BDJ Clinician’s Guides

Saj Jivraj Editor

Graftless Solutions
for the Edentulous
Patient
Second Edition
BDJ Clinician’s Guides
This series enables clinicians at all stages of their careers to remain well
informed and up to date on key topics across all fields of clinical dentistry.
Each volume is superbly illustrated and provides concise, highly practical
guidance and solutions. The authors are recognised experts in the subjects
that they address. The BDJ Clinician's Guides are trusted companions,
designed to meet the needs of a wide readership. Like the British Dental
Journal itself, they offer support for undergraduates and newly qualified,
while serving as refreshers for more experienced clinicians. In addition they
are valued as excellent learning aids for postgraduate students.
The BDJ Clinician’s Guides are produced in collaboration with the British
Dental Association, the UK’s trade union and professional association for
dentists.
Saj Jivraj
Editor

Graftless Solutions
for the Edentulous
Patient
Second Edition
Editor
Saj Jivraj
Anacapa Dental Art Institute
Oxnard, CA, USA

ISSN 2523-3327     ISSN 2523-3335 (electronic)

BDJ Clinician’s Guides

ISBN 978-3-031-32846-6    ISBN 978-3-031-32847-3 (eBook)

https://doi.org/10.1007/978-3-031-32847-3

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
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Foreword 1

Dr. Saj Jivraj has assembled in this textbook a quintessential team of talented
world-renowned surgeons and restorative dentists who extensively share their
vast knowledge in the latest innovations in Implant Dentistry. In order to
address the ever-increasing magnitude of patients in need of extensive implant
treatment, graft-less implant solutions must be combined with an in-depth
knowledge of surgical and restorative procedures through a rigorous and
well-coordinated interdisciplinary approach.
This textbook displays in an effective and methodical manner the modern
foundation for the diagnosis and graft-less treatment of edentulous patients
with fixed implant supported prosthetics. It provides clear and understand-
able concepts through basic and advanced implant principles that are required
in the initial comprehensive diagnosis and digital workflow all the way
through the interdisciplinary teamwork necessary to manage tilted and zygo-
matic implants, and ultimately produce high-quality implant full arch
restorations.
We have greatly benefited over the past years at Augusta University from
the great teachings of Dr. Jivraj and we trust that this important work will be
enjoyed worldwide as a reference textbook in modern Implant Dentistry.

Louisiana State University School of Dentistry Gerard J. Chiche

New Orleans, LA, USA

v
Foreword 2

It is my pleasure to be invited to write another foreword to this book for Dr.

Saj Jivraj with whom I have interacted with for over 25 years in the capacity
of being his programme director, colleague and friend.
I have seen his stature grow with time; he is dedicated to give the best care
to his patients and has been a sought-after presenter to major conferences all
over the world.
Dental Implants are one of the most useful tools that we have to replace
missing teeth. Early in the process of using osseointegrated implants strin-
gent protocols were required. One of the criteria included placement of dental
implants in host bone. Over the years many ways of grafting bone were pre-
sented, autogenous grafts from extraoral and intraoral sites, as well as
allografts and xenografts. Many articles and reviews have been published
regarding the efficacy of the different materials used in grafting and the tech-
niques used. Many of the articles compare techniques and graft types but
many do not have the priority of placing implants into non-­grafted sites. This
significantly reduces the variable of grafting.
Compared to the earlier times when implants were placed into healed sites
success rates in the longer term seem to produce very good long-term and
predictable results. With the new technology of being able to alter screw
channel directions to facilitate screw retention when implants are placed “off
axis”, technicians better at fabricating replica of missing soft tissues we are
able to have implants placed into host bone and avoid using grafts.
This newer edition of the book is a comprehensive overview of graft-less tech-
niques for full mouth implant rehabilitation from diagnosis to delivery. A strong
emphasis has been placed on diagnosis and treatment planning. Many chapters
are dedicated to the digital workflow and how digital technologies can help the
clinician become more efficient. With sufficient information more easily col-
lected the clinician is able to execute treatment with precision and predictability.
I congratulate Dr. Jivraj on his book and the assembled contributors for
providing clinicians with a comprehensive understanding of the risk vs ben-
efit considerations when choosing treatment options for their patients based
on the multiple factors that are outlined in this text.

Ralph and Jean Bleak Professor Restorative Dentistry Winston Chee

Herman Ostrow School of Dentistry
of University of Southern California,
Los Angeles, CA, USA

vii
Preface

Implant dentistry has seen remarkable progress over the last 25 years.
Clinicians strive for long-term predictable results. Many of the original con-
cepts in implant dentistry have been challenged. To obtain fixed permanent
teeth, patients often had to go through extensive surgical procedures and be
transitioned in an uncomfortable removable appliance.
Full arch fixed implant rehabilitation can be performed in a single day in
the right indication and successful results can be achieved with an experi-
enced team.
Today, the “Graft-less Concepts” eliminate the need for grafting and
long waiting periods prior to the reconstruction of the edentulous or the
patients with “terminal dentition”. The ability to remove the patient’s fail-
ing dentition, place implants and fabricate a fixed, immediate load prosthe-
sis has changed the manner in which many of our colleagues treat their
patients in 2023.
With that said as clinicians we should not be dogmatic in a particular treat-
ment philosophy. Treatment planning should be based on a sound diagnosis.
Risk factors should be understood and only in the right indication should a
patient’s teeth be removed in favour of implant placement.
There is always going to be a debate over how many implants should be
placed in an edentulous arch. The answer to that question is “It Depends”. It
depends on the patient’s medical history, it depends on the quality of bone, it
depends on the anticipated occlusal force on the restoration and it depends on
the operators skill. Although the All on 4™ concept has shown to be highly
successful, it is indicated for specific clinical circumstances and should not be
considered as a panacea for treatment of all edentulous patients. Unfortunately
many patients have been treated with this concept incorrectly. Often there is
ample bone to place 6–8 implants and diagnose the patient as having a tooth
only defect. In this instance additional implants are placed to be able to seg-
ment the prosthesis and minimal or no bone reduction is required. Today we
should be practicing minimally invasive full arch implant dentistry and be
questioning the need for haphazard bone reduction.
The authors of this text have outlined the importance of diagnosis, treat-
ment planning, surgical as well as the prosthetic protocols and techniques for
the treatment of the edentulous as well as the “terminal dentition” patients.
The purpose of the book is to provide an understanding of diagnosis and
treatment planning. Each clinician should understand and be fully familiar
with analogue techniques before a digital workflow is adopted. Digital

ix
x Preface

t­echnologies add to our armamentarium of tools but are by no means a sub-

stitute for analogue principles.
The book has been designed so the chapters build on each other. It will
take the reader on a journey from diagnosis to delivery.
Diagnosis is critical from both a restorative and surgical perspective. An
accurate diagnosis results in the correct treatment plan. Today we have many
digital technologies that can assist us in our diagnostics. Armed with suffi-
cient information the practitioner is able to execute treatment with precision
and efficiency.
We have some world-renowned talented clinicians who are experts in their
respective fields who have laboured tirelessly to put this text together. Words
cannot express how appreciative and honoured I am to have been able to work
with them.
Our hope is the reader will gain a solid foundation in treating the edentu-
lous or soon to be edentulous patient.
Enjoy.

Oxnard, CA, USA Saj Jivraj

Acknowledgements

“Teamwork is the ability to work together towards a common vision. The ability to
direct individual accomplishments towards organisational objectives. It is the fuel
that allows common people to attain uncommon results”.
Andrew Carnegie

As the years pass, the things that become important really come into per-
spective. It is to these important aspects of my life that I wish to dedicate this
book.
To My Family
First and foremost, and without hesitation I would like to thank my beauti-
ful wife Dilaz. She is my life, my inspiration and a wonderful mother to my
two beautiful children Sara and Zain. You said “yes” to everything which
should have been “no”; you allowed me the time to become professionally
what I dreamed about as a young graduate. You persevered when times got
tough and gave up everything moving with me to the USA. For the countless
hours I did not spend with you and the kids, for the unconditional love, friend-
ship, and unwavering support I thank you. To Sara and Zain, words cannot
express the profound love I have for you. You have taught me to appreciate
life in ways I thought were not possible, the little things you do and say make
me a better person, husband and father. I will always be by your side to sup-
port you in anything you do. Work hard and dream big and believe in the
impossible. You can do what you set your mind to and don’t let anybody else
tell you otherwise.
I would also like to dedicate this book to the memory of two exceptional
women: Mrs. Amina and Rukiya Jivraj who were taken from this world far
too early. Not a day goes by when I don’t think of you. I feel your presence in
all the important decisions that I make. I miss you both dearly and wish we
could have created more memories together. When people say, “Life is too
short”, I now understand what that means. I do know we will meet again, and
it is that day to which I look forward.
To My Colleagues
I’d like to thank Drs. Winston Chee, Terry Donovan and George Cho and
who believed in me and who provided me with the opportunity to complete
my Prosthodontic education at the Herman Ostrow USC School of Dentistry.
I will be forever grateful. Dr. Robert Schneider who opened doors and
believed that one day I would realise my potential. Credit should also be
reserved for Dr. Jonathan Gordon. He is an amazing surgeon and I continue

xi
xii Acknowledgements

to learn so much working with him. Many of the cases you see in this book
are a result of our collaboration together. Lastly Dr. Hooman Zarrinkelk with
whom I started the graft-less journey and who has also contributed many
patient cases that are documented in this text.
Without my co-authors this text would not have come to fruition. I would
like to thank Dr. Hooman Zarrinkelk, Dr. Carlos Aparicio, Dr. Bobby Birdi,
Dr. Sundeep Rawal, Dr. Faraj Edher, Dr. Steven Bongard, Dr. Glen Liddelow,
Dr. Graham Carmichael, Dr. Keith Klaus, Dr. Jay Neugarten, Dr. Udatta
Kher, Dr. Ali Tunkiwala, Dr. Stephanie Yeung, Dr. Andrew Dawood, Dr.
Michael Klein, Dr. Frank Tuminelli, Dr. Satish Kumar, Dr. David Powell, Dr.
Susan Tanner, Dr. Kian Karimzadeh, Dr. Vishy Broumand, Dr. Jayson
Kirchhofer, Dr. Komal Majumdar, Dr. Ana Ferro, Dr. Mariana Nunes, Dr.
Diogo Santos, Dr. Armando Lopes, Dr. Filipe Melo, Dr. Miguel de Araujo
Nobre and Dr. Martin Wanendaya for their contributions to the text.
The laboratory section was graciously written by Mr. Kenji Mizuno and
Mr. Aram Torosian, and Mr. Michael Tuckman; I truly appreciate the count-
less hours they spent documenting the lab phase and putting it into a format
that is practical. I would like to thank Digital Dental Arts Laboratory in
Ventura. Much of the laboratory work documented is a result of their
collaboration.
I would like to acknowledge all the students and faculty involved with the
advanced Prosthodontic and Periodontics programme at Herman Ostrow
USC School of dentistry from whom I have learnt so much and continue to
do so.
I would be remiss if I did not thank my team at Anacapa Dental Art
Institute. Laura Castellanos RDA has assisted me for the last 10 years and has
been instrumental in developing protocols we use on a day-to-day basis. She
is someone who always works with a smile on her face and makes a complex
day go very smoothly. Sonia Escamilla for her positive demeanour, amazing
leadership and ability to bring the best out of people, Ale Prado for keeping
everything light when the day gets tough, and willingness to do whatever it
takes, Maricel Estoque for her excellent patient management skills and warm
and caring attitude towards everyone she meets, Erika Simental for her kind-
ness and professionalism, Amber Padilla RDH who started the journey with
me as my assistant and progressed to becoming a wonderful hygienist and
Darlene Herrera RDH who has assisted me in the maintenance of these
patients and whose attention to detail is exceptional. My whole team is amaz-
ing. They make coming into work each day enjoyable and always go the extra
mile for our patients. Their dedication and commitment are second to none
and I want to let you know I appreciate everything you do.
Special thanks also go to my team at the Digital Dental Arts Laboratory in
Ventura. Kenji Mizuno for his exceptional work ethic and the ability to get
the job done, Dmytro Tytarenko for his skill in digital workflows and pushing
me to become a better clinician, Margaryta Pisnia for her organisation and
attention to detail, Ahmet Tanay for his positive demeanour and professional-
Acknowledgements xiii

ism and Artyom Avanesov for his amazing artistry in ceramics. Without a
great Laboratory partner we cannot do what we do for patients.
I would also like to thank Melker Nielsson for his friendship and advice
over the years. It was through his guidance and support that I pursued graft-
less solutions as an option for my patients.
To My Patients
Who make each and every day enjoyable for me. Thank you for allowing
me to compile these clinical photographs. It’s caring for these patients that
makes my profession so rewarding and makes me look forward to the next
day.
To God
Who has made everything possible. His guidance has allowed me to pur-
sue my dreams and realise them.

Saj Jivraj
Contents

1 Diagnosis and Treatment Planning: A Restorative

Perspective����������������������������������������������������������������������������������������   1
Saj Jivraj
2 Surgical Diagnostic Considerations in Graft-Avoiding
Dental Implant Reconstruction of Atrophic Jaws������������������������ 15
Hooman M. Zarrinkelk
3 Guided Surgery for Full-Arch Implant-Supported
Restorations�������������������������������������������������������������������������������������� 25
Michael Klein, Jay Neugarten, and Allon Waltuch
4  igital Workflows in Full Arch Implant Prosthodontics�������������� 101
D
Faraj Edher, Sundeep Rawal, and Saj Jivraj
5 3D Printing Protocols in Full-Arch Reconstruction:
A Complete Workflow �������������������������������������������������������������������� 117
Keith Klaus and Saj Jivraj
6  he Zygoma Anatomy-Guided Approach (ZAGA)
T
for Preventing Complications Using Zygomatic Implants ���������� 129
Carlos Aparicio
7 Pterygoid Implants as Alternative to Bone
Augmentation in Implant Dentistry ���������������������������������������������� 147
Vishtasb Broumand and Jayson Kirchhofer
8 Scientific Basis of Immediate Loading
and the Biomechanics of Graftless Solutions�������������������������������� 167
Bobby Hardeep Birdi, Komal Majumdar, and Saj Jivraj
9 FP1 Concepts in Rehabilitating the Edentulous
Patient with Implant-Supported Restorations������������������������������ 205
Martin Wanendeya and Saj Jivraj
10  raftless Surgical Protocol: Diagnosis to Delivery ���������������������� 263
G
Ana Ferro, Mariana Nunes, Diogo Santos, Armando Lopes,
Filipe Melo, and Miguel de Araújo Nobre
11  urgical–Anatomical and Prosthetic–Biomechanical ZAGA
S
Criteria to Determine the Zygomatic Implant Trajectory ���������� 295
Carlos Aparicio, Arnau Aparicio, and John Brunski

xv
xvi Contents

12  linical Techniques for Immediate Loading �������������������������������� 313

C
Stephanie Yeung and Saj Jivraj
13  aterial Considerations for Full-­Arch Implant-Supported
M
Restorations�������������������������������������������������������������������������������������� 337
Saj Jivraj and Sundeep Rawal
14 Clinical Steps for Fabrication of a Full-Arch
Implant-Supported Restoration ���������������������������������������������������� 359
Udatta Kher and Ali Tunkiwala
15 Speech and Facial Aesthetic Considerations
for the Contour of Fixed Prostheses ���������������������������������������������� 387
Glen Liddelow and Graham Carmichael
16  aboratory Fabrication of Full-­Arch Implant-Supported
L
Restorations�������������������������������������������������������������������������������������� 401
Kenji Mizuno, Aram Torosian, Saj Jivraj,
and Michael Tuckman
17  rosthetic Complications with Immediately Loaded,
P
Full-­Arch, Fixed Implant-Supported Prostheses�������������������������� 447
Frank J. Tuminelli, Saj Jivraj, Steven Bongard,
and David Powell
18 Management of Failure and Implant-Related Complications
in Graft-Less Implant Reconstructions (for Atrophic Jaws) ������ 473
Andrew Dawood and Susan Tanner
19  aintenance of Full-Arch Implant-­Supported Restorations:
M
Peri-­Implant and Prosthetic Considerations�������������������������������� 495
Satish Kumar, Kian Kar, and Saj Jivraj
20  linical Patient Presentations �������������������������������������������������������� 517
C
Saj Jivraj
Contributors

Arnau Aparicio ZAGA Center, Private Practice QDT Center, Houston,

TX, USA
Carlos Aparicio International Teaching Scholar Indiana University
School of Dentistry, Indianapolis, IN, USA
Director of Zygomatic Unit at Hepler Bone Clinic, ZAGA Center, Barcelona,
Spain
Bobby Hardeep Birdi University of Minnesota School of Dentistry,
Minneapolis, MN, USA
Private Practice, Vancouver, BC, Canada
Steven Bongard Private Practice, Toronto, ON, Canada
Vishtasb Broumand Oral and Maxillofacial Surgery Private Practice,
Desert Ridge Oral Surgery Institute, Phoenix, AZ, USA
Department of Oral and Maxillofacial Surgery, University of Arizona
College of Medicine at Banner University Medical Center Phoenix, Phoenix,
AZ, USA
John Brunski Division of Plastic and Reconstructive Surgery, Department
of Surgery, Stanford University, Stanford, CA, USA
Graham Carmichael School of Dentistry, University of Western Australia,
Crawley, WA, Australia
Craniofacial Unit, Princess Margaret Hospital, Subiaco, WA, Australia
Maxillofacial Department, Royal Perth Hospital, Perth, WA, Australia
Andrew Dawood Department of Head and Neck Surgery, University
College London Hospital, London, UK
The Dawood and Tanner Specialist Dental Practice, London, UK
Miguel de Araújo Nobre Research, Development and Education
Department, Maló Clinic, Lisbon, Portugal
Faraj Edher Digital Dentistry Institute, BC Dental Study Club, University
of British Columbia, Vancouver, BC, Canada
Ana Ferro Oral Surgery Department, Maló Clinic, Lisbon, Portugal
Saj Jivraj, BDS, MS.Ed, Anacapa Dental Art Institute, Oxnard, CA, USA

xvii
xviii Contributors

Kian Kar Herman Ostrow School of Dentistry of USC, University of

Southern California, Los Angeles, CA, USA
Udatta Kher , Mumbai, India
Jayson Kirchhofer Oral and Maxillofacial Surgery Private Practice, Desert
Ridge Oral Surgery Institute, Phoenix, AZ, USA
Department of Oral and Maxillofacial Surgery, University of Arizona
College of Medicine at Banner University Medical Center Phoenix, Phoenix,
AZ, USA
Keith Klaus Private Practice, Flowood, MS, USA
Michael Klein Advanced Implant Dentistry and Oral Restoration,
Cedarhurst, New York, NY, USA
Satish Kumar Arizona School of Dentistry and Oral Health, A. T. Still
University, Mesa, AZ, USA
Glen Liddelow School of Dentistry, University of Western Australia,
Crawley, WA, Australia
Craniofacial Unit, Princess Margaret Hospital, Subiaco, WA, Australia
Armando Lopes Oral Surgery Department, Maló Clinic, Lisbon, Portugal
Komal Majumdar Om Dental Clinic, Navi Mumbai, India
Filipe Melo Prosthodontics Department, Maló Clinic, Lisbon, Portugal
Kenji Mizuno Anacapa Dental Art Institute, Oxnard, CA, USA
Jay Neugarten Department of Oral and Maxillofacial Surgery, Weill-­
Cornell Medical Center, New York-Presbyterian Hospital, New York,
NY, USA
Mariana Nunes Oral Surgery Department, Maló Clinic, Lisbon, Portugal
David Powell Private Practice, Toronto, ON, Canada
Sundeep Rawal Implant Support Services, Aspen Dental,
Chicago, IL, USA
The Digital Dentistry Institute, Orlando, FL, USA
Diogo Santos Oral Surgery Department, Maló Clinic, Lisbon, Portugal
Susan Tanner The Dawood and Tanner Specialist Dental Practice, London,
UK
Aram Torosian Ronald Goldstein Center for Esthetic and Implant Dentistry,
Dental College of Georgia at Augusta University, Augusta, GA, USA
Michael Tuckman Osteon Medical, Mulgrave, VIC, Australia
Frank J. Tuminelli American Board of Prosthodontics, Saint Paul,
MN, USA
VA NY Harbor Healthcare System, New York, NY, USA
Hofstra Northwell School of Medicine, Hempstead, NY, USA
Contributors xix

Private Practice, Manhasset, NY, USA

Ali Tunkiwala Mumbai, India
Allon Waltuch Advanced Implant Dentistry and Oral Restoration,
Cedarhurst, New York, NY, USA
Martin Wanendeya Ten Dental, London, UK
Stephanie Yeung Private Practice, Los Angeles, CA, USA
Hooman M. Zarrinkelk Diplomate American Board of Oral and
Maxillofacial Surgeons, Chicago, IL, USA
Fellow American College of Oral and Maxillofacial Surgeons,
Washington, DC, USA
Private Practice, Ventura, CA, USA
 Diagnosis and Treatment
Planning: A Restorative
1
Perspective

Saj Jivraj

Abstract ables that affect both the aesthetic and functional

aspect of the prosthesis.
Treatment of the edentulous patients with
The routine treatment for edentulism has been
implant-supported restorations presents a sig-
complete dentures. Epidemiological data has
nificant challenge to the treating clinician.
reported that the adult population in need of one or
Patient expectations in regard to aesthetics,
two dentures would increase from 35.4 million
phonetics, form, and function are high.
adults in 2000 to 37.0 million adults in 2020 [2];
There are a myriad of factors that need to be
and the researchers warn that their estimates may be
evaluated to determine if the patient is a suitable
“significantly conservative”. Clinical studies have
candidate for a fixed vs. a removable implant-
reported that patients with dentures have shown
supported restoration. Evaluation of the edentu-
only a marginal improvement in the quality of life
lous patient is also complicated by the fact that
when compared with implant therapy [3]. The
patients may not only be missing clinical crown
common reasons for dissatisfaction in patients
height but in addition may have experienced a
using dentures include but are not limited to pain,
combination of tooth, soft tissue, and bone loss,
poor retention and stability, and difficulty eating [4].
with associated changes in facial form.
A review of the literature noted that prostheses
The purpose of this article is to evaluate the
supported by osseointegrated implants
diagnostic factors that are critical in treatment
significantly improved the life of edentulous
planning a patient for fixed implant-supported
patients when compared with conventional
restorations.
dentures [5].
Many patients tolerate complete dentures
The predictability of successful osseointegrated despite the dissatisfaction.
implant rehabilitation of the edentulous jaw as Reasons for this could be:
described by Branemark et al. [1] introduced a
new era of management for the edentulous • Anatomic. They have been told they are not
predicament. implant candidates because of pneumatized
Implant rehabilitation of the edentulous sinuses and severe resorption of the posterior
patient remains one of the most complex restor- mandible.
ative challenges because of the number of vari- • Cost.
• Lack of education. They have not been
S. Jivraj (*) educated about dental implants and do not
Anacapa Dental Art Institute, Oxnard, CA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 1

