periodontol 2011;82:395–402. 30. Sener E, Onem E, Akar GC, et al. Anatomical landmarks of mandibular interforaminal region related to dental implant placement with 3D CBCT: Comparison between edentulous and dental mandibles. Surg Radiol Anat 2018;40:615–623. 31. Cheng DC, Chen LW, Shen YW, Fuh LJ. Computer-assisted system on mandibular canal detection. Biomed Tech (Berl) 2017;62:575– 580. 32. Del Fabbro M, Ceresoli V. The fate of marginal bone around axial vs. tilted implants: A systematic review. Eur J Oral Implantol 2014;7(suppl 2):S171–S189. 33. Chrcanovic BR, Albrektsson T, Wennerberg A. Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis. Int J Oral Maxillofac Surg 2015;44:493–506. 34. Balshi TJ, Wolfinger GJ, Stein BE, Balshi SF. A long-term retrospective analysis of survival rates of implants in the mandible. Int J Oral Maxillofac Implants 2015;30:1348–1354. 35. Busenlechner D, Mailath-Pokorny G, Haas R, et al. Graftless full-arch implant rehabilitation with interantral implants and immediate or delayed loading—Part II: Transition from the failing maxillary dentition. Int J Oral Maxillofac Implants 2016;31:1150–1155. 36. Busenlechner D, Mailath-Pokorny G, Haas R, et al. Graftless full-arch implant rehabilitation with interantral implants and immediate or delayed loading—Part I: Reconstruction of the edentulous maxilla. Int J Oral Maxillofac Implants 2016;31:900–905. 37. Patras M, Kourtis S, Sykaras N. Creating natural-looking removable prostheses: Combining art and science to imitate nature. J Esthet Restor Dent 2012;24:160–168. 38. Kirtley GE. Aesthetics and removable prosthetics. Dent Today 2016;35:100–103. 39. Login GR. Creating durable and esthetic gingival anatomy on a polyoxymethylene overdenture by using a chairside procedure. J Am Dent Assoc 2017;148:525–528.

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Treating the Fully Edentulous Maxilla

T

reatment of the fully versus partially edentulous maxilla is similar, with only a few key differences; therefore, portions of this chapter are identical to chapter 7. This chapter is meant to be comprehensive to allow the reader to review the steps prior to an upcoming maxillary case. Until the advent of the minimally invasive implant techniques used in the full-arch implant rehabilitation (FAIR) procedure, bone augmentation was almost always required to restore the atrophic edentulous maxilla, and with this came the associated time, expense, and potential for increased risk of morbidity. FAIR reduces not only inconvenience and risk during surgery and recovery but also time and cost for both clinicians and patients. However, these benefits can only be offered when clinicians have taken the time to master the complex FAIR technique. For example, same-day loading of the prosthesis is particularly attractive to patients, but accompanying this advantage are the intricacies of placing tilted implants and positioning tilted abutments. Additionally, placement of implants parallel to the wall of the anterior sinus generally requires computer guidance or meticulous attention to anatomical landmarks. Fortunately, many implant systems provide such aid to help clinicians navigate the terrain of the maxilla, and FAIR and its sister technologies have excellent short- and long-term results.1–5

The FAIR Vision Treating the fully edentulous maxilla using the FAIR protocol is an invaluable way for clinicians to develop expert

CHAPTER

skills.6–14 Similar to the carpentry maxim “measure twice; cut once,” the implant clinician should “visualize the case multiple times; perform surgery once.”15–17 This process can be facilitated by the use of a virtual three-dimensional (3D) computed tomography (CT) stereolithographic (STL) model based on the patient’s examination records or the models of similar cases, sometimes including physical measurements taken inside the patient’s oral cavity. It can also include performing a practice surgery on an STL bone model prior to the actual patient surgery. Such planning is particularly important in cases where the alveolar bone is minimal, making the selection of the implants and their angulation and positioning more critical.18–20 The FAIR procedure usually involves only four implants, but it is deceptively complex, requiring extensive preoperative planning and surgical vision.

Preoperative Procedure The clear denture duplicate template for the procedure is cut (either in the laboratory or by the clinician) so that the buccal flange is 15 mm from the incisal edge from premolar to premolar (Fig 5-1). This will provide a measure for the amount of bone recontouring that will be required. The posterior flanges of the denture are not cut; otherwise, the denture might be overseated. The FAIR surgery can be quite lengthy, possibly up to 2 to 4 hours, and it therefore requires a unique approach to anesthesia for patient comfort.21–23 Intravenous sedation is not recommended. Although it allows the patient to bite and to follow commands, the clinical cost can be prohibitive

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Fig 5-1 The clear denture duplicate template should have the buccal flange from premolar to premolar trimmed to 15 mm from the incisal edges of the teeth.

due to the length of the procedure.24 General anesthesia is not a good option either because it makes it nearly impossible to obtain proper occlusion, even if the patient is nasally intubated, and requires the clinician to manipulate the patient’s jaws.25 Bupivacaine (eg, Marcaine, Pfizer), which lasts 7 to 12 hours but can take up to 30 minutes to take effect, can be used simultaneously with lidocaine, which typically takes only 5 minutes for onset but lasts 2.5 to 3 hours. In this way, if the surgery is lengthy, the Marcaine can still provide the patient with the necessary comfort once the lidocaine has dissipated. Dosage is important, and less Marcaine is often required if used in conjunction with lidocaine. Triazolam (eg, Halcion, Pfizer) may be a good addition to help relax the patient.26

FAIR Surgical Procedure Initial incisions and tissue reflection Under local anesthesia, the surgery begins with an incision from the first molar to the contralateral first molar. The incision can be made midcrestal or slightly palatal, depending on the experience of the clinician (Fig 5-2). The nasopalatine nerve is generally located palatal to the midline, but in cases of bone resorption it may be located more anteriorly, slightly palatal, or midcrestal. So rather than palatally, the clinician should cut slightly buccal to the midcrestal aspect of a resorbed ridge. A notch is cut buccally to avoid the nasopalatine nerve. Such an incision helps to not only avoid the nerve but also to facilitate repositioning of the tissues when the flap is reflected to accomplish even suturing from the midline posteriorly, avoiding suturing gaps. A 6- to 9-mm

vertical incision is made on the buccal aspect of the ridge in the molar areas bilaterally. The buccal and palatal aspects of the ridge are reflected for different reasons. If a midcrestal incision is made, then the palatal flap must be reflected properly to enable drilling. If the incision is slightly palatal, less palatal reflection is necessary. Nevertheless, reflecting the palatal flap provides needed access to place multiple implants. In the absence of sufficient surgical assistance, temporary suturing can aid the clinician in reflecting a flap (Fig 5-3). With the palatal flap fixed in place, the clinician can focus on buccal flap reflection. With the aid of a retractor and the tissue reflected, the clinician can begin reducing the height of the alveolar bone in accordance with the clear denture duplicate template to ensure a 15-mm clearance from the incisal edge of the denture to the bone. However, if the reduction is only 2 or 3 mm, then a periodontal probe can be used instead to measure the distance for grinding based on radiographic or CT imaging (Figs 5-4a and 5-4b). The clinician should make sure that the bone shelf remains sufficiently wide. Eliminating cortical bone may result in a lack of unicortical stability. To restore this stability, the apex of the implant must be placed in the cortical bone of the nasal floor. This can be visually determined via reflection of approximately 2 to 3 mm of tissue on the lateral piriform rim or the lateral aspect of the nose (the mesial aspect of the sinus and the distal aspect of the nasal floor) (Fig 5-4c). The entrance point of the implant is halfway between the first and the second premolar sites (Fig 5-4d). However, unlike the sinus membrane, the nasal floor cannot be patched if it is perforated. Instead, the procedure must be aborted due to the risk of infection, and the area must be repaired.27

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CASE 1

a

b

c

d

e

f

Fig 5-2 Case 1 (a and b) Clinical measurements to confirm the presence of at least 22 mm of interarch space since both arches are being treated. This may also be performed radiographically. (c and d) Immediate dentures are placed in the mouth to get an accurate bite registration to aid in seating the maxillary denture accurately after the maxillary flap has been raised. (e) In the midline area, a small buccal notch of tissue is created to avoid the nasopalatine nerve in this moderately-to-severely resorbed ridge and to allow for accurate repositioning of the flap to its original position. (f) Reflecting the flap palatally provides the necessary access for multiple implant placement.

Brånemark recommended an alternative approach. To determine the location of the anterior portion of the sinus for placing the apex of the implant, elevate only the sinus floor, not the nasal floor, using a no. 8 round bur to make an opening through which a probe may be placed. The probe must be a periodontal probe, not a straight or a bendable duck probe, which can damage the sinus membrane because of its angle. Brånemark recommended neither grafting nor plugging the hole but simply putting the implant in place.28 Fig 5-3 Temporary suturing of the palatal flap allows the clinician to focus on buccal flap reflection.

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CASE 1 a

b

c

d

Fig 5-4 Case 1 (cont) (a) A periodontal probe can be used to measure the distance for grinding. (b) The bone is reduced as necessary to create the bone shelf. (c) Identifying the nasal floor and the lateral piriform plate. (d) The tilted implants will be aimed from the first/second premolar area to the inferolateral piriform rim.

The wall that separates the nasal cavity from the maxillary sinus is the bone-substantive canine area, as reflected in the length of canine teeth. Teeth anterior to the canines have shorter roots. The FAIR method uses canine-length implants as the distal implants. Implant placement Landmarking the positions of the sinus membrane and nasal floor is important before the anterior implants are placed. It will determine if they will be placed vertically or if they need to be tilted to have adequate bone for the implant length. To create higher torque values for the implants at placement, the clinician can undersize the osteotomy.29–32 Tilting the implants when needed can also potentially increase the anteroposterior (AP) spread of all the implants placed. The clinician can line up the bur with the planned osteotomy path to visualize the planned implant position (Fig 5-5a).

After double-checking the angulation, the next step is to make a pilot hole using a sharp and aggressive bur such as a Lindemann bone bur (Fig 5-5b). Once the pilot hole has been created, the clinician can begin to use a sequence of burs to create the osteotomy for implant placement (Figs 5-5c to 5-5h), all the while checking for accuracy of diameter and depth based on the physical and virtual models studied before the surgery. Instead of punching a hole through the sinus membrane, the clinician can also make a window with a diamond bur to elevate the sinus membrane and view the anterior portion of the sinus (ie, the posterior portion of the nose). The area can also be viewed with transillumination. The goal is to determine proximity to the sinus wall.33,34 Alternatively, the nasal floor and lateral piriform rim are identified and used as the landmark to guide apical placement of the implant. This is the preferred method for the FAIR procedure (see Fig 5-4c).

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CASE 1

a

b

c

d

e

f

g

h

Fig 5-5 Case 1 (cont) (a) Visualizing implant angulation by lining up the bur appropriately. (b) Drilling a pilot hole. (c to h) After the pilot bur, sequentially larger diameter burs are used. In cases of thin ridges, burs can be operated in reverse, or expanders can be used instead.

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CASE 1 Fig 5-6 Using the widest and longest implant possible provides maximum stability.

Regarding implant sizing, it is advisable to use wide (ie, deep) pitch threading for aggressive penetration of the osteotomy and to make sure the diameter of the osteotomy is smaller than that of the implant itself to allow aggressive torqueing (Fig 5-6). Most implant manufacturers label their implants and burs the same size, but the bur size is actually smaller in diameter to facilitate aggressive torque. When the clinician places implants in soft bone (both in the maxilla and mandible, which are not uniformly dense from patient to patient), undersizing the osteotomy is even more important so that bone is compressed or densified when the implant is placed. It is therefore prudent to use a bur size smaller than the implant size, and even smaller still for soft bone. Each case can be different based on a number of patient characteristics, including race, sex, and systemic and dental health. In cases with denser bone, using an undersized osteotomy is not as necessary, and implant placement can be combined with coronal flaring of the implant osteotomy for better implant seating and anchorage. In fact, when a series of burs is used to widen the osteotomy before implant placement, additional stability can be gained by drilling short (ie, by 3 to 4 mm) and undersizing the apical end of the implant with the final bur only. This is done so the final bur does not go to depth or is not used at all depending on the softness of the bone. Using bone expanders instead of additional burs can be another way to achieve greater initial stability, both in regular and soft bone35,36 (Fig 5-7). A 2.0-mm hole can be drilled, then progressively larger expanders can be used, and finally the implant can be placed. Expanders compress and densify the bone. In lieu of expanders, burs operated in reverse will achieve the same effect by pushing the bone forward instead of cutting it. Some burs are available that are designed specifically for this function.37 However, the heat generated by compressing bone with burs in reverse

can adversely affect initial stability and osseointegration, so this should be done with caution. Standard implants are usually 3.7 to 4.2 mm in diameter. The bone availability and quality tend to be poor in most FAIR cases, so 3.7- to 4.2-mm implants are good options. Additionally, the prosthetic platforms and abutments for these implants are often exactly the same. Conversely, a larger-diameter implant may result in a change of platforms and abutments. The additional hardware should be a consideration if clinicians are contemplating a largerdiameter implant. If the osteotomy is undersized, using a larger implant will probably not be necessary. In addition, in cases where platelet-rich plasma (PRP) is being used as a growth factor adjunct, the implants can be soaked in the PRP to enhance the surface for better bonding strength38 (Fig 5-8). For fully edentulous cases, PRP will probably not be used because no bone grafting is expected; however, PRP is generally used in partially edentulous cases that require extractions and socket grafting. Tilted distal implants, which are typically 16 mm in length to obtain apical engagement in the cortical plate (Fig 5-9), are generally placed at 30-degree angles. There are two options regarding the positioning of the coronal portion: (1) place the mesial part flush with bone and the distal portion deeper, or (2) place the distal aspect flush with bone and the mesial side protruding above the bone. That is, either the mesial threads are exposed or the distal portion of the implant is buried (Fig 5-10). An implant system should be chosen so that the coronal-most 2 mm are suitable for bone and soft tissue; the rough surface should never extend to the top of the implant because it is too rough for soft tissue and could result in peri-implantitis.39 An implant system with a 2-mm transition zone can prevent peri-implantitis. For example, the coronal portion of the ImplantVision implant has 2 mm of microthreads. Laser-etched and nonroughened surfaces on the coronal 2 mm of the implant are also suitable. This transition zone is essential for the FAIR procedure. If a clinician is forced to use an implant with a roughened surface spanning the entire implant length, the only option is to make the mesial coronal portion flush and bury the distal coronal portion; with microthreads, the clinician has the option to place either the mesial or distal coronal aspect flush with bone. For a strict FAIR concept, the preference is to seat the distal coronal aspect of the distal implant below the bone,

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CASE 1

a

b

c

d

Fig 5-7 Case 1 (cont) (a and b) A 2.5-mm bone expander is used first. (c and d) This is followed by the use of 2.8-mm and then 3.0-mm bone expander drills to compress and densify the bone.

Fig 5-8 Implants can be soaked in PRP to enhance the surface properties.

Fig 5-9 A 16-mm implant appropriate for use as a distal tilted implant.

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should protrude through the trough of the template. If an anterior implant is tilted facially, a 9- or 18-degree multiunit abutment, angled palatally, could be used to make sure the prosthetic components will fit within the trough. Abutment attachment

Fig 5-10 Distal tilted implant with the mesial part of the coronal portion flush and the the distal portion submerged.

which will require aggressive flaring of the osteotomy to allow for the eventual placement of the prosthetic components. A possible alternative could be an implant system designed with a 30-degree angle coronally, such as the Astra Tech Implant System EV (OsseoSpeed EV; Dentsply Sirona) for a sloped ridge. Implants with such an angle could be used as the two distal implants with the FAIR concept. When placing the distal tilted implants, the mesial threads in the transition zone must be exposed, or if they are flush, the distal aspect of the osteotomy must be flared for the prosthetic parts to fit properly. Flaring once the implant is placed is too difficult. To place the anterior implants, the clinician should first measure the distance from the nasal floor to the crest of the alveolar ridge, which usually ranges from 5 to 15 mm. All implants for the FAIR procedure should have wide-pitch threads to maximize initial stability (Fig 5-11). Tilted implants are used posteriorly and straight implants anteriorly (although the anterior implants may require a buccal or lingual tilt and occasionally a mesial or distal tilt). The abutment should not be screwed and unscrewed repeatedly to determine the proper angulation because this is time-consuming and may damage the implant threads. Direction indicators should be used to verify the osteotomy path and the depth of the implants (Fig 5-12). The indicators aid in drilling as well as implant placement and include a tiny attachment ball that snaps in and out. When used with a clear denture duplicate template, the indicators

A multiunit abutment must be chosen that matches the implant diameter and has the appropriate angulation; the implant direction indicator indicates whether the implant is tilted approximately 0, 9, 18, or 30 degrees. The cuff height of the abutment is also crucial. If it is too high, then the prosthesis will be positioned too supragingivally. For example, if the tissue is 3 mm thick and the abutment cuff is 5 mm, there will be a 2-mm gap between the prosthesis and the soft tissue. Therefore, the clinician should aim for a cuff height that mirrors tissue thickness. The ideal height is usually 3 mm, but a cuff height of 4 mm or more could be used for very thick tissues. If there is not enough clearance, a shorter cuff may be necessary. However, from a manufacturing perspective, the multiunit abutment is weakened considerably when the cuff height is less than 3 mm, so this is not generally recommended. Tilted abutments have a disposable handle for holding them in place during tightening (Fig 5-13). This handle protrudes through the trough of the clear denture duplicate template. The driver will be at the same angle as the implant during tightening (Figs 5-14a and 5-14b). The multiunit abutment is torqued to 25 to 30 Ncm, depending on the implant system, with a prosthetic driver (torque wrench), which has a longer handle and tightening knob to better adjust the torque value (Fig 5-14c). For the straight abutments, the hex driver holds the abutment in place, eliminating the need for a handle (Figs 5-14d to 5-14f). Prosthesis placement and attachment The process of prosthesis placement and attachment (Figs 5-15 to 5-17) is discussed in detail in chapter 4 (see pages 28 to 30). Figure 5-18 describes a second case treatment for a fully edentulous maxilla.