S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_1
2 S. Jivraj

visit a dentist because they feel nothing can be Most patients will look toward an implant
done for them. rehabilitation hoping to acquire a fixed prosthe-
sis. Treatment planning of edentulous patients
Restoration of the edentulous patients with with fixed restorations on dental implants has
dental implants is costly whichever method is undergone a paradigm shift since the introduc-
used to restore the patient. Fixed reconstructions tion of graftless solutions. In particular, the
require more laboratory assistance and implant All-on-4 method™.
parts and, thus, are a lot more costly. Today, patients have options whereby in the
Due to economic factors, many patients have right indication complete rehabilitation can be
been provided with implant- and mucosa-­ accomplished by the use of four implants per
supported overdentures. arch. The major advantages of this procedure
However, cost needs to be considered not only are the reduced number of implants and the
during fabrication of the prosthesis but also dur- ability to bypass extensive grafting procedures.
ing maintenance. Overdentures seem to have This rehabilitation not only satisfies aesthetics
more post-insertion maintenance than their fixed and function but also considerably reduces
counterparts. If this is consistent, it could be costs for the patient. This ultimately results in
questioned whether an economic indication for increased patient acceptance and an increased
choosing an overdenture could be justified when number of patients treated. Very few patients
there is sufficient bone to support implants for a today are able to afford extensive implant reha-
fixed prosthesis. The patient must be made aware bilitations on six to eight implants, and the
that maintenance costs for removable prostheses All-on-4™ or graftless protocol is gaining pop-
on implants will be higher than that of a fixed ularity as being the treatment of choice for the
prosthesis. Today, clinicians are seeing an edentulous patient.
increasing number of dentate patients where the Clinicians must be cognizant that the All-on-4
dentition is terminal. These patients would have concept™ is indicated for specific clinical situa-
been edentulous a long time ago if it had not been tions namely:
for the efforts of skilled restorative dentists.
Clinical treatments have involved maintaining 1. There is minimal bone in, with pneumatized
nonrestorable teeth for as long as possible to sinuses and posterior mandibular resorption.
avoid a removable appliance. Patients understand In this circumstance the clinician can only
that maintaining a terminal dentition has conse- place four implants due to anatomical limita-
quences on the bone. However, the fear of eden- tions. To avoid grafting tilted implant, con-
tulism forces them to ignore failing oral cepts are employed.
conditions. 2. Adequate lip support.
In spite of the increasing numbers of 3. Where the patient has lost a significant amount
edentulous or soon-to-be edentulous patients, of bone and strategic implant placement is
there still appears to be many reasons why required to obtain bicortical anchorage.
patients avoid treatment with dental implants.
These reasons could include: It is the authors’ opinion that more than four
implants are required when:
• The fear of wearing a removable appliance in
the transitional phase. 1. There is an abundance of bone and
• The notion that the proposed treatment is biomechanically cantilevers can be avoided.
time-consuming and unpredictable. 2. The patient presents with a dentition that
• The number of visits involved and the fear of exhibits signs and symptoms of excessive
pain. force.
• Cost.
1 Diagnosis and Treatment Planning: A Restorative Perspective
3. Patient has uncontrolled metabolic disease
which compromises healing.
4. Poor quality bone.
The advantages and considerations of placing
more implants and preserving bone include the
following:
1. There is the ability to segment the prosthesis
and complication management becomes eas-
ier for the clinician.
2. If in the future an implant were to fail, there
are enough implants where the patient may
not have to undergo surgery again.
3. The thought process that making an
impression on four implants is easier than
making an impression on five or six does not
hold merit. Today, with advancements in
digital technologies, analogue impression
making may soon become obsolete at multi-
unit abutment level.
4. When placing implants, the clinician must
begin with the end in mind visualizing the
definitive restoration. Zirconia requires spe-
cific connector dimensions and requires
appropriate distance between implants.
Zirconia also requires specific thickness for
biomechanical integrity. The implants
together with the multi-unit abutments must
be positioned three dimensionally to allow
for this.
5. Maintenance of bone in between the implants
can be obtained by banking roots.
6. If a catastrophic failure were to occur and
all the implants were lost, then the clini-
cian still has the opportunity to retreat the
patient.
Treatment planning should be based on a
thorough diagnosis to culminate in an appropriate
treatment plan for the patients presenting clinical
situation. Unfortunately, the All-on-4™ concept
has been used as a panacea for full arch implant
reconstruction, and often patients are treated dog-
matically with this treatment protocol. Often
bone is removed needlessly to satisfy a certain
treatment philosophy.
3
Minimally invasive full arch implant
dentistry adheres to concept of preserving and
maintaining bone. Bone reduction is virtually
eliminated, and the patient maintains their own
gingiva. Although four implants are considered
standard, the placement of additional implants
is considered advantageous. As a practicing cli-
nician, implant failure is always a concern and
should one of four implants fail, the definitive
restoration needs to be remade at the restorative
dentist’s cost. If more than four implants have
been placed, then there are reserve implants to
work with.
As in all phases of dentistry, diagnosis is
critical in obtaining a predictable outcome. An
incomplete or erroneous diagnosis can yield
unsatisfactory results for both the patient and
treating clinician.
The decision-making parameters when
rehabilitating patients require the clinician to
make a decision as to whether a fixed or a
removable prosthesis would be more suitable.
Zitzmann and Marinello [6] and Jivraj et al. [7]
described in detail parameters that need to be
evaluated. A fixed restoration should not be
promised to a patient until all diagnostic criteria
are evaluated. These criteria must include
quality and quantity of bone available to support
implants, lip line, lip support, and aesthetic
demands. Implants should not be placed until a
definitive treatment plan has been established as
implant positions may vary depending on type
of prostheses to be delivered.
From a diagnostic perspective, several
parameters need to be evaluated before deciding
upon the type of prosthesis that is most
appropriate for the patient. The following
considerations pertain to restorative treatment
planning (Fig. 1.1). Surgical considerations will
be presented in a separate chapter.
Diagnostic considerations include but are not
limited to:
1. Positioning of the maxillary and mandibular
incisal edge
2. Restorative space
3. Lip support
4 S. Jivraj
Fig. 1.1 Factors that need consideration before deciding upon a fixed vs. removable implant rehabilitation
4. Smile line and lip length
5. Contours and emergence
6. Tissue contact
7. Occlusion
1.1 Positioning the Maxillary
and the Mandibular
Incisal Edge
The maxillary incisal edge position is determined
utilizing the principles of aesthetics and phonetics.
Traditional guidelines tell us that when the patient
makes the “F” sound, the incisal edge should touch
the vermillion border of the lower lip. Once the
incisal edge position has been established, the
length for the central incisors is determined. On
average, the length of the central incisors is
10.5 mm; this can be more in elderly patients who
exhibit gingival recession [8]. The axial inclina-
tion of the central incisor should be placed so as to
provide adequate support for the upper lip. Once
the crown length, angulation, and coronal form
have been determined, the distance between the
cervical crown margin and residual bone must be
established to determine if adequate space exists
for the anticipated restoration. Often the maxillary
incisal edge is over-erupted and treatment plan-
ning involves repositioning the incisal edge more
apically (Fig. 1.2). Putting the maxillary central in
the right position may require alveolectomy to
provide sufficient running room from the head of
the implant fixture to the emergence profile as it
exits the free gingival margin [9].
To determine if a fixed or removable
restoration would be appropriate, a wax try-in is
done without a flange. For a fixed restoration,
the clinical crown should ideally end up at the
soft tissue level of the alveolar ridge. In this
situation, minimal resorption would have
occurred, interarch space will be favourable,
and an optimal tooth-lip relationship is present.
When a large vertical distance exists between
the cervical aspect of the tooth and the alveolar
ridge but the tooth-lip relationship is favourable,
pink ceramic or acrylic may be utilized to
disguise the tooth length and a fixed restoration
is still possible. When there is both a vertical
and horizontal discrepancy between the ideal
position of the tooth and the alveolar ridge, and
the tooth-lip relationship is not optimal, this
may be an indication for use of a removable
1 Diagnosis and Treatment Planning: A Restorative Perspective
Fig. 1.2 Re-positioning the incisal edge more apically will have an impact on the implant placement. Alveolectomy
will need to be performed prior to implant placement in this patient’s case
prosthesis. The flange will provide adequate lip
support, and the teeth can be positioned
appropriately to satisfy the parameters of
aesthetics. It is the authors’ opinion.
The mandibular incisal edge is positioned
for function. The clinician must provide shal-
low guidance, sufficient to provide posterior
disclusion in both protrusive and lateral excur-
sions. Anterior guidance must be smooth and
distributed amongst as many anterior teeth as
possible.
A thorough evaluation must be made of the
existing mandibular incisal edge position. When
patients are missing posterior teeth and have been
diagnosed as having lack of posterior support, the
mandibular incisal edge is often in the incorrect
position. The clinician must decide whether to
reshape, reposition, restore, or remove if the
maxillary arch is being considered for implant-­
supported restorations. Conventional prosth-
odontic guidelines will place the mandibular
incisal edge just at the level of the lower lip with
0.5–1.0 mm of the incisal edge visible. Guidelines
in relation to the lower mandibular occlusal plane
can also be sought from anatomical landmarks
such as the retromolar pad.
If the clinician is planning a fixed implant-­
supported restorations for the mandible, adequate
restorative space must be provided. The over-­
eruption of teeth brings with it an excess of bone,
which must be reduced prior to the implants
being placed.
5
1.2 Restorative Space
Insufficient restorative space is the most common
error when planning full arch restorations.
Inadequate space results in either premature fail-
ure of the restoration or changing the treatment
plan from one restoration to another to accom-
modate the space requirements.
To accommodate adequate designs, different
types of restorations require different
dimensional tolerances [7]. Accurately
mounted casts are critical in assessing pros-
thetic space limitations. Spatial constraints
must be considered as a matter of practicality.
The limiting factor in edentulous patients is the
available inter-arch space [10]. Adequate
restorative space is critical, and guidelines
exist depending upon the type of prosthesis
being treatment planned. There must be ade-
quate space for bulk of restorative material that
also permits a prosthesis design to establish
aesthetics and hygiene. If space is limited, re-­
establishing a patient’s vertical dimension or
altering the opposing occlusion should be con-
sidered [11].
Guidelines for space requirements for
ceramic-based restorations are 10–13 mm for a
screw retained ceramic-based restorations and
14–16 mm for acrylic resin/titanium-based resto-
rations. Clinicians should select the material that
requires the least bone removal and satisfies the
requirements of aesthetics, contour, and biome-
6 S. Jivraj

Fig. 1.3 Inadequate

restorative space can
result in restoration
fracture

Fig. 1.4 Resin-based restorations require 15–18 mm of restorative space

chanics. Acrylic titanium restorations are very 1.3 Lip Support

rarely done in the maxillary arch due to the
amount of restorative space and bone removal
required. They should be reserved for the man-
dibular arch when opposing a maxillary denture
(Figs. 1.3 and 1.4) [6, 7].
One of the best diagnostic tools is the patient’s
existing maxillary denture. The clinician can
evaluate the patient’s denture to determine what
likes and dislikes there are regarding aesthetics,
speech, and function. Each point should be noted
for improvements in the new restoration. There is
1 Diagnosis and Treatment Planning: A Restorative Perspective 7

Fig. 1.5 Looking at the profile view of the patient with the denture in and out can give the clinician an indication if the
flange of the denture is required for lip support

Fig. 1.6 This patient has an obvious lack of lip support with a concave facial profile

always a tendency for patients to prefer fixed
over removable prostheses. It is the restorative
dentists’ responsibility to determine if this is fea-
sible. Facial support is an important decision in
this regard.
Assessment of the patient’s facial support with
and without the denture in place, with the patient
facing forward and in profile, needs to be made so
the clinician can determine which type of prosthe-
ses would be more suitable (Figs. 1.5 and 1.6).
Facial support, if inadequate, is obtained mainly
by the buccal flange of a removable restoration.
Lip support is derived from the alveolar ridge
shape and cervical crown contours of the anterior
teeth. Resorption of the edentulous maxilla pro-
ceeds cranially and medially, and this often results
in a retruded position of the anterior maxilla.
When evaluating a diagnostic setup with the
anterior teeth in proper relation to the lip, the
position of the anterior teeth is often anterior to
the alveolar ridge (Figs. 1.7 and 1.8). Depending
on the severity of the resorption, there can be a
discrepancy between the ideal location of the
teeth and the ridge. This, in turn, leads to a dis-
crepancy of the anticipated position of the
implants in relation to the teeth. This discrepancy
must be taken into consideration to achieve a
prosthesis that satisfies the parameters of ade-
quate speech, lip support, hygiene, sufficient
tongue space, and patient acceptance.
If the anticipated position of the teeth and
implant results in a large horizontal discrepancy,
a number of options must be considered before
finalizing implant placement.
8 S. Jivraj

Fig. 1.7 When requesting a diagnostic denture setup from a dental technician, a flangeless try-in should be requested

Fig. 1.8 Patient with flangeless try-in. This patient is a candidate for a fixed implant-supported restoration

Fig. 1.9 If a patient with inadequate lip support requests implant placed higher up so the emergence of the restora-
fixed restorations, the clinician must assess to see if this is tion can start higher up
possible. On occasion bone must be removed and the
1 Diagnosis and Treatment Planning: A Restorative Perspective 9

If the horizontal discrepancy is quite large,
options include:
(a) Bone reduction and a deeper implant
placement to allow the contours of the
restoration to satisfy the parameters of lip
support and hygiene. Without bone reduction,
undesirable contours in the restoration are
developed, which make it very difficult for
the patient to maintain hygiene (Fig. 1.9).
(b) LeFort 1 osteotomy—Most patients are
reluctant to undergo this type of surgery
(c) Use of a removable flange and fabrication of
an implant-supported overdenture
1.4 Smile Line and Lip Length
The movement of the upper lip during speech and
smiling should be evaluated. Tjan et al. [8] described
the average smile as having the position of the upper
lip such that 75–100% of the maxillary incisors and
interproximal gingival are displayed. In a high smile
line, additional gingival was exposed, and in a low
smile line, less than 75% of the maxillary anterior
teeth are displayed. Lip length should also be evalu-
ated because it influences the position of the maxil-
lary anterior teeth. In a patient with a short upper lip,
the maxillary anterior teeth will be exposed in repose
(Fig. 1.10), whereas in patients with a long upper lip,
the anterior teeth will usually be covered.
Dentate patients with a terminal dentition may
present with excessive gingival display. Causes
of excessive gingival display include but are not
limited to:

Fig. 1.10 A short lip poses a challenge. The transition zone may be visible

Fig. 1.11 For an edentulous patient, the denture is removed and the patient asked to smile without the denture in place;
the ridge should not be visible
10
Fig. 1.12 If the ridge is visible, alveolectomy may be necessary to hide the transition zone, depending upon the type
of restoration to be fabricated
1. Vertical maxillary excess
2. Short upper lip
3. Hyperactive upper lip
4. Dentoalveolar extrusion
5. Delayed passive eruption
6. Multiple aetiologies [12]
The clinician must have an adequate diagnosis
prior to embarking upon a treatment plan.
Edentulous patients should be asked to
smile with and without the denture in place
(Figs. 1.11 and 1.12). If the soft tissue of the
edentulous ridge cannot be seen, the transition
between an implant-supported prosthesis and
the residual ridge crest will not be visible,
resulting in flexibility for colour matching and
the contour change of the prosthesis at the
junction of the soft tissue. If the alveolar ridge
crest is displayed during smiling, the aesthet-
ics can be very challenging because the junc-
tion between the restoration and the gingival
complex will be visible and bear aesthetic
consequences. If the patient has minimal
resorption, conventional metal ceramic resto-
rations or zirconia-based restorations sup-
ported by implants can be planned, and the
existing soft tissue can be developed to
enhance aesthetics. However, if an implant-
S. Jivraj
supported denture (hybrid/profile prosthesis)
is being planned, the alveolar ridge display
will detract from the aesthetics. In situations
like this, alveolectomy as part of a proactive
protocol must be considered prior to implant
placement. If alveolectomy is not performed,
the restorative outcome will display the transi-
tion zone, which, ultimately, is very difficult
to retreat. Alveolectomy must only be per-
formed when there is an indication for it, and
the minimum amount of bone must be removed
to satisfy the clinical objectives.
1.5 Contours and Emergence
The contours of the restorations have to be planned
from the outset. The emergence profile of the resto-
rations should be straight as it exits from the gingival
margin. Often this requires alveolectomy to create
sufficient space. The restorative dentist requires this
space to develop adequate mechanics, aesthetics,
and cleansability. This space creation must be com-
municated to the surgeon through the use of a bone
reduction guide, and it becomes the surgeon’s
­responsibility to provide this space [13]. One mis-
conception about graftless protocols is that they
always require a significant amount of bone reduc-
1 Diagnosis and Treatment Planning: A Restorative Perspective 11

Fig. 1.13 Haphazard bone reduction need not be done; there has to be a specific reason for alveolectomy

Fig. 1.14 A bone reduction guide must be stable and have a reference point from which the surgeon can measure

tion. Bone reduction has to have a rationale, and the
minimum bone reduction must be done to satisfy the
requirements of implant placement and fabrication
of a biomechanically sound restoration [14].
Rationale for bone reduction include but are
not limited to:
1. Adequate buccolingual width of bone to place
implants
2. Adequate space for hygiene
3. Adequate space for biomechanics of the
restoration
4. Adequate space so that the patient can clean
the undersurface
5. Hide transition zone
6. Improve emergence of the restoration
(Figs. 1.13 and 1.14)
1.6 Appropriate Tissue Contact
As in any aspect of restorative dentistry, the
provisional is key to the success of the definitive
restoration. From a patient’s perspective, the
communication of aesthetics and phonetics is
important. From a clinician’s perspective, biome-
chanics, occlusion, and cleansability are key
areas of concern. The original hybrid prostheses
were designed to provide a “highwater” design.
This was done predominantly to facilitate oral
hygiene. Today, patients often complain of food
entrapment with these types of designs. The pro-
visional/immediate load prosthesis must satisfy
the following criteria:
(a) Reduce food entrapment—Following
3 months of healing, the acrylic provisional
12 S. Jivraj

Fig. 1.15 The undersurface of the immediate load provisional restorations must be convex and highly polished

Fig. 1.16 The provisional restoration must be used to shape the tissue over time. When the clinician makes an
impression, the tissue surface should be concave so the restoration surface can be convex

should be relined so that it compresses the 1.7 Occlusion

tissue surface and creates a concave tissue
surface allowing a convex restoration
surface.
(b) Provide cleansable contours by developing
the tissue as outlined above (Figs. 1.15 and
1.16).
(c) Eliminate speech impairment. The t and d
sounds relate to the palatal aspects of the
maxillary prosthesis, and this area can be
adjusted to accommodate for that. The “S”
sound is developed utilizing the closest
speaking space and this should also be cor-
rected in the provisional prior to proceed to
the definitive restoration.
(d) The tissue contact should be intimate, but
accessible to oral hygiene procedures.
(e) The tissue surface should be highly polished.
Occlusion in this article pertains to the occlusion
on the immediate load provisional restoration.
Occlusion for the definitive prosthesis will be
addressed in a subsequent article. In regard to
occlusion, there are no literature references citing
the superiority of one occlusal scheme over
another, one tooth form over another, and
patients’ preference of one occlusal scheme to
another. Unfortunately, there are no randomized
controlled clinical trials guiding the clinician to
develop the occlusal scheme on the immediate
load provisional prosthesis. Most occlusal
schemes are based on biomechanics and distribu-
tion of the occlusal forces over areas which are
most likely able to tolerate them.
Clinical guidelines for developing occlusion
include but are not limited to [10, 15–17]:

(a) Good AP spread of implants

1 Diagnosis and Treatment Planning: A Restorative Perspective
Fig. 1.17 Force distribution requirements of the immediate load transitional restoration
(b) Minimum vertical overlap
(c) Bilateral simultaneous contact
(d) No interferences in lateral excursion
(e) Cross-arch stabilization with a passive screw
retained acrylic prosthesis which has suffi-
cient rigidity to withstand occlusal forces
without breaking
(f) No cantilevers
(g) Occlusal contacts from canine to canine only
with shimstock drag on the posterior teeth.
The rationale for this approach is centred
around bone quality and occlusal forces. The
posterior implants are in the weakest bone
quality. The occlusal forces are highest the
further we go back in the mouth. The rationale
is to protect the implants in the weakest qual-
ity bone being subjected to the highest occlu-
sal forces. If this requires developing a ramp
on the palatal aspect of the anterior teeth, this
should be completed with cold cured acrylic
resin. If the patient has a severe class two inci-
sor relationship, the above will not be possible
in which case occlusal contacts are evenly dis-
tributed around the arch (Fig. 1.17).
Achieving successful outcomes with graft less
solutions is significantly more challenging than
with conventional restorations. Diagnosis and
appropriate treatment planning are critical in
obtaining a successful outcome. Implant con-
cepts have undergone a significant evolution, not
only in terms of designs, materials, and surfaces
but also in clinical and technical management.
13
Clearer understanding of both the surgical and
restorative protocols enables the clinician to bet-
ter plan the outcomes of implant therapy.
References
1. Branemark PI, Hansson BO, Adell R, Breine U,
Lindstrom J, Hallen O, et al. Osseointegrated implants
in the treatment of the edentulous jaw. Experience
from a 10-year period. Scand J Plast Reconstr Surg
Suppl. 1977;16:1–132.
2. US Bureau of the Census. Statistical abstract of the
United States: 1996. 116th ed. Washington, DC: US
Bureau of the Census; 1996. p. 15, tables II, No. 16,
p 17, table II, No. 17.
3. 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(10):662.
4. Heath MR. The effect of maximum biting force and
bone loss upon masticatory function and dietary
selection of the elderly. Int Dent J. 1982;32:345–56.
5. Turkyilmaz I, Company AM, McGlumphy
EA. Should edentulous patients be constrained to
removable complete dentures? The use of dental
implants to improve the quality of life for edentulous
patients. Gerodontology. 2010;27(1):3–10.
6. Zitzmann NU, Marinello CP. Treatment plan for
restoring the edentulous maxilla with implant
supported restorations: removable overdenture
versus fixed partial denture design. J Prosthet Dent.
1999;82(2):188–96.
7. Jivraj S, Chee W, Corrado P. Treatment planning of the
edentulous maxilla. Br Dent J. 2006;201(5):261–79.
8. Tjan AH, Miller GD, The JG. Some aesthetic factors
in a smile. J Prosthet Dent. 1984;51:24–8.
9. Schwarz MS, Rothman SL, Rhodes ML, Chafetz
N. Computed tomography: part II. Pre-operative
14
assessment of the maxilla for endosseous implant
surgery. Int J Maxillofac Implants. 1987;2:143–8.
10. Schnitman PA, Wohrle PS, Rubenstein JE, DaSilva
JD, Wang NH. Ten-year results for bra°nemark
implants immediately loaded with fixed prostheses
at implant placement. Int J Oral Maxillofac Implants.
1997;12:495–503.
11. Wicks RA. A systematic approach to definitive
planning for osseointegrated implant prostheses. J
Prosthodont. 1994;3(4):237–42.
12. Robins JW. Differential diagnosis and treatment of
excess gingival display. Pract Periodont Aesthet Dent.
1999;11(2):265–72.
13. Bedrossian E. Implant treatment planning for the
edentulous patient. Maryland Heights: Mosby
Elsevier; 2008.
S. Jivraj
14. Balshi TJ, Wolfinger GJ, Balshi SF. Int J Oral
Maxillofac Implants. 1999;14(3):398–406.
15. Brunski JB, Int J. Oral Implantol. 1988;5(1):31–4.
16. Malo P, Rangert B, Nobre M. “All on 4”, immediate
function concept with Branemark implants for
completely edentulous mandible. A retrospective clinical
study. Clin Implant Dent Relat Res. 2003;5(Suppl
1):2–9.
17. Capelli M, Zuffeti F, Testori T, Del Fabbro
M. Immediate rehabilitation of completely
edentulous jaws with fixed prosthesis supported
by upright and tilted implants. A multicenter
clinical study. Int J Oral Maxillofac Implants.
2007;22:639–44.
 Surgical Diagnostic Considerations
in Graft-Avoiding Dental Implant
2
Reconstruction of Atrophic Jaws

Hooman M. Zarrinkelk

Abstract According to the US National Health Surveys

Treatment of edentulism has always been a
challenge to the dental profession.
Reconstruction of atrophic jaws caused by
edentulism has necessitated sometimes com-
plex grafting procedures. Grafting procedures
carry significant morbidity and cost associated
with them. Today, there is great interest from
the public and dental professionals in the less-­
invasive graftless approaches to the atrophic
jaw rehabilitation. Graftless approaches to
treatment involves a specific manner of place-
ment of sufficient number of dental implants
in strategic positions of patients’ existing bone
structures. The surgeon must understand the
three absolute surgical requirements for suc-
cessful treatment. Diagnostic factors to be
considered by the surgeon to fulfil these abso-
lute requirements for rehabilitation are dis-
cussed in this chapter.
H. M. Zarrinkelk (*)
Diplomate American Board of Oral and Maxillofacial
Surgeons, Chicago, IL, USA
Fellow American College of Oral and Maxillofacial
Surgeons, Washington, DC, USA
Private Practice, Ventura, CA, USA
e-mail: DrZ@VenturaOralSurgery.com
conducted over the past five decades, the rate of
edentulism has been declining from 18.9% in
1957–1958 to 4.9% of the adult population in
2009–2012 (NHANES: U.S. Depart of Health
and Human Services). The continuing decline
will be offset partially by population growth and
population aging such that the predicted number
of edentulous patients will only decline from
today’s more than 20 million to 12.2 million indi-
viduals in 2050 [1]. On the global scale, the num-
ber of edentulous individuals is predicted to be
much higher, and therefore, treatment of edentu-
lism will be a daily challenge to clinicians for
many years to come. Edentulous patients suffer
from functional deficiencies caused by their lack
of natural dentition or poor-fitting removable
appliances [2]. Today’s aging population is more
active and social than the past generations and
will demand a much higher quality of life.
Historically, treatment of edentulism, and in par-
ticular atrophic edentulism, has been towards
reconstruction of the tissue lost through natural
atrophy. The lack of adequate bone volume for
conventional implant-supported appliances and
complex surgical treatments to correct the defi-
ciencies are the major obstacles facing both
patients and clinicians involved in their care.
Over the past 30 years, advances in bone and soft
tissue grafting procedures and materials have
made the concept of tissue regeneration in the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 15

S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_2
16
maxillofacial region more routine and predict-
able but remain technique sensitive [3–6].
Autogenous bone grafts, xenografts, allografts,
or alloplasts have been utilized to augment defi-
cient areas of the maxilla and mandible for prepa-
ration of implant sites. In the case of atrophic
edentulous jaws, the gold standard remains
autogenous bone. However, selection of the
appropriate surgical technique and graft material
remains difficult to ascertain from the hetero-
genic and often poorly designed available
­literature [7–9]. The financial burden on patient
and community as well as pain and morbidity
associated with grafting procedures are large
obstacles to treatment. There will be increased
pressure on the medical community to reign in
the cost associated with treatments rendered.
Clinicians are required to justify the rationale for
more costly and invasive procedures if less costly
and invasive procedures are as effective. There is
growing evidence that edentulous patients can be
treated with fixed full-arch dental restorations
while avoiding major grafting procedures with as
few as four dental implants [10–12] (Fig. 2.1). It
is with the above understanding that we begin to
appreciate the great interest in the dental com-
munity to learn about the less-invasive surgical
concepts and protocols that rehabilitate the eden-
tulous patient without bone grafts. The goal of
this article is to provide a brief overview and
introduction to the absolute surgical diagnostic
and treatment planning requirements for sur-
geons and restorative dentists.
Fig. 2.1 Successful, aesthetic, and functional rehabilitation of patient utilizing a graftless approach to maxilla and
mandible. Four implants per jaw were used in an immediate load protocol
H. M. Zarrinkelk
Diagnosis and treatment planning of the eden-
tulous patient is a complex and challenging task.
Treatment planning of this often older and medi-
cally compromised patient population should
always begin with a complete medical evalua-
tion. In brief, any uncontrolled disease process
that would compromise complete bone and soft
tissue healing should exclude a patient from
implant therapy. Diabetes, osteoporosis, and car-
diovascular diseases may be of concern but if
controlled are not absolute contraindications for
implant therapy [13]. Currently, the most worri-
some contraindication for implant therapy is
intravenous bisphosphonate or other antiresorp-
tive therapies [14].
The surgical evaluation of the patient’s oral
condition should be systematic and methodical.
The diagnostic criteria are ultimately used by the
surgeon to determine the correct course of action
to satisfy the three absolute surgical
requirements:
1. Space: Adequate inter-arch space required for
the prosthesis.
2. Spread: Adequate A-P spread to support the
prosthesis (Fig. 2.2).
3. Stability: High primary stability of placed
dental implants.
The surgical diagnostic criteria discussed in
this article will apply to a patient who is being
treatment planned for a full-arch, fixed metal-­
ceramic, FP1 [15], implant-supported fixed den-
2 Surgical Diagnostic Considerations in Graft-Avoiding Dental Implant Reconstruction of Atrophic Jaws
Fig. 2.2 The A-P spread is determined by the distance
between the lines intersecting the platform of the distal
implants and the most anterior implants. The A-P spread
ture [16], profile prosthesis [17], or
fixed-removable (overdenture) [18] prosthetic
restoration. The surgeon must evaluate the fol-
lowing anatomic factors for all restorative options
listed above:
1. Magnitude of three-dimensional anatomical
defect.
2. The position of the prosthetic transition line
relative to the animated lip position.
3. The relative position of the planned incisors to
the existing alveolar ridge.
4. The volume and quality of alveolar bone
available in the maxilla and mandible.
5. Position of the inferior maxillary sinuses,
nasal cavity, alveolar nerve, and mental
foramen.
The prosthetic diagnostic criteria and con-
cerns will be discussed in another chapter.
Loss of teeth and subsequent resorption of sup-
porting structures create an anatomical defect
within the maxillofacial structures that will have
profound influence on the type of the restoration
best suited to the patient. Subsequently, the type of
restoration selected to satisfy the patient’s condi-
tion and desires will determine the implant posi-
tions. Therefore, loss of tissue should be assessed
first to determine the correct position of the osse-
ous anchorage. Loss of teeth creates a “tooth-only”
17
should be as large as possible to compensate for the mag-
nified occlusal forces of the cantilever
defect, whereas subsequent loss of supporting
bone and soft tissue creates what is termed a “com-
posite defect” [19]. In patients where a tooth-only
defect with minimum resorption of the supporting
structures has occurred, a metal-ceramic/zirconia-
ceramic FP1 implant-­supported prosthesis is the
most appropriate. A FP1 prosthesis can be fabri-
cated on four implant anchorage with precise
implant position and minimal bone contouring
when indicated. However, in most cases, edentu-
lous patients present with varying degrees or hori-
zontal as well as vertical composite defects. To
assess the magnitude of the resorptive defect, a
digital or analogue dental setup with appropriate
tooth position, inter-arch relationship, and occlu-
sion must be completed. The denture setup is sub-
sequently duplicated in a transparent clear acrylic
and worn by the patient. With the clear denture in
place, two dimensions are measured:
1. The relative space between the cervical line of
the denture teeth to the residual ridge. This
measurement represents the available restor-
ative space (Fig. 2.3).
2. The facial surface of the teeth to apex of the
residual crest, representing the lip support
requirements.
With the data available from these two mea-
surements, the restorative and surgical clinicians
18
can determine the appropriate restoration for the
patient. The decision to fabricate a metal-ceramic
appliance without pink ceramic gingiva vs. a
hybrid appliance is made by the restorative den-
tist based on the relative position of the proposed
teeth to the existing alveolar ridge and lips. The
surgical specialist must have a clear u­ nderstanding
of the space required to satisfy the aesthetic and
structural requirements of the planned restoration
[20, 21]. In the case of a fixed implant denture,
approximately 15 mm of space is required per
arch measured from the incisal edge to implant
platform. The management of restorative space is
an absolute prosthetic requirement but a surgical
Fig. 2.3 Assessment of available restorative space by uti-
lization of clear acrylic dental setup. Note the distance
from planned incisal edge to the existing alveolar ridge.
Horizontal and vertical relationship between the incisal
edge and the alveolar ridge can be measured
Fig. 2.4 Examples of both tooth and tissue-borne bone
reduction guides. This guide is used by the surgeon to
determine the desired position of the alveolar platform for
implant placement. The final incisal edge position is simu-
H. M. Zarrinkelk
responsibility. If insufficient inter-arch space is
detected, then space should be created. Most
often, the creation of space is accomplished by
bone reduction or alveolectomy. The surgeon and
restorative dentist should collaborate on determi-
nation of the magnitude of bone reduction
required in each of the jaws to satisfy prosthetic
requirements. The dimensions of alveolectomy
are communicated to the surgeon by the “bone
reduction guide”. This surgical stent is a tissue or
tooth-supported acrylic stent fabricated on an
altered plaster model with markings for reduction
(Fig. 2.4).
A large horizontal deficiency will create a
prosthetic ledge which will be both unaesthetic
and unhygienic for the patient. The surgeon may
alter the vertical position of the dental implants
relative to the incisal edge to allow for an appro-
priate labial curvature of the appliance. The avail-
able vertical dimensions of the bone must be
taken into consideration. If insufficient vertical
bone dimension exists to allow appropriate verti-
cal position of the implants, then a removable
implant-supported overdenture with a flange may
be selected [22].
The next step in clinical evaluation of patient
is assessment of the “transition line”. This line
represents the junction of the dental prosthesis
and residual alveolar gingiva. The failure to
assess the visibility of the transition line may
result in an unaesthetic outcome for the patient
lated in the stent and surgeon removes appropriate height
of alveolar bone to assure sufficient restorative space and
proper prosthetic labial contours
2 Surgical Diagnostic Considerations in Graft-Avoiding Dental Implant Reconstruction of Atrophic Jaws
Fig. 2.5 Transition line is defined as the junction of
hybrid dental prosthesis and natural gingiva. Assessment
of visible alveolus (line) during lip animation and smiling
is critical preoperatively to ascertain the magnitude of
Fig. 2.6 The measurement of subnasale to stomion rep-
resent the lip length. The change in this measurement
between repose and animation represents the magnitude
(Fig. 2.5). The transition line may become visible
during normal animation of the lips particularly
during smiling. The edentulous patients’ typical
hesitation to smile during examination may be a
source of underestimation of the exposure.
Therefore, the evaluation of the lip animation
should begin during the initial conversations with
patients. This should be documented using pho-
tographs and video. Next, lip length is measured
from subnasale to stomion with the patient pro-
viding their biggest smile. This is requested with
the denture in place (Fig. 2.6). Subsequently, the
denture is removed and patient asked to smile and
verified with measurement of lip length. Any vis-
ible alveolar ridge during the maximal smiling is
noted and measured. Ideally in an edentulous
patient, the final transition line should be 3–5 mm
above the highest animated smile line. For an
edentulous patient with a visible ridge on smil-
19
bone reduction in order to hide the transition line above
the smile line and avoid an unaesthetic result for the
patient (arrow)
of lip mobility and must be considered during treatment
planning. An active lip may necessitate substantial bone
reduction to hide the transition line
ing, the decision to conserve or resect alveolar
bone is based on the patients’ aesthetic demands.
If artificial ceramic or acrylic gingiva is unac-
ceptable to the patient, then the dental implants
will have to be placed in precise teeth positions
and a metal-ceramic/zirconia-ceramic prosthesis
of appropriate teeth proportions constructed. If a
patient has a composite defect and the ridge is
visible, then metal-ceramic prosthesis without
gingival porcelain may not be feasible. In this
class of patient’s teeth will appear long and
unaesthetic without gingival coloured soft tissue
component. In a situation where alveolar ridge is
visible and artificial gingiva are not of aesthetic
concern to the patient, then alveolar resection is
indicated. Extra attention should be paid to
patients with short or hyperactive lips. The
dimension of alveolar reduction will be the sum
of visible ridge measurement plus an additional
20 H. M. Zarrinkelk

Fig. 2.7 Prefabricated provisional shell and surgical stent

3–5 mm of reduction. The entire visible alveolar

ridge from the pre-maxilla to the tuberosity must
be considered when planning for alveolectomy.
Once the vertical dimensions of alveolectomy in
all zones of the maxilla or mandible are deter-
mined, the patient radiographs will be evaluated
to assess the anticipated remaining alveolar bone
below the sinus and nasal cavity and above the
inferior alveolar nerve.
Factors such as patients’ age, excessive gingi-
val show, or aesthetic demands may be contrain-
dications to alveolectomy. In such cases the
Fig. 2.8 Precise implant position with consideration of
technical and cost-saving advantages of the graft the final tooth position
avoiding procedures may still be realized. For
these cases the implants are placed in precise
three-dimensional positions to allow for appro-
priate emergence profile of the appliance. A tis-
sue or tooth indexed surgical guide is fabricated
(Fig. 2.7). The final position of the teeth is deter-
mined via the guide. Implants are placed to sat-
isfy the three absolute surgical requirements
discussed earlier. Implants are placed with mini-
mal tissue reflection and trauma. Implant angula-
tion and depth are adjusted to provide enough
space for multi-unit abutments or angled screw Fig. 2.9 Appropriate emergence of the multi-unit abut-
channel system (Fig. 2.8). The emergence of the ment screw through the palatal aspect of the tooth
multiunit abutment access screw should be
through the cingulum of the incisors (Fig. 2.9). A functional and aesthetic factors. The goal of the
provisional replacing just the tooth portion space creation through bone removal is to facilitate
(Fig. 2.10) and a definitive restoration (Fig. 2.11) fabrication of a prosthesis with adequate flexure
can be fabricated for the patient while avoiding resistance and appropriate contours where the tran-
alveolectomy. sition line is not visible in conversation or smile.
In summary, the decision to resect or preserve The third and final step in systematic diagno-
the alveolar bone is determined by a number of sis of an edentulous patient is radiographic deter-
2 Surgical Diagnostic Considerations in Graft-Avoiding Dental Implant Reconstruction of Atrophic Jaws
Fig. 2.10 A tooth only provisional in the maxilla sculpt-
ing tissues (Provisional Courtesy of Saj Jivraj B.D.S.)
Fig. 2.11 A definitive zirconia restoration adapted to the
tissue in the maxilla (Definitive restoration courtesy of Saj
Jivraj B.D.S.)
mination of available bone for dental implant
placement. Three-dimensional radiography and
virtual planning software has made the diagnosis
and treatment planning predictable. Bedrossian
has described the delineation of maxilla into
three zone for a simplified treatment planning
[19]. A treatment plan can be developed by the
clinician after determination of presence of suf-
ficient bone in the three zones of the maxilla. The
alveolar bone of the anterior maxilla from canine
to contralateral canine is designated as zone 1,
the premolar region as zone 2, and the molar
region as zone 3 (Fig. 2.12).
If zones 1, 2, and 3 have available bone vol-
ume, then preferred number of axial implants
may be placed (Fig. 2.13a). If zones 1 and 2 are
available, then tilted posterior implant in combi-
nation with axial or tilted anterior implants can
21
Fig. 2.12 The three zones of maxillary alveolar bone
used in a simplified treatment planning protocol as
described by Bedrosian. Zone 1 = incisor region (red),
zone 2 = bicuspid region (gold), zone 3 = molar region
(green)
be considered (Fig. 2.13b). And finally if zone 1
is the only available bone, then zygomatic or
pterygoid plate implant concepts may be con-
sidered for posterior support and axial or tilted
implants for anterior support (Fig. 2.13c). If
complete atrophy of the maxilla is evident with
unavailability of bone in all three zones of the
maxilla, then two zygomatic implants bilater-
ally may be used to provide support for the pros-
thesis (Fig. 2.13d). The reason for tilting of
implant up to 45 degrees is to avoid placement
of implants in anatomic structures such as the
maxillary sinus, nasal cavity, or mental fora-
men. Tilting of the distal implants increases the
A-P spread by positioning the platform of the
implant further posteriorly while avoiding the
mentioned structures (Fig. 2.14). By bypassing
these structures, bone grafting procedures are
avoided or minimized. If any combination of the
implant position schemes satisfy the three abso-
lute requirements of spread, stability, and space,
then immediate loading of the appliance is
considered.
Selection of the appropriate implants for each
case must begin with a complete understanding
of the available implants systems and corre-
sponding straight or angled prosthetic abutments.
Lekholm and Zarb [23] have classified the degree
of resorption of the alveolar process and basal
bone. A classification was also proposed for asso-
ciated bone quality. Selection of implant length
and diameter is dependent on alveolar anatomy
and bone density. A thorough preoperative as
well as intraoperative evaluation of the alveolar
22
a b
c d
Fig. 2.13 Treatment planning of the edentulous maxilla
can be done by evaluation of bone availability in the three
zones of the maxilla: (a) zones 1+ 2 + 3 = Axial implant
placement; (b) zones 1 + 2 = Axial anterior + tilted poste-
Fig. 2.14 Tilting of the implants up to 45° (blue) allows
distalization of the platform of the implant while avoiding
structures such as the maxillary sinus. The primary benefit of
this manoeuvre is the reduction of the cantilever effect (gold)
ridge will guide the diameter of implant used.
The goal of surgeon should be to maintain ade-
quate bone thickness of at least 2 mm along the
entire length of the implant [24]. Assuming that
the minimal implant diameter used will be nar-
row platform or 3.3–3.5 mm (Nobel Biocare,
Zurich, Switzerland), a minimum of 5–6 mm of
alveolar crest ridge width is required in planning
of the implant positions. Wider alveolar ridges
allow for placement of wider implants with more
flexibility of components and increased bone/
metal contact surface area for osseointegration
and therefore should be favoured. Bone reduction
H. M. Zarrinkelk
rior implant placement; (c) zone 1 only = Axial anterior +
zygoma implant placement; (d) No Zone = quad zygoma
implant concept
creates decortication of the alveolar ridge and
exposure of the spongy marrow space for implant
placement. Alveolar atrophy or bone reduction
will have the beneficial effect of bringing the
crest of the alveolus closer to confluence of dense
bone plates of the piriform rim. The position of
the distal tilted implant should be so that the
eventual prosthetic cantilever is minimized.
Implant length selection is to assure primary sta-
bility by engagement of areas of dense bone such
as the piriform rim, nasal floor, or inferior border
of the mandible while placing the implant plat-
form as far posteriorly as possible [25] (Fig. 2.15).
Therefore, in the maxilla the posterior implant if
angled should be at the minimum long enough to
reach from the bicuspid region to the piriform
rim. In the mandible the distal implant is posi-
tioned with the platform above the mental fora-
men and tilted to avoid the anterior loop of the
Inferior alveolar nerve while engaging the dense
inferior border cortex.
Decision on number of implants to be placed
is beyond the scope of this article and is not an
absolute criteria for success. The appropriate
number of implants for each individual patient is
dependent on factors such as health status, type
of bone, type and size of implant used, type of
prosthesis planned, biomechanical configura-
2 Surgical Diagnostic Considerations in Graft-Avoiding Dental Implant Reconstruction of Atrophic Jaws
Fig. 2.15 Primary stability of the implants placed is criti-
cal to osseointegration and success. The immediate stabil-
ity is dependent on design of implant used and the quality
tions of the placed implants, and other variables
[26]. However, as early as 1977, Brånemark sug-
gested that positioning four implants in the eden-
tulous maxilla and mandible in an adequate A-P
spread configuration can successfully reconstruct
the patient oral handicap and prevent further
bone loss [27]. Today, there is growing evidence
that immediate loaded, axial, or tilted dental
implants utilizing the patients existing bone
structures while following strict biological and
biomechanics principals discussed can provide
patients a viable long-term solution to edentulism
[28–31].
References
1. Slide GD, Akinkugbe AA, Sanders AE. Projections
of US edentulism prevalence following 5 decades of
decline. J Dent Res. 2014;93(10):959–65.
2. Kerschbaum T. Long-term prognosis of con-
ventional prosthodontic restorations. In: Naert
I, Van Steenberghe D, Worthington P, editors.
Osseontegration in oral rehabilitation. London:
Quintessence. p. 33–49.
3. Stellingsma C, Raghoebar GM, Meijer HJ, Batenburg
RH. Reconstruction of the extremely rebreed
­mandible with interposed bone grafts and placement
of endosseous implants. A preliminary report on out-
come of treatment and patients satisfaction. Br J Oral
Maxillofac Surg. 1998;36:290–5.
23
of bone engaged. The goal should be to engage areas of
jaws with dense bone such as inferior border of the man-
dible, nasal floor, or piriform rim, for example
4. Triplett RG, Nevins M, Marx RE, Spagnoli DB,
Oates TW, Moy PK. Pivotal, randomized, paral-
lel evaluation of recombinant human bone mor-
phogenetic protein-­ 2/absorbable collagen sponge
and autogenous bone graft for maxillary sinus
floor augmentation. J Oral Maxillofac Surg.
2009;67:1947–60.
5. Keller EE, Tolman DE, Eckert SE. Maxillary antral-­
nasal inlay autogenous bone graft reconstruction of
compromised maxilla: a 12 year retrospective study.
Int J Oral Maxillofac Implants. 1999;14:707–21.
6. Block MS, Baughman DG. Reconstruction of severe
anterior maxillary defect using distraction osteogene-
sis. Bone grafts and implants. J Oral Maxillofac Surg.
2005;63:291–7.
7. Aghaloo TL, Moy PK. Which hard tissue augmen-
tation techniques are the most successful in furnish-
ing bony support for implant placement? Int J Oral
Maxillofac Implants. 2007;22(suppl):49–70.
8. Blackburn TK, Cawood JI, Stoelinga PJW, Lowe
D. What is the quality of evidence base for pre-implant
surgery of the atrophic jaw? Int J Oral Maxillofac
Surg. 2008;37:1073–9.
9. Esposito M, Grusovin MG, Coulthard P, Worthington
HV. The efficacy of various bone augmentation pro-
cedures for dental implants: a Cochrane systematic
review of randomized controlled clinical trials. Int J
Oral Maxillofac Implants. 2006;21:696–710.
10. Brånemark PI, Svensson B, van Steenberge D. Ten
year survival rates of fixed prostheses on four or six
implants ad modum Branemak in full edentulism.
Clin Oral Implants Res. 1995;6:227–31.
11. Agliardi E, Panigatti S, Clericó M, Villa C, Maló
P. Immediate rehabilitation of the edentulous jaw
with full fixed prostheses supported by four implants:
24
interim results of a single cohort prospective study.
Clin Oral Implants Res. 2010;21:459–65.
12. Maló P, de Araújo NM, Lopes A, Moss S, Molina G. 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;142:310–20.
13. Laney WR, Tolman DE. The Mayo Clinic experience
with tissue-integrated prostheses. In: Albrektsson T,
Zarb GA, editors. The Brånemark Osseointegrated
implant. Chicago: Quintessence; 1989. p. 165–95.
14. American Association of Oral and Maxillofacial
Surgeons. Position paper: medication-related osteo-
necrosis of the jaw—2014 update. Chicago: American
Association of Oral and Maxillofacial Surgeons;
2014.
15. Misch CE. Fixed prosthesis replaces only the crown.
In: Contemporary implant dentistry. 2nd ed. St Louis,
MO: Mosby; 1999. p. 68–70.
16. Sadowsky SJ. The implant-supported prosthesis for
the edentulous arch: design considerations. J Prosthet
Dent. 1997;78(1):28–33.
17. Schnitman P. The profile prosthesis: an aesthetic fixed
implant-supported restoration for the resorbed max-
illa. Pract Periodont Aesthet Dent. 1999;11:143–51.
18. Fortin Y, Sullivan RM, Rangert B. The Marius
implant bridge: surgical and prosthetic rehabilita-
tion of the completely edentulous upper jaw with
­moderate to severe resorption: a 5-year retrospec-
tive clinical study. Clin Implant Dent Relat Res.
2002;4:69–77.
19. Bedrossian E. Implant treatment planning for the
edentulous patient, a Graftless approach. St. Louis:
Mosby; 2011.
20. Aboul-Ela LM. The evaluation of the interocclu-
sal distance in complete dentures. Egypt Dent J.
1967;13:56.
21. Owen WD, Douglas JR. Near or full occlusal verti-
cal dimension increase of severely reduced inter-­
arch distance in complete dentures. J Prosthet Dent.
1971;26:134.
22. Fortin Y, Sullivan RM, Rangert BR. The Marius
implant bridge: surgical and prosthetic rehabilita-
H. M. Zarrinkelk
tion for the completely edentulous upper jaw with
moderate to severe resorption: a 5-year retrospec-
tive clinical study. Clin Implant Dent Relat Res.
2002;4(2):69–77.
23. Lekholm U, Zarb GA. Osseointegration in clinical
dentistry. Chicago: Quintessensce; 1985. p. 199–209.
24. Ding X, Lia SH, Zhu XH, et al. Effect of diameter
and length on stress distribution of the alveolar crest
around immediate loading implants. Clin Implant
Dent Relat Res. 2008;11:279.
25. Jensen OT, Adams MW. The maxillary M-4: a techni-
cal and biomechanical note for the all-on-4 manage-
ment of severe maxillary atrophy. J Oral Maxillofac
Surg. 2009;67:1739.
26. Brunski JB. Biomechanical aspects of the
optimal number of implants to carry a cross-
arch full restoration. Eur J Oral Implantol.
2014;7(Suppl2):S111–32.
27. Brånemark PI, Hansson BO, Adell R, et al.
Osseointegrated implants in treatment of the edentu-
lous jaw. Experience from a 10-year period. Scand J
Plast Reconstr Surg Suppl. 1977;16:1–32.
28. Bedrossian E. Immediate function with zygomatic
implant: a graftless solution for the patient with
mild to advanced atrophy of the maxilla. Int J Oral
Maxillofac Implants. 2006;21(6):937–42.
29. Malo P, Nobre M, Lopes A. The rehabilitation of
completely edentulous maxillae with different
degrees of resorption with four or more immedi-
ately loaded implants: a 5-year retrospective study
and a new classification. Eur J Oral Implantol.
2011;4:227–43.
30. Krakmenov L, Kahn M, Rangert B, et al. Tilting of
posterior mandibular and maxillary implants for
improved prosthesis support. Int J Oral Maxillofac
Implants. 2000;15:405–14.
31. Duyck J, et al. Magnitude and distribution of occlu-
sal forces on oral implants supporting fixed pros-
thesis: an in vivo study. Clin Oral Implants Res.
2000;11:465–75.
 Guided Surgery for Full-Arch
Implant-Supported Restorations
3
Michael Klein, Jay Neugarten, and Allon Waltuch