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CASE 1

a

b

c

d

f

e

Fig 5-11 Case 1 (cont) (a and b) This wide-pitch implant has deeper threads than typical implants and is tilted posteriorly. (c and d) Once the implant is placed appropriately, the implant mount is removed. (e and f) The anterior implants, also with deeper threads than typical implants, are placed straight, and the implant mounts are removed.

2

1

a

b

c

d

Fig 5-12 Direction indicators can be used to verify not only the osteotomy path but also the soft tissue thickness. (a) A 0-degree indicator. (b) A 9-degree indicator. (c) An 18-degree indicator. (d) A 30-degree indicator.

Fig 5-13 The angled abutment has a disposable handle to hold in place (1) while tightening with the hex driver (2).

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CASE 1 a

b

d

c

e

f

Fig 5-14 Case 1 (cont) (a and b) The driver is angled during tightening to the same angle as the implant. (c) The multiunit abutment is torqued to 25 to 30 Ncm. (d and e) In straight multiunit abutments, the hex driver becomes the carrier, eliminating the need for a handle. (f) Straight and angled abutments are in place and fully tightened.

a

b

Fig 5-15 Case 1 (cont) (a and b) Bite registration material can be applied to the intaglio surface of the denture to mark the implant abutment locations on the prosthesis for drilling.

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CASE 1

c

d

e

f

Fig 5-15 Case 1 (cont) (c and d) The marked areas on the prosthesis are then cut out to create apertures for the titanium sleeves, and the bite registration material is removed. (e and f) The titanium sleeves should protrude from the implant multiunit abutments through the denture apertures to allow the provisional and definitive prostheses to be attached to the abutments.

a

b

Fig 5-16 (a and b) Titanium sleeves.

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CASE 1 a

b

d

c

Fig 5-17 Case 1 (cont) (a and b) The clinician should liberally add acrylic with a brush or inject MucoHard (Parkell) to penetrate the undercuts of the denture apertures and the titanium sleeves so that the denture bonds to the titanium sleeves on all sides. (c and d) Once the bonding is complete, the titanium sleeves are unscrewed, and a multiunit abutment and implant analog are placed. (e and f) The titanium sleeves are cut with a disk or bur, and then an acrylic bur is used to flatten the intaglio surface of the denture, eliminating any concavities. e

f

f

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FAIR Surgical Procedure

CASE 1

g

i

h

j

Fig 5-17 Case 1 (cont) (g) The modified denture before placement. (h) The modified denture is placed and checked for fit. (i and j) The modified prosthesis is screwed into the multiunit abutments to 15 Ncm. (k) After verifying the occlusion for evenness and balance, the holes are filled with a composite resin such as Fermit (Ivoclar Vivadent).

k

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Treating the Fully Edentulous Maxilla

CASE 2 a

b

c

d

e

f

g

h

Fig 5-18 Case 2 (a and b) This patient has a fully edentulous maxilla. (c) The vertical dimension is measured. (d) The incision is made, and the palatal flap is temporarily sutured so that the clinician can focus on the buccal flap reflection. (e) The bone shelf is leveled with a specialized bur, and ridge spreaders are used to expand the ridge. (f to h) Two tilted implants are placed posteriorly, two slightly tilted implants are placed anteriorly, and appropriate multiunit abutments are tightened into place.

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FAIR Surgical Procedure

CASE 2 1

i

j

l

k

m

o

n

p

Fig 5-18 Case 2 (cont) (i and j) Bite registration material is applied to the intaglio surface of the denture to mark the implant abutment locations on the denture prosthesis for drilling. (k) The marked areas on the denture are then cut out. (l) Titanium sleeves to be placed on the multiunit abutments to confirm adequate and accurate openings. (m) The bite registration material is removed. (n) The titanium sleeves should protrude through the denture apertures to confirm locations for abutments to attach to the provisional and definitive prostheses. (o) The rubber dam is marked, and holes are punched according to the locations of the titanium sleeves. (p) The site is ready for the denture to be bonded to the titanium sleeves.

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Treating the Fully Edentulous Maxilla

CASE 2 1 q

r

s

t

u

w

v

x

Fig 5-18 Case 2 (cont) (q) Acrylic material is mixed to be added to the denture apertures. (r) Rubber dam is placed over the surgical site with the titanium sleeves protruding through the prepunched holes. (s) GI-Mask is placed into the holes of the titanium sleeves to prevent hard acrylic from entering the sleeves during pickup. (t) Acrylic is added into the intaglio surface of the denture and holes that were drilled. (u) MucoHard is placed around the sleeves. (v) The denture is then placed over the rubber dam, making sure that the titanium sleeves pass through the holes. (w) Excess acrylic material is wiped off, and everything is checked to ensure that the acrylic is distributed evenly into the holes. (x) GI-Mask is removed to expose the titanium sleeve screws.

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CASE 2 1

y

z

aa

cc

bb Fig 5-18 Case 2 (cont) (y and z) Screws are removed to detach the denture apparatus from the multiunit abutments. (aa) The underside of the denture apparatus is checked. Additional acrylic is added as necessary to the intaglio side to ensure a strong bond before the rubber dam is removed. (bb and cc) Pins are placed to cover the titanium sleeve holes while more acrylic is applied to ensure that the titanium sleeves are bonded firmly to the denture. (dd) The denture apparatus with acrylic is placed in a hot water bath to allow for maximum acrylic strength and minimal porosity.

dd

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CASE 2 1 ee

ff

gg

hh

ii

jj

kk

ll

Fig 5-18 Case 2 (cont) (ee to gg) Once the acrylic has set, the denture is trimmed, adjusted, and polished. (hh) The flaps are sutured around the abutments. (ii to ll) The denture is further trimmed and adjusted to ensure correct AP spread, and it is refined and polished further as necessary.

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References

CASE 2 1

mm

nn

oo

qq

pp

rr

Fig 5-18 Case 2 (cont) (mm) The finished provisional prosthesis. (nn) The provisional prosthesis is tightened into place. (oo) Fermit is applied into the holes to temporarily cover the screws. (pp) The Fermit is light cured. (qq) The occlusion is checked. (rr) The patient goes home with a provisional prosthesis that allows healing and function, and follow-ups are scheduled for the fabrication of a definitive prosthesis.

References 1. Misch CE, Degidi M. Five-year prospective study of immediate/ early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system. Clin Implant Dent Relat Res 2003;5:17–28. 2. Barbosa GA, Bernardes SR, de França DG, das Neves FD, de Mattos Mda G, Ribeiro RF. Stress over implants of one-piece cast frameworks made with different materials. J Craniofac Surg 2016;27:238–241.

3. Motta M, Monsano R, Velloso GR, et al. Guided surgery in esthetic region. J Craniofac Surg 2016;27:e262–e265. 4. Uhlendorf Y, Sartori IA, Melo AC, Uhlendorf J. Changes in lip profile of edentulous patients after placement of maxillary implant-supported fixed prosthesis: Is a wax try-in a reliable diagnostic tool? Int J Oral Maxillofac Implants 2017;32:593–597. 5. Zoidis P. The All-on-4 modified polyetheretherketone treatment approach: A clinical report. J Prosthet Dent 2017;119:516–521. 6. 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;65:1010–1016.

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CASE 2

7. 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;24:887–895. 8. Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept for completely edentulous maxillae: A clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14(suppl 1):e139–e150. 9. Avrampou M, Mericske-Stern R, Blatz MB, Katsoulis J. Virtual implant planning in the edentulous maxilla: Criteria for decision making of prosthesis design. Clin Oral Implants Res 2013;24(suppl A100):152–159. 10. Agliardi EL, Pozzi A, Stappert CF, Benzi R, Romeo D, Gherlone E. Immediate fixed rehabilitation of the edentulous maxilla: A prospective clinical and radiological study after 3 years of loading. Clin Implant Dent Relat Res 2014;16:292–302. 11. Cavalli N, Barbaro B, Spasari D, Azzola F, Ciatti A, Francetti L. Tilted implants for full-arch rehabilitations in completely edentulous maxilla: A retrospective study. Int J Dent 2012;2012:180379. 12. Jensen OT, Cottam JR, Ringeman JL, Graves S, Beatty L, Adams MW. Angled dental implant placement into the vomer/nasal crest of atrophic maxillae for All-on-Four immediate function: A 2-year clinical study of 100 consecutive patients. Int J Oral Maxillofac Implants 2014;29:e30–e35. 13. Maló P, de Araújo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623. 14. Tallarico M, Meloni SM, Canullo L, Caneva M, Polizzi G. Five-year results of a randomized controlled trial comparing patients rehabilitated with immediately loaded maxillary cross-arch fixed dental prosthesis supported by four or six implants placed using guided surgery. Clin Implant Dent Relat Res 2016;18:965–972. 15. Warreth A, McAleese E, McDonnell P, Slami R, Guray SM. Dental implants and single implant-supported restorations. J Ir Dent Assoc 2013;59:32–43. 16. Bryington M, De Kok IJ, Thalji G, Cooper LF. Patient selection and treatment planning for implant restorations. Dent Clin North Am 2014;58:193–206. 17. De Kok IJ, Thalji G, Bryington M, Cooper LF. Radiographic stents: Integrating treatment planning and implant placement. Dent Clin North Am 2014;58:181–192. 18. Menini M, Pesce P, Bevilacqua M, et al. Effect of framework in an implant-supported full-arch fixed prosthesis: 3D finite element analysis. Int J Prosthodont 2015;28:627–630. 19. Siadat H, Alikhasi M, Beyabanaki E, Rahimian S. Comparison of different impression techniques when using the All-on-Four implant treatment protocol. Int J Prosthodont 2016;29:265–270. 20. Michelinakis G. The use of cone beam computed tomography and three dimensional printing technology in the restoration of a maxillectomy patient using a dental implant retained obturator. J Indian Prosthodont Soc 2017;17:406–411. 21. Faraco FN, Kawakami PY, Mestnik MJ, Ferrari DS, Shibli JA. Effect of anesthetics containing lidocaine and epinephrine on cardiovascular changes during dental implant surgery. J Oral Implantol 2007;33:84–88.

22. Sánchez-Siles M, Torres-Diez LC, Camacho-Alonso F, Salazar-Sánchez N, Ballester Ferrandis JF. High volume local anesthesia as a postoperative factor of pain and swelling in dental implants. Clin Implant Dent Relat Res 2014;16:429–434. 23. Valieri MM, de Freitas KM, Valarelli FP, Cançado RH. Comparison of topical and infiltration anesthesia for orthodontic mini-implant placement. Dental Press J Orthod 2014;19:76–83. 24. Schwamburger NT, Hancock RH, Chong CH, Hartup GR, Vandewalle KS. The rate of adverse events during IV conscious sedation. Gen Dent 2012;60:e341–e344. 25. Stronczek MJ. Determining the appropriate oral surgery anesthesia modality, setting, and team. Oral Maxillofac Surg Clin North Am 2013;25:357–366. 26. Dionne RA, Yagiela JA, Coté CJ, et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. J Am Dent Assoc 2006;137:502–513. 27. de Almeida Ferreira CE, Martinelli CB, Novaes AB Jr, et al. Effect of maxillary sinus membrane perforation on implant survival rate: A retrospective study. Int J Oral Maxillofac Implants 2017;32:401–407. 28. Perelli M, Abundo R, Corrente G, Saccone C, Arduino PG. Sinus floor elevation with modified crestal approach and single loaded short implants: A case report with 4 years of follow-up. Case Rep Dent 2017;2017:7829179. 29. Greenstein G, Cavallaro J, Greenstein B, Tarnow D. Treatment planning implant dentistry with a 2-mm twist drill. Compend Contin Educ Dent 2010;31:126–132. 30. González-Martín O, Lee EA, Veltri M. CBCT fractal dimension changes at the apex of immediate implants placed using undersized drilling. Clin Oral Implants Res 2012;23:954–957. 31. Coelho PG, Marin C, Teixeira HS, et al. Biomechanical evaluation of undersized drilling on implant biomechanical stability at early implantation times. J Oral Maxillofac Surg 2013;71:e69–e75. 32. Jimbo R, Tovar N, Anchieta RB, et al. The combined effects of undersized drilling and implant macrogeometry on bone healing around dental implants: An experimental study. Int J Oral Maxillofac Surg 2014;43:1269–1275. 33. Al-Dajani M. Recent trends in sinus lift surgery and their clinical implications. Clin Implant Dent Relat Res 2016;18:204–212. 34. Kao SY, Lui MT, Cheng DH, Chen TW. Lateral trap-door window approach with maxillary sinus membrane lifting for dental implant placement in atrophied edentulous alveolar ridge. J Chin Med Assoc 2015;78:85–88. 35. Mohamed JB, Alam MN, Singh G, Chandrasekaran SN. Alveolar bone expansion for implant placement in compromised aesthetic zone—Case series. J Clin Diagn Res 2014;8:237–238. 36. Jha N, Choi EH, Kaushik NK, Ryu JJ. Types of devices used in ridge split procedure for alveolar bone expansion: A systematic review. PLoS One 2017;12:e0180342. 37. Lahens B, Neiva R, Tovar N, et al. Biomechanical and histologic basis of osseodensification drilling for endosteal implant placement in low density bone. An experimental study in sheep. J Mech Behav Biomed Mater 2016;63:56–65. 38. Agrawal AA. Evolution, current status and advances in application of platelet concentrate in periodontics and implantology. World J Clin Cases 2017;5:159–171. 39. Rakic M, Galindo-Moreno P, Monje A, et al. How frequent does peri-implantitis occur? A systematic review and meta-analysis. Clin Oral Investig 2018;22:1805–1816.

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Treating the Fully Edentulous Mandible

CHAPTER

T

he full-arch implant rehabilitation (FAIR) procedure can virtually eliminate the need for bone augmentation, making full-arch restoration an attractive alternative for patients who suffer from functional and esthetic challenges due to an atrophic edentulous mandible. The morbidity associated with bone regeneration has kept many would-be dental rehabilitation patients from seeking such procedures, and the absence of bone augmentation is one of the many advantages the FAIR protocol offers its patients. Immediate provisionalization, shorter recovery time, and lower cost are additional advantages. By placing tilted implants and tilted abutments together with axial implants in the mandible, the FAIR restoration concept can be adapted to suit a number of unique patient needs.1–6

a

FAIR in the Mandible The structure and bone composition of the mandible, as opposed to the maxilla, have made it the more attractive and successful location for full-arch rehabilitation.7–16 As with the maxilla, mandibular rehabilitation planning is accomplished via a clear denture duplicate template (Fig 6-1a) and three-dimensional (3D) stereolithographic (STL) model of the patient’s bone anatomy. Alveolar bone availability is a crucial factor for the fabrication of models and the selection of implants, positioning, angulation, and complementary abutment attachments17–20 (Fig 6-1b). The FAIR procedure involves four to six implants and requires extensive preoperative planning and creative surgical vision.

b Fig 6-1 (a) A clear acrylic denture duplicate template is fabricated for the mandibular FAIR procedure. (b) The dental team inspects and prepares the patient’s mandible for surgery, visually examining the availability of alveolar bone.

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CASE 1 a

b

c

d

Fig 6-2 Case 1 (a and b) The preoperative vertical dimensions are measured to ensure that they can be replicated after surgery and prosthesis placement. (c and d) Bite registration material is used to record the occlusion.

Preoperative Procedure The clear denture duplicate template for the procedure is fabricated in the laboratory or by the clinician. To ensure that the prosthesis will be properly seated after surgery, marks are made to determine the proper vertical distance or dimension with dentures in place. The nose and chin points are marked and measured (Figs 6-2a and 6-2b), using the retromolar pad to ensure the accuracy of the mandibular denture seating. For the clinician to obtain a bite registration, the maxillary denture is seated first, followed by the bite registration material. Then the mandibular denture is placed, and the patient closes the mouth with the dentures in place (Figs 6-2c and 6-2d). Because the FAIR surgery and denture conversion can often last up to 4 hours, anesthesia and patient comfort are crucial.21–23 The effects of lidocaine can last up to 3 hours after a 5-minute onset, but Marcaine (Pfizer) can provide patient comfort for 7 to 12 hours after its 30-minute onset. Therefore, the two anesthetics can be

applied simultaneously for lengthy surgeries, with careful attention to limiting Marcaine dosage in conjunction with lidocaine. While Halcion (Pfizer) may be a viable oral sedation option for anesthetizing the FAIR patient, intravenous sedation can be cost prohibitive, and general anesthesia prevents the clinician from obtaining proper occlusion measurements.24–26

FAIR Surgical Procedure Initial incisions and tissue reflection The incision design is similar to that of the maxilla, but instead of the vertical incisions proceeding posteriorly, there is a single midline vertical releasing incision of approximately 7 mm. As the most distal implants are placed at the sites of the first to second premolars, a midcrestal incision from first molar to first molar is adequate (Fig 6-3). Whereas in the maxilla the palate is used to seat the clear denture duplicate template, the retromolar pad area is used for this

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FAIR Surgical Procedure

CASE 1

b

a

Fig 6-3 Case 1 (cont) (a and b) A vertical releasing incision of approximately 7 mm is made with exposure from first molar to first molar.