Abstract cal guides are thought of as quicker and easier

paths to surgery; however, with today’s tech-
This chapter will discuss and instruct the user
nology, even using the most comprehensive
in the type of data required for surgical and
planning and preparation for guided surgery,
prosthetic planning, how to collect that data,
the clinician can often go from the initial
and how to create a prosthetic plan and then a
patient consultation directly to performing
surgical plan. The different types of devices
guided surgery at the next visit.
and techniques for guided surgery will be
described and differentiated. Step by step
instruction for implementation of each type of
3.1 Why Perform Guided
guided surgery will be covered. The discus-
Surgery as Opposed
sion will start with a review of understanding
to Freehand Surgery or
what is seen in surgical planning software and
Using a Conventional Shell
will be followed by what diagnostic data is
Surgical Guide?
required for prosthetic and surgical planning
and how to collect it. The different types of
The ultimate goal of any implant surgical tech-
guided surgery and the specifics of their tech-
nique is to create precision, accuracy, and effi-
niques (data, planning, preparation, imple-
ciency for the ideal functional and aesthetic result
mentation) for full-arch restorations including
for any given patient. Freehand surgery relies
all forms of surgical guides, dynamic naviga-
completely on the clinical expertise and experi-
tion, and robotic surgery will be described.
ence of the implant surgeon. It requires a com-
Freehand surgery or conventional shell surgi-
plete understanding of the surgical anatomical
considerations as well as a thorough understand-
ing of the three-dimensional prosthetic, aesthetic,
M. Klein (*) · A. Waltuch
Advanced Implant Dentistry and Oral Restoration, and functional implications of the specific
Cedarhurst, New York, NY, USA implant position chosen [1]. This all must be
e-mail: mklein@keystonedental.com decided real time at the time of surgery. The use
J. Neugarten of a conventional shell surgical guide brings a lot
Department of Oral and Maxillofacial Surgery, of information to the surgery in regard to the sur-
Weill-Cornell Medical Center,
gical as well as prosthetic implant positioning
New York-­Presbyterian Hospital,
New York, NY, USA [2]. However, guided surgery allows a very thor-
e-mail: drNeugarten@nycoms.com ough surgical and prosthetic planning with com-

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 25

S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_3
26
plete integration of the two plans [3, 4]. All the
planning is then translated into tools that guide
the clinician to systematically perform the ideal
surgical procedure to produce the planned foun-
dation for the planned prosthetic restoration. The
rationale for guided surgery for full-arch restora-
tions is the same for single and limited span
bridges.
The steps required for guided surgery include
data collection, presurgical prosthetic restora-
tion design, surgical planning, and the imple-
mentation of the plan through presurgical
manufactured devices or real-time technology
used during surgery. There are multiple tech-
niques for guided surgery including surgical
guides, real-time dynamic guided surgery, and
robotic surgery.
3.2 Planning Software
An understanding of planning software is criti-
cal to be able to properly evaluate both surgical
and prosthetic plans. There are software dedi-
cated to surgical planning that have basic pros-
thetic planning features. These features are
designed for placement of a virtual prosthetic
restoration contours to enable surgical planning
Fig. 3.1 Comprehensive treatment planning is done very efficiently by integrating CT scan data and iOS scan data in
diagnostic planning software
M. Klein et al.
while visualizing three dimensionally the pros-
thetic restoration and the impact of the surgical
implant position on the restoration (e.g., what
type of abutments would be necessary, can the
restoration be screw retained or does it have to
be cementable, will a custom abutment be
required, what are the dimensions of aesthetic
tooth placement, and can a crown and bridge
style (FP-1) restoration be made with natural
soft tissue or will a pink prosthetic apron be
required). These prosthetic planning options are
not designed to be used to create stl manufactur-
ing files to produce a provisional restoration.
There are separate prosthetic planning software
(e.g., 3Shape design, exocad, Dental Wings,
etc.) where pure prosthetic design is done. These
prosthetic restoration design stl files can be
imported into the surgical planning software to
aid in surgical planning, as well as to be used as
manufacturing files to produce provisional
restorations.
Proper planning today includes comprehen-
sive prosthetic planning merged with surgical
planning. This type of planning software can
then design surgical guides and produce stl
manufacturing files for the surgical guides or
guide dynamic or robotic implant surgery
(Fig. 3.1).
3 Guided Surgery for Full-Arch Implant-Supported Restorations 27

3.2.1 Surgical Planning Software one 3D image there can be surgical and pros-
thetic analysis (as well as the influence of each on
Surgical planning software requires two types of the other) (Fig. 3.5a, b).
datasets to be able to properly plan prosthetically Surgical planning software will accept the
driven implant surgical procedures. The two sets dicom data from cone beam or conventional CT
of data are the dicom data from a CT scan scanners.
(Fig. 3.2a, b) (most commonly cone beam CT
scan data) of the patient and the intraoral surface
(iOS) scans of the patient (iOS scans of the max-
illa, mandible, and bite) (Fig. 3.3). Conventional
analogue impressions may be taken of the patient
and then converted into digital data with a labora-
tory scanner (Fig. 3.4a, b) or your CBCT scanner
[5, 6]. The iOS scans (or lab scanned models) are
used to perform a virtual diagnostic prosthetic
wax up for the patient. The CT scan dicom data is
used to be able to analyse in 3D the bone struc-
tures as well as the soft tissue structures in and
around the bony structures. Surgical planning Fig. 3.3 Intraoral surface scan technology enables virtual
software integrates both these datasets so that in models for every full-arch implant patient

a b

Fig. 3.2 (a, b) The convenience of having a cone beam CT scanner directly in the dental office enables rapid compre-
hensive diagnostic patient evaluation
28 M. Klein et al.

a b

Fig. 3.4 (a, b) Those clinicians who do not yet have the capability to take intraoral surface scans may take conventional
impressions and have the stone models scanned in a laboratory scanner

Fig. 3.5 (a, b) The merging of the CT scan data with the surface scan data in surgical and prosthetic planning software
allows for true comprehensive treatment planning
3 Guided Surgery for Full-Arch Implant-Supported Restorations 29

b This dicom data will then be reformatted by

the surgical planning software into user-friendly
pictures. The picture orientations include a pan-
oramic view (Fig. 3.6a), axial view (Fig. 3.6b),
cross-sectional view (Fig. 3.6c), and 3D recon-
struction (Fig. 3.6d) [7, 8].
There will be multiple pictures from each of
these views, the number depending on slice
thickness and parameters set by each proprietary
software.
The reformatted CT dicom data by itself has
a lot of information to allow the clinician to
completely evaluate the surgical site; however,
when combined with surface scans of the exist-
ing teeth and soft tissue in the patient’s mouth, a
much more thorough analysis can be done. The
volume and position of bone as it relates to the
prosthetic restoration gives critical information
when designing and evaluating the plan for
guided surgery: what is the aesthetic dimension
Fig. 3.5 (continued)
of a tooth, where will the free gingival margin
be, is there enough room for all the required

a b

Fig. 3.6 (a–d) Surgical planning software will reformat the CT dicom data into panoramic views, axial views, cross-­
sectional views, and a complete 3D reconstruction
30
c d
Fig. 3.6 (continued)
Fig. 3.7 The outline of the diagnostic wax-up can be
seen in blue with critical measurements taken for diagnos-
tic assessment in the cross-sectional view
prosthetic components, will bone have to be
reduced or bone grafting be done to accomplish
the desired result for the patient (Fig. 3.7-cross-
section with measurements and pros profile).
All these factors require incorporation of the
prosthetic planning with the surgical planning.
Today’s technology creates a workflow to make
M. Klein et al.
complex comprehensive planning efficient and
effective [9].
3.2.2 Prosthetic Planning Software
Prosthetic planning and design software is a free-­
standing software that has many design features.
Stl files of the patients’ mandible and maxilla are
obtained through intraoral surface scanning in
the dental clinic, or by laboratory scanning of
models of the patients’ mandible and maxilla.
Vertical dimension and correct centric records
are also taken by the intraoral or lab scanners.
Full-face photographs can also be introduced and
incorporated into the planning with the intraoral
(iOS) or lab scanning. Design features include
the ability to extract teeth, place virtual teeth of
all shapes and sizes, as well modify any of the
tooth dimensions as appropriate to any specific
patient. Features to add pink aprons as well as
many other patient specific items are in many of
these prosthetic design software. A specific pros-
thesis design (for an anticipated restoration) can
be made. This prosthesis design (including teeth
to be extracted, etc.) can then be imported into
the surgical planning software to aid in creating
the ideal surgical plan for each specific patient.
3 Guided Surgery for Full-Arch Implant-Supported Restorations
Decision-making for the full-arch patient can
then be made as to appropriate implant type, size,
position, abutment type, number of implants,
prosthetic pink apron or crown and bridge resto-
ration, and material type for provisional and final
a b
c d
Fig. 3.8 (a, b) Preliminary data for prosthodontic evalua-
tion includes full-face photography and intraoral photos. (c,
d, e) Intraoral surface scans are taken and a virtual diagnos-
tic wax-up is completed. The virtual diagnostic wax-up is
integrated into the full-face photo. This is a critical factor
which shows here that the tooth transition zone will not be
exposed in the smile line. Therefore, this patient may have a
31
restoration (zirconia, titanium bar, peek, PMMA,
nanoceramics, porcelain to metal, etc). This pros-
thetic plan can also be used as a manufacturing
file to 3D print or CNC mill prosthetic restoration
(Figs. 3.8a–g, 3.9a–i, and 3.10a–p) [10, 11].
e
crown and bridge style restoration with no pink apron even
though the teeth may be a little long. (f, g) Once the diagnos-
tic wax-up is confirmed, it may be integrated into the surgi-
cal planning software. Surgical implant planning must
follow the tooth position from the diagnostic wax-up, as it
has been determined that a crown and bridge style prosthesis
will be made with teeth emerging from natural soft tissue
32 M. Klein et al.

a b

c e d

f g

Fig. 3.9 (a, b) Pretreatment smiling photos and intraoral
photos are taken. (c, d, e) Intraoral surface scans of the
maxilla and mandible are articulated. Virtual extractions
are done, and a complete wax-up of the maxilla is com-
pleted with a pink prosthetic apron in anticipation of
excessively long teeth being seen in the patient’s smile. (f,
g) The virtual wax-up is integrated into the smile of the
patient verifying the need for a prosthetic pink apron. (h,
i) The determination from the diagnostic wax-up of the
need for a pink prosthetic apron determines rules for
implant positioning. This includes freedom from mesial to
distal tooth position, as you will not see teeth emerging
from natural soft tissue
3 Guided Surgery for Full-Arch Implant-Supported Restorations 33

Fig. 3.9 (continued)

34
a b c d
e f
h i
j k
Fig. 3.10 (a–d) The diagnostic data for the edentulous
arch will include photos of the full face and smile, intra-
oral photos, and dual-scan CT scan data. (e, f, g) The two
datasets from the dual scan CT scans are used in the surgi-
cal planning software to merge the denture tooth (or diag-
nostic wax-up) position with the bone. The internal
surface of the denture creates the simulated soft tissue for
the planning software; therefore, it is critical that there is
an intimate fit of the denture to the soft tissue when scan-
ning. (h, i) The scanned denture (from the dual scan tech-
nique) is modified to an ideal virtual wax-up for the
M. Klein et al.
g
l
patient’s aesthetic requirements. (j, k, l) The virtual wax-
up is merged with the patient’s photos to confirm the inci-
sal edge. (m, n, o) The virtual wax-up may be converted
into a diagnostic try-in to confirm tooth position, and aes-
thetics, tooth measurements, midline, as well as exposure
of the transition zone in the smile line. (p) The determina-
tion of aesthetic tooth length from the virtual wax-up and
diagnostic try-in instructs the surgical planning. This res-
toration will be a crown and bridge style restoration with
aesthetic tooth lengths. Ideal implant tooth positioning is
critical
3 Guided Surgery for Full-Arch Implant-Supported Restorations
m n
Fig. 3.10 (continued)
3.2.2.1 Incorporating Prosthetic
Planning into Surgical Planning
Software
Historically, prosthetic planning was incorpo-
rated into surgical planning by the use of a radio-
graphic guide while taking the CT scan. This
required creating a physical diagnostic template
by mounting diagnostic casts of the patient and
creating a diagnostic setup of anticipated tooth
position. This would then be converted into a CT
scan appliance (usually removeable) which the
patient would place into their mouths prior to tak-
ing the CT scan. Radiopaque markers would be
placed into these appliances by incorporating
either barium sulphate into the acrylic being used
to create the teeth in the appliance or gutta-­percha
or some other radiopaque materials which would
be placed into the teeth in the appliance to dem-
35
o
onstrate the contours of the proposed prosthesis
design. Removable dentures or fixed provisional
restorations could also be duplicated and used
this way. This can be effective, but it is time-­
consuming and requires extra visits and there is
limited data gained from this (only pure surgical
planning can be done) (Fig. 3.11a–e—ct appli-
ance picture and ct to go with it) [12].
Today, the most efficient process to incorpo-
rate prosthetic planning into a surgical plan is to
incorporate intraoral scans (iOS) of the patient
into the surgical planning software. These intra-
oral scans are taken at the initial consultation
visit of the patient with any conventional intra-
oral scanner. For the full-arch implant patient, a
full face and profile picture should also be taken
to aid in planning. The full face can be incorpo-
rated into the prosthetic planning software. Using
36
this integrated data, the prosthesis design is then
made. The profile picture is used to anticipate
changes to the lip position if there will be changes
to the overjet or any bodily or angular movement
of the anterior teeth (maxilla or mandible) anteri-
orly, posteriorly, or arch circumference changes.
The stl file of the prosthesis design is then
a c
b d
Fig. 3.11 (a–e) Dentures duplicated with barium sul-
phate mixed with acrylic were an effective way of demon-
strating tooth position in CT scan data prior to the
a b
Fig. 3.12 (a, b) Analysis of the patient’s smile line
reveals a high smile line exposing the tooth to soft tissue
interface (the transition zone), as well as an unaesthetic
smile. The profile picture clearly demonstrates the buccal
flaring of the maxillary anterior teeth. (c, d) When the
diagnostic wax-up (yellow) is overlayed on the pretreat-
ment intraoral surface scans (turquoise), the retraction of
the maxillary anterior teeth can be seen. (e, f, g) The diag-
nostic wax-up is then imported into the surgical planning
software to aid in proper implant positioning. The pre-
M. Klein et al.
imported into the surgical planning software for
the surgical planning. Alternatively, diagnostic
casts of the patient can be scanned using a labora-
tory scanner, and then the same protocol of
including full-face photography, prosthesis
design in prosthetic design software followed by
surgical planning can be done (Fig. 3.12a–i).
e
development of the dual-scan technique. These CT scan
appliances could then be converted into surgical guides
treatment photographs revealed a high smile line. The
diagnostic wax-up was designed with ideal tooth dimen-
sions. The integration of the datasets was then used to
evaluate the residual bone position available for implant
placement and what the distance to the free gingival mar-
gin would be. This then determined that an aesthetic tooth
to soft tissue relationship could be developed even with
the patient’s high smile line. (h, i) The immediate provi-
sional restoration placed at implant surgery demonstrates
effective presurgical evaluation and planning
3 Guided Surgery for Full-Arch Implant-Supported Restorations 37

c d

e f g

h i

Fig. 3.12 (continued)

38 M. Klein et al.

a b c

Fig. 3.13 (a, b, c) Photos of the patient with lips at repose, smiling, and wide smiling aid the diagnostic wax-up

3.2.2.2 Data Required for Full-Arch

Implant Restoration Surgical
Planning
These are the sets of data required: surface scans
of the mandible and maxilla if there are any teeth
present; dual CT scans for patients with an eden-
tulous arch that requires planning; one of the CT
appliance, and one of the arch that requires plan-
ning with the CT appliance in place (today that is
usually a cone beam CT scan); a full-face photo-
graph of the patient with a wide smile, regular
smile, and their lips at repose (ideally also a pro-
file picture (Fig. 3.13a–c), consider a video of the
patient speaking and smiling if that will aid with
any virtual wax-up); and any conventional radio-
graphs or clinical measurements (periodontal
Fig. 3.14 The dual-scan technique requires scanning the
charting, mobility charting, etc.) that will aid and patient with an acrylic prosthesis. This prosthesis must
support in an appropriate diagnosis. seat completely and be stable on the soft tissue. The
patient’s denture may be used if their denture is represen-
3.2.2.3 Dual-Scan Technique tative of where teeth are to be positioned in the final resto-
ration. A reline of the patient’s denture is recommended if
If the arch that is being treated with the full-arch it is not a recently made prosthesis
implant treatment is edentulous, then a dual-scan
technique should be employed. If the patient is
wearing a denture and the tooth position in the no denture or there will be changes to the tooth
denture will be copied (arch circumference, inci- position, then a diagnostic denture should first be
sal edge position, occlusal plane position, overall made.
tooth position), then scan markers (usually five
radiopaque balls) can be affixed to the denture to 3.2.2.4 Placing the Radiopaque
create a scan appliance. The denture should be Markers
stable when seated in the patient’s mouth; if not, There are radiopaque markers that are fixed in
then reline the denture first (Fig. 3.14). If there is position with preplaced adhesive, or you may cut
3 Guided Surgery for Full-Arch Implant-Supported Restorations 39

holes in the denture and place barium or gutta
percha as markers (Figs. 3.15a, b and 3.16a, b).
Ideally place five markers in an anterior posterior
and mesial to distal distant positions around the
arch to create a tripod position. These markers
are for use to combine the two CT scans in the
dual-scan technique. They are not intended for
the planning itself. The markers may be placed in
or on the buccal or lingual denture flanges
(including the palate). A CT scan is taken off the
scan appliance at low Ma (usually 2–3 Ma)
(Fig. 3.17), and then a separate scan is taken with
this appliance seated in the patients’ mouth at
conventional settings (Fig. 3.18a, b). Many cone
beam CT scanners have preset settings for the
dual-scan technique. These two scans are inte-
grated in the surgical planning software
(Fig. 3.19). The low Ma setting of the scan appli-
ance allows the denture acrylic to be seen. The
tooth position and soft tissue position are thus
seen to aid in proper diagnosis and planning
(Fig. 3.20) [13].

a b

Fig. 3.15 (a, b) Five radiopaque balls are placed around the arch on the removeable prosthesis used in the dual-scan
technique

a b

Fig. 3.16 (a, b) Radiopaque material such as gutta-percha may be placed into holes cut into the prothesis to be scanned
via dual-scan technique
40 M. Klein et al.

Fig. 3.19 The independent prosthesis scan is integrated

Fig. 3.17 The removeable prosthesis with radiopaque with the patient scan in the surgical planning software
markers is scanned independently in the CT scanner and a
second time in the patient’s mouth

a b

Fig. 3.18 (a, b) The radiopaque balls can be seen in the independent removeable prosthesis CT scan as well as in the
patient scan
3 Guided Surgery for Full-Arch Implant-Supported Restorations 41

All surgical guides have several common ele-

ments. They use most of the common planning
software for their planning. The planning soft-
ware will require the capability for designing
the surgical guide after the actual implant plan-
ning is complete. The software that plans and
then designs the surgical guide will output an stl
file that is used for manufacturing the surgical
guide. Commonly these guides are 3D printed
from this stl file (Fig. 3.21); however, CNC
machining the guide can also be done from
these stl files (CNC machining surgical guides
usually is more time-­consuming and costly than
3D printing) (Fig. 3.22). Metal sleeves are
placed into these surgical guides that are com-
patible with the surgical tools that are part of the
different types of systems used with guides dur-
ing surgery. These metal sleeves are specific to
these surgical systems and different implant
systems. The sleeve type is indicated in the
guide design software so that the hole to receive
the sleeve is manufactured to the sleeve specifi-
cation (Fig. 3.23a–c).

Fig. 3.20 The profile of the tooth position in the remove-

able prosthesis can be clearly seen. The soft tissue profile
is created by the intimate fit of the removeable prosthesis
to the soft tissue

3.2.3 Surgical Guides

3.2.3.1 Types of Surgical Guides

Surgical guides are custom devices that seat
on the soft tissue, teeth, bone, or a combina-
tion of teeth and soft tissue. They may be
secured in position by fixing to teeth, bony
landmarks, or soft tissue by pinning them to
the bone with pins or screws. Guides may even
on occasion be used with just finger pressure
on the guide while it sits on the soft tissue.
The data collected for surgical and prosthetic
planning is the same regardless of the type of
guide used. The surgical planning may have
slight differences depending on the type of Fig. 3.21 3D printers efficiently and cost-effectively
guide used. manufacture surgical guides
42
Fig. 3.22 Surgical guides can be produced with CNC
machining; however, this is usually a more time-
consuming process
a b
Fig. 3.23 (a, b, c) The surgical design software has
libraries of sleeve designs. The guided surgical system to
be used dictates the library selection in the software. After
M. Klein et al.
3.2.3.2 Fully Guided Surgical Guides
Fully guided surgical guides will guide the entire
sequence of drilling including insertion of the
implant. They will produce a completed osteot-
omy with the planned overall location, angle, and
depth for any given implant. The sleeves used in
the surgical guide will have a large internal lumen
to accommodate and guide the specific tools
(guides with handle-spoons, DGS tool, or large
barrelled drills) specific to the surgical system
and implant system being used. This large lumen
will also accommodate and guide an implant
insertion key to deliver the implant to its planned
position. Although fully guided systems are
designed for the entire sequence of drilling and
implant placement, it may be used for the drilling
sequence only partially or with or without implant
placement. It is a tool to be used according to the
preferences of the clinician.
The Indications and Benefits of the Fully
Guided Surgical Guide
The fully guided surgical guide provides guid-
ance for the complete osteotomy drilling
sequence and implant insertion and seating. They
guide the entire preparation of the implant oste-
otomy to set the location, angle, and depth of the
osteotomy. Implant insertion can then be com-
pleted seating the implant to its final position,
including controlling the prosthetic connection
orientation (Fig. 3.24a, b).
c
manufacturing the surgical guide, the metal sleeves are
installed in the surgical guide
3 Guided Surgery for Full-Arch Implant-Supported Restorations 43

a b

Fig. 3.24 (a, b) The Keystone Paltop implant is guided implant insertion key and sleeve design determine the
through the surgical guide to its final position with a dedi- implant placement depth as well as the implant prosthetic
cated implant insertion key. The combined design of the connection orientation

The major benefits of the fully guided surgical
guide are the ability to rapidly locate osteotomy
3D positions and continue rigid guidance through
the entire drilling sequence. After confirming
appropriate pilot osteotomy position, the com-
plete drilling sequence is completed being guided
by the surgical guide ensuring implant position-
ing the duplicates the surgical planning. Using a
fully guided surgical guide ensures complete rep-
lication of the surgical plan from the planning
software. In the case of immediate provisional-
ization, a provisional restoration can be premade
with holes corresponding to planned implant
locations. This predesigned and pre-surgically
fabricated provisional restoration can then be
rapidly completed by luting temporary cylinders
to the provisional restoration while seated on the
final implant position (Fig. 3.25a–z5).
44
a b
d e
Fig. 3.25 (a, b, c) A comprehensive evaluation of the
patient included full-face photos and 3D-printed and
mounted diagnostic cast. The mounted casts demonstrated
the class three bony relationship of the maxilla to the man-
dibular tooth position. (d, e, f) Intraoral surface scans
were taken to aid in the evaluation of the existing tooth
positions created by his removeable maxillary and man-
dibular prosthesis. Scans were taken with and without the
mandibular prosthesis. (g) The panoramic view of the CT
scan shows adequate vertical height for implant place-
ment. (h) Careful surgical planning was done using the
dual-scan technique. (i, j) The implant positions from the
surgical planning software were integrated into the pros-
thetic planning software creating a virtual model of
planned implant position. This new prosthetic model is
now used to create a provisional prosthesis design with
prosthetic component libraries. (k, l, m) The provisional
prosthesis design is completed based on anticipated
M. Klein et al.
c
f
implant positions from the surgical planning software. (n,
o, p) The provisional prosthesis stl file is used to 3D print
the provisional prosthesis. The prosthesis design includes
holes larger than the anticipated temporary cylinders to be
used to allow for leeway in the final implant position. (q,
r, s) The surgical guide is 3D printed and secured to the
patient’s maxilla with lateral pins. (t, u, v) Following
implant insertion, multi-unit abutments were placed.
Temporary cylinders are secured to the multi-unit abut-
ments. The provisional prosthesis was seated over the
temporary cylinders, and the cylinders were cured into
place with a flowable resin material. (w, x) The provi-
sional prosthesis was trimmed, polished, and inserted into
the patient’s mouth. (y, z1, z2, z3, z4, z5) The final pros-
thesis design modifications were based off the provisional
prosthesis design. These Nexus iOS restorations were
designed as titanium milled bars overlaid with monolithic
zirconia supported by Keystone Paltop implants
3 Guided Surgery for Full-Arch Implant-Supported Restorations 45

i j

k l m

n o p

Fig. 3.25 (continued)

46 M. Klein et al.

q r s

t u v

w x

y z1 z2

z3 z4 z5

Fig. 3.25 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations 47

What Data Do You Need to Prepare for rapid preliminary osteotomy position, assess-
the Guides ment of the position, and ability to allow for flex-
The data required to prepare a fully guided sur- ibility to alter the osteotomy position during
gical guide is the same data used for pilot sur- surgery. Different surgical design software have
gical guides: the dicom data from a CT scan different functionality. There are software that
and iOS (intraoral surface) scans of the man- will automatically lock in the 3D sleeve position
dible and maxilla with a centric mounting and depending on the fully guide system selected,
any other data required to properly plan implant while others will allow the designer to decide the
positions (e.g., photos, conventional radio- vertical height sleeve position. Some fully guided
graphs, clinical charting). If the arch is edentu- systems have dedicated drill lengths that ­correlate
lous, then the dicom data from a dual-scan to implant length; other systems may have vary-
technique will be required (the dual-scan tech- ing length drills. Systems with dedicated drill
nique has been previously described). A com- length to implant length are easier to use, while
prehensive surgical plan is developed from this systems with variable length require more think-
data (including a virtual wax-up). All this data ing during the procedure but allow for more flex-
is utilized in surgical planning software that ibility and a greater range of applications. This all
has a surgical guide design module (e.g., must be taken into consideration during planning
3Shape Implant studio, Exoplan, Anatomage, (Fig. 3.26a, b).
Columbia scientific SimPlant, Blue Sky Bio, There is also flexibility where within one
etc.). These planning software have libraries of guide you can have some osteotomies using pilot
guide sleeves. The planning laboratory will sleeves while other osteotomies may have sleeves
select the library for the fully guided sleeve to control full guidance. This may be done for the
appropriate to the procedure, surgical guided reasons described for selecting pilot or full
system, and implant system being planned. The guidance.
guide design software will automatically incor- In the full-arch surgical scenario, there is the
porate the geometry required to house this frequent use of lateral pins to secure the surgical
guide sleeve in the guide design. After manu- guide (pilot or fully guided); these lateral pins
facture of the guide (3D printing or machin- usually use a pilot guide-type sleeve dedicated to
ing), the laboratory will insert the appropriate lateral pins.
guide sleeve. When patients have remaining teeth that will
be extracted, consideration should be given to
3.2.3.3 Surgical Planning utilizing two or three teeth to secure the surgical
Considerations (Surgical, guide during osteotomy preparation and only
Prosthetic) extracting those teeth after osteotomy prepara-
The surgical planning for a fully guided surgical tion. If these teeth will interfere with implant
guide will be the same as for any other computer-­ positions, consider using two surgical guides
guided technique (fully guided, dynamic guid- staggering tooth extraction or using the teeth to
ance, robotic). When there is questionable secure a pilot surgical guide that will create lat-
planning due to poor data being used for planning eral pin osteotomies. Once the lateral pin osteoto-
(patient movement during CT scan, inadequate mies are complete, the lateral pin surgical guide
surface structure capture in iOS or lab scanning, is removed. The remaining teeth are then
questionable or immature bone grafts, unclear extracted, and a second surgical guide is inserted
CT data), new data should be acquired. If this is and secured in position with lateral pins that will
not possible, then consideration for use of the engage the previously made lateral pin osteoto-
pilot guide should be taken due to its allowance mies (Figs. 3.27a–y and 3.28a–z).
48 M. Klein et al.

a b
Implant information
Implant position (UNN) 3
Manufacturer Paltop
Type Advanced 3.75x13.0
Order number 20-70003
Sleeve Surgical Guide Length, mm 13
Height Diameter (Ø), mm 3.75
Color Green
Sleeve Sleeve Offset Sleeve information
Minimum
Drill Length* Name Paltop 4mm Engage
Type Universal
Implant Order number 30-70409
Offset, mm 12
Color Silver
Drill information
Minimum drill length 25

Fig. 3.26 (a, b) The calculation for sleeve placement in the
surgical guide is determined by measuring from the coronal
end of the implant position to a measurement dictated by the
surgical guide system being used. The length of the implant
planned and the additional dimension for the apex of the
drill are added to complete the calculation for sleeve posi-
tion. The Keystone Paltop guided system uses a variable
measurement with consideration for soft tissue thickness
and three lengths of drills to choose from. A drilling report
lists the proper drill length to use for the final guide design

a b

Fig. 3.27 (a, b, c) Lateral pin placement considerations
include not interfering with definitive implant positions
and creating a wide anterior to posterior spread to develop
surgical guide fixation and stability. Planning the lateral
pin sites must consider surgical accessibility to the lateral
pin sleeves. (d, e, f) The stl file shows the surgical guide
design and the removeable overlay which fits over the sur-
gical guide. When assembled together the overlay aids in
positioning the surgical guide during lateral pin place-
ment. (g, h, i, j, k, l) The printed surgical guide is seated
on the edentulous maxilla and secured with lateral pins.
Pilot osteotomies are drilled through the guide and unre-
flected soft tissue. The surgical guide may then be
removed, and an incision was made to expose the alveolar
crest. Pilot osteotomy positions can then be evaluated
3 Guided Surgery for Full-Arch Implant-Supported Restorations 49

d e f

g h

i j

k l

Fig. 3.27 (continued)

50
b c
e f
Fig. 3.28 (a, b) This patient will demonstrate the use of
two sequential surgical guides. A failing maxillary dentition
can be seen. (c, d) A diagnostic wax-up is performed and
integrated into the surgical planning software. (e, f, g) The
surgical plan was designed for two phases. The anterior
teeth were virtually extracted allowing seating of a surgical
guide supported by remaining posterior teeth for placement
of the anterior implants. (h, i, j) A second phase plan was
then made to include extracting the posterior teeth and
design of a second surgical guide to place the remaining
posterior implants. (k, l, m) The surgical guide was pre-
pared, maxillary anterior teeth extracted, and the first phase
surgical guide seated, supported, and retained by the poste-
rior teeth. (n, o) The anterior osteotomies were prepared
through the surgical guide. Keystone Paltop Dynamic
implants were placed through the surgical guide. (p, q)
Immediate provisionalization procedures were begun fol-
lowing the Nexus iOS protocol. Multi-unit abutments were
M. Klein et al.
g
inserted and torqued to 30 ncm. Nexus scan gauges were
placed, and first-stage iOS scanning per the Nexus protocol
was completed. (r, s) The remaining maxillary teeth were
extracted, and the second phase surgical guide was inserted.
The full coverage of the palate secured the surgical guide;
however, the addition of lateral pins would have given addi-
tional stability to the guide. The Keystone Palto fully guided
surgical system is used even in limited inter-arch space. (t,
u) Multi-unit abutments were placed on the second phase
posterior implants. Nexus scan gauges were placed on all
the multi-units and were scanned per the Nexus protocol for
immediate provisionalization. Multi-unit healing abutments
were then secured to the multi-unit abutments and suturing
was completed. (v, w, x, y, z) The provisional restoration
was 3D printed and finished with a pink apron. The immedi-
ate provisionalization was completed by inserting the provi-
sional restoration, securing it with multi-unit screws and
evaluating and adjusting the occlusion
3 Guided Surgery for Full-Arch Implant-Supported Restorations 51

i j

k l m

k l m

n o

Fig. 3.28 (continued)

52 M. Klein et al.

p q

r s

t u

v w

Fig. 3.28 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations
x y
Fig. 3.28 (continued)
3.2.3.4 Surgical Systems Used
with Fully Guided Surgical
Guides
There are three types of surgical systems used
with fully guided surgical guides. All three
­systems integrate with surgical guides that have a
master sleeve as part of the surgical guide. This
master sleeve guides the surgical system to pre-
pare the correct osteotomy 3D position and inser-
tion of the dental implant. There are systems that
use drill guides with handles, sometimes called
spoons. These spoons fit into the master sleeve in
a retrievable manner. The spoons/drill guides are
sized so the external diameter of the spoon fits
precisely into the master sleeve in the surgical
guide. The spoons have varying internal diame-
ters that both guide the actual drills and allow
them to spin free. The clinician follows the drill-
ing protocol appropriate to the implant system
choosing the appropriate spoon according to drill
diameter and changing spoons to accommodate
the changing diameters of the drills. The limita-
tions of this type of system include having to be
very careful with irrigation as much of it is
blocked due to the drill fitting precisely in the
spoon. The drills are long and must be placed
53
directly perpendicular to and over the master cyl-
inder and sleeve to be able to enter the spoon for
drilling. This requires the patient to open very
wide, and there will be limitations to interarch
space as you prepare osteotomies in the posterior
maxilla and mandible. The drills spinning in the
spoons may also cut small flakes of the cylinder
(usually made of titanium), and these flakes may
end up in the surgical site (which will require
careful inspection and cleaning) (Fig. 3.29a–f).
The second fully guided system has drills
where the shaft/barrel of the drill has varying
sizes to mate with the master cylinder in the
surgical guide. There are varying diameters of
the cutting segment of the drills, but all drills
have a shank segment that will guide the drill
while cutting bone. This shank segment guides
the drill to place. The limitation of this type of
system includes blocking irrigation to the drill
as well as limitations due to interarch space as
previously discussed with spoon-type systems.
Depending on the system if the cutting seg-
ment of the drill engages the master cylinder
during drilling, then flakes of the master cylin-
der may also fall into the surgical site
(Fig. 3.30a, b).
54 M. Klein et al.

a b

c d

e f

Fig. 3.29 (a, b) Guided surgical kits that use drill guides guide should be supported in position while the drill guide
on handles (spoons) have dedicated drills that mate with handle needs to be held and the drill is operated by a third
the drill guides. (c, d) The use of a drill guide on a handle hand. (e, f) The implant is inserted into the final position
(spoon) to guide the drill requires multiple hands. The through the surgical guide by a dedicated implant driver
3 Guided Surgery for Full-Arch Implant-Supported Restorations 55

a b

Fig. 3.30 (a, b) This drill system uses a large bore shank that fits into the diameter of the drill guide sleeve. The metal
sleeve in the surgical guide directly guides the drill

The third type of fully guided system is a
newer innovation that uses contra-angle guid-
ance. There is a dedicated contra-angle hand-
piece that engages a device called a DGS
(digital guidance sleeve) (Fig. 3.31). This DGS
fits precisely into the master cylinder in the
surgical guide in a manner that allows vertical
and rotational movement of the DGS. All drills
used in the drilling protocol are designed to fit
into the DGS. The DGS will guide the entire
preparation of the osteotomy. The DGS has a
window for irrigation to enter and cool the drill
during osteotomy preparation (Fig. 3.32a, b).
The cutting edges of the drill do not engage the
master cylinder, so there are no flakes of mate-
rial from the master cylinder. Guidance is pro-
vided by the DGS in the master cylinder
(Fig. 3.33a, b). The DGS does not have any
cutting edges. The drills may enter the master
cylinder at an angle because they do not engage
the master cylinder (so there is freedom of
movement around the drill). There is only
uprighting of the drills when the DGS enters
the master cylinder, and this is only the last
several millimetres (Fig. 3.34a–c). Therefore,
most osteotomies even posteriorly can be pre-
pared to completion when using contra-angle
guidance.
56 M. Klein et al.