3–5 mm

7–9 mm

Anterior loop of mental nerve Fig 6-4 Placement of tilted posterior implants and relatively straight anterior implants.

purpose in the mandible, and a midcrestal incision that is too long will prevent proper seating. At the same time, too short of a midcrestal incision will prevent placement of the implants. To avoid soft tissue sloughing at the crestal area and possible damage due to limited blood supply, the clinician should carefully adhere to precautions associated with nerves and vascular structures in atrophic mandibular bone.27–29 Careful incision design facilitates the avoidance of nerve damage and the repositioning of the soft tissues after flap reflection and implant/abutment placement to avoid suturing gaps. Lingual and even buccal flap retraction can be accomplished with temporary suturing if desired. Once flap reflection is completed, alveolar bone height reduction can commence, based on the clear denture

duplicate template, to guarantee a minimum height of 15 mm of clearance from the incisal edge of the teeth to the bone. Using specialized acrylic burs helps to ensure sufficient width and shape of the remaining bone shelf if adjustment is necessary.

Implant placement The start of the implant osteotomy will be located directly above the mental foramen in the area of the first to second premolar for the distal tilted implants. The apex will be located 3 to 5 mm anterior to the anterior loop of the mental nerve depending on the degree of tilt necessary (typically 30 degrees) to place the implant (Fig 6-4).

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CASE 1 a

b Fig 6-5 Case 1 (cont) (a) An anterior pilot hole is drilled 3.5 mm from the midline. (b) Crestal bone flaring may be required for proper seating of the multiunit abutment. (c) The mandible is ready for implant placement.

c

The surgeon locates the midline of the mandible to determine where to place the two anterior implants. Pilot holes are drilled 3.5 mm from the midline on each side (Fig 6-5a) to allow even distribution and spacing. If more than four implants are used in the mandible, depending on the case, adjustments must be made to spacing based on the patient’s bone anatomy and the implant body diameters. For example, if five implants were placed, one of the anterior implants would be placed in the midline and the other two would be approximately 7 mm from the midline. When placing the implants, the clinician must always be sure to allow for the multiunit abutment fit, angulation, and position. In cases where the coronal aspect of the tilted implant is flush with the bone on the mesial and below the crest of bone on the distal, bone flaring in the submerged region is required for proper seating of the multiunit abutment (Fig 6-5b). Of course, at all times, the tilted implants should remain anterior to the anterior loop of the mental nerve. The microthreads can be left exposed when placing the implant, but the macrothreads cannot.

The implants are placed and torqued to seating at proper depths (Figs 6-5c to 6-5h). The anteroposterior dimension is increased by tilting the implants for prosthetic stability and minimizing the cantilever of the prosthesis. Reliance on drilling guides offered by some implant systems can be counterproductive because cases often require the clinician to visualize the alignment of the implants for placement by positioning the bur appropriately before drilling the pilot hole with sequential burs. This must be done while checking for accuracy, diameter, and depth based on the preoperative physical and virtual models. Undersizing the osteotomy can create higher torque values for implants.30–33 The clinician may prefer deep pitch and aggressive threading on the implant, ensuring that the osteotomy diameter is smaller than the implant thread diameter to facilitate aggressive torquing. To accomplish this kind of effective torquing, implant manufacturers routinely create burs smaller in diameter than implants of the same size. Undersizing the osteotomy is not as crucial in the mandible as it is in the maxilla, where bone is uniformly

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CASE 1

d

e

f

g

Fig 6-5 Case 1 (cont) (d and e) The anteroposterior dimension is increased by tilting the implants. (f and g) The implants are placed. (h) The implants are torqued to seat at the proper depths.

h

softer. The clinician may nevertheless continue to use a bur size smaller than usual for the implant size when treating the mandible to compress and densify the bone as the implant is placed. While patient race, sex, and systemic and dental health make each case unique, in general less undersizing of the implant osteotomy can be used in denser bone. Additionally, when the clinician uses sequential burs for osteotomy widening, drilling short by 3 to 4 mm at the apical end with the final bur for an implant can add stability. Of

course, the clinician may decide to forego using the final bur before implant placement in especially soft bone conditions. Yet another bur-related technique for improving initial implant stability is to compress the bone by operating the bur in reverse, although the correct osteotomy depth can be difficult to achieve when employing this technique unless drill stops are used.34 Additionally, osseointegration may be subsequently impaired due to the heat associated with such drilling. Finally, and regardless of the consistency of

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CASE 1 a

b

Fig 6-6 Case 1 (cont) (a and b) The two distal tilted implants were placed with the distal coronal aspect submerged, which requires flaring of the osteotomy to allow seating of the multiunit abutment.

Fig 6-7 Direction indicators are used to determine the best angled multiunit abutment.

the alveolar bone, color-coded bone expanders can be used in lieu of burs to improve implant stability at placement by compressing and densifying bone.35,36 Although FAIR patients often present with compromised quality and availability of alveolar bone, undersizing the osteotomy is usually enough to ensure initial implant stability. Implants with greater surface area and diameter (eg, 4.7 mm) could be used instead of the standard diameters (ie, 3.7 mm to 4.2 mm). However, larger implant inventories often include the complexity and cost associated with an expanded complement of platforms and abutments. Distal tilted implant lengths are typically 16 mm. Options for placement include having the coronal mesial threads exposed or the distal portion submerged (in which case the distal portion of the implant osteotomy must be flared to allow for seating of the multiunit abutment). To help prevent

Fig 6-8 Angled abutments are held by disposable handles and tightened with a hex driver aligned with the long axis of the implant.

peri-implantitis, the clinician should plan for the first 2 mm of the crestal surface of the implant to be nonroughened or microthreaded, thus providing a suitable transition zone for contact with bone and soft tissue.37

Abutment attachment For a proper fit, submerging the implant must be accompanied by complementary adjustment for the placement of the prosthetic abutments, including flaring the osteotomy in the areas where the implant is submerged in bone (Fig 6-6). Direction indicators are used to determine the best angled multiunit abutment so that the clinician does not risk damaging the abutment through repeated trial-and-error attachments to the implant (Fig 6-7).

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CASE 1

a

b

c Fig 6-9 Case 1 (cont) (a and b) The hex driver holds and places straight abutments. (c) Two angled abutments are placed posteriorly, and two straight abutments are placed anteriorly.

Another function of direction indicators is to help determine the subtle differences of angulation from implant to implant, including different angulations of posterior/anterior implant pairs. The hex of the implant determines its tilted or straight status for connecting to the abutment and prosthesis. The proper height of the cuff (generally standardized at 3 mm) is critical to ensure the optimal height of the prosthesis in relation to the tissue to eliminate intervening gaps. The hex driver holds and places straight abutments, while tilted abutments are held by disposable handles that protrude through the trough of the clear denture duplicate template, and the hex driver is tilted during tightening so that it is in line with the long axis of the implant (Figs 6-8 and 6-9a to 6-9c). If abutments are seated slightly below the bone, bone flaring is required. Aggressive bone flaring and angle adjustments are common for FAIR procedures because seating the abutment below the bone is frequently necessary for tilted implants. The implant is torqued into place at 45 to 75 Ncm. A torque wrench with a handle and tightening knob to better

adjust the torque is used to place the multiunit abutments, typically at 25 to 30 Ncm. The soft tissue must be measured to ensure the multiunit abutments are 1 to 2 mm above the soft tissue to prevent complications later. Once the abutments are tightened, soft tissue suturing may commence (Figs 6-9d and 6-9e). Temporary caps are optional during this stage. When suturing is complete, the temporary caps are removed, and the titanium sleeves are placed. Retromolar pads, used previously for bite registration, should be sufficient to check proper seating of the denture (Figs 6-9f and 6-9g).

Prosthesis placement and attachment The process of prosthesis placement and attachment (Fig 6-10) is discussed in detail in chapter 4 (see pages 28 to 30). Figure 6-11 describes a second case example of a patient with a fully edentulous mandible. This treatment uses guided surgery.

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CASE 1 e

d

f

g

Fig 6-9 Case 1 (cont) (d and e) Suturing around the abutments. (f) Bite registration material is placed into the intaglio surface of the denture. (g) The denture is seated to mark the positions of the multiunit abutments.

a

b

c

d

Fig 6-10 Case 1 (cont) (a and b) Once marked, holes are drilled through the bite registration material and through the underlying denture to allow for the titanium sleeves to be bonded to the denture. (c) Titanium sleeves are placed. (d) The titanium sleeves protrude through the denture prosthesis apertures.

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CASE 1

e

f

g

h

i

j

Fig 6-10 Case 1 (cont) (e and f) Acrylic is added liberally to the denture apertures and to the titanium sleeve (as well as to the intaglio surface of the denture) so that the denture bonds to the titanium sleeves. (g and h) The denture is cut distally, the distance of half to one tooth past the distal titanium sleeves. For larger cuts, the clinician can use a disk; for finer trimming, a diamond bur should be used. (i) The palate, borders, and flanges are trimmed. (j) Acrylic is applied as needed to even the surface. (k) After making the adjustments, the prosthesis is polished.

k

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CASE 1 l

m

n

o

p

q Fig 6-10 Case 1 (cont) (l and m) Finished provisional prosthesis. (n) Screw access holes are filled with Fermit (Ivoclar Vivadent) or Cavit (3M). (o and p) The occlusion is checked using articulation paper and adjusted as necessary. (q) The patient’s bite and esthetics are checked.

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FAIR Surgical Procedure

CASE 2

a

b

c

d

e

g

f

h

Fig 6-11 Case 2 (a and b) Midcrestal and vertical releasing incisions are made to expose the bone. (c) Computer-designed guide is placed. (d) Implant guide system. (e) Pins are inserted to keep the guide in place. (f) The guide is used for drilling into the bone to create the osteotomy for the implants. (g) The implants are placed. (h) The denture is tried in.

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CASE 2 1 j

i

k

l

m

o

n

p

Fig 6-11 Case 2 (cont) (i) Multiunit abutments are placed. (j) Registration material is placed in the intaglio surface of the denture to mark the multiunit abutment locations. (k and l) Holes are drilled into the denture in the positions of the multiunit abutments marked on the bite registration material. (m and n) After the holes are drilled, the bite registration material is removed, and the holes are further drilled and refined to do a pickup with the titanium sleeves. (o) Holes have been drilled, and the prosthesis is ready for pickup. (p) The flap is sutured around the multiunit abutments.

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CASE 2 1

q

r

s

u

t

v

Fig 6-11 Case 2 (cont) (q and r) Rubber dam is marked through the holes, and holes are punched, reflecting the locations of abutments. (s) Titanium sleeves are placed and tightened onto the abutments. (t) Titanium sleeves should fit through the holes with ease, and the bite is checked. (u) MucoHard (Parkell) bonding agent is applied to the prosthesis and the titanium sleeves. (v) Acrylic is mixed. (w) GI-Mask (Coltene) is placed into the holes of the titanium sleeves to prevent hard acrylic from getting inside during pickup.

w

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Treating the Fully Edentulous Mandible

CASE 2 1 x

y

aa

z

bb

dd

cc

ee

Fig 6-11 Case 2 (cont) (x to z) Acrylic is added into the denture intaglio surface and holes that were drilled. (aa) MucoHard is placed around the sleeves. (bb) The denture is then placed over the rubber dam, ensuring that the titanium sleeves are passing through. (cc) Excess acrylic material is wiped off so that the acrylic is distributed evenly. (dd) Accurate positioning is checked. (ee) GI-Mask is removed from the holes to expose the screws.

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FAIR Surgical Procedure

CASE 2 1

ff

gg

hh

jj

ii

kk

Fig 6-11 Case 2 (cont) (ff) The prosthesis is unscrewed and detached from the multiunit abutments. (gg) The denture is checked. (hh and ii) Implant analogs are placed into the titanium sleeves. (jj and kk) Acrylic is applied liberally to ensure that the titanium sleeves bond to the prosthesis maximally.

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CASE 2 1 ll

nn

pp

mm

oo

qq Fig 6-11 Case 2 (cont) (ll) The prosthesis is placed in a hot water bath. (mm) Once the acrylic has set, the denture is trimmed, adjusted, and polished. (nn) The borders and flanges are trimmed. (oo) Holes are cleared of obstructions. (pp) The denture is further trimmed, adjusted, and polished. (qq and rr) A well-trimmed and polished provisional prosthesis.

rr

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CASE 2 1

ss

tt

uu

ww

vv

xx

Fig 6-11 Case 2 (cont) (ss and tt) The provisional prosthesis is placed and tightened into the multiunit abutments. (uu) The bite is checked. (vv to yy) Fermit is used to fill in the holes, excess is removed, and the Fermit is light cured.

yy

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References 1. Misch CE, Degidi M. Five-year prospective study of immediate/early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system. Clin Implant Dent Relat Res 2003;5:17–28. 2. Babbush CA, Kutsko GT, Brokloff J. The All-on-Four immediate function treatment concept with NobelActive implants: A retrospective study. J Oral Implantol 2011;37:431–445. 3. Özdemir Dogan E, Gül EB. Evaluation of ˘ D, Polat NT, Polat S, Seker ˛ “All-on-Four” concept and alternative designs with 3D finite element analysis method. Clin Implant Dent Relat Res 2014;16:501–510. 4. Patzelt SB, Bahat O, Reynolds MA, Strub JR. The All-on-Four treatment concept: A systematic review. Clin Implant Dent Relat Res 2014;16:836–855. 5. Barbosa GA, Bernardes SR, de França DG, das Neves FD, de Mattos Mda G, Ribeiro RF. Stress over implants of one-piece cast frameworks made with different materials. J Craniofac Surg 2016;27:238–241. 6. Motta M, Monsano R, Velloso GR, et al. Guided surgery in esthetic region. J Craniofac Surg 2016;27:e262–e265. 7. Ganeles J, Rosenberg MM, Holt RL, Reichman LH. Immediate loading of implants with fixed restorations in the completely edentulous mandible: Report of 27 patients from a private practice. Int J Oral Maxillofac Implants 2001;16:418–426. 8. Maló P, Rangert B, Nobre M. “All-on-Four” immediate-function concept with Brånemark System implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent Relat Res 2003;5(suppl 1):2–9. 9. Chiapasco M. Early and immediate restoration and loading of implants in completely edentulous patients. Int J Oral Maxillofac Implants 2004;19(suppl):76–91. 10. Morton D, Jaffin R, Weber HP. Immediate restoration and loading of dental implants: Clinical considerations and protocols. Int J Oral Maxillofac Implants 2004;19(suppl):103–108. 11. Gallucci GO, Bernard JP, Bertosa M, Belser UC. Immediate loading with fixed screw-retained provisional restorations in edentulous jaws: The pickup technique. Int J Oral Maxillofac Implants 2004;19:524– 533. 12. Castellon P, Blatz MB, Block MS, Finger IM, Rogers B. Immediate loading of dental implants in the edentulous mandible. J Am Dent Assoc 2004;135:1543–1549. 13. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: A multicenter clinical study. Int J Oral Maxillofac Implants 2007;22:639–644. 14. Khatami AH, Smith CR. “All-on-Four” immediate function concept and clinical report of treatment of an edentulous mandible with a fixed complete denture and milled titanium framework. J Prosthodont 2008;17:47–51. 15. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Del Fabbro M. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: Interim results of a single cohort prospective study. Clin Implant Dent Relat Res 2008;10:255–263. 16. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP. Implant loading protocols for edentulous patients with fixed prostheses: A systematic review and meta-analysis. Int J Oral Maxillofac Implants 2014;29(suppl):256–270. 17. De Kok IJ, Thalji G, Bryington M, Cooper LF. Radiographic stents: Integrating treatment planning and implant placement. Dent Clin North Am 2014;58:181–192.