Fig. 3.31 The DGS (digital guidance

sleeve) is a component of the proprietary
Keystone dental guided surgical system.
The DGS is inserted and locked into a
dedicated contra-angle handpiece

a b

Fig. 3.32 (a, b) Irrigation cools the length of the drill during the drilling process by entering a window in the side of
the DGS
3 Guided Surgery for Full-Arch Implant-Supported Restorations 57

a b

Fig. 3.33 (a, b) The drill is guided by engagement of the DGS with the sleeve in the surgical guide. No cutting flutes
touch the surgical guide sleeve

a b c

Fig. 3.34 (a, b, c) The drill does not engage the drill reaches the bone. Most implant osteotomies can be per-
guide cylinder and is smaller in diameter than the drill formed with guidance even with limited interarch
guide sleeve. Therefore, the drill can be brought into the distance
sleeve at an angle and only uprighted when the drill
58
How Do You Use the Guide During Surgery
The surgical guide is prepared for surgery usually
with a cold sterilization technique. The guide
should be tried into the patient’s mouth prior to
beginning the surgery to ensure proper seating. If
there are teeth that will be extracted that interfere
with seating, then this try-in will be done only
after tooth extraction. The surgical guide that is
tooth borne should be designed with windows
anteriorly and posteriorly that demonstrate com-
plete seating of the surgical guide. When the
guide is seated, the edges of the window (or
opening in the guide) will be in intimate contact
with the tooth or structure beneath it; if there is
any space, then the guide is not seated and must
be removed and evaluated to determine why it is
not seated (Fig. 3.35a, b). The most frequent
causes of not seating are deep embrasure spaces,
diastemas between teeth, and significant under-
cuts. All these may be resolved by removing from
the surgical guide the material that is causing the
interference. This can usually be done liberally
because there will still be adequate guide planes
to secure the surgical guide. Try not to remove
material adjacent to the guide windows. It is
always possible that there was an inadequate
impression or intraoral scan. Care must be taken
to always record good data. In the case of the
edentulous arch, the surgical guide seats on the
soft tissue (fully guided surgical guides may also
be made as bone-borne guides). The guide should
be very stable when inserted and held in place
with two fingers. The patient should be able to
bring their teeth into occlusion or in contact with
the opposing arch so that the opposing arch can
a b
Fig. 3.35 (a, b) Windows are designed in the surgical guide so there can be confirmation of complete seating of the
surgical guide
M. Klein et al.
secure the guide position without displacing it. A
rigid bite registration may be used to accomplish
this (Fig. 3.36a–h). Once the edentulous full-arch
surgical guide is held stably in place, the osteoto-
mies for lateral pins may be performed to secure
the surgical guide in place. The drilling of the
osteotomies for the lateral pins should be done
prior to any soft tissue reflection. One drill (usu-
ally a 2 mm twist drill) is used to create the oste-
otomy. The lateral pin that is part of the pilot
system should be placed, and then the next lateral
pin osteotomy is performed. Usually, the first pin
may be the most distal pin followed by the con-
tralateral distal pin, followed by an anterior lat-
eral pin. Following securing the guide in a tripod
fashion, any additional pins including vertical
ridge and palatal pins are placed (Fig. 3.37a–l).
Following confirmation of seating and secur-
ing the guide, the implant surgical procedure may
be continued. In the case where there are remain-
ing teeth that are not supporting the guide, these
may be extracted (if not already done). Incisions,
flap reflection, surgical debridement, and ridge
preparation are now completed. In consideration
for ridge preparation, adjusting the alveolar ridge
so that it will be perpendicular to the osteotomy
preparation will aid in ensuring proper position-
ing of the initial drill. If there will be drilling into
the bone that is at an angle (other than perpen-
dicular), the drill may slip from its intended posi-
tion even with guidance from a surgical guide
(Fig. 3.37a–z14).
In the edentulous arch, it is recommended to
make pilot osteotomies prior to any soft tissue
reflection. The surgical guide will be most stable
3 Guided Surgery for Full-Arch Implant-Supported Restorations
a b
d e
g h
Fig. 3.36 (a, b, c) The surgical guide is seated on the soft
tissue. There should be confirmation that the surgical guide
seat is stable. Two fingers can be used to check stability and
positive seating. (d, e, f, g) A rigid bite registration material
is placed in between the surgical guide and the opposing
dentition, while the guide is held firmly in position. After
completion of setting of the bite registration material, the
prior to reflecting the soft tissue. After preparing
pilot osteotomies, the lateral pins may be disen-
gaged, the surgical guide removed, and incision
and soft tissue reflection performed. If the soft
tissue can be left unreflected posteriorly (man-
dibular retromolar pads, maxillary tuberosity,
palate), the combination of posterior soft tissue
support with lateral pins will allow for a very
stable surgical guide. After reflecting the soft tis-
sue (this can usually be done as a modest reflec-
tion), the osteotomy positions can be evaluated
visually as well as with guide pins placed. The
fully guided surgical guide is removed, and the
clinician may assess the osteotomy 3D position
by placing a guide pin in the osteotomy. Location,
depth, assessment of surrounding bone, angle
and orientation to adjacent implant pilot osteoto-
mies, proximity to adjacent implant osteotomies,
proximity to adjacent clinically visible structures,
59
c
f
patient is instructed to continue biting their teeth together.
The dedicated lateral pin drill creates an osteotomy, and
then a lateral pin is placed. The second lateral pin osteot-
omy is prepared, and its lateral pin is placed. The final lat-
eral pin osteotomy is prepared and its lateral pin placed. (h)
Following securing the surgical guide with the lateral pins,
the implant pilot osteotomies may be begun
orientation to adjacent structures, and anticipated
restorability are shown (Fig. 3.38a–c). All can be
evaluated at this point prior to committing to this
osteotomy as the final osteotomy position.
Intraoperative radiographs (periapical, pan-
oramic, or CT scan) may be taken with guide pins
in place to assess the osteotomy position in the
bone where it is not clinically visible. Proximity
to adjacent implants, mental foramen, inferior
alveolar canal, maxillary sinus, floor of the nose,
pterygoid complex, etc. may be assessed and
adjustment made if necessary to the osteotomy
position. These adjustments may be to location,
angle, as well as osteotomy depth. If the adjust-
ment is made to correct the osteotomy position
because the pilot drill slipped while cutting on a
sloped ridge, then the fully guided surgical guide
may be reinserted and secured to position with
the lateral pins. The pilot drill must be reused in
60
a b
d e
Fig. 3.37 (a, b, c, d, e) This full-arch case was planned
as a full-arch sequential extraction case with the provi-
sional restoration supported by provisional abutment
teeth. The diagnostic data was collected including full-­
face photo and iOS scans. A diagnostic wax-up was com-
pleted and integrated into the full-face photo to evaluate
the tooth length and exposure with a wide smile. Although
the wax-up shows long teeth, the smile line with the inci-
sal edge of the incisors in the appropriate position does
not show excessive tooth length. (f, g, h, i) The diagnostic
wax-up was integrated with the CT scan data and surgical
planning was completed. No pink apron was required due
to the patient’s low lip line. A crown and bridge style res-
toration was planned so tooth positions were adhered to in
the surgical planning. (j, k, l, m, n) The patient presented
for a presurgical appointment and provisional abutment
teeth were prepared and iOS impressions taken. The wax-
­up was transferred to the virtual model with the prepared
teeth, and a PMMA provisional was manufactured to fit
precisely to the abutment teeth. The model with the pre-
pared teeth and diagnostic wax-up was then integrated
with the CT scan and implant planning. The surgical
guide was designed to seat on the prepared abutment teeth
following tooth extraction. (o, p, q, r) The teeth planned
for removal were extracted leaving the planned provi-
sional abutment teeth. The surgical guide was seated on
M. Klein et al.
c
the prepared abutment teeth and osteotomy preparations
were performed. (s, t, u) Following osteotomy prepara-
tion, implant body try-ins were placed to confirm the
implant 3D position. After confirmation of implant posi-
tion, the surgical guide was reinserted and the implants
were placed. (v, w) Angled implants were placed posteri-
orly so angulated multi-unit abutments were tried in to
verify correct orientation of the implant prosthetic con-
nection. The design of the Keystone premium multi-unit
allows for subcrestal implant placement without requiring
bone profiling for seating of the angled multi-unit abut-
ment. (x, y, z1, z2) The prepared provisional restoration
was then inserted onto the retained provisional abutment
teeth. The occlusion was checked and the provisional res-
toration cemented. (z3) Postoperative radiographs con-
firm proper implant positioning according to the
presurgical plan. (z4) Following 4 months of healing and
confirmation of integration, the provisional abutment
teeth were extracted. Multi-unit abutments were placed
and iOS impressions taken. (z5, z6, z7) The provisional
restoration was designed and manufactured. The screw
access hole positions confirm good implant placement.
(z8, z9, z10) The provisional restoration was inserted and
radiographs were taken. (z11, z12, z13, z14) Two weeks
post-tooth extraction, the soft tissues show good healing
and adaptation to the provisional contours
3 Guided Surgery for Full-Arch Implant-Supported Restorations 61

f g

h i j

k l

m n

o p q r

s t u

Fig. 3.37 (continued)

62 M. Klein et al.

v w

x y z1 z2

z3

z4

z5 z6 z7

Fig. 3.37 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations 63

z8 z9

z10

z11 z12 z13 z14

Fig. 3.37 (continued)

a b c

Fig. 3.38 (a, b, c) When there may be questionable seat- mental foramen. The pilot osteotomy was performed fol-
ing of the surgical guide, the initial osteotomies will ben- lowed by placement of a guide pin and exposure of the
efit from verification. This edentulous mandible has a plan mental foramen
with angled implants placed in close proximity to the
64
the corrected osteotomy opening. Verification
should then be done by removing the guide and
visually confirming the corrected osteotomy. The
fully guided sequence may then be continued.
However, if the pilot osteotomy correction was
due to improper planning, poor data, or changes
in the bone, then following correction that oste-
otomy must be completed freehand.
Once the osteotomy position is confirmed, the
clinician will reinsert the surgical guide and rap-
idly continue the osteotomy preparation to com-
pletion with the subsequent drills for the fully
guided kit and implant system being used. Care
should be taken not to deviate from the position
due to poor quality of bone in areas where there
may be dense bone on one side of the osteotomy
and poor quality of bone on an opposing side. This
can lead to changing the final osteotomy position.
This consideration most frequently should be con-
sidered when placing implants into immediate
extraction sites where there is usually dense bone
to the lingual or palatal and air or poor-quality
bone to the buccal of the implant position
(Fig. 3.39a, b). To prevent displacement of the
osteotomy, think about the dense bone while drill-
ing and hold the drilling path true to the surgical
plan. The other cause for deviation is drilling into
a sloped ridge (e.g., anterior mandible). Always
review the surgical plan prior to surgery and have
it available for viewing during surgery. If there has
been deviation, then remove the guide and evalu-
ate. If the malposition is in angle or location that is
slightly off (up to 1 mm) from the planned osteot-
omy, then take the pilot drill and expand the incor-
rect osteotomy to the correct anticipated location
a b
Fig. 3.39 (a, b) The implant body try-in confirms the successful palatal positioning of the implant and confirms
implant parallelism as well as complete osteotomy depth preparation
M. Klein et al.
or change the angle within the opening of the oste-
otomy if the entry point is correct. Levelling the
bone so it is perpendicular to the drill entry also
aids in drilling true to the planned osteotomy posi-
tion. This is all done freehand and must be done
with great care. These adjustments may be to loca-
tion, angle, as well as osteotomy depth. If the
adjustment is made to correct the osteotomy posi-
tion because the pilot drill slipped while cutting on
a sloped ridge, then the fully guided surgical guide
may be reinserted and secured to position with the
lateral pins. The pilot drill must be reused in the
corrected osteotomy opening after reinserting and
securing the surgical guide. Verification should
then be done by removing the guide and visually
confirming the corrected osteotomy. The fully
guided sequence may then be continued
(Figs. 3.40a–z23 and 3.41a–z3).
Once osteotomy creation is complete, then
remove the surgical guide and place implant try
in bodies (appropriate to the implant system
being used) to confirm correct osteotomy loca-
tion, angle, and depth. This will also aid when
evaluating the final seating position of the implant
(Fig. 3.39a, b).
Most fully guided systems will then have
implant drivers or keys to deliver the implant
through the surgical guide to the correct position.
The implant insertion key usage is system depen-
dent. Some systems will deliver the implant to a
bottomed-out implant key position. These sys-
tems control placement position through sleeve
position in the surgical guide. Other systems will
have markings and numbers that correlate to a
drilling report produced by the surgical planning
3 Guided Surgery for Full-Arch Implant-Supported Restorations
a b
Fig. 3.40 (a, b, c) Diagnostic records including dual CT
scan, iOS scans, and full-face photos were taken. (d, e, f)
The dual-scan data and the iOS scan data were imported
into the prosthetic planning software to complete a diag-
nostic wax-up. The diagnostic wax-up was then inte-
grated with the patient’s full-face photos. (g, h, i) The
diagnostic wax-up was 3D printed and confirmed with a
try-in. (j, k, l) The surgical plan was created. The tooth
length to soft tissue is measured, and it is determined that
a crown and bridge style restoration may be made with
teeth emerging from natural soft tissue. This style of res-
toration dictates the surgical positioning of the implants
to tooth-specific sites with proper emergence profile
dimensions. (m, n, o) The surgical guide was seated and
secured to the maxillary soft tissue with lateral pins. (p,
q) The Keystone Paltop fully guided kit was used begin-
ning with the combined pilot drill with a soft tissue tre-
phine. This patient had a very wide zone of keratinized
tissue which allowed flapless surgery. (r, s, t) The com-
bined pilot drill with a soft tissue trephine was guided by
the surgical guide. Frequently, there will be incomplete
cutting when using a soft tissue trephine through a surgi-
cal guide. To complete the soft tissue removal, an inde-
pendent soft tissue trephine was used to sever any
remaining soft tissue attachment. (u, v, w) The Paltop
fully guided protocol was then followed beginning with
the 2 mm twist drill with a 20 mm length. The DGS
engages the drill guide sleeve by the drill always entering
the previous prepared osteotomy. The drilling with every
drill is complete when the DGS bottoms out on the surgi-
cal guide. (x, y, z1) The next length (25 mm) 2 mm twist
drill is used with the DGS engaging the guide sleeve until
it bottoms out on the surgical guider. There is also a
30 mm length twist drill in the kit. The drilling length 20,
25, or 30 mm is dictated by the drilling report produced
in the guide design software. (z2, z3) The drill diameter
is now increased to the 3.25 mm drill 20 mm length fol-
lowed by the 25 mm length (according to the drilling pro-
tocol indicated on the drilling report). (z4, z5, z6) The
drill diameter is increased according to the drilling proto-
col indicated on the drilling report. This fully guided kit
has diameters of final shaping drills for implant diameters
3 mm, 3.25 mm, 3.75 mm, 4.2 mm, and 5 mm. The colour
bands indicating drill diameter and length can be seen
through the DGS window. All the shaping drills come in
the 20, 25, and 30 mm lengths. (z7, z8, z9) Once the final
65
c
osteotomy preparation is complete (the final drill proto-
col may include undersizing or countersinking depending
on bone quality), the contra-angle adaptor is inserted into
the contra-angle along with the implant insertion key
indicated on the drilling report. The implant is then
inserted to the depth indicated on the drilling report and
can be seen on the shank of the implant key. The connec-
tion orientation can also be controlled by aligning the flat
of the implant key with the midbuccal groove on the sur-
gical guide sleeve. (z10) The lateral pins are disengaged
and the surgical guide is removed. Implant depth can be
evaluated and adjusted with a torque driver as well as
obtaining a true insertion torque umber. The insertion
torque felt when used with the implant key in the surgical
guide is not accurate due to the contact of the implant key
with the surgical guide sleeve. (z11, z12) Immediate pro-
visionalization was planned so the four anterior multi-
unit abutments were placed and torqued to 30ncm. The
sleek and debulked contours of the Keystone multi-unit
abutment allow for subcrestal implant placement without
bone interfering with abutment seating. (z13, z14) Four
scan bodies are placed on the four anterior multi-unit
abutments, and a scanning appliance is inserted engaging
the lateral pin osteotomies. iOS sans are taken which
record the anterior implant position in relation to the
scanning appliance which enables transfer of the tooth
position as well as CR and VD. (z15, z16, z17, z18) The
scanning appliance is removed. The anterior scan bodies
are removed, and the posterior KDG premium angled
multi-units are placed. The design contours of these
angled multi-units frequently do not require bone profil-
ing to be seated. The Nexus scan gauges were placed on
all implants, and the Nexus scanning protocol for accu-
rate implant position transfer was performed. (z19, z20)
The presurgical diagnostic wax-up was integrated with
the final implant and multi-unit positions, and the provi-
sional design file was 3D printed. The screw access hole
positions in the 3D printed provisional demonstrate the
careful planning and surgical implementation with a
guided surgery protocol. (z21, z22) The provisional res-
toration is inserted, the multi-unit abutment screws tight-
ened, and the occlusion evaluated and adjusted. (z23,
z24) At 1 month postop, good soft tissue healing is seen
with aesthetic tooth dimensions. Surgery Dr Michael
Abrams
66 M. Klein et al.

d e f

g h i

j k l

m n o

Fig. 3.40 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations 67

p q

r s t

u v w

x y z1

Fig. 3.40 (continued)

68 M. Klein et al.

z2 z3

z4 z5 z6

Fig. 3.40 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations 69

z7 z8 z9a z9b

z11

z10
z12

z13 z14

Fig. 3.40 (continued)

70 M. Klein et al.

z15 z16 z17 z18

z19 z20

z21 z22

z23 z24

z25 z26

Fig. 3.40 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations
a b
d e
Fig. 3.41 (a, b, c) A plan for immediate implant place-
ment with immediate provisionalization was made for this
patient with a failing maxillary dentition. (d, e) iOS scans
of the patient’s maxilla, mandible, and bite were taken. A
diagnostic wax-up of the maxilla was completed. (f, g)
The diagnostic wax-up was integrated with full-face pho-
tos to confirm aesthetics and evaluation of the soft tissue
in the transition zone. (h, i, j, k) The iOS scans were inte-
grated with the patient’s cone beam CT scan and then
overlayed with the diagnostic wax-up. Implant planning
was then completed. (l, m) Careful analysis of anterior
tooth length, distance from the free gingival to implant
connection, as well as divergence of implant positions was
completed prior to finalizing the surgical and prosthetic
plan. (n, o, p) The surgical guide was designed to be tooth
borne for maximum stability. (q, r, s) Only the teeth inter-
71
c
fering with implant position were extracted prior to
implant placement. Multi-unit abutments were placed on
the implants. Nexus scan gauges were placed and secured
to the multi-unit abutments, and the Nexus scanning pro-
tocol was followed. The remaining teeth in the maxillary
arch were critical to integration of the multi-unit abutment
positions with the presurgical wax-up. Following scan-
ning, the remaining teeth were extracted. (t, u, v, w) The
diagnostic wax-up file was integrated with the multi-unit
abutment positions and the provisional design was com-
pleted. (x, y) The provisional design was 3D printed from
the stl file. Postprocessing and finishing included adding
pink gingival tissues to the posterior units. (z1, z2, z3) The
provisional restoration was inserted, and the occlusion
adjusted. Final radiographs confirm complete seating of
the provisional restoration
72 M. Klein et al.

f g

h i j

k l

Fig. 3.41 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations 73

m n o

p q

r s

t u v w

Fig. 3.41 (continued)

74 M. Klein et al.

x y

z1 z2

z3

Fig. 3.41 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations
a b
Fig. 3.42 (a, b, c, d, e) The drilling report indicates the appropriate drill length (25 mm), implant size (3.75 × 13), as
well as the depth measurement on the implant driver to deliver the implant to its planned depth (Offset-12)
software. These drilling reports indicate the drill-
ing depth as well as the correct vertical implant
delivery position by indicating a number that will
correlate to a number on the implant delivery
insertion key (Fig. 3.42a–e). The implant inser-
tion keys will also have features that indicate
implant connection orientation. Control of the
connection orientation is critical when using
angled multi-unit abutments. The indication for
use of an angled multi-unit abutment is to align
the restorative platform of the multiunit abutment
into proper alignment and restorative path of
draw with the other multi-unit abutments. Straight
multi-units are nonengaging, so connection ori-
entation is not critical; however, to take advan-
tage of angled multi-unit abutments (which are
engaging), connection orientation is critical
(Fig. 3.37v, w).
The insertion torque felt when inserting the
implant through the guide will not be accurate
due to the rubbing of the implant insertion key
against the sleeve in the surgical guide. It is rec-
ommended to evaluate insertion torque without
the surgical guide in position. This can be done
by turning the last 1–3 insertion turns without the
surgical guide and with a torque driver (Fig. 3.43).
Options That Aid Immediate
Provisionalization
Some surgical planning software (e.g., 3Shape,
Exocad, etc.) will allow the conversion of the
surgical planning stl into their prosthetic plan-
ning software. This will create a model with
75
c d e
Fig. 3.43 Final implant seating should be done with a
torque driver without the surgical guide. When the implant
driver comes in contact with the surgical guide sleeve, true
insertion torque cannot be felt
the planned implants in place as if the implants
were in the patient’s mouth and iOS impres-
sions had been taken. Abutments may be
selected and the provisional prosthesis
designed. However, due to the reality that the
actual implant positions will not be exactly in
the positions planned, the provisional must be
designed with space around the abutment that
will allow for slight variations between the
planned implant position and the actual implant
position after placement. This will allow pas-
sive seating of the provisional restoration with
a quick reline process to secure the abutment
cylinders to the provisional prosthesis for a
screw retained provisional or a quick crown
and bridge style reline for a cementable provi-
sional prosthesis (Fig. 3.25a–w).
76
Limitations of the Guide
Fully guided surgical guides when used for the
complete surgical protocol require a commitment
to the planned implant position. There are occa-
sions where the data used for planning was
incomplete (poor impression analogue or IOS),
difficult to read CT scans due to a lot of metal
artifact, or not up to date data (there was addi-
tional healing or pathology resulting in a clinical
reality that is different from the data used for
planning). On occasion, the patient cannot open
wide enough for the selected surgical tools. In
these scenarios the surgical guide may not be
able to be used or may only act as a pilot guide,
or perhaps osteotomies can be completed but
implant insertion is done freehand. Consideration
should always be given to use the guide for the
guidance and information to best serve the indi-
vidual clinician and patient. That may mean some
osteotomies have pilot guidance and some full
guidance, maybe the osteotomies are prepared
and implant delivery is freehand. Moreover, dif-
ficult implant placement for angled implants,
sited adjacent to mental foramen maxillary sinus,
etc. are managed with the surgical guide
(Fig. 3.44) [14].
Fig. 3.44 Long drill lengths in patients with limited
interarch space can usually be managed with the DGS
guided surgery systems. However, the implant delivery
with the implant insertion driver and implant will be lon-
ger and may require freehand implant insertion
M. Klein et al.
3.2.3.5 Pilot Guides
Pilot guides will just guide the initial drill used for
positioning the implant. They will produce an oste-
otomy with the planned overall location, angle, and
depth for any given implant. Generally, the drill
diameter used is 1.5–2 mm in diameter. The sleeves
used in the surgical guide will then only have an
internal lumen to accommodate and guide the spe-
cific diameter for the pilot drill being used. The
pilot drill can be universal to any implant system as
it only guides the initial osteotomy whose diameter
at this point is generic to all systems.
The Indications and Benefits of the Pilot
Guide
Pilot surgical guides provide rapid guidance for
the initial pilot drill (usually 1.5 or 2 mm in diam-
eter) while allowing flexibility for the clinician to
make changes at the time of surgery. Following
pilot osteotomy preparation, the pilot guide is
removed and the clinician may assess the osteot-
omy 3D position by placing a guide pin in the
osteotomy. Location, depth, assessment of sur-
rounding bone, angle and orientation to adjacent
implant pilot osteotomies, proximity to adjacent
implant osteotomies, proximity to adjacent clini-
cally visible structures, orientation to adjacent
subcrestal structures, and anticipated ­restorability
can all be evaluated at this point prior to commit-
ting to this osteotomy as the final osteotomy posi-
tion. Intraoperative radiographs (periapical,
panoramic, or CT scan) may be taken with guide
pins in place to assess the osteotomy position in
the bone where it is not clinically visible.
Proximity to roots of adjacent teeth, implants,
mental foramen, inferior alveolar canal, maxil-
lary sinus, floor of the nose, pterygoid complex,
etc. may be assessed and adjustments made to the
osteotomy position. These adjustments may be to
location, angle, as well as osteotomy depth.
Once the osteotomy position is confirmed or
adjusted, the clinician can rapidly continue the
osteotomy preparation to completion with the
subsequent conventional drills indicated for the
implant system being used following the path
created by the pilot osteotomy. Care should be
3 Guided Surgery for Full-Arch Implant-Supported Restorations
taken not to deviate from the position due to poor
quality of bone or areas where there may be
dense bone on one side of the osteotomy and
poor quality of bone on an opposing side (such as
an extraction site). This can lead to changing the
final osteotomy position (Fig. 3.45) [15].
The major benefits of the pilot surgical guide
are the ability to rapidly locate osteotomy 3D
positions while giving the clinician flexibility to
make changes during the surgical procedure.
When designing the surgical guide for a fully
guided surgical guide, the guide sleeves may also
be too close in proximity to an adjacent guide
sleeve or tooth, and this may require use of a
Fig. 3.45 Great care must be taken when preparing osteot-
omies in extraction sockets. The palatal or lingual bone will
push the drill buccally into the open space of the extraction
socket causing the implant to be angled buccally
a b
Fig. 3.46 (a, b) Fully guided guide sleeve diameter may interfere with teeth retained to support the surgical guide and
may require the use of a pilot sleeve
77
smaller-diameter guide sleeve such as a pilot
guide sleeve (Fig. 3.46a, b).
Data You Need to Prepare Pilot Guides
The data required to prepare a pilot guide is the
same data for fully guided surgical guides: the
dicom data from a CT scan and iOS (intraoral
surface) scans of the mandible and maxilla with a
centric mounting and any other data required to
properly plan implant positions (e.g., photos,
conventional radiographs, clinical charting). If
the arch is edentulous, then the dicom data from
a dual scan technique will be required (the dual-­
scan technique has been previously described). A
comprehensive surgical plan is developed from
this data (including a virtual wax-up). All this
data is utilized in surgical planning software that
has a surgical guide design module (e.g., 3Shape
Implant studio, Exocad, Exoplan, Anatomage,
Columbia scientific SimPlant, Blue Sky Plan,
etc.). These planning software have libraries of
guide sleeves. The planning laboratory will select
the library for the pilot guide sleeve appropriate
to the procedure being planned (Fig. 3.47). The
guide design software will automatically incor-
porate the geometry required to house this guide
sleeve in the guide design. After manufacture of
the guide (3D printing or machining), the labora-
tory will insert the appropriate guide sleeve.
78 M. Klein et al.