18. Bryington M, De Kok IJ, Thalji G, Cooper LF. Patient selection and treatment planning for implant restorations. Dent Clin North Am 2014;58:193–206. 19. Menini M, Pesce P, Bevilacqua M, et al. Effect of framework in an implant-supported full-arch fixed prosthesis: 3D finite element analysis. Int J Prosthodont 2015;28:627–630. 20. Siadat H, Alikhasi M, Beyabanaki E, Rahimian S. Comparison of different impression techniques when using the All-on-Four implant treatment protocol. Int J Prosthodont 2016;29:265–270. 21. Faraco FN, Kawakami PY, Mestnik MJ, Ferrari DS, Shibli JA. Effect of anesthetics containing lidocaine and epinephrine on cardiovascular changes during dental implant surgery. J Oral Implantol 2007;33:84– 88. 22. Sánchez-Siles M, Torres-Diez LC, Camacho-Alonso F, Salazar-Sánchez N, Ballester Ferrandis JF. High volume local anesthesia as a postoperative factor of pain and swelling in dental implants. Clin Implant Dent Relat Res 2014;16:429–434. 23. Valieri MM, de Freitas KM, Valarelli FP, Cançado RH. Comparison of topical and infiltration anesthesia for orthodontic mini-implant placement. Dental Press J Orthod 2014;19:76–83. 24. Dionne RA, Yagiela JA, Coté CJ, et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. J Am Dent Assoc 2006;137:502–513. 25. Schwamburger NT, Hancock RH, Chong CH, Hartup GR, Vandewalle KS. The rate of adverse events during IV conscious sedation. Gen Dent 2012;60:e341–e344. 26. Stronczek MJ. Determining the appropriate oral surgery anesthesia modality, setting, and team. Oral Maxillofac Surg Clin North Am 2013;25:357–366. 27. Greenstein G, Tarnow D. The mental foramen and nerve: Clinical and anatomical factors related to dental implant placement: A literature review. J Periodontol 2006;77:1933–1943. 28. Tolstunov L. Implant zones of the jaws: Implant location and related success rate. J Oral Implantol 2007;33:211–220. 29. Greenstein G, Cavallaro J, Tarnow D. Practical application of anatomy for the dental implant surgeon. J Periodontol 2008;79:1833–1846. 30. Greenstein G, Cavallaro J, Greenstein B, Tarnow D. Treatment planning implant dentistry with a 2-mm twist drill. Compend Contin Educ Dent 2010;31(2):126–128,130,132. 31. González-Martín O, Lee EA, Veltri M. CBCT fractal dimension changes at the apex of immediate implants placed using undersized drilling. Clin Oral Implants Res 2012;23:954–957. 32. Coelho PG, Marin C, Teixeira HS, et al. Biomechanical evaluation of undersized drilling on implant biomechanical stability at early implantation times. J Oral Maxillofac Surg 2013;71:e69–e75. 33. Jimbo R, Tovar N, Anchieta RB, et al. The combined effects of undersized drilling and implant macrogeometry on bone healing around dental implants: An experimental study. Int J Oral Maxillofac Surg 2014;43:1269–1275. 34. Lahens B, Neiva R, Tovar N, et al. Biomechanical and histologic basis of osseodensification drilling for endosteal implant placement in low density bone. An experimental study in sheep. J Mech Behav Biomed Mater 2016;63:56–65. 35. Mohamed JB, Alam MN, Singh G, Chandrasekaran SN. Alveolar bone expansion for implant placement in compromised aesthetic zone— Case series. J Clin Diagn Res 2014;8:237–238. 36. Jha N, Choi EH, Kaushik NK, Ryu JJ. Types of devices used in ridge split procedure for alveolar bone expansion: A systematic review. PLoS One 2017;12:e0180342. 37. Rakic M, Galindo-Moreno P, Monje A, et al. How frequent does peri-implantitis occur? A systematic review and meta-analysis. Clin Oral Investig 2018;22:1805–1816.

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7 CHAPTER

Treating the Partially Edentulous Maxilla

T

reatment of the fully versus partially edentulous maxilla is similar, with only a few key differences; therefore, portions of this chapter are identical to chapter 5. This chapter is meant to be comprehensive to allow the reader to review the steps prior to an upcoming partially edentulous maxillary case (Fig 7-1). Until the advent of the minimally invasive implant techniques used in the full-arch implant rehabilitation (FAIR) procedure, bone augmentation was almost always required to restore the moderate to advanced atrophic partially edentulous maxilla, and with this came an increased risk of morbidity. FAIR reduces not only inconvenience and risk during surgery and recovery but also time and cost for both clinicians and patients. However, these benefits can only be offered when clinicians have taken the time to master the complex FAIR technique. For example, same-day loading of the prosthesis is particularly attractive to patients, but accompanying this advantage are the intricacies of placing the tilted implants and positioning the tilted abutments. Additionally, placement of implants parallel to the wall of the anterior sinus generally requires a high degree of surgical skill and stereolithographic (STL) models of the patient’s maxilla or computer guidance. Fortunately, many implant systems provide such aid to help clinicians navigate the terrain of the maxilla, and FAIR and similar other technologies have excellent short- and long-term results.1–5

The FAIR Vision Treating the partially edentulous maxilla using the FAIR protocol is an invaluable way for clinicians to develop expert

Fig 7-1 This patient is partially edentulous in the maxilla.

skills.6–14 Similar to the carpentry maxim “measure twice; cut once,” the implant clinician should “visualize the case multiple times; perform surgery once.”15–17 This process can be facilitated by the clinician’s use of virtual three-dimensional (3D) computed tomography (CT) STL models in addition to the CT scan review itself. It can also include making measurements on and performing a practice surgery on an STL bone model of the patient’s maxilla prior to the actual patient surgery (Fig 7-2). Such planning is particularly important in cases where the alveolar bone is minimal, making the selection of the implants and their angulation and positioning more critical.18–20 The FAIR procedure usually involves only four to six implants, but it is deceptively complex, requiring extensive preoperative planning and surgical vision.

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a

Fig 7-2 This 3D STL model is based on the patient’s CT scan.

Preoperative Procedure The clear denture duplicate template for the procedure is cut (either in the laboratory or by the clinician) so that the buccal flange is 15 mm from the incisal edge from premolar to premolar (Fig 7-3). This will provide a measure for the amount of bone recontouring that will be required. The posterior flanges of the denture are not cut; otherwise, the denture might be overseated into the vestibule. The FAIR surgery can be quite lengthy, especially for partially edentulous patients, and it therefore requires a unique approach to anesthesia for patient comfort.21–23 Raising the soft tissue flaps, extracting the teeth, contouring the bone, placing the implants, and making the denture conversion together make up a lengthy procedure routinely lasting up to 4 hours. Intravenous sedation is not generally recommended. Although it allows the patient to bite and to follow commands, the clinical cost can be prohibitive due to the length of the procedure.24 General anesthesia is not a good option either because it makes obtaining proper occlusion nearly impossible, even if the patient is nasally intubated, and requires the clinician to manipulate the patient’s jaws.25 Bupivacaine (eg, Marcaine, Pfizer), which lasts 7 to 12 hours but can take up to 30 minutes to take effect, can be used simultaneously with lidocaine, which typically takes only 5 minutes for onset but lasts 2.5 to 3 hours. That way, if the surgery is lengthy, the Marcaine can still provide the patient with the necessary comfort once the lidocaine has dissipated. Dosage is important, and less Marcaine is often required if used in conjunction with lidocaine. Triazolam (eg, Halcion, Pfizer) may be a good addition to help relax the patient.26

b

15 mm

c

d Fig 7-3 (a and b) The patient’s traditional denture. (c and d) The clear denture duplicate template is cut in the laboratory or by the clinician for correct bone reduction and visualization of correct multiunit abutment placement.

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CASE 1

a

b

15 mm

c

d

Fig 7-4 Case 1 (a to c) Vertical releases are created at the distal extent of the incision bilaterally, and a flap is reflected buccally and palatally. (d) A clear denture duplicate template with the buccal flange cut to 15 mm from premolar to premolar is used as a guide for bone reduction.

FAIR Surgical Procedure Initial incisions and tissue reflection Once anesthesia is employed, the surgery can begin with an incision design made from first molar to first molar around the existing teeth. Vertical releases are created at the distal extent of the incision bilaterally, and a flap is reflected buccally and palatally27 (Figs 7-4a to 7-4c). With the aid of a retractor and the tissue reflected, the clinician can begin reducing the height of the alveolar bone in accordance with the clear denture duplicate template to ensure a clearance of 15 mm from the incisal edge of the denture to the bone (Fig 7-4d). The ridge can be reduced using a variety of tools, including a sagittal saw, a Hall drill (Conmed) with round bur, a piezoelectric surgery unit with a small saw blade, or an implant motor handpiece with a large round bur. The author’s recommendation is to use the implant motor and handpiece with a specialized bur with a smooth tip to prevent tearing of the palatal soft tissue (Fig 7-4e) to create the ideal shape for the ridge (Figs 7-4f and 7-4g). Landmarking the positions of the sinus membrane and nasal floor is important before the anterior implants are placed, usually vertical or slightly tilted to reach accessible

bone beyond an area of less-than-ideal bone. The distal implants are placed so that the apex of the implant engages the lateral piriform rim (Fig 7-4h). The anterior implants are placed so that the apex engages the bone of the nasal floor. The entrance point of the distal implants is halfway between the first and the second premolars, and they essentially follow the path of the anterior maxillary sinus wall. If the soft tissues of the sinus floor are perforated, the procedure should be aborted or the implant repositioned due to the risk of inadequate implant stability or sinus infection.28 For this reason, it is frequently beneficial to perform a sinus floor elevation and grafting to avoid the possibility of perforation while attempting to engage the bone of the nasal floor. Implant placement Regarding implant sizing categories, it is preferable to use deep pitch threading for aggressive penetration of the osteotomy. The osteotomy diameter should be smaller than the actual diameter of the implant itself to allow for aggressive torquing. Thus, it is prudent to use a bur size smaller than the usual bur size for a particular implant size and even smaller for softer bone. In cases with denser bone, same-size burs and implants can be used. In cases of even denser bone,

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CASE 1 e

g

f

h

Fig 7-4 Case 1 (cont) (e to g) The ridge can be reduced using the implant motor and handpiece with a specialized bur. (h) The tilt of the right distal implant is visualized.

the osteotomy can be complemented by coronal flaring. Each case is different. Using bone expanders instead of additional burs and drilling can be another way to achieve greater initial stability, both in regular and soft bone.16,17 A 2.0-mm hole can be drilled and then followed up with color-coded expanders, followed by the implant (Fig 7-5). Expanders compress and densify the bone. In lieu of expanders, burs operated in reverse will have the same effect by pushing the bone forward instead of cutting it. However, the heat generated in the bone by compressing it this way can adversely affect bone cell integrity, potentially leading to localized bone necrosis and delayed osseointegration. Additionally, operating the bur in reverse complicates the creation of the correct depth of the osteotomy unless the bur kit includes a drill stop apparatus. Standard implant diameter is usually 3.7 to 4.2 mm. The implant that offers the greatest surface area while still being surrounded by bone should be chosen as the optimal diameter. Bone availability and quality are likely to be poor in FAIR cases, so although 3.7 to 4.2 mm are good diameter options, a 4.7-mm-diameter implant might be a better choice if possible, especially to help minimize the gaps in

extraction sockets if an implant is partially or completely placed into an extraction site. In addition, if platelet-rich plasma (PRP) is being used as a growth-factor adjunct, then the implants can be soaked in the PRP to enhance the surface for better and faster osseointegration.19 For partially edentulous cases, PRP will generally be used because bone grafting is expected for the extraction sockets. Distal implants are generally tilted at approximately 30 degrees; the length is typically 16 mm to obtain apical engagement in the cortical plate of the lateral piriform rim. There are two options regarding the positioning of the coronal portion of distal implants placed at an angle: with the mesial portion flush and the distal submerged, or with the distal aspect flush and the mesial protruding; thus, either the mesial threads are exposed, or the distal portion of the implant is submerged. Therefore, an implant system should be chosen in which the coronal-most 2 mm are suitable for bone or soft tissue, so if the implant threads are submerged, they integrate; if not, they allow for soft tissue health instead of resulting in peri-implantitis.21 For a strict FAIR concept, the preference is to seat the distal coronal aspect of the distal implant below the bone, thus

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CASE 1

a

b

d

c

Fig 7-5 Case 1 (cont) (a to d) A 2.0-mm hole can be drilled and then followed up with color-coded 2.3-, 3.0-, and 3.5-mm expanders, followed by the implant.

a

b

Fig 7-6 Case 1 (cont) (a) Direction indicators are used to determine the best multiunit abutment angle. (b) Finished provisional prosthesis.

minimizing exposure of the threads on the mesial aspect of the implant and the associated potential tissue aggravation. However, submerging the distal aspect of the implant may require aggressive flaring of the osteotomy to allow seating of the prosthetic abutment. Mesial-distal tilted implants are generally used posteriorly, whereas straight or buccolingually tilted implants are generally used anteriorly in the partially edentulous maxilla.

Abutment attachment Once the implants are placed, the direction indicators are snapped into the implants. When used with a clear denture duplicate template, the direction indicators should to protrude through the palatal trough, thus indicating the optimal prothetic abutment angulation. The implant direction indicator indicates whether the implant is tilted approximately 0, 9, 18, or 30 degrees (Fig 7-6a). The cuff

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CASE 2 1 a

b

c

e

d

f

Fig 7-7 Case 2 (a to e) The clear denture duplicate template is measured and marked to create a 15-mm flange from premolar to premolar and a palatal trough for implant placement. (f) The patient’s immediate denture. This will be converted to the fixed transitional prosthesis if implants have adequate torque on placement or delivered as a removable denture if they do not.

height of the abutment is also crucial. If it is too high, then the prosthesis will be positioned too supragingivally. For example, if the tissue is 3 mm thick and the abutment cuff is 5 mm, there will be a 2-mm gap between the prosthesis and the soft tissue. Therefore, the clinician should aim for a cuff height that mirrors tissue thickness. The ideal height is usually 3 mm, but a cuff height of 4 mm or more could be

used for very thick tissues. If there is not enough clearance, a shorter cuff may be necessary. However, from a manufacturing perspective, the multiunit abutment is weakened considerably when the cuff height is less than 3 mm, so this is not generally recommended. The hex driver is used to hold and place the straight abutment. The tilted abutment has a disposable handle for

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FAIR Surgical Procedure

CASE 2 1

g

i

h

j

Fig 7-7 Case 2 (cont) (g and h) The nose and chin are marked to measure the vertical dimension. (i to k) The remaining maxillary teeth are evaluated and extracted.

k

holding while tightening. When the multiunit abutment is aligned correctly, this handle will protrude through the trough of the clear denture duplicate template. During tightening, the driver is tilted at the same angle as the implant. The multiunit abutment is torqued to 25 to 30 Ncm, depending on the implant system, with a prosthetic torque wrench.

Prosthesis placement and attachment The process of prosthesis placement and attachment (Fig 7-6b) is discussed in detail in chapter 4 (see pages 28 to 30). Figure 7-7 demonstrates a second partially edentulous case example.

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CASE 2 1 l

n

m

o

p

r

q

s

Fig 7-7 Case 2 (cont) (l) The flap is reflected to expose the bone. (m) The clear denture duplicate template is placed. (n and o) Using this guide, the bone is measured and marked with a surgical saw. (p) The ridge is cut to ensure a minimum of 15 mm of interocclusal space to the opposing dentition. (q to s) The flap is temporarily sutured out of the way, and the ridge is smoothed down with an ImplantVision ridge-contouring bur.

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CASE 2 1

t

u

v

w

x

y

z

aa

Fig 7-7 Case 2 (cont) (t) An electrocautery unit in coagulation mode should be used to cauterize any bleeding areas in the surgical site. (u and v) The nasal floor membrane is reflected. (w) The initial bur is used to create the osteotomy. (x) Paralleling pins are used to determine osteotomy angulation. (y) Two tilted implants are placed posteriorly, and two straight implants are placed anteriorly. (z) Implants are torqued sufficiently for immediate loading. (aa) Direction indicators are used to determine the best angles for the multiunit abutments. 79

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References 1. Misch CE, Degidi M. Five-year prospective study of immediate/ early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system. Clin Implant Dent Relat Res 2003;5:17–28. 2. Barbosa GA, Bernardes SR, de França DG, das Neves FD, de Mattos Mda G, Ribeiro RF. Stress over implants of one-piece cast frameworks made with different materials. J Craniofac Surg 2016;27:238–241. 3. Motta M, Monsano R, Velloso GR, et al. Guided surgery in esthetic region. J Craniofac Surg 2016;27:e262–e265. 4. Uhlendorf Y, Sartori IA, Melo AC, Uhlendorf J. Changes in lip profile of edentulous patients after placement of maxillary implant-supported fixed prosthesis: Is a wax try-in a reliable diagnostic tool? Int J Oral Maxillofac Implants 2017;32:593–597. 5. Zoidis P. The All-on-4 modified polyetheretherketone treatment approach: A clinical report. J Prosthet Dent 2017;119:516–521. 6. 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;65:1010–1016. 7. 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;24:887–895. 8. Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept for completely edentulous maxillae: A clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14(suppl 1):e139–e150. 9. Avrampou M, Mericske-Stern R, Blatz MB, Katsoulis J. Virtual implant planning in the edentulous maxilla: Criteria for decision making of prosthesis design. Clin Oral Implants Res 2013;24(suppl A100):152–159. 10. Agliardi EL, Pozzi A, Stappert CF, Benzi R, Romeo D, Gherlone E. Immediate fixed rehabilitation of the edentulous maxilla: A prospective clinical and radiological study after 3 years of loading. Clin Implant Dent Relat Res 2014;16:292–302. 11. Cavalli N, Barbaro B, Spasari D, Azzola F, Ciatti A, Francetti L. Tilted implants for full-arch rehabilitations in completely edentulous maxilla: A retrospective study. Int J Dent 2012;2012:180379. 12. Jensen OT, Cottam JR, Ringeman JL, Graves S, Beatty L, Adams MW. Angled dental implant placement into the vomer/nasal crest of atrophic maxillae for All-on-Four immediate function: A 2-year clinical study of 100 consecutive patients. Int J Oral Maxillofac Implants 2014;29:e30–e35. 13. Maló P, de Araújo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623.