Fig. 3.47 Most surgical

planning software with
surgical guide design
features will have pilot
sleeve libraries

Surgical Planning Considerations

(Surgical, Prosthetic) for the Pilot Guide
The surgical planning for a pilot guide will be the
same as for any other computer-guided technique
(fully guided, dynamic guidance, robotic). There
is also flexibility where within one guide you can
have some osteotomies using pilot sleeves, while
other osteotomies may have sleeves to control
full guidance. This may be done for the reasons
described for selecting pilot or full guidance.
Pilot guides are secured in position with teeth or
lateral pins just as with fully guided surgical
guides (see fully guided surgical guides). Pilot
guides are used with the same techniques as the
preliminary pilot drill of fully guided sequences.
All the same considerations and techniques
described for fully guided surgical guides should
be followed.

Surgical Tools Used with Pilot Guides
The surgical armamentarium used with the pilot
guide includes pilot drills that are indicated to
be used with the pilot guide sleeves placed into
the pilot surgical guide. This is system depen-
dent. The drills and guide sleeves should be uti-
lized as a system so that rigid initial drilling
guidance is controlled while allowing adequate
tolerances for the spinning of the drill. Some
systems will have one dedicated drill, while
others may have two or three different lengths
(Fig. 3.48).
Fig. 3.48 Pilot drill kits are designed to be used with spe-
cific pilot guide sleeves
How to Use the Guide During Surgery
Follow the surgical protocols described for fully
guided surgery through the pilot osteotomy step.
When the pilot guide is used, the guide pins can
be evaluated relative to the opposing arch and
anatomic landmarks including the mental fora-
men (if exposed). After evaluation of the correct
pilot osteotomy placement, the drilling protocol
3 Guided Surgery for Full-Arch Implant-Supported Restorations 79

may be completed freehand. It is recommended deviation is a more common occurrence. The

to periodically check to confirm no deviation anterior maxilla, posterior mandible (molar
from the plan during freehand drilling. In a dense sites), and all extraction sites are more prone to
anterior mandible, this is unlikely to happen. In potential deviation during freehand drilling
the posterior mandible and maxilla, potential (Fig. 3.49a–l).

a b

c d e

f g

Fig. 3.49 (a, b) Data required for surgical and prosthetic
planning for a pilot guide is the same as with fully guided
surgery and requires the same data. For the edentulous
arch, the dual-scan protocol is used, and decision-making
about pilot guide or fully guided is only made after analy-
sis of the data. (c, d, e) The surgical guide will use the
same lateral pin systems as fully guided guides. Pilot drill
systems that use different length pilot drills may be colour
coded. The pilot sleeves may be colour coded to indicate
which length drill is used in which sleeve position. (f, g)
The pilot surgical guide is secured with lateral pins prior
to tissue reflection to ensure it is secured in the most stable
position. (h) After the pilot osteotomies are created, the
pilot surgical guide is removed and guide pins are placed
to verify the osteotomy positions. The relationship and
orientation of the pins are analysed relative to each other
as well as the opposing arch. After confirmation of oste-
otomy positions, the osteotomies are completed freehand.
(i, j) Immediate provisionalization options are the same as
with a fully guided surgical procedure. In this patient,
multi-unit abutments were placed followed by securing
titanium temporary cylinders to the multi-unit abutments.
(k, l) The provisional restoration was prepared from the
diagnostic wax-up with large holes in planned implant
positions. The provisional was then fitted and relined over
the temporary cylinders
80
h i
j k
Fig. 3.49 (continued)
Limitations of the Guide
Surgical guides must be positioned correctly.
Any deviation in positioning of the guide will
result in improper implant positioning. This
deviation can be in location, angle, as well as
depth. Care must be taken to ensure proper seat-
ing with verification of that position. When
using a pilot guide, attention must be paid to not
M. Klein et al.
deviating from the pilot position (unless it is
indicated to do so). The patient’s ability to open
wide must also be a consideration when using
guided surgery guides. The drill length must
take into account the height of the surgical
guide. They will usually be 20–30 mm in length
in addition to the height of the head of the
contra-angle.
3 Guided Surgery for Full-Arch Implant-Supported Restorations
3.2.3.6 Bone-Borne Guides
The Indications and Benefits of Bone-­
Borne Guides
Bone-borne guides seat directly on the bone
which will require reflection of the soft tissue.
Bone-borne guides will have a very stable base to
secure the guide as long as no significant osteo-
plasty is done to the seating area of the guide
[16].
Bone-borne guides are secured in place by
broad coverage of bone and do not require teeth
to secure them in position. A large surgical flap is
usually required to provide access to seat the
guide. Bone-borne guides are also used as bone
reduction guides to guide indicated osteoplasty.
Bone-borne guides may be designed as pilot sur-
gical guides or fully guided surgical guides fol-
lowing the considerations listed previously.
The Data You Need to Prepare Bone-Borne
Guides
The data required to prepare a bone-borne guide
is the same data required for pilot guides and for
fully guided surgical guides: the dicom data from
a CT scan and IOS (intraoral surface) scans of the
mandible and maxilla with a centric mounting
and any other data required to properly plan
implant positions (e.g., photos, conventional
radiographs, clinical charting). If the arch is
edentulous, then the dicom data from a dual-scan
technique will be required (the dual-scan tech-
nique has been previously described). A compre-
hensive surgical plan is developed from this data
(including a virtual wax-up). All this data is uti-
lized in surgical planning software that has a sur-
gical guide design module (e.g., 3Shape Implant
studio, Columbia scientific SimPlant, Blue Sky
Bio, etc). These planning software have libraries
of guide sleeves. The planning laboratory will
select the library for the guide sleeve appropriate
to the procedure being planned. The guide design
software will automatically incorporate the
geometry required to house this guide sleeve in
the guide design. After manufacture of the guide
(3D printing or machining), the laboratory will
insert the appropriate guide sleeve (surgical plan-
ning considerations: surgical, prosthetic).
81
Surgical planning considerations will follow
the same protocols and considerations as
described for the pilot and fully guided surgical
guides. When planning the bone-borne guide,
usually all remaining teeth in the arch will be
extracted prior to seating the guide. Care must be
taken to not remove excessive bone during the
virtual planning as this will prevent complete
seating of the bone-borne guide.
The surgical planning for a bone-borne guide
will be the same as for any other computer-guided
technique (fully guided, dynamic guidance,
robotic). When there is questionable planning
due to poor data being used for planning (patient
movement during CT scan, inadequate surface
structure capture in iOS or lab scanning, ques-
tionable or immature bone grafts, unclear CT
data), then new data must be acquired.
In the full-arch surgical scenario, if broad
bone coverage will be used to provide a stable
and secure surgical guide, then lateral pins may
not be required.
Surgical Tools Used with Bone-Borne
Guides
The surgical tools will be the same for bone-­
borne guides as pilot or fully guided surgical
guides. These surgical systems are all previously
described in each of the pilot and fully guided
sections.
How to Use the Guide during Surgery
When using a bone-borne guide, the remaining
teeth in the arch are extracted and all pathology
removed. If any osteoplasty was planned that will
not affect the proper seating or retention of the
surgical guide, then perform the osteoplasty prior
to seating the guide. An incision large enough to
allow access to fully seat the guide is done with
adequate flap reflection. This will require the
incision and flap reflection to usually be extended
two teeth beyond the most distal extent of the
bone-borne guide. The flap reflection must also
extend well beyond the borders of the flanges of
the surgical guide to allow complete seating of
the bone-borne guide. The surgical systems are
used in the same manner as described in the sec-
tions for pilot guides and fully guided surgical
82
guides. Verification of seating of the guide is also
done through windows in the guide that demon-
strate intimate contact of bone with the guide.
This is the reason that care must be taken with
a b
d e
f g
Fig. 3.50 (a, b, c) Following surgical planning the bone-­
borne guide is designed on the virtual bone model and
converted into a manufacturing stl file. (d, e) The bone-­
borne guide may be used to create a bone reduction guide
as well as a surgical guide. (f, g) The bone-borne guide
has the advantage of creating a very stable base in the
edentulous arch. In order to create this stable base, a
broad area needs to be covered with the guide which will
require a more extensive flap reflection. (h, i) The bone
reduction guide will be designed to cover the same area
as the subsequent surgical guide for drilling. Intimate fit
of the guide should be seen to ensure proper seating and
guide orientation. (j, k) This guide was designed to
reduce the bone in the areas planned for implant place-
ment while preserving the adjacent bone to support the
M. Klein et al.
any osteoplasty done prior to seating the guide.
Following verification of guide seating, follow
the protocols and procedures for pilot or fully
guided surgical systems (Fig. 3.50a–p).
c
provisional removeable denture. (l) The complete seating
of the surgical guide for implant osteotomies and place-
ment is verified with windows to see intimate contact of
bone to surgical guide. (m, n) The bone-borne guide may
be designed as a pilot or fully guided surgical guide. Care
must be taken to create windows to verify complete guide
seating in areas that the bone will not be modified prior to
implant osteotomy preparation. (o) The surgical kit for
the bone borne guide is selected based on the sleeve sys-
tem used in the guide. The sleeve systems used and surgi-
cal kits used are the same for bone-borne guides as
tooth- or soft tissue-borne guides. (p) Implant placement
with bone borne guides is accomplished following the
same protocols as with tooth-borne or soft tissue-borne
guides
3 Guided Surgery for Full-Arch Implant-Supported Restorations 83

h i

j k

l m

Fig. 3.50 (continued)

84
o p
Fig. 3.50 (continued)
Options That Aid Immediate
Provisionalization
See provisionalization of implants planned and
placed with fully guided surgical guides.
Limitations of the Bone-Borne Guide
The bone-borne guide will require a longer incision
and more extensive flap reflection than for pilot and
fully guided surgical guides. There is no option of
a flapless surgery or a minimally invasive surgical
flap design. Verification of seating can be difficult,
and adjustment to the guide when seating is more
difficult to accomplish successfully. If there is scat-
ter at the level of the bone in the CT dicom data or
immature bone that does not show up clearly in the
images, then the guide will be made improperly
and will not seat (Figs. 3.51a, b, 3.52 and 3.53).
The tooth-borne or soft tissue-borne guides can be
made to seat properly regardless of any scatter
caused by metal artifact in the CT images because
the iOS images are used for the guide design and
there will not be metal scatter in that data.
M. Klein et al.
3.2.3.7 Stackable Surgical Guides
The Indications and Benefits of Stackable
Guide Systems
Stackable surgical guides are surgical guide sys-
tems that provide a stable secure foundation that
does not rely on teeth in the arch. The surgical
guide integrates with a foundation platform, and
the platform acts as a guide for bone reduction.
After guided implant placement through the sur-
gical guide, the surgical guide is removed from
the foundation component, and an additional
platform that supports the correct positioning of
the provisional restoration integrates with the
foundation. The provisional restoration is
secured to the provisional cylinders while posi-
tioned on the foundation at the correct vertical
position, A-P position, angle, and occlusion.
Some of the resources for stackable systems are
Roe-Chrome, N-Sequence, Co-Diagnostics, etc.
[17].
3 Guided Surgery for Full-Arch Implant-Supported Restorations 85

a b

Fig. 3.51 (a, b) When double images are seen in the axial or cross-sectional images, it means the patient moved during
the CT scan and the scan data will not be accurate for surgical planning

Fig. 3.52 The distortion caused by scatter reflecting off

metal restorations can make the ct images difficult to read
and use

Fig. 3.53 This CT cross-sectional image shows an image

The Data You Need to Prepare the Guides
The data required to prepare a stackable guide is
the same data required for pilot guides and for
fully guided surgical guides: the dicom data from
a CT scan and iOS (intraoral surface) scans of the
mandible and maxilla with a centric mounting
and any other data required to properly plan
implant positions (e.g., photos, conventional
with very poor bone quality that can sometimes make it
difficult to properly preposition the implant at the surgical
planning phase of guided surgery
radiographs, clinical charting). If the arch is
edentulous, then the dicom data from a dual-scan
technique will be required (the dual-scan tech-
86 M. Klein et al.

nique has been previously described). A compre- guide for positioning of the lateral pins. The
hensive surgical plan is developed from this data foundation component may seat on the bone and
(including a virtual wax-up). All this data is uti- be secured to the bone. After positioning of the
lized in surgical planning software that has a sur- foundation component, this foundation compo-
gical guide design module. The planning and nent may guide the amount of bone reduction
design software for stackable guides vary and required for each individual arch. After bone
may be proprietary to the stackable system. These reduction the surgical guide component stacks
planning software have libraries of guide sleeves. onto and integrates with the foundation compo-
The planning laboratory will select the library for nent. The implant osteotomies and implant deliv-
the pilot guide sleeve appropriate to the proce- ery are accomplished according to the protocol of
dure being planned. The guide design software the fully guided surgical system used and implant
will automatically incorporate the geometry system specifics. The surgical guide component
required to house this guide sleeve in the guide is removed leaving the foundation component in
design. After manufacture of the guide (3D print- place. Multi-unit abutments are placed.
ing or machining), the laboratory will insert the Provisional cylinders are secured to the multi-­
appropriate guide sleeve. unit abutments. The provisional restoration is
positioned either on a prosthetic platform that
Surgical Planning Considerations stacks onto the foundation component or to the
(Surgical, Prosthetic) foundation component itself. The provisional
The surgical planning for a stackable surgical cylinders are then cured to the provisional either
guide will be the same as for any other computer-­ at one time or sequentially. The provisional is
guided technique (fully guided, dynamic guid- then removed and finished in the laboratory add-
ance, robotic). When there is questionable ing any deficient material and then trimming and
planning due to poor data being used for planning polishing. The foundation component is removed
(patient movement during CT scan, inadequate from the patient’s mouth and any required bone
surface structure capture in IOS or lab scanning, grafting performed. Multi-unit healing abutments
questionable or immature bone grafts, unclear are secured to the multi-unit abutments at a lower
CT data), then consider acquiring new data. insertion torque, then the abutments were inserted
Some stackable guides fix the foundation plat- at, and suturing is completed. The bone grafting
form to place with lateral pins, while others use a and suturing may be done while the provisional is
bone borne approach for their foundations. being completed in the laboratory. The provi-
sional is now seated and occlusion evaluated and
Surgical Tools Used with Stackable Guides adjusted (Fig. 3.54a–v).
Stackable guides may be used with the same sur-
gical systems as fully guided surgical guides. Options That Aid Immediate
These guided surgical systems and their usage Provisionalization
have been previously described. Stackable guides are generally used for bone
reduction guidance, implant osteotomy position-
How to Use the Stackable Surgical Guide ing, implant placement, as well as positioning the
During Surgery predesigned provisional in the correct position;
The stackable guide technical protocols vary the provisional is designed according to the spe-
according to the specific type of stackable guide cific protocols of each stackable system.
(e.g., Chrome, N-Sequence, Co-Diagnostics,
etc). However, the basic surgical workflow is Limitations of the Guide
positioning of the foundation component. This The stackable guides rely on accurate initial posi-
may be done with a lateral pin positioning guide tioning of the foundation component. If there is
that uses a pilot guide type of drilling process. an inaccuracy in the positioning of the foundation
The foundation component may engage this component, that error will translate through to
3 Guided Surgery for Full-Arch Implant-Supported Restorations
a b
c d
e f
Fig. 3.54 (a) This patient was planned for fixed full-arch
restorations in the maxilla and mandible with immediate
provisionalization. A stackable guide solution was chosen
to manage the surgical and immediate provisionalization
stages. (b, c) A guide to seat the foundation bar is fit to the
mandibular teeth. (d, e) The foundation bar is secured to
the mandible with lateral pins prior to extraction of the
remaining mandibular teeth. (f) The remaining mandibu-
lar teeth are now extracted. The foundation bar is posi-
tioned in the planning software to the level that bone
reduction is required. (g, h) The bone is reduced to the
level of the foundation bar. (i) The surgical guide is now
fit securely into the foundation bar. (j, k) The Keystone
Paltop fully guided kit is used with the stackable guide to
create all implant osteotomies. (l, m) The implants are
placed through the stackable guide to their final position.
(n) The surgical guide component is removed from the
foundation bar after completion of implant placement. (o,
p) The provisional restoration platform is seated securely
into the foundation bar. If it does not seat passively, then
87
there is bone interfering with the platform. It is critical
that it seats passively. The multi-unit abutments are seated
without the prosthetic platform in place. The platform is
reseated after seating the multi-unit abutments. The pros-
thetic platform holds the provisional restoration in the
planned vertical dimension and centric relation position.
(q, r) Temporary cylinders are secured to the multi-unit
abutments. The premade provisional restoration is seated
on the restorative platform so that it fits intimately to the
platform. The screw access chambers are blocked out with
wooden sticks, and resin is injected around the temporary
cylinders to secure the temporary cylinders to the provi-
sional restoration. (s) The prosthetic platform holds the
provisional restoration in the planned vertical dimension
and centric relation. (t, u, v) The provisional restoration is
finished in the laboratory filling in any gaps in the resin
securing the provisional cylinders. The finished polished
provisional restoration is seated on the multi-unit abut-
ments and secured with multi-unit screws
88 M. Klein et al.

g h

i j

k l

Fig. 3.54 (continued)

3 Guided Surgery for Full-Arch Implant-Supported Restorations 89

n o

p q

r s

t u

Fig. 3.54 (continued)

90 M. Klein et al.

the implant positioning as well as the positioning The Indications and Benefits of Robotic
and orientation of the provisional restoration. Implant Systems
Haptic robotic-guided systems are indicated
3.2.3.8 Robotic Surgery for single to full-arch implant placement and
A robotic dental implant system is a computer-­ for implant bone levelling. The outcome bene-
controlled device used to assist in the placement fits are precise, accurate, predictable, and
of dental implants. It typically includes a robotic reproducible implant placement [19].
arm that is guided by software to precisely posi- Intraoperatively, the benefits are as follows: the
tion the implant in the jawbone. The system inte- device is directly connected to the patient,
grates imaging technology, such as CT scans and physical guidance (haptic feedback), depth
intra-oral scanning to create a 3D model of the control, and intraoperative changes along with
jawbone to plan the implant placement. The goal visual, audible, and tactile feedback. The abil-
of a robotic dental implant system is to increase ity to perform flapless or minimal invasive sur-
the accuracy, consistency, and predictability of gical access is also a clear and favourable
implant placement, which can lead to better out- indication for haptic robotic-guided implant
comes for patients [18]. The currently available placement. The attachment of the device to the
FDA-approved robotic system on the market is patient is either based on the existing teeth, or
called Yomi (made by Neocis Inc) (Fig. 3.55). if teeth are of poor quality, limited structure, or
The Yomi device is approved for single to full-­ not present, a bone-borne device is placed. In
arch implant placement and bone levelling. This the Yomi system, these are called Yomi link
type of robotic system gives the surgeon real-­ teeth (YLT) or Yomi link bone (YLB)
time feedback. This is also known as haptic guid- (Figs. 3.56 and 3.57). The planning software is
ance. Robotic haptic guidance implant placement proprietary to the Yomi system and not com-
allows the surgeon to follow the alignment and patible with any other systems available. A
trajectory to the planned implant placement. It CBCT is necessary for implant planning with a
will restrict all movements to the surgeon except field of view documenting the planned surgical
for occlusal to apical movements (up and down). site. The software system allows for complete
The apical movement is limited and restricted to visualization of teeth, roots, nerves, sinuses,
the inferior aspect of the implant planned and inferior alveolar nerve mapping. A CBCT
position. can be obtained and used preoperatively for