14. Tallarico M, Meloni SM, Canullo L, Caneva M, Polizzi G. Five-year results of a randomized controlled trial comparing patients rehabilitated with immediately loaded maxillary cross-arch fixed dental prosthesis supported by four or six implants placed using guided surgery. Clin Implant Dent Relat Res 2016;18:965–972. 15. Warreth A, McAleese E, McDonnell P, Slami R, Guray SM. Dental implants and single implant-supported restorations. J Ir Dent Assoc 2013;59:32–43. 16. Bryington M, De Kok IJ, Thalji G, Cooper LF. Patient selection and treatment planning for implant restorations. Dent Clin North Am 2014;58:193–206. 17. De Kok IJ, Thalji G, Bryington M, Cooper LF. Radiographic stents: Integrating treatment planning and implant placement. Dent Clin North Am 2014;58:181–192. 18. Menini M, Pesce P, Bevilacqua M, et al. Effect of framework in an implant-supported full-arch fixed prosthesis: 3D finite element analysis. Int J Prosthodont 2015;28:627–630. 19. Siadat H, Alikhasi M, Beyabanaki E, Rahimian S. Comparison of different impression techniques when using the All-on-Four implant treatment protocol. Int J Prosthodont 2016;29:265–270. 20. Michelinakis G. The use of cone beam computed tomography and three dimensional printing technology in the restoration of a maxillectomy patient using a dental implant retained obturator. J Indian Prosthodont Soc 2017;17:406–411. 21. Faraco FN, Kawakami PY, Mestnik MJ, Ferrari DS, Shibli JA. Effect of anesthetics containing lidocaine and epinephrine on cardiovascular changes during dental implant surgery. J Oral Implantol 2007;33:84–88. 22. Sánchez-Siles M, Torres-Diez LC, Camacho-Alonso F, Salazar-Sánchez N, Ballester Ferrandis JF. High volume local anesthesia as a postoperative factor of pain and swelling in dental implants. Clin Implant Dent Relat Res 2014;16:429–434. 23. Valieri MM, de Freitas KM, Valarelli FP, Cançado RH. Comparison of topical and infiltration anesthesia for orthodontic mini-implant placement. Dental Press J Orthod 2014;19:76–83. 24. Schwamburger NT, Hancock RH, Chong CH, Hartup GR, Vandewalle KS. The rate of adverse events during IV conscious sedation. Gen Dent 2012;60:e341–e344. 25. Stronczek MJ. Determining the appropriate oral surgery anesthesia modality, setting, and team. Oral Maxillofac Surg Clin North Am 2013;25:357–366. 26. Dionne RA, Yagiela JA, Coté CJ, et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. J Am Dent Assoc 2006;137:502–513. 27. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: A multicenter clinical study. Int J Oral Maxillofac Implants 2007;22:639–644. 28. Khatami AH, Smith CR. “All-on-Four” immediate function concept and clinical report of treatment of an edentulous mandible with a fixed complete denture and milled titanium framework. J Prosthodont 2008;17:47–51.

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Treating the Partially Edentulous Mandible

8 CHAPTER

F

ull-arch implant rehabilitation (FAIR) can be an attractive choice for patients who suffer from the functional and esthetic challenges of an atrophic edentulous mandible, whether their condition includes complete or partial edentulism. For partially edentulous patients (Fig 8-1), bone augmentation cannot be ruled out as part of the treatment procedure because multiple tooth extractions are often required before the full-arch prosthesis can be placed. Rehabilitation of the extraction sockets is often necessary, whether the sockets are simply cleaned and covered, grafted, or used as one of the four to six implant sites required for the immediate loading and provisionalization of the FAIR procedure. Morbidity associated with this kind of bone augmentation is relatively minor and rarely deters would-be dental restoration patients (especially considering the other benefits of FAIR, such as brief recovery time and reduced cost).1–10 Preparing the partially edentulous patient for the FAIR method involves multiple unique challenges.11–14 As a result, the clinician’s expertise in placing tilted implants and abutments in conjunction with axial implants in the mandible is tested beyond the usual unique patient needs and addressed through a variety of implant systems designed for the fully edentulous arch.15–20

FAIR in the Mandible: Special Considerations for Partial Edentulism The bone structure and composition of the mandible have always made it an attractive location for full-arch

Fig 8-1 This patient has a partially edentulous mandible.

rehabilitation, but partially edentulous patients will have one or more fresh extraction sockets for the clinician to treat.21–30 To complete the FAIR procedure, these sockets may serve as possible implant sites. Consequently, the clinician should use a blood draw from the patient for platelet-rich plasma (PRP) to hydrate a particulate freeze-dried bone allograft (FDBA), which can be used to graft the extraction sites31–33 (Fig 8-2). PRP membranes, PRP-hydrated bone, and gummy bone (a mixture of autogenous fibrin glue and bone graft) may be part of the healing therapy for the extraction sites34 (Table 8-1). Bilateral blocks rather than infiltrations (as when simply placing implants) are used when extracting the remaining teeth in the mandible. Once teeth are extracted, a round bur (no. 8 carbide) or piezoelectric unit with a round diamond tip can be used to clean the extraction sockets.35 If it is necessary to recontour the mandible, handpieces may be used, preferably a 1:1 surgical handpiece (instead of the usual 20:1 gear reduction implant handpiece), so the speed of the bur will be 40,000 rpm.

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a

b

Fig 8-2 (a and b) The particulate FDBA is hydrated with PRP liquid from autogenous blood drawn from the patient and used to graft the extraction site.

TABLE 8-1

Properties of different autogenous blood concentrates

MATERIAL

TEST TUBE

INDICATIONS [AU: Please provide column headings.]

PRP liquid (PRP-L)

Plastic test tube with anticoagulant with vacuum

• • • •

PRP gel (PRP-G)

Vacuum glass test tube

• Crestal sinus grafting • Socket grafting

PRP membrane (PRP-M)

Vacuum glass test tube

• • • • • • •

PRP exudate (PRP-E)

Vacuum glass test tube

• Hydrate particulate graft material • Hydrate collagen membrane barriers

PRP plug

Vacuum glass test tube

• Socket grafting

Gummy bone

Vacuum glass test tube

• • • •

Hydrate particulate graft material Hydrate porous block grafts Hydrate collagen membrane barriers Place into an implant osteotomy

Coverage over a socket graft Coverage over a sinus graft Placement over a torn sinus membrane Coverage over a block graft Use in soft tissue grafting procedures Place into a connective tissue graft harvest site Put on the implant prior to attaching the healing abutment

Graft ridges with tenting screws or titanium mesh Graft extraction sockets Maxillary sinus grafting Ridge expansion grafting

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FAIR Surgical Procedure

a

b

Fig 8-3 (a) The patient’s denture. (b) A clear denture duplicate template.

Preoperative Procedure

FAIR Surgical Procedure

The vertical dimension is determined, and the clinician marks points on the nose and chin and uses a palate or retromolar pad to ensure accurate occlusion estimates for both arches. The clinician then obtains a bite registration by seating the maxillary denture, followed by the mandibular denture. Alveolar bone availability determines the selection of implants as well as their position, angle, and abutment attachments.36–39 A dental laboratory or the dental office can fabricate the clear denture duplicate template for assisantace in proper implant positioning. If the laboratory does not provide a clear duplicate denture template (Fig 8-3), one can be fabricated simply with the mandibular denture and a Denture Duplicator Kit (Lang Dental), which uses alginate and a separating medium. The lengthiness of FAIR surgery demands close attention to patient anesthetization and comfort.40–42 Lidocaine can be used in conjunction with Marcaine (Pfizer) to provide patient comfort in the short and long term, though the Marcaine dosage is moderated in conjunction with lidocaine. Halcion (Pfizer) is a viable oral sedation option, but intravenous sedation is usually cost prohibitive, and general anesthesia precludes proper occlusion measurements.43–45

Initial incisions and tissue reflection The clinician makes a vertical releasing incision in the midline area, followed by a crestal incision, exposing the ridge from first molar to first molar. This incision design is ideal for placing the distal tilted implants in the first to second premolar sites. Too short of an incision prevents proper implant placement, while too long of an incision prevents proper seating of the denture on the retromolar pads (Fig 8-4). The clinician must adhere to precautions required for nerves and blood vessels in atrophic mandibular bone to avoid soft tissue sloughing at the crestal area.46–48 Careful incision design prevents nerve damage and suturing gaps during implant/abutment placement. After flap reflection, the remaining teeth are extracted, and the clear denture duplicate template is used to reduce alveolar bone height while preserving a minimum clearance of 15 mm from the incisal edge of the denture to the bone. Radiographic or computed tomography (CT) scans can help guide the reduction. Sufficient bone width of the remaining bone shelf is preserved, and the ridge is recontoured ideally (Figs 8-5 and 8-6a) using specialized burs.

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CASE 1 a

b

c

d

Fig 8-4 Case 1 (a and b) Making the incisions and reflecting the flap to identify the mental foramen and nerve and expose the bone. (c and d) The teeth are extracted atraumatically.

Fig 8-5 Specialized bur used to contour the ridge.

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FAIR Surgical Procedure

CASE 1

a

b

Fig 8-6 Case 1 (cont) (a) Ridge reduction based on the clear denture duplicate template using the specialized ridge reduction bur. (b) Checking the trajectory of the pilot hole for the first tilted implant.

Implant placement For posterior tilted implant placement, the clinician should aim to start the osteotomy above the first or second premolar area, directly above the mental foramen (Fig 8-6b). The clinician should plan for the apex of the implant to be located approximately 3 to 5 mm anterior to the anterior loop of the mandibular nerve, and this will usually cause the implant tilt to be approximately 30 degrees. The clinician locates the midline of the mandible to help guide and place the two anterior implants by drilling pilot holes for these implants approximately 3.5 mm to each side of the midline. This practice allows for even distribution and spacing as well as adequate space between the implant margins to maintain the interproximal bone and minimize the likelihood of peri-implantitis (Fig 8-7a). The clinician must adjust the spacing if more than four implants are used. If three implants are used in the anterior region, then one is placed in the midline and the other two 7 mm to each side of the midline. Allowances must be made for the fit of the multiunit abutments before the implants are placed; in particular, flaring of the osteotomy will be necessary to properly seat the abutment when the mesial coronal aspect of a tilted distal implant is flush with bone and the distal coronal aspect of the implant is subcrestal. Implant macrothreads should not be exposed, but microthreads can be exposed if necessary when tilted distal implants are placed with

the distal coronal aspect flush with bone and the mesial coronal aspect exposed. Tilting the implants increases the anteroposterior dimension, and in many cases, the clinician should rely less on drilling guides and more on visualizing the proper implant alignment via sequential bur positioning and checking for accuracy, diameter, and depth as preplanned with physical and virtual case models (Figs 8-7b to 8-7f). Deep pitch implant threading ensures aggressive entrance to the osteotomy and high initial stability. This stability is complemented by coronal osteotomy flaring for proper multiunit abutment seating, drilling short of the apical end of the implant by 3 to 4 mm, and the use of high torque values by undersizing the osteotomy49–52 or even omitting the final bur in the sequence altogether before placing the implant to maximize implant torque. The general concept of reversing the drill direction and/or the use of color-coded bone expanders can be substituted for sequential burs as an alternative method to enhance implant stability at placement.53–55 Another stabilizing technique uses implants with more surface area and greater diameter (eg, a 4.7-mm-diameter implant instead of the standard 3.7- to 4.2-mm diameter). The implants should be torqued into place at 45 to 75 Ncm. The clinician should note that a greater inventory of implant diameters may mean increased complexity and cost due to expanded complements of platforms and abutments needed for the prosthetic portion of the procedure.

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CASE 1 b

a

d

c

e

f

g

h

Fig 8-7 Case 1 (cont) (a and b) A sharp pilot bur is used to start the osteotomy, followed by the 2.0-mm bur. (c and d) Pin guides show the future positions of implants in the edentulous arch and within the trough of the clear denture duplicate template. (e and f) The next larger-diameter bur is used to expand the osteotomy for implant placement. (g) Placing the first anterior implant. (h) Placing the second anterior implant.

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FAIR Surgical Procedure

CASE 1

j

i

k

l

Fig 8-7 Case 1 (cont) (i to l) Placing a distal (tilted) implant. In this case, a fifth implant was placed. However, it will not be used; a cover screw is placed and the implant covered.

Although tilted implants are usually 13 to16 mm long, the implant can be anchored even if the mandible is only 10 mm high because of the angulation. In some cases, there is space for three anterior implants, permitting the clinician to submerge one for future use if one of the others fails (Figs 8-7g to 8-7l). As previously mentioned, placement options for the tilted implants are exposed mesial threads or a submerged distal portion. Peri-implantitis may be prevented if the implants have a suitable transition zone for bone and soft tissue contact via nonroughened or laser-etched portions or microthreads on at least the coronal 2 mm of the implant, allowing the clinician to choose either placement option. With the FAIR procedure, it is recommended for all threads to be in bone when possible.56 In the mandible, once the anterior implants are placed, the posterior implants are placed, followed by grafting of the extraction sockets. (Note that in the maxilla, the posterior implants are placed first, followed by the anterior implants.)

Submerging or exposing implant threads takes on even greater significance in the partially edentulous mandible. Exposure compromises are typical in partially edentulous cases when implants are placed in extraction sockets, and bone preservation is essential. As stated earlier, only microthreads should be exposed if necessary but never the macrothreads, and bone must be flared if a portion of the implant is going to be submerged. The clinician should use the direction indicators to determine the best angulation and position of the implant. More bone contouring may be required as well, and is done as needed. Freeze-dried bone should be hydrated, preferably with PRP (see Fig 8-2) via oversaturating to ensure complete hydration; the excess is removed with gauze (Fig 8-8). If the clinician has trouble seating the abutment, the bone can be flared further but with care to avoid damage to the top of the implant. A cover screw is placed on any implants that will be submerged, and grafting material is then added.

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Fig 8-8 Freeze-dried bone must either be hydrated with PRP for 1 to 2 hours or mixed quickly with PRP via oversaturating and then removing the excess with gauze. Hydrating for an extended amount of time is unadvisable, so the latter option is recommended.

a

b

Fig 8-9 (a) Straight abutment used with the anterior implants. (b) Angled abutments used with tilted implants.

Abutment attachment The clinician can avoid damaging the abutment during repeated insertion through trial and error by using direction indicators to verify not only the osteotomy path but also the abutment angulation and possibly the tissue thickness. Direction indicators help determine the subtle differences in angulation between posterior/anterior implant pairs as well as the relationship between implants and the trough in the clear denture duplicate template. Proper abutment cuff height (generally 2 to 5 mm) is also critical as it eliminates intervening gaps between the prosthesis and the gingival tissue. For straight abutments, the hex driver should be used as a carrier, with 25 to 30 Ncm torqued in place. For the tilted abutment, a disposable handle is used, and the screwdriver

enters on the side (Figs 8-9, 8-10a, and 8-10b). The handle should protrude through the trough of the clear denture duplicate template and is held during tightening of the abutment. Once the abutment is tightened in place, the handle is discarded. Sufficient flaring of the bone is important so that excess bone does not prevent the abutment from being seated on a subcrestally placed portion of an implant. Before suturing, the extraction sockets should be grafted and the bone condensed (Figs 8-10c to 8-10f). Prosthesis placement and attachment The process of prosthesis placement and attachment (Fig 8-11) is discussed in detail in chapter 4 (see pages 28 to 30). Figure 8-12 demonstrates a second case example of a partially edentulous patient.

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FAIR Surgical Procedure

CASE 1

b

a

d

c

e

f

Fig 8-10 Case 1 (cont) (a) Straight abutments are held and placed by the hex driver. (b) Disposable handles hold the angled abutments while the hex driver tightens the retaining screw along the long axis of the implant. (c to f) The extraction sockets should be grafted and the bone condensed. The area is covered with a PRP membrane before suturing.

a

b

Fig 8-11 Case 1 (cont) (a and b) The immediate provisional denture is tried in and the occlusion and vertical dimension of occlusion are checked.

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CASE 1 c

e

h

j

d

g

f

i

k

Fig 8-11 Case 1 (cont) (c and d) Rubber dam is marked, the holes are punched, titanium sleeves are placed on the multiunit abutments, and the punched rubber dam is placed over the prosthesis. Holes are then made in the denture for the titanium sleeves to protrude through. (e) The acrylic is mixed. (f and g) The acrylic is placed around the titanium sleeves and into the intaglio surface of the denture. (h) After the acrylic is set, the titanium sleeve retaining screws are unscrewed, freeing the entire unit from the mouth. Acrylic is further added liberally to the denture (as well as to the undercuts on both sides of the denture) so that the denture bonds more thoroughly and completely to the titanium sleeves. (i) The titanium sleeves are cut flush to the modified denture. The acrylic is cut and adjusted. (j and k) The provisional screw-retained prosthesis should be modified to provide a cantilever of approximately one tooth distal to the most distal implant on each side. The underside should have only a minor concavity or preferably be flat.

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FAIR Surgical Procedure

CASE 1

l

n

m

o

Fig 8-11 Case 1 (cont) (l to n) The prosthesis is delivered and the retaining screws torqued to 15 Ncm. (o) The occlusion is checked to be a balanced occlusal scheme from the most distal implant on the contralateral side. Everything distal to the distal implants on each side should be 1 to 2 mm out of occlusion. (p) The titanium sleeves should be filled with Fermit-N (Ivoclar Vivadent) and then light cured to set. (q) Final result of the FAIR provisional prosthesis.

p

q

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CASE 2 a

b

d

c

e

g

f

h

Fig 8-12 Case 2 (a and b) A vertical releasing incision is made in the midline, approximately 10 mm long, to allow release of the flap and an intracircular incision is made around the necks of the teeth. (c to e) All remaining teeth are extracted atraumatically. (f) A round bur is used to clean the extraction sockets. (g) The ridge is recontoured to remove bone if necessary. (h) The flap is reflected sufficiently to allow bilateral visualization of the mental foramen.

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FAIR Surgical Procedure

CASE 2 1

i

j

k

l

m

n

Fig 8-12 Case 2 (cont) (i) The midline osteotomy is created. (j) The bur is measured and the subsequent osteotomies created. (k and l) Implants are placed sequentially. (m) The implant mounts are removed with the hex driver. (n) The abutments are tightened. (o) The patient’s own blood is collected for PRP.

o

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CASE 2 1 p

q

r

s

t

u Fig 8-12 Case 2 (cont) (p) FDBA is hydrated with PRP exudate. (q) Healing abutments are placed. (r and s) Hydrated FDBA is packed into the sockets. (t and u) PRP membranes are placed over the grafted sites. (v) Sutures are used to close the site.

v

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References

Conclusion The FAIR clinician meets patients’ demands for restoring function and esthetics to the partially edentulous mandible with moderate to advanced periodontal disease and associated bone loss through a variety of well-tested implant systems conducive to this treatment concept. Bone augmentation and other restorative therapies are essential elements of the FAIR treatment because multiple tooth extractions often precede full-arch dental implants and provisionalization. Rehabilitation of the extraction sockets often involves transforming these extraction sockets into implant sites for one or more of the four to six straight and tilted implants essential to the procedure. Nonetheless, these challenges are generally manageable, contributing to a low morbidity rate while complementing the other benefits of reduced cost and recovery time.

References 1. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19(suppl):12–25. 2. John V, De Poi R, Blanchard S. Socket preservation as a precursor of future implant placement: Review of the literature and case reports. Compend Contin Educ Dent 2007;28:646–653. 3. Petrungaro PS. An update on implant placement and provisionalization in extraction, edentulous, and sinus-grafted sites. A clinical report on 3200 sites over 8 years. Compend Contin Educ Dent 2008;29(5):288–300. 4. Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012;23(suppl 5):22–38. 5. Ormianer Z, Piek D, Livne S, et al. Retrospective clinical evaluation of tapered implants: 10-year follow-up of delayed and immediate placement of maxillary implants. Implant Dent 2012;21:350–356. 6. Horowitz R, Holtzclaw D, Rosen PS. A review on alveolar ridge preservation following tooth extraction. J Evid Based Dent Pract 2012;12(3 suppl):149–160. 7. Santos PL, Gulinelli JL, Telles Cda S, et al. Bone substitutes for peri-implant defects of postextraction implants. Int J Biomater 2013;2013:307136. 8. Sanz M, Donos N, Alcoforado G, et al. Therapeutic concepts and methods for improving dental implant outcomes. Summary and consensus statements. The 4th EAO Consensus Conference 2015. Clin Oral Implants Res 2015;26(suppl 11):202–206. 9. Peron C, Javed F, Romanos GE. Immediate loading of tantalum-based implants in fresh extraction sockets in patient with sjogren syndrome: A case report and literature review. Implant Dent 2017;26:634–638.

10. Velasco-Ortega E, Wojtovicz E, España-Lopez A, et al. Survival rates and bone loss after immediate loading of implants in fresh extraction sockets (single gaps). A clinical prospective study with 4 year follow-up. Med Oral Patol Oral Cir Bucal 2018;23:e230–e236. 11. Artzi Z, Kohen J, Carmeli G, Karmon B, Lor A, Ormianer Z. The efficacy of full-arch immediately restored implant-supported reconstructions in extraction and healed sites: A 36-month retrospective evaluation. Int J Oral Maxillofac Implants 2010;25:329–335. 12. Covani U, Orlando B, D’Ambrosio A, Sabattini VB, Barone A. Immediate rehabilitation of completely edentulous jaws with fixed prostheses supported by implants placed into fresh extraction sockets and in healed sites: A 4-year clinical evaluation. Implant Dent 2012;21:272–279. 13. Grandi T, Guazzi P, Samarani R, Grandi G. Immediate loading of four (All-on-4) post-extractive implants supporting mandibular cross-arch fixed prostheses: 18-month follow-up from a multicentre prospective cohort study. Eur J Oral Implantol 2012;5:277–285. 14. Krennmair S, Seemann R, Weinländer M, Krennmair G, Piehslinger E. Immediately loaded distally cantilevered fixed mandibular prostheses supported by four implants placed in both in fresh extraction and healed sites: 2-year results from a prospective study. Eur J Oral Implantol 2014;7:173–184. 15. Misch CE, Degidi M. Five-year prospective study of immediate/ early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system. Clin Implant Dent Relat Res 2003;5:17–28. 16. Babbush CA, Kutsko GT, Brokloff J. The All-on-Four immediate function treatment concept with NobelActive implants: A retrospective study. J Oral Implantol 2011;37:431–445. 17. Özdemir Dog˘an D, Polat NT, Polat S¸eker E, Gül EB. Evaluation of “All-on-Four” concept and alternative designs with 3D finite element analysis method. Clin Implant Dent Relat Res 2014;16:501–510. 18. Patzelt SB, Bahat O, Reynolds MA, Strub JR. The All-on-Four treatment concept: A systematic review. Clin Implant Dent Relat Res 2014;16:836–855. 19. Barbosa GA, Bernardes SR, de França DG, das Neves FD, de Mattos Mda G, Ribeiro RF. Stress over implants of one-piece cast frameworks made with different materials. J Craniofac Surg 2016;27:238–241. 20. Motta M, Monsano R, Velloso GR, et al. Guided surgery in esthetic region. J Craniofac Surg 2016;27:e262–e265. 21. Ganeles J, Rosenberg MM, Holt RL, Reichman LH. Immediate loading of implants with fixed restorations in the completely edentulous mandible: Report of 27 patients from a private practice. Int J Oral Maxillofac Implants 2001;16:418–426. 22. Maló P, Rangert B, Nobre M. “All-on-Four” immediate-function concept with Brånemark System implants for completely edentulous mandibles: A retrospective clinical study. Clin Implant Dent Relat Res 2003;5(suppl 1):2-9. 23. Chiapasco M. Early and immediate restoration and loading of implants in completely edentulous patients. Int J Oral Maxillofac Implants 2004;19(suppl):76–91. 24. Morton D, Jaffin R, Weber HP. Immediate restoration and loading of dental implants: Clinical considerations and protocols. Int J Oral Maxillofac Implants 2004;19(suppl):103–108. 25. Gallucci GO, Bernard JP, Bertosa M, Belser UC. Immediate loading with fixed screw-retained provisional restorations in edentulous jaws: The pickup technique. Int J Oral Maxillofac Implants 2004;19:524–533.

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26. Castellon P, Blatz MB, Block MS, Finger IM, Rogers B. Immediate loading of dental implants in the edentulous mandible. J Am Dent Assoc 2004;135:1543–1549. 27. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: A multicenter clinical study. Int J Oral Maxillofac Implants 2007;22:639–644. 28. Khatami AH, Smith CR. “All-on-Four” immediate function concept and clinical report of treatment of an edentulous mandible with a fixed complete denture and milled titanium framework. J Prosthodont 2008;17:47–51. 29. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Del Fabbro M. Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: Interim results of a single cohort prospective study. Clin Implant Dent Relat Res 2008;10:255– 263. 30. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP. Implant loading protocols for edentulous patients with fixed prostheses: A systematic review and meta-analysis. Int J Oral Maxillofac Implants 2014;29(suppl):256–270. 31. Rutkowski JL, Fennell JW, Kern JC, Madison DE, Johnson DA. Inhibition of alveolar osteitis in mandibular tooth extraction sites using platelet-rich plasma. J Oral Implantol 2007;33:116–121. 32. Del Fabbro M, Corbella S, Taschieri S, Francetti L, Weinstein R. Autologous platelet concentrate for post-extraction socket healing: A systematic review. Eur J Oral Implantol 2014;7:333–344. 33. Del Fabbro M, Bucchi C, Lolato A, Corbella S, Testori T, Taschieri S. Healing of postextraction sockets preserved with autologous platelet concentrates. A systematic review and meta-analysis. J Oral Maxillofac Surg 2017;75:1601–1615. 34. Sohn DS, Huang B, Kim J, Park WE, Park CC. Utilization of autologous concentrated growth factors (CGF) enriched bone graft matrix (sticky bone) and CGF-enriched fibrin membrane in implant dentistry. Jr Implant Adv Cli Dent 2015;7:11–29. 35. Arakji H, Shokry M, Aboelsaad N. Comparison of piezosurgery and conventional rotary instruments for removal of impacted mandibular third molars: A randomized controlled clinical and radiographic trial. Int J Dent 2016;2016:8169356. 36. De Kok IJ, Thalji G, Bryington M, Cooper LF. Radiographic stents: Integrating treatment planning and implant placement. Dent Clin North Am 2014;58:181–192. 37. Bryington M, De Kok IJ, Thalji G, Cooper LF. Patient selection and treatment planning for implant restorations. Dent Clin North Am 2014;58:193–206. 38. Menini M, Pesce P, Bevilacqua M, et al. Effect of framework in an implant-supported full-arch fixed prosthesis: 3D finite element analysis. Int J Prosthodont 2015;28:627–630. 39. Siadat H, Alikhasi M, Beyabanaki E, Rahimian S. Comparison of different impression techniques when using the All-on-Four implant treatment protocol. Int J Prosthodont 2016;29:265–270.

40. Faraco FN, Kawakami PY, Mestnik MJ, Ferrari DS, Shibli JA. Effect of anesthetics containing lidocaine and epinephrine on cardiovascular changes during dental implant surgery. J Oral Implantol 2007;33:84–88. 41. Sánchez-Siles M, Torres-Diez LC, Camacho-Alonso F, Salazar-Sánchez N, Ballester Ferrandis JF. High volume local anesthesia as a postoperative factor of pain and swelling in dental implants. Clin Implant Dent Relat Res 2014;16:429–434. 42. Valieri MM, de Freitas KM, Valarelli FP, Cançado RH. Comparison of topical and infiltration anesthesia for orthodontic mini-implant placement. Dental Press J Orthod 2014;19:76–83. 43. Dionne RA, Yagiela JA, Coté CJ, et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. J Am Dent Assoc 2006;137:502–513. 44. Schwamburger NT, Hancock RH, Chong CH, Hartup GR, Vandewalle KS. The rate of adverse events during IV conscious sedation. Gen Dent 2012;60:e341–e344. 45. Stronczek MJ. Determining the appropriate oral surgery anesthesia modality, setting, and team. Oral Maxillofac Surg Clin North Am 2013; 25:357–366. 46. Greenstein G, Tarnow D. The mental foramen and nerve: Clinical and anatomical factors related to dental implant placement: A literature review. J Periodontol 2006;77:1933–1943. 47. Tolstunov L. Implant zones of the jaws: Implant location and related success rate. J Oral Implantol 2007;33:211–220. 48. Greenstein G, Cavallaro J, Tarnow D. Practical application of anatomy for the dental implant surgeon. J Periodontol 2008;79:1833–1846. 49. Greenstein G, Cavallaro J, Greenstein B, Tarnow D. Treatment planning implant dentistry with a 2-mm twist drill. Compend Contin Educ Dent 2010;31(2):126–132. 50. González-Martín O, Lee EA, Veltri M. CBCT fractal dimension changes at the apex of immediate implants placed using undersized drilling. Clin Oral Implants Res 2012;23:954–957. 51. Coelho PG, Marin C, Teixeira HS, et al. Biomechanical evaluation of undersized drilling on implant biomechanical stability at early implantation times. J Oral Maxillofac Surg 2013;71:e69–e75. 52. Jimbo R, Tovar N, Anchieta RB, et al. The combined effects of undersized drilling and implant macrogeometry on bone healing around dental implants: An experimental study. Int J Oral Maxillofac Surg 2014;43:1269–1275. 53. Lahens B, Neiva R, Tovar N, et al. Biomechanical and histologic basis of osseodensification drilling for endosteal implant placement in low density bone. An experimental study in sheep. J Mech Behav Biomed Mater 2016;63:56–65. 54. Mohamed JB, Alam MN, Singh G, Chandrasekaran SN. Alveolar bone expansion for implant placement in compromised aesthetic zone—Case series. J Clin Diagn Res 2014;8:237–238. 55. Jha N, Choi EH, Kaushik NK, Ryu JJ. Types of devices used in ridge split procedure for alveolar bone expansion: A systematic review. PLoS One 2017; 21;12:e0180342. 56. Rakic M, Galindo-Moreno P, Monje A, et al. How frequent does peri-implantitis occur? A systematic review and meta-analysis. Clin Oral Investig 2018;22:1805–1816.

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9 CHAPTER

FAIR Prosthetics

T

he full-arch implant rehabilitation (FAIR) concept allows treatment of a growing population of partially and fully edentulous patients who have opted for a low-morbidity and relatively low-cost remedy to their dental challenges. Because the FAIR concept is employed after minimal or no regenerative preparations of the patient’s bone-compromised alveolar arches, a two-step prosthetic protocol provides patients with immediate partial function via a provisional prosthesis, followed by excellent restoration of esthetics and function via a definitive prosthesis. A nearly 100% survival rate after 2 years with this type of treatment complements these restorative benefits.1 The clinician must become thoroughly familiar with the prosthetic protocols of the FAIR concept, including those associated with immediate and definitive loading, prosthetic materials, occlusion assessment and control (including impression procedures and accuracy), and peri-implant health and disease.2–26 This chapter provides a step-by-step description of the application of these prosthetic protocols to assist the clinician in understanding the means for providing the restorative benefits of the FAIR system (Fig 9-1).

Fig 9-1 A completed maxillary FAIR prosthesis.

Cantilever length AP spread

Fig 9-2 Cantilever length should not exceed twice the anteroposterior (AP) spread or a maximum of 20 mm.

Biomechanical Factors The clinician should avoid a cantilever or, at the very least, minimize cantilever length when planning the occlusal scheme for immediate loading for the FAIR concept (Fig 9-2). There should be simultaneous bilateral contact points on all teeth; however, this consideration does not pertain to teeth located distal to implant emergence. The clinician

should strive for balanced occlusion or guidance with flat linear pathways when moving laterally or in protrusion; additionally, there should be minimal overbite. The clinician should create balancing contacts during excursive movements, especially when the prosthesis opposes a complete removable denture.

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b

a

c

d

Fig 9-3 (a) The intaglio surface of the denture is lined with Futar. (b) Holes are drilled in the denture for the titanium sleeves. (c) The denture is then placed over the titanium sleeves, ensuring a passive fit. (d) The titanium sleeves are trimmed to the correct height either before (as shown) or after the pickup procedure.

Regarding contact points, the clinician should strive for simultaneous bilateral contacts on the canines and posterior teeth and grazing contacts on the incisors. The clinician should leave the most distal tooth of the provisional prosthesis on both sides marginally out of occlusion. In excursive movements, one or more balancing contacts should be sought. Finally, relatively flat cusps should characterize the occlusal pattern, meaning that the inclination of the cuspal planes should not exceed the inclination of the condylar path. The clinician should be sure to eradicate premature or nonworking-side contacts on the distal cantilever when the teeth of the distal cantilever are not as heavily loaded. As a result, the guiding surfaces of the incisors and canines will eventually undergo increasing abrasions.

The Provisional Prosthesis The oral surgery and placement of the provisional prosthesis follows a predictable process. The immediate denture is created after adjustments have been made to a wax try-in denture designed to confirm esthetics, dimension,

phonetics, and facial support. Prior to surgery, the clinician measures and marks the vertical dimension of occlusion. To help ensure that the correct vertical dimension is preserved, the clinician places the dental implants guided by a clear denture duplicate template generally created by the dental laboratory. Multiunit abutments are then attached to the implants, occasionally followed by healing caps. The clinician indexes the position of the abutments by lining the intaglio surface of the denture with Futar (Kettenbach) and seating it properly in the mouth (Fig 9-3a). Next, the clinician drills holes in the denture for the multiunit abutments and titanium sleeves (Fig 9-3b). The denture is then placed over the titanium sleeves with a passive fit (Fig 9-3c). The next step is optional. The clinician may reduce the height of the titanium sleeves, enabling the patient to bite down. A permanent marker is used to indicate the height at which the titanium sleeve is to be cut. Before or after the pickup procedure is done with the acrylic, the clinician trims the titanium sleeves to the correct height (Fig 9-3d). To create a barrier between the surgical and restorative materials, the clinician places rubber dam around the titanium sleeves (Fig 9-3e). A

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e

f

g Fig 9-3 (cont) (e) Rubber dam is used around the titanium sleeves. (f) The prosthesis is unscrewed, and the prosthetic screws are removed with a hex driver. (g and h) The palate, borders, and flanges are trimmed, and the surface of the denture is smoothed and polished to eliminate sharp angles and edges. (i and j) An ovate pontic contour is created on the intaglio surface of the denture. (k) Prosthetic screws are used to attach the provisional prosthesis to the abutments. The screws are torqued to 15 Ncm with a hex driver.

h

j

light-body impression material or GI-Mask (Coltene) is placed into and on top of the titanium sleeves, preventing acrylic from entering them. The clinician then uses the preoperative bite registration to determine proper seating and denture alignment or uses the palate as a guide for the maxillary denture and the retromolar pad as a guide for the mandibular denture when seating. Pickup materials can be any exothermic polymer acrylic. Next, the clinician removes the prosthesis with the titanium sleeves attached in acrylic. A hex driver is used to unscrew the prosthesis and to remove the prosthetic screws (Fig 9-3f). A healing cap is attached to the abutments until the provisional prosthesis is completed. Next, to convert the immediate denture to a fixed implant-supported prosthesis, the clinician trims the palate,

i

k

borders, and flanges, and then removes most of the distal cantilevers (Fig 9-3g). The surface of the fixed implant denture is then smoothed and polished to eliminate sharp angles and edges (Fig 9-3h). For easy hygienic maintenance, an ovate pontic type shape or flat contour is created on the intaglio surface of the prosthesis (Figs 9-3i and 9-3j). The clinician then uses prosthetic screws to attach the provisional prosthesis to the multiunit abutments, torquing the screws to 15 Ncm with a hex driver (Fig 9-3k). Screw access is filled in with Fermit-N (Ivoclar Vivadent) and composite. Occlusion is adjusted via articulation paper. During the 3- to 6-month healing phase of implant osseointegration, the patient should consume a soft diet, such as cooked vegetables, cooked fruits, and meats. Raw vegetables, raw fruits, and nuts must be avoided.

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Fig 9-3 (cont) (l) For the first 2 weeks following FAIR surgery and provisionalization, the patient should rinse gently witih oral rinses. (m) A commercial tartar and stain remover can be used to clean the prosthesis.

l

m

Fig 9-4 (a and b) An alginate impression is taken to prepare for the custom trays that will be manufactured by the laboratory.

a

For the first 2 weeks following FAIR surgery and provisionalization, the patient should rinse gently with oral rinses (eg, Stellalife) (Fig 9-3l). A water pick and soft-bristle brush with nonabrasive toothpaste can be used for cleaning starting in week 3. The patient should be scheduled for regular hygiene maintenance visits every 3 to 6 months; during these visits, the clinician should evaluate the provisional prosthesis for plaque buildup and the presence of red or inflamed soft tissue. A hygienist can clean around the implants surrounded by healthy tissue the same way cleaning is performed for an ovate pontic on a denture. Red or inflamed tissue and any calculus that has lodged on the prosthesis should alert the clinician to remove the prosthesis (using the hex driver first to remove the screws holding the prosthesis in place) and to clean it ultrasonically. A commercial tartar and stain remover can be used to clean the prosthesis as well (eg, Dr. Berland’s Cleanadent

b

Crystals, Fig 9-3m). Alcohol or sterile water can be used to soak the prosthetic screws. If the screws are removed more than twice, they should be replaced with new ones and torqued to 15 Ncm with the hex driver.

The Definitive Prosthesis Evaluation of the FAIR patient for the definitive prosthesis should begin with an assessment of the patient’s current esthetics and function as provided by the provisional prosthesis. Restorative and surgical issues of note should be documented before placement of the definitive prosthesis, including a too-far palatal or facial screw access hole caused by misaligned abutment position, or less than 15 to 17 mm of vertical space between the coronal margin of the implant and the occlusal plane of the opposing dentition

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(or, for double-arch restorations, less than 24 to 30 mm of vertical space between the coronal margins of the maxillary and mandibular implants). To create the custom tray impression, the clinician should use the hex driver to unscrew the provisional denture. Next, the clinician takes an alginate impression to prepare for the custom trays that will be manufactured by the laboratory (Fig 9-4). An impression of the opposing arch is also taken if required. An impression of the provisional denture should be taken as a baseline of the patient’s preferences. For the final impression, the clinician should unscrew the provisional denture using the hex driver. Next, the open-tray multiunit impression copings are attached to the multiunit abutments, followed by a radiograph to confirm proper seating. The clinician then lutes the impression copings with orthodontic wire or floss and light-curing flowable composite material or Pattern Resin (GC) to create a rigid, accurate frame, and the impression is taken and poured (Fig 9-5). To further ensure accuracy, the dental laboratory will also lute the abutment replicas when the impression copings are attached and the master cast is poured. The clinician must ensure that the custom tray clears the open-tray impression copings; any necessary adjustment of the open tray should be made. Heavy-body impression material should be used around the impression copings. For the tissue area, a medium-body impression material should be used. To make the master impression, the clinician should decide if the patient’s particular case permits the single-stage final process, thus reducing the amount of chair time and other restorative procedures. The FAIR protocol uses 0-, 9-, 18-, or 30-degree multiunit abutments for each implant, allowing any implant angle to be compatible with the prosthesis and simplifying the final impression and future maintenance. When authorizing laboratory work, the clinician should create the following prescription: “Fabricate implant-retained occlusion rim for bite registration for future hybrid denture and fit verification jig.” The laboratory will return a screw-retained occlusion rim to provide a very stable platform for bite registration, and at least two copings should be embedded in the rim, enabling the clinician to correctly stabilize and affix it using screws. The next series of steps employs the basics of dentistry, complemented by screwing or unscrewing the prosthesis: The clinician marks midlines, smile lines, and bite; takes shades; and reviews and selects the proper tooth mold. Usually the palate of the occlusion rim

Fig 9-5 After the clinician places and firmly seats the impression copings, light-curing flowable composite material or Pattern Resin can be used to lute the transfers together. Once the impression copings are placed and luted together, the clinician take the impression.

will be removed to more closely resemble the final product. A bite registration can be taken once the rim is affixed and once fit is confirmed. Additionally, a fit verification jig will be made to verify the accuracy of the implant cast if the impression transfers were not luted together intraorally via Pattern Resin (Fig 9-6). The jig is tried in through a series of steps, which start with removing the healing collars, screwing in the jig on one end and hand-tightening, verifying visually and with an explorer that the remaining posts are engaged and not encumbered by tissue, and taking a radiograph to verify questionable engagement. Next, if one or more posts are not engaged, the clinician sections the jig if necessary, then engage the posts, screws the jig in again, and picks up the jig in a new pickup impression—with no blockout under the bar, and using long screws if possible. Now the clinician can replace the provisional prosthesis. The multiunit abutment analogs are placed and luted by the dental laboratory into the impression copings, ensuring accuracy (Fig 9-7). The laboratory then uses the new pickup impression to pour the new and verified master cast. An impression of the opposing arch can also be taken and is sent to the dental laboratory—along with the cast, occlusion rim, tooth shade, bite registration, and fit verification jig. The written prescription for the laboratory should read, “Model verified and bite registration taken. Fabricate wax try-in for future hybrid restoration.”

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a

b Fig 9-6 (a) The impression copings are luted with Pattern Resin to fashion a rigid, accurate frame. (b) The custom tray is adjusted to clear the open-tray impression copings. (c) A heavy-body impression material is used around the splinted fit verification jig.

c Fig 9-7 This fit verification jig pickup was poured by the laboratory. (Courtesy of Pinhas Adar.)

The next visit is simiply a wax try-in to confirm the esthetics and occlusion of the selected tooth molds introrally. As with a conventional removable denture, the clinician should check phonetics, esthetics, and lip support, with the obvious difference that all lip support via the FAIR concept is provided by the teeth because there is minimal denture flange. For additional support, the cervical portions of the

teeth can be moved labially. After a successful try-in, the clinician returns the case to the dental laboratory for final staging with the prescription, “Try-in approved. Finish final hybrid restoration for final insertion.” The seating of the definitive prosthesis (Fig 9-8) begins with the removal of the provisional. Once the definitive prosthesis is seated, a radiograph verifies proper fit with the

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a b

c

d

Fig 9-8 (a) Intaglio surface of mandibular all-zirconia prosthesis. (b) Intaglio surface of maxillary all-zirconia prosthesis. (c) Both all-zirconia prostheses mounted on an articulator. (d) Both all-zirconia prostheses ready for delivery. (Courtesy of Pinhas Adar.)

a

b

Fig 9-9 (a) The definitive FAIR prosthesis should seat firmly against the soft tissue. (b) The screw access holes should be blocked out with suitable materials to protect the screw heads, and the screw access areas should be sealed with composite.

prosthesis resting firmly against the soft tissue, not unlike an ovate pontic. The soft tissue should roll over the buccal and lingual aspects based on the design of the tissue interface for the definitive prosthesis. The clinician should always use new screws to attach the definitive prosthesis to the multiunit abutments, torquing the screws to 15 Ncm

(Fig 9-9a). The screw access holes should be blocked out with Fermit-N or other suitable materials to protect the screw heads, and the screw access areas should be sealed with composite (Fig 9-9b). The patient should be provided with a nightguard once the procedure is complete.

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References 1. Soto-Penaloza D, Zaragozí-Alonso R, Penarrocha-Diago M, Penarrocha-Diago M. The All-on-Four treatment concept: Systematic review. J Clin Exp Dent 2017;9:e474–e488. 2. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: A multicenter clinical study. Int J Oral Maxillofac Implants 2007;22:639–644. 3. Barndt P, Zhang H, Liu F. Immediate loading: From biology to biomechanics. Report of the Committee on Research in Fixed Prosthodontics of the American Academy of Fixed Prosthodontics. J Prosthet Dent 2015;113:96–107. 4. Chrcanovic BR, Albrektsson T, Wennerberg A. Immediately loaded non-submerged versus delayed loaded submerged dental implants: A meta-analysis. Int J Oral Maxillofac Surg 2015;44:493–506. 5. Francetti L, Corbella S, Taschieri S, Cavalli N, Del Fabbro M. Medium- and long-term complications in full-arch rehabilitations supported by upright and tilted implants. Clin Implant Dent Relat Res 2015;17:758–764. 6. Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I. All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: A 7-year clinical and 5-year radiographic retrospective case series with risk assessment for implant failure and marginal bone level. Clin Implant Dent Relat Res 2015;17(suppl 2):e531–e541. 7. Browaeys H, Dierens M, Ruyffelaert C, Matthijs C, De Bruyn H, Vandeweghe S. Ongoing crestal bone loss around implants subjected to computer-guided flapless surgery and immediate loading using the All-on-4 concept. Clin Implant Dent Relat Res 2015;17:831–843. 8. Ayna M, Gülses A, Açil Y. Comprehensive comparison of the 5-year results of All-on-4 mandibular implant systems with acrylic and ceramic suprastructures. J Oral Implantol 2015;41:675–683. 9. Babbush CA, Kanawati A, Kotsakis GA. Marginal bone stability around tapered, platform-shifted implants placed with an immediately loaded four-implant-supported fixed prosthetic concept: A cohort study. Int J Oral Maxillofac Implants 2016;31:643–650. 10. Sannino G, Barlattani A. Straight versus angulated abutments on tilted implants in immediate fixed rehabilitation of the edentulous mandible: A 3-year retrospective comparative study. Int J Prosthodont 2016;29:219–226. 11. Niedermaier R, Stelzle F, Riemann M, Bolz W, Schuh P, Wachtel H. Implant-supported immediately loaded fixed full-arch dentures: Evaluation of implant survival rates in a case cohort of up to 7 years. Clin Implant Dent Relat Res 2017;19:4–19. 12. Malo P, de Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310–320.

13. Cavalli N, Barbaro B, Spasari D, Azzola F, Ciatti A, Francetti L. Tilted implants for full-arch rehabilitations in completely edentulous maxilla: A retrospective study. Int J Dent 2012;2012:180379. 14. 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;24:263–270. 15. Maló P, de Araújo Nobre MA, Lopes AV, Rodrigues R. Immediate loading short implants inserted on low bone quantity for the rehabilitation of the edentulous maxilla using an All-on-4 design. J Oral Rehabil 2015;42:615–623. 16. Lopes A, Maló P, de Araújo Nobre M, Sanchez-Fernández E. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A prospective report on medium- and long-term outcomes. Clin Implant Dent Relat Res 2015;17(suppl 2):e406–416. 17. Tallarico M, Canullo L, Pisano M, Peñarrocha-Oltra D, PeñarrochaDiago M, Meloni SM. An up to 7-year retrospective analysis of biologic and technical complication with the All-on-4 concept. J Oral Implantol 2016;42:265–271. 18. Babbush CA, Kanawati A, Brokloff J. A new approach to the All-on-Four treatment concept using narrow platform NobelActive implants. J Oral Implantol 2013;39:314–325. 19. Ehsani S, Siadat H, Alikhasi M. Comparative evaluation of impression accuracy of tilted and straight implants in All-on-Four technique. Implant Dent 2014;23:225–230. 20. Papaspyridakos P, Chen CJ, Gallucci GO, Doukoudakis A, Weber HP, Chronopoulos V. Accuracy of implant impressions for partially and completely edentulous patients: A systematic review. Int J Oral Maxillofac Implants 2014;29:836–845. 21. Gherlone EF, Ferrini F, Crespi R, Gastaldi G, Capparé P. Digital impressions for fabrication of definitive “All-on-Four” restorations. Implant Dent 2015;24:125–129. 22. Gherlone E, Capparé P, Vinci R, Ferrini F, Gastaldi G, Crespi R. Conventional versus digital impressions for “All-on-Four” restorations. Int J Oral Maxillofac Implants 2016;31:324–330. 23. Siadat H, Alikhasi M, Beyabanaki E, Rahimian S. Comparison of different impression techniques when using the All-on-Four implant treatment protocol. Int J Prosthodont 2016;29:265–270. 24. Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol 2015;42(suppl 16):S158–S171. 25. Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C, Berglundh T. Peri-implantitis - onset and pattern of progression. J Clin Periodontol 2016;43:383–388. 26. Calvo Guirado JL, Lucero-Sánchez AF, Boquete Castro A, et al. Peri-implant behavior of sloped shoulder dental implants used for All-on-Four protocols: An histomorphometric analysis in dogs. Materials (Basel) 2018;11.

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Possible Complications

T

he dental implant clinician must anticipate a number of possible negative outcomes following the surgery and placement of a full-arch prosthesis that restores nearly complete function for the fully or partially edentulous patient. Invariably, the complications are usually not implant-based (eg, failure of an implant to osseointegrate) because implant failure rates have dropped steadily over the years.1–3 Additionally, dental procedures that employ the full-arch implant rehabilitation (FAIR) treatment concept can be performed without bone grafting and bone reconstruction, immediately removing a number of complications and opportunities for morbidity associated with these bone-enhancing procedures.4 Morbidity is also reduced during the surgical procedure because many clinicians use flapless surgery via prefabricated and customized guides derived from stereolithographic (STL) models; these guides facilitate surgical accuracy to help avoid vital anatomical structures and complications, though complications associated with guided implant placement may still occur5,6 (Fig 10-1). Nonetheless, complications related to implant stability and healing could still evolve. Moreover, miscalculations involving the patient’s smile line and gingiva exposure could result in esthetic concerns (Fig 10-2), and additional complications can arise from lack of patient hygiene and prosthetic care. Complications can be classified as surgical, patient-related, or prosthetic. The most common types of complications with the FAIR procedure are related to the prosthetic structure itself; namely, acrylic fracturing.7,8 A number of things can cause acrylic fracture, including improper conversion of a denture to a prosthesis, failing to account for a sufficient amount of interarch space when implants are placed,

Fig 10-1 Models of the maxilla and mandible are sometimes used to educate the patient and illustrate how dental implants, abutments, and crowns align inside the patient’s mouth.

a

b

Fig 10-2 (a) The transition line of the prosthesis should be hidden by the lips. (b) If the patient has a high smile or laugh line, the transition of the prosthesis will show, and esthetics will be unsatisfactory.

insufficient cantilever support, nonpassive prosthetic fit, and simply the cumulative occlusal forces acting on the prosthesis over time. Many (if not most) of these complications can be resolved with proper treatment planning and prevention. This chapter discusses how the complications can develop, how to prevent them, and how to deal with them once they occur.

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a

b

Fig 10-3 (a) Bone loss is common when the minimum distance between implants is not maintained. (b) The implant shows peri-implantitis and extensive bone loss.

Complications Unrelated to Prosthesis Fracture Bone loss is common when the minimum distance between implants is not maintained (Fig 10-3a). For example, the implant could show indications of peri-implant mucositis or peri-implantitis, and lack of treatment for peri-implant inflammation can lead to implant failure (Fig 10-3b). If an implant is determined to be unstable before the definitive prosthesis is placed, the clinician must remedy the instability by removing the implant and placing it in a different site to allow greater insertion torque. Over half of implants afflicted with untreated peri-implant inflammation have resulted in failures.9 However, if treatment is received early (ie, within the first year of implant placement), most cases end successfully.10 In such cases, the clinician can treat the infection and irritation by debriding the area mechanically and using antibacterial protocols. Another implant can be placed next to the problematic implant and allowed to osseointegrate before prosthetic loading. Both the treated implant and the new implant should be inspected for stability and accuracy before the definitive prosthesis is placed. Of course, as is the case with many infection-related elements of dental practice, identifying risk indicators is essential for preventing and treating peri-implantitis, especially in patients with periodontitis, those who smoke, those with uncontrolled diabetes, and those with cardiovascular disease.11,12

To avoid another fairly common type of non-prosthesisrelated complication, the clinician should ensure that no transition line between the patient’s gingiva and the prosthesis will be visible when the patient smiles. Before the implants are placed, the clinician must assess whether or not the patient’s gingiva is visible when the patient smiles with the maximum level of lip elevation, which is typically higher in women than in men.13 If the gingiva is visible, then the bone will require reduction so that the transition between the prosthesis and the gingiva will be hidden under the lip. Some cases may require the prosthesis to be fitted with a minor facial flange to reduce the sign of any transition between gingiva and prosthesis if bone reduction was inadequate. Implant rehabilitation planning protocol for the edentulous patient should anticipate the possible replacement of teeth and tissue, including a flange for lip support and improved esthetics with a high smile line.14 Another complication unrelated to prosthesis fracture results from improper hygiene and prosthetic care. This complication can be avoided only if the patient is willing and able to cooperate with the clinician’s instructions on care and hygiene (Fig 10-4). For decades, routine maintenance— including daily maintenance by patients themselves—has been recognized as necessary to ensure long-term success for the oral rehabilitation of fully or partially edentulous patients via dental implants.15 Proper oral hygiene must be considered in the context of other clinical guidelines and treatment planning for rehabilitation success, including

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Fig 10-4 Proper oral hygiene, including the mental will and physical ability to accomplish the task twice daily, are essential in maintaining overall health of the FAIR prosthesis.

Fig 10-5 Prosthesis-related complications include the loosening or fracture of screws.

the number and location of implants placed and possible segmentation of the prosthesis.16 Definitive prosthesis design should facilitate cleaning and be tailored for each patient biometrically, including the use of a flat or convex base to aid in hygiene.17 Because plaque and calculus can be as damaging to implants as to natural teeth, the patient must have the physical ability and the mental will to maintain a daily cleaning regimen for the prosthesis. Just as in the dentate oral cavity, plaque can accumulate over time and irritate the soft tissues beneath the prosthesis. Different dental appliances (eg, oral irrigators, specialty brushes) can be used to clean under the prosthesis. Of course, it is up to the clinician to ensure that the intaglio surface of the prosthesis has tight, rounded pinpoint contact with the patient’s alveolar ridge to help keep food and other debris from lodging between the two surfaces.

clinician to take advantage of the baselines of function and esthetics provided by the removable denture.19 Obviously, reliable decision making for both the clinician and patient concerning full-arch restorations depends on their knowing the functional and esthetic differences between a removable prosthesis and a fixed prosthesis.20 Moreover, fracturing can occur near the temporary titanium sleeve used to help convert the denture to a fixed prosthesis if the denture material is inadequate. One of the best ways to avoid this complication is to ensure proper occlusion, making sure the arches function as a team. The acrylic structure must have a sufficient thickness to withstand the occlusal forces being reintroduced into the patient’s eating and speaking functions. Other complications related to the transitional prosthesis include the loosening or fracture of screws (Fig 10-5), generally resolved by screw tightening; occlusion-related complications, usually involving occlusal-based wear over time; and patient-related issues, such as applying excessive occlusal pressure through eating and other lifestyle habits, usually addressed via patient instruction and cooperation.21 Another frequently reported problem is an element of the definitive prosthesis becoming detached.18,22 Additionally, a recent tooth-fracture study involving full-arch restorations reported fairly frequent complications related to simple mechanical maintenance of the prosthesis.23 For example, fractures occur more frequently when the arch opposing the full-arch prosthesis is natural dentition and not a denture or implant-supported overdenture, suggesting that occlusal forces are stronger via the arch with natural dentition.

Complications Related to Prosthesis Fracture Fracturing of the acrylic transitional prosthesis is the most frequently reported complication and is most often addressed by relining the prosthesis, by adjusting the occlusion, and by prescribing a nightguard.18 A provisional prosthesis used to immediately load the newly placed implants can fracture within months after restoration. This is often the result of a poor conversion of the patient’s former denture into a full-arch prosthesis, despite attempts by the

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a

b Fig 10-6 (a to c) Loosening and fracturing of screws retaining the definitive prosthesis.

c Fig 10-7 If any gaps appear between the framework and the implants, then a passive fit has not been achieved.

Additionally, the increased abrasiveness of the enamel of the dentate arch and the ceramics of the fixed prosthesis can be factors. In some cases, the laboratory preparation of the definitive prosthesis could be faulty (eg, cracks at abutment access holes). In such cases, the clinician must be sure to carefully inspect the prepared prosthesis and have the laboratory repair the faults to prevent future complications.24

Loosening and fracturing of screws can also occur after occlusal loading25 (Fig 10-6). Using a computer-aided design/computer-assisted manufacturing (CAD/CAM) prosthesis can result in more predictable results as well as fewer complications.26 Nevertheless, the clinician must remain aware of the potential for distortion in such manufactured prosthetic frameworks, including miscalculations in the horizontal, sagittal, and vertical planes.27

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The definitive prosthesis can be damaged if the clinician fails to account for a sufficient amount of interarch space when implants are placed. Many clinicians suggest a minimum of only 12 mm of restorative space per arch for an acrylic-metal prosthesis and 15 mm for a zirconia prosthesis. However, it is important to have a minimum of 15 to 17 mm of space regardless of the materials used. To obtain these margins, the clinician can use existing dentures and clear denture duplicate templates as a guide when preparing the case. This method of prevention is well worth the time spent to avoid future complications.28,29 Insufficient cantilever support by the prosthesis framework can also lead to prosthesis fracture. This kind of fracture can be caused by flaws in the design of the prosthesis; for example, if the titanium bar does not extend past the last implant distally, this can lead to a reduction in the mechanical retention of the acrylic. Crucial measurements include prosthesis thickness at the openings of the distal screw access points, crown height, and cantilever length.30 Additional important measurements include the ratios of cantilever lengths and anteroposterior spreads.31 Other types of prosthetic fractures can be caused by errant occlusal forces resulting from the clinician’s failure to provide a passive fit of the titanium or zirconia bar within the framework on the abutments, and several studies suggest a variety of methods for helping to ensure a passive fit32–35 (Fig 10-7). Of particular concern is nonpassive fit resulting from abutments with poor angulation. Some implant manufacturers provide abutment configurations that can compensate for extreme implant angulation, and the clinician may wish to consider these alternatives in case the standard abutments for full-arch implants do not provide the optimal angulation given the patient’s individual circumstances. A nonpassive fit can result in occlusal forces that lead to screw fracture. To fix this kind of prosthesis-related fracture, the clinician can section the prosthesis, reconstruct the framework using laser welding, and repair the prosthetic acrylic, or fabricate an entirely new definitive prosthesis.

Fig 10-8 A preoperative botulinum toxin type A injection has been shown to enhance FAIR rigidity and reduce the incidence of complications due to implant micromovement.

Two additional fracture- or wear-related complications can arise from the accumulation of occlusal forces on the prosthesis over time. For example, if the prosthetic posterior support has been compromised through wear or fracture, the resulting occlusal forces can cause the anterior teeth of the prosthesis to be damaged to the point that they actually separate from the prosthesis. Additionally, for some patients, acrylic wear of the prosthesis can occur over time due to bruxing or grinding.36 The surface effects caused by bruxing can be delayed by having the patient wear a nightguard, but more proactive preventive measures can be taken as well. Reinforcing a full-arch provisional restoration to help ensure rigidity might facilitate osseointegration via reduction of implant micromovements.37 Additionally, promising results have been found from using botulinum toxin type A preoperatively for full-arch restoration patients that had dental implants loaded immediately after being placed in fresh extraction sockets38 (Fig 10-8).

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Fig 10-9 FAIR is a single-day procedure with a lengthy surgical time. Extreme precision and attention to detail is required to avoid chairside complications.

Conclusion A number of complications could arise following the placement of a full-arch prosthesis, the goal of which is to restore function and esthetics for the fully or partially edentulous patient via general morbidity-reducing protocols. Relatively infrequent complications include failure of one or more implants to osseointegrate, failure of prefabricated and customized guides derived from STL models to avoid vital anatomical structures, esthetic miscalculations involving the patient’s smile line and gingiva exposure, and soft tissue inflammation and infection arising from poor patient hygiene and prosthesis maintenance. However, the most common types of complications for the full-arch restoration procedure involve acrylic fracturing from poor conversion of a denture to a prosthesis, miscalculations concerning interarch space during implant placement, inadequate cantilever support, nonpassive prosthetic fit, and errant occlusal forces on the prosthesis that develop over time (Fig 10-9).

References 1. Chrcanovic BR, Albrektsson T, Wennerberg A. Periodontally compromised vs. periodontally healthy patients and dental implants: A systematic review and meta-analysis. J Dent 2014;42:1509–1527. 2. Chrcanovic BR, Albrektsson T, Wennerberg A. Dental implants inserted in male versus female patients: A systematic review and meta-analysis. J Oral Rehabil 2015;42:709–722. 3. Chrcanovic BR, Albrektsson T, Wennerberg A. Bone quality and quantity and dental implant failure: A systematic review and meta-analysis. Int J Prosthodont 2017;30:219–237.

4. Sudhakar KNV, Mohanty R, Singh V. Evaluation of donor site morbidity associated with iliac crest bone harvest in oral and maxillofacial, reconstructive surgery. J Clin Diagn Res 2017;11:ZC28–ZC33. 5. Faeghi Nejad M, Proussaefs P, Lozada J. Combining guided alveolar ridge reduction and guided implant placement for All-on-4 surgery: A clinical report. J Prosthet Dent 2016;115:662–667. 6. Moraschini V, Velloso G, Luz D, Barboza EP. Implant survival rates, marginal bone level changes, and complications in full-mouth rehabilitation with flapless computer-guided surgery: A systematic review and meta-analysis. Int J Oral Maxillofac Surg 2015;44:892–901. 7. Alshahrani FA, Yilmaz B, Seidt JD, McGlumphy EA, Brantley WA. A load-to-fracture and strain analysis of monolithic zirconia cantilevered frameworks. J Prosthet Dent 2017;118:752–758. 8. Yilmaz B, Alp G, Seidt J, Johnston WM, Vitter R, McGlumphy EA. Fracture analysis of CAD-CAM high-density polymers used for interim implant-supported fixed, cantilevered prostheses. J Prosthet Dent 2018;120:79–84. 9. Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis: A review. Head Face Med 2014;10:34. 10. Heitz-Mayfield LJ, Mombelli A. The therapy of peri-implantitis: A systematic review. Int J Oral Maxillofac Implants 2014;29(suppl):325–345. 11. Renvert S, Quirynen M. Risk indicators for peri-implantitis. A narrative review. Clin Oral Implants Res 2015;26(suppl 11):15–44. 12. Ting M, Craig J, Balkin BE, Suzuki JB. Peri-implantitis: A comprehensive overview of systematic reviews. J Oral Implantol 2018;44:225– 247. 13. Kourkouta S. Implant therapy in the esthetic zone: Smile line assessment. Int J Periodontics Restorative Dent 2011;31:195–201. 14. Lago L, Rilo B, Fernández-Formoso N, DaSilva L. Implant rehabilitation planning protocol for the edentulous patient according to denture space, lip support, and smile line. J Prosthodont 2017;26:545–548. 15. Hamada Y, Shin D, John V. Peri-implant disease: A significant complication of dental implant supported restorative treatment. J Indiana Dent Assoc 2016;95:31–38. 16. Gallucci GO, Avrampou M, Taylor JC, Elpers J, Thalji G, Cooper LF. Maxillary implant-supported fixed prosthesis: A survey of reviews and key variables for treatment planning. Int J Oral Maxillofac Implants 2016;31(suppl):s192–s197. 17. Penarrocha-Diago M, Penarrocha-Diago M, Zaragozí-Alonso R, Soto-Penaloza D, On Behalf Of The Ticare Consensus M. Consensus statements and clinical recommendations on treatment indications, surgical procedures, prosthetic protocols and complications following All-on-4 standard treatment. 9th Mozo-Grau Ticare Conference in Quintanilla, Spain. J Clin Exp Dent 2017;9:e712–e715. 18. Francetti L, Corbella S, Taschieri S, Cavalli N, Del Fabbro M. Medium- and long-term complications in full-arch rehabilitations supported by upright and tilted implants. Clin Implant Dent Relat Res 2015;17:758–764. 19. Michalakis KX, Touloumi F, Calvani L, Bedi A, Hirayama H. Simplifying prosthetic procedures while converting an interim maxillary removable complete denture to an interim implant-supported fixed complete denture. J Prosthodont 2011;20:408–413. 20. Drago C, Carpentieri J. Treatment of maxillary jaws with dental implants: Guidelines for treatment. J Prosthodont 2011;20:336–347. 21. Malo P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310–320.

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22. Lopes A, Malo P, de Araujo Nobre M, Sanchez-Fernandez E. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A prospective report on medium- and long-term outcomes. Clin Implant Dent Relat Res 2015;17:e406–e416. 23. Ventura J, Jimenez-Castellanos E, Romero J, Enrile F. Tooth fractures in fixed full-arch implant-supported acrylic resin prostheses: A retrospective clinical study. Int J Prosthodont 2016;29:161–165. 24. Cho SH, Thompson GA. A method of facilitating the fabrication of access openings for implant-supported complete fixed dental prostheses. J Prosthet Dent 2017;117:814–816. 25. Drago C, Howell K. Concepts for designing and fabricating metal implant frameworks for hybrid implant prostheses. J Prosthodont 2012;21:413–424. 26. Keerthi S, Proussaefs P, Lozada J. Clinical and laboratory steps for fabricating a complete-arch fixed prosthesis using CAD/CAM. Int J Periodontics Restorative Dent 2015;35:473–480. 27. Al-Meraikhi H, Yilmaz B, McGlumphy E, Brantley WA, Johnston WM. Distortion of CAD-CAM-fabricated implant-fixed titanium and zirconia complete dental prosthesis frameworks. J Prosthet Dent 2018;119:116–123. 28. De Luca Canto G, Pachêco-Pereira C, Lagravere MO, Flores-Mir C, Major PW. Intra-arch dimensional measurement validity of laserscanned digital dental models compared with the original plaster models: A systematic review. Orthod Craniofac Res 2015;18:65–76. 29. Kiviahde H, Bukovac L, Jussila P, et al. Inter-arch digital model vs. manual cast measurements: Accuracy and reliability. Cranio 2017;36:222–227. 30. Rojas Vizcaya F. Retrospective 2- to 7-year follow-up study of 20 double full-arch implant-supported monolithic zirconia fixed prostheses: Measurements and recommendations for optimal design. J Prosthodont 2018;27:501–508.

31. Drago C. Cantilever lengths and anterior-posterior spreads of interim, acrylic resin, full-arch screw-retained prostheses and their relationship to prosthetic complications. J Prosthodont 2017;26:502–507. 32. Ercoli C, Geminiani A, Feng C, Lee H. The influence of verification jig on framework fit for nonsegmented fixed implant-supported complete denture. Clin Implant Dent Relat Res 2012;14(suppl 1):e188–e195. 33. Abduo J. Fit of CAD/CAM implant frameworks: A comprehensive review. J Oral Implantol 2014;40:758–766. 34. Manzella C, Bignardi C, Burello V, Carossa S, Schierano G. Method to improve passive fit of frameworks on implant-supported prostheses: An in vitro study. J Prosthet Dent 2016;116:52–58. 35. Spazzin AO, Camargo B, Bacchi A. Ensuring passivity and retrievability for immediate complete-arch implant-supported prostheses. J Prosthet Dent 2017;117:214–217. 36. Lopes A, Maló P, de Araújo Nobre M, Sánchez-Fernández E, Gravito I. The NobelGuide All-on-4 treatment concept for rehabilitation of edentulous jaws: A retrospective report on the 7-years clinical and 5-years radiographic outcomes. Clin Implant Dent Relat Res 2017;19:233–244. 37. Yamaguchi K, Ishiura Y, Tanaka S, Baba K. Influence of the rigidity of a provisional restoration supported on four immediately loaded implants in the edentulous maxilla on biomechanical bone-implant interactions under simulated bruxism conditions: A three-dimensional finite element analysis. Int J Prosthodont 2014;27:442–450. 38. Mijiritsky E, Mortellaro C, Rudberg O, Fahn M, Basegmez C, Levin L. Botulinum toxin type a as preoperative treatment for immediately loaded dental implants placed in fresh extraction sockets for full-arch restoration of patients with bruxism. J Craniofac Surg 2016;27:668–670.

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Arun K. Garg, DMD

1 Evolution of the FAIR Protocol

FU LL- ARCH IMP LA NT R E H A B ILITATI O N

is considered one of the world’s foremost authorities on bone biology, harvesting, and grafting for dental implant surgery. Alongside Dr Robert E. Marx, he pioneered the use of platelet-rich plasma (PRP). He received his dental degree from the University of Florida College of Dentistry in Gainesville, Florida, and completed his residency at the University of Miami Jackson Memorial Hospital in Miami, Florida. He went on to serve for almost two decades as Professor of Surgery in the Division of Oral and Maxillofacial Surgery and as Director of Residency Training at the University of Miami Leonard M. Miller School of Medicine, where he was frequently awarded Faculty Member of the Year by his residents. Dr Garg has published 8 medical textbooks and over 150 journal articles and is currently the president of the International Dental Implant Association. An international lecturer, he also maintains six private practices throughout southern Florida and is the founder of Implant Seminars, a leading dental continuing education company.

Garg

CONTENTS 2 History of Tilted Implants with an Immediate Prosthesis 3 Identifying and Evaluating Candidates 4 The FAIR Technique and Its Modifications 5 Treating the Fully Edentulous Maxilla 6 Treating the Fully Edentulous Mandible 7 Treating the Partially Edentulous Maxilla 8 Treating the Partially Edentulous Mandible 9 FAIR Prosthetics 10 Possible Complications

Arun K. Garg, DMD

FULL-ARCH IMPLANT

The full-arch implant rehabilitation (FAIR) protocol is one of the newest implant therapy innovations to treat the edentulous or nearly edentulous patient. The FAIR prosthesis is immediate, fixed, esthetically pleasing, highly functional, inexpensive, and maintainable, and it can frequently be installed without bone grafting. This book describes how the FAIR protocol works, who it should be used for, and methods to implement it successfully for different patients. The system can be used in both arches and in patients with total or near-total edentulism. Several chapters are devoted to describing step-by-step treatment with detailed clinical photographs documenting every stage from initial assessment to prosthesis delivery. Even those new to fixed denture systems will find the procedures easy to follow and can begin implementing the FAIR approach for their patients.

REHABILITATION

ISBN 978-0-86715-809-0

90000>

9 780867 158090

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