Fig. 3.55 The Yomi

robot with the key
components labelled is
necessary to perform
full-arch implant
placement
3 Guided Surgery for Full-Arch Implant-Supported Restorations
a b
Fig. 3.56 (a, b, c) Yomi link bone which is used to con-
nect the patient to the patient tracking arm to place man-
dibular implants. Bone screws can be visualized to
a b
Fig. 3.57 (a, b) 2 Yomi link bones connected to the
patient: one in the maxilla for placing maxillary implants
and one to the mandible for the mandibular implants.
preplanning, but a day of surgery CBCT scan
must be obtained to align the robot with the
physical guidance to the patient. Implant and
prosthetic planning are complete to the robotic
planning software. The prosthetic planning is
either through a prosthetic library or using a
dual-scan approach.
91
c
securely connect the patient to the Yomi link bone. These
are placed below or in between planned implant sites
Bone screws can be visualized connecting the patient to
the Yomi link bone for the maxilla and mandible
Data Necessary for Robotic Implant
Placement
The data necessary is the same as for guided sur-
gery; however, there needs to be physical connec-
tion of the robot to the patient. With robotic-guided
surgery, a day of surgery CBCT must be obtained.
This would allow for a patient to be seen for a con-
92
sult and surgery all in the same day if desired.
However, most implant patients are seen initially
for a consult and then scheduled for surgery at
some point in the future. The approach moving
forward will be based on two appointments. On
the patient’s first appointment, photos and a CBCT
would be obtained from the implant site. The site
would be evaluated and considered for implant
placement regardless of modality to place the
implant. Volume of bone and quality of soft tissue
are all factors to consider. The site must be evalu-
ated from a prosthetic approach. One would col-
laborate with the restorative dentist and approach
the overall treatment plan similar to freehand,
guided, and dynamic guidance surgery. After
establishing candidacy of the patient for proper
prosthetically placed implant(s), the patient can be
scheduled for surgery.
Surgical Planning Considerations
(Surgical, Prosthetic)
Surgical planning for robotic implant placement
is the same as fully guided or dynamic guidance.
The ability to accomplish the plan starts with
appropriate data. Poor-quality CBCT or pros-
thetic plan will result in a less than optimal out-
come with robotic implant surgery. The planning
considerations have been previously described.
a b
Fig. 3.58 (a, b) Fiducial array in place on a YLB and ready for scanning. The dual-arch YLB is in place after extrac-
tions and is now prepared for implant placement
M. Klein et al.
Surgical Tools Used with Robotic-Assisted
Surgery
Robotic surgery can be accomplished with any
dental implant system. The handpiece and drill
base are specific to the robotic system and cannot
be interchanged. In addition, the YLT and YLB
are necessary. Whichever device is used must be
firmly attached to the patient. Even the slightest
amount of movement will result in suboptimal
accuracy. If the YLB or YLT is loose, it must be
reconnected to the patient and the process
repeated. There is a specific handpiece as well for
bone levelling. Both the implant and straight
handpiece for the robot are tested and specific
only for that robot. They are not interchangeable
to other systems. While in surgery the clinician
will be able to perform the osteotomy and implant
placement with their eyes on the surgical field.
How to Use the Haptic Robotic Implant
System
On the day of surgery, either a YLB or YLT is
placed. In planning a single or multiple implants,
the YLB would be placed (Figs. 3.56, 3.57 and
3.58a, b). The YLB or YLT is placed on the arch
where the implants are to be placed. If implants
are planned for both the maxilla and mandible on
the same day, the “link” would be placed on both
3 Guided Surgery for Full-Arch Implant-Supported Restorations 93

arches. The YLT is attached to the dentition using Both these dimensions are entered into the Yomi
a polyarylamide (Ixef). The YLT is attached to software. The landmark must pass or the entire
the patient using at least three bone screws. The plan/setup is not accurate. After the landmark is
screws are 2.0 mm × 16,18, or 20 mm long with passed, the implant surgery can proceed. The
consideration of where the dental implants will implants can be placed flaplessly, flapped, as well
be placed. These screws can be placed monocor- as immediately into extraction sockets. When
tically or bicortically. Bicortical will ensure a teeth need to be removed, it is the author’s prefer-
higher level of osseous stability to the YLB ence to have them extracted the day of implant
(Figs. 3.56, 3.57 and 3.58a, b). The bone screws surgery but prior to the preoperative planning
should be apical as possible but balancing engag- CBCT. This is to obtain a clear picture of the
ing a quality of bone to establish stability for the bone level and osseous architecture. A recent
link. Once the YLB or YLT are placed and stable, software innovation is the ability to create or
the fiducial array screwed on and attached to the approach an osteotomy using lateral access. This
YLT/YLB for the arch having surgery and a allows for access in those patients with small
CBCT is taken. The fiducial array is unscrewed mouth openings or difficult access. As stated
off the YLT/YLB. The CBCT is imported as above every drill in the implant osteotomy prepa-
dicom format into the Yomi planning software.
The data goes through postprocessing and adju-
dication. If a preplan was done, the plan is
imported and aligned to the day of surgery scan.
In addition, a dual-scan technique can be utilized
(Fig. 3.59). This is similar to what was discussed
previously in the guided surgery section. Implants
are placed in a traditional fashion and drilling
protocol that the surgeon is comfortable using.
Once the surgeon is ready, a known landmark
must pass a landmark test. A site on the CBCT
plan is cross-referenced clinically to assure accu-
racy and consistency. Every bur placed into the
handpiece and used in surgery must be measured
for length, as the width is known (Fig. 3.60).

Fig. 3.60 Measuring the length of drill bite. This infor-

Fig. 3.59 Dual-scan protocol showing the implant emer- mation is integrated into the Yomi software prior to
gence through the transitional prosthesis. This is accom- implant drilling. This is repeated for each drilling that is
plished in the Yomi planning software attached to the handpiece
94 M. Klein et al.

ration sequence must be measured and properly

recorded for the osteotomy site preparation to be
correct (Fig. 3.60). As the surgeon is ready to
move the robotic arm, the system is placed in free
mode which allows the surgeon to approach the
implant site. Upon close proximity to the site, a
verbal command of “guided” is stated to the
driver. The driver is the assistant or technician
who will carry out the verbal commands of the
surgeon and data enter the commands using
mouse clicks and/or keystrokes into the computer
that is controlling the Yomi robot. In the guided
position, the surgeon moves the handpiece into
its ultimate locked position by angulating or
rotating the handpiece under direct visualization
as seen on the Yomi computer screen (Fig. 3.61).
As the locked position is confirmed, auditory sig-
nalling of beeps directs the surgeon that the final
position has been reached (Fig. 3.61). At that
time the handpiece is “locked on”, meaning in the
exact three coordinates that the implant was
planned for that implant site (Fig. 3.62). Once the
proper osteotomy is created, the implant is then
placed. If at the time of implant drilling a change
is desired by the surgeon, the plan can be altered
intraoperatively within the software, and the plan
adjustment will be immediate to facilitate the
change. As the surgeon prepares the osteotomy,
visual, auditory, and tactile information is deliv-
ered to the surgeon. Once the handpiece is Fig. 3.62 Shows the patient tracking arm connected to
“locked on” to the planned implant position, the the mandible. Implant handpiece with drill in place

a b

Fig. 3.61 (a, b) Demonstrating the guided position of the jectory of the planned osteotomy. The drill is active in the
handpiece and then approaching the “locked-on” position. osteotomy
Figure 3.60b shows the implant drill aligned with the tra-
3 Guided Surgery for Full-Arch Implant-Supported Restorations 95

osteotomy is completed based on their drilling
protocol to proper width and depth. Upon com-
pletion of the implant osteotomy, the implant is
delivered on a standard implant mount. Prior to
placement the distance from the top of the implant
is entered into the Yomi. Insertion torque and
RPMs for implant placement are based on the
discretion of the surgeon. This sequence is
repeated for each implant or one drill can be used
on all sites or variations of such. Once the
implant(s) are in place, final site verification
should be performed to assess if any shifting
occurred to the YLT or YLB. The Yomi link
device would be removed. At this point next steps
would be based on surgeons/restorative dentist
desires; either immediate loading protocols or
cover screws or healing abutments would be pur-
sued. A postsurgical CBCT would follow for
confirmation of the synergy between plan and
actual treatment (Fig. 3.63a, b).
A recent addition to the robotic implant sys-
tem is the ability to perform robotic-assisted bone
levelling using the Yomi under haptic guidance.
In the planning software, a bone levelling plane is
established. The handpiece utilized for this
approach is a straight handpiece 1:1 aspect ratio.
The boundaries are confined by the surgeon’s
area to bone level. The boundaries are manipu-
lated in the software and executed by the surgeon
in similar fashion to the implant placement.
Landmark site verification must pass as in the
implant placement algorithm to ensure proper
spatial relationships between the Yomi and the
patient. The Yomi software aligns the patient in
space as the clinician identifies the same land-
mark in the clinical setting. A known landmark
must adjudicate clinically. If the clinical refer-
ence and the software reference point do not
coordinate, the bone levelling sequence should
be aborted based on the dataset. If it is the clini-
cian’s desire to use bone levelling robotically and
there is a mismatch, the data gathering and adju-
dication must be repeated and passed before pro-
ceeding to the robotic haptic-assisted levelling.
The bur length is measured prior to landmark
check. Currently, only one bur is FDA cleared for
use in this approach. Upon completion of the
bone levelling, the handpiece is changed to the
implant handpiece, and the implant workflow
described above would be executed.
3.2.3.9 Real-Time Dynamic Guidance
Real-time dynamic navigation for implant place-
ment utilizes an implant system that uses aug-
mented freehand to optimize implant placement
to improve outcomes, improve implant stability,
and reduce surgical time. The surgical technique
uses a device which generates a 3D visual implant
plan and visual feedback as the implants are
placed into the jaw bone (Fig. 3.64) [20]. One of
the benefits is the ability to guide the placement
of dental implants in real time during surgery.
The technology includes a surgical navigation
system that uses 3D imaging and real-time track-
ing to guide the implant placement, allowing for
more accurate and precise placement of the
implants. The goal is to deliver better outcomes
for patients, such as improved implant stability,
reduced surgical time, and less trauma to sur-
rounding tissue.

a b

Fig. 3.63 (a, b) Prosthesis with projection of the implants through the scanned position of the teeth. Postoperative
CBCT showing the position of the dual-arch implant reconstruction
96
Fig. 3.64 Surgical implant is facilitated through real-­ or prosthetic plan will result in a less than opti-
time dynamic navigation such as the example below
X-Nav and Clarinov are two brands of real-­
time dynamic navigation systems for dental
implant placement. They are computer-aided sur-
gery systems that use 3D imaging and real-time
tracking to guide the placement of dental
implants. They both work with a variety of
implant systems and are designed to work both
traditional implant placement and guided surgery
protocols. The system is intended to improve the
accuracy and precision of implant placement,
which can lead to better outcomes for patients,
such as improved implant stability, reduced sur-
gical time, and less trauma to surrounding
tissue.
M. Klein et al.
The Indications and Benefits of Real-Time
Dynamic Guidance Systems
The technology allows the clinician to accurately
and precisely place and implant(s) in the 3D
arena [21]. Real-time navigation can be particu-
larly useful in cases where the patient has a com-
plex jaw anatomy, limited jawbone, or other
anatomic challenges that may make traditional
implant placement more difficult The use of real-­
time navigation can be beneficial for guided
­surgery, where the surgeon uses a preoperative
plan to place the implant in a specific location
and orientation. Real-time navigation can be used
to place immediate-load dental implants, which
are loaded with a prosthetic tooth or bridge
immediately after placement.
Data Necessary for Real-Time Dynamic
Guidance Implant Placement
The data necessary for dynamic guidance is simi-
lar to guided and robotic implant placement as
has been previously described.
Surgical Planning Considerations
(Surgical, Prosthetic)
Surgical planning for robotic implant placement
is the same as fully guided or robotic implant
placement. The ability to accomplish the plan
starts with appropriate data. Poor-quality CBCT
mal outcome with robotic implant surgery. The
planning considerations have been previously
described.
Surgical Tools Used with Real-Time
Dynamic Guidance Implant Placement
Real-time dynamic guidance systems use infra-
red cameras or optoelectronic computer naviga-
tion to track in the fiducial markers. The
technology employed by the existing optoelec-
tronic CA navigation devices onto the market is
based on either visible light or infrared stereo-
scopic cameras (Fig. 3.65). There are over 18
devices currently available that use varied tech-
nology to accomplish real-time dynamic guid-
ance. Optoelectronic navigation devices require a
continuous direct line-of-sight of the fiducial
markers to ensure consistent accuracy.
3 Guided Surgery for Full-Arch Implant-Supported Restorations 97

or dual scanning with intraoral scanning are

options to use to develop prosthodontically
driven treatment planning. The calibration to reg-
ister the spatial relationship between the surgical
field and the drill tip position and angulation of
the drill is done based on protocols dependent on
which CAR navigation device is being used.
Visualizations of the drill relative to the CBCT
image of the patient’s anatomy from various per-
spectives that are native to the CA navigation sys-
tem were conducted. Recalibration is done from
precision to twist and between different twist
drills in the drilling sequence. Dynamic tracking
and navigation of the surgical tool are
­accomplished by utilizing a stereoscopic camera
and fiducial markers that maintain a rigid rela-
tionship to the surgical field and to the surgical
tool used for osteotomy (Fig. 3.65). The opera-
tor’s navigation of the surgical tool relative to the
preplanned implant site location can then be
guided by both visual and auditory means. There
are differences in the calibration methods specific
to each CA navigation system.
The procedure is performed using either flap-
Fig. 3.65 Example of such visible light or infrared light less or a full-thickness mucoperiosteal flap at the
is seen below with clear line of sight to the sensors
intended surgical site(s). The osteotomies are
prepared according to the implant manufacturers’
How to Use the Real-Time Dynamic protocol. The drilling handpiece is not proprie-
Guidance Implant Placement tary to the CA navigational system implant sur-
The day of surgery a tooth or bone-borne device gery. As the osteotomy is prepared, the surgeon
specific to the system being used will be attached visualizes the cross-hairs on the digital screen
to the patient. The patient then has a CBCT taken display to ensure they are within the confines of
with the tooth or bone-borne device/fiducial array the plane (Fig. 3.66a, b). The handpiece and sur-
in place. For some systems the teeth-borne device geon have complete freedom in all directions as
can be created prior to the day of the implant sur- the osteotomy is prepared. There are no boundar-
gery. The digital tomogram is exported from the ies or constraints within the CA navigational sys-
CBCT in a DICOM file format and imported into tem. The feedback is both visual and auditory.
the CA navigation device for planning of the sur- These systems do not have physical or haptic
gical implant placement. The software planning feedback. There is the feasibility to make intra-
module of the CA navigation device enables the operative adjustments to the plan. Bone levelling
clinician to determine the desired implant size, in many of the CA navigational devices is another
location, and angulation. Both radiopaque teeth option as well.
98
a b
Fig. 3.66 (a, b) Picture represents a surgeon’s view of
key three-dimensional views for implant placement and
the handpiece and array. As the handpiece is moved, real-­
3.3 Conclusion
Surgical guides for surgical guidance during
implant surgery can take many forms. They
should not be used as a replacement for surgical
skill and understanding. They should be used to
help predictably implement a well-thought out
surgical and prosthetic plan. They will produce
efficiency and generally allow for a more mini-
mally invasive procedure. They can aid in simpli-
fying the immediate provisionalization procedure.
The clinician should be prepared and have the
ability to make real-time changes during the sur-
gical procedure even when using a surgical guide.
Computer-generated surgical guides are depen-
dent on good CT scan data and iOS (or lab scan)
data. Inaccurate data will produce a surgical
guide that will not guide the clinician to the
planned implant position. Computer guidance is
not a replacement for surgical skill, understand-
ing biology, or expertise and experience to make
real-time decisions during surgery and imple-
ment them real time.
M. Klein et al.
time data acquisition changes moment to moment giving
the surgeon a clear image of the surgical plan
References
1. Yogui FC, Verri FR, de Luna Gomes JM, Lemos
CAA, Cruz RS, Pellizzer EP. Comparison between
computer-guided and freehand dental implant
placement surgery: a systematic review and meta-­
analysis. Int J Oral Maxillofac Surg. 2021;50(2):242–
50. ISSN 0901-5027. https://doi.org/10.1016/j.
ijom.2020.08.004.
2. Gargallo-Albiol J, Barootchi S, Marqués-Guasch
J, Wang HL. Fully guided versus half-guided and
freehand implant placement: systematic review
and meta-analysis. Int J Oral Maxillofac Implants.
2020;35:1159–69. https://doi.org/10.11607/
jomi.7942.
3. Becker CM, Kaiser DA. Surgical guide for dental
implant placement. J Prosthet Dent. 2000;83(2):248–
51. ISSN 0022-3913. https://doi.org/10.1016/
S0022-­3913(00)80018-­9.
4. Weber H-P, Margvelashvili-Malament M, De Souza
AB. Clinical applications of digital dental technology
in implant surgery. In: Clinical applications of digi-
tal dental technology; 2023. p. 217–39. https://doi.
org/10.1002/9781119800613.
5. Ganz SD. Techniques for the use of CT imaging
for the fabrication of surgical guides. Atlas Oral
Maxillofac Surg Clin North Am. 2006;14:75–97.
6. Lee CYS, Ganz SD, Wong N, Suzuki JB. Use of
cone beam computed tomography and a laser intra-
3 Guided Surgery for Full-Arch Implant-Supported Restorations
oral scanner in virtual dental implant surgery: part
1. Implant Dent. 2012;21(4):265–71. https://doi.
org/10.1097/ID.0b013e31825e5739. 15.
7. Ganz SD. Computer-aided design/computer-aided
manufacturing applications using CT and cone
beam CT scanning technology. Dent Clin N Am.
2008;52(4):777–808. ISSN 0011-8532. https://doi.
org/10.1016/j.cden.2008.07.001.
8. Hakobyan G, Grigoryan H, Manukyan M, Martirosyan
T, Sahakyan H. Computer-supported implant guided 16.
surgery using 3D planning software. Bull Stomatol
Maxillofac Surg. 2022;26(7):67–73. https://doi.
org/10.58240/1829006X-­2022.
9. El Chaar E. Digital workflow in surgery. In: Practical
techniques in periodontics and implant dentistry; 2022.
p. 132–7. https://doi.org/10.1002/9781119793588.
10. Kernen F, Kramer J, Wanner L, et al. A review of vir- 17.
tual planning software for guided implant surgery—
data import and visualization, drill guide design and
manufacturing. BMC Oral Health. 2020;20:251.
https://doi.org/10.1186/s12903-­020-­01208-­1.
11. Vercruyssen M, Laleman I, Jacobs R, Quirynen
M. Computer-supported implant planning and guided 18.
surgery: a narrative review. Clin Oral Implants Res.
2015;26:69–76. https://doi.org/10.1111/clr.12638.
12. Klein M, et al. A computerized tomography (CT) scan
appliance for optimal presurgical and preprosthetic 19.
planning of the implant patient. Pract Periodont
Aesthet Dent. 1993;5(6):33–9; quiz 39.
13. Moura GF, Siqueira R, Meirelles L, Maska B, Wang
H-L, Mendonça G. Denture scanning technique
for computer-guided implant-supported restoration
treatment of edentulous patients. J Prosthet Dent. 20.
2021;125(5):726–31. ISSN 0022-3913. https://doi.
org/10.1016/j.prosdent.2020.03.034.
14. Meloni SM, De Riu G, Pisano M, Tullio A. Full arch
restoration with computer-assisted implant surgery 21.
and immediate loading in edentulous ridges with
dental fresh extraction sockets. One year results of
10 consecutively treated patients: guided implant
surgery and extraction sockets. J Maxillofac Oral
99
Surg. 2013;12(3):321–5. https://doi.org/10.1007/
s12663-­012-­0429-­8.
Schulz MC, Hofmann F, Range U, Lauer G, Haim
D. Pilot-drill guided vs. full-guided implant inser-
tion in artificial mandibles-a prospective labo-
ratory study in fifth-year dental students. Int J
Implant Dent. 2019;5(1):23. PMID: 31240421;
PMCID: PMC6593025. https://doi.org/10.1186/
s40729-­019-­0176-­4.
Mijiritsky E, Ben Zaken H, Shacham M, Cinar IC,
Tore C, Nagy K, Ganz SD. Variety of surgical guides
and protocols for bone reduction prior to implant
placement: a narrative review. Int J Environ Res
Public Health. 2021;18(5):2341. PMID: 33673563;
PMCID: PMC7956849. https://doi.org/10.3390/
ijerph18052341.
Yang JW, Liu Q, Yue ZG, Hou JX, Afrashtehfar
KI. Digital workflow for full-arch immediate
implant placement using a stackable surgical guide
fabricated using SLM technology. J Prosthodont.
2021;30(8):645–50. Epub 2021 May 26. https://doi.
org/10.1111/jopr.13375.
Bolding SL, Reebye UN. Accuracy of haptic robotic
guidance of dental implant surgery for completely
edentulous arches. J Prosthet Dent. 2021;128:639.
https://doi.org/10.1016/j.prosdent.2020.12.048.
Vieira DM, Sotto-Maior BS, de Barros CAV, Reis
ES, Francischone CE. Clinical accuracy of flapless
computer-guided surgery for implant placement in
edentulous arches. Int J Oral Maxillofac Implants.
2013;28(5):1347–51. https://doi.org/10.11607/
jomi.3156.
Block MS, Emery RW, Lank K, Ryan J. Implant
placement accuracy using dynamic navigation. Int J
Oral Maxillofac Implants. 2017;32(1):92–9. https://
doi.org/10.11607/jomi.5004.
Block MS, Emery RW, Cullum DR, Sheikh A. Implant
placement is more accurate using dynamic navigation.
J Oral Maxillofac Surg. 2017;75(7):1377–86. https://
doi.org/10.1016/j.joms.2017.02.026.
 Digital Workflows in Full Arch
Implant Prosthodontics
4
Faraj Edher, Sundeep Rawal, and Saj Jivraj

Abstract data, CBCT imaging, facial scans, adjunctive

photography, and the use of surgical guides,
Treatment of edentulous patients with implant-­
CAD/CAM, and digital impressions.
supported restorations presents significant
Additionally, the chapter describes the use of
challenges for clinicians in meeting high
different types of guided implant placement
patient expectations for aesthetics, phonetics,
and the functional verification process and
form, and function. With the introduction of
provides an in-depth overview of the digital
innovative digital technologies into clinical
workflows in full-arch implant prosthodontics
practice, the delivery of implant-borne pros-
and highlights the benefits of these
thetics has been significantly advanced. This
technologies for both clinicians and patients.
chapter describes the six phases of the digital
workflow, namely, preliminary digital data
The delivery of tooth- and implant-borne
acquisition, treatment planning in software,
prosthetics has been significantly advanced by
surgical execution with guidance, definitive
the rapid introduction of innovative digital
data acquisition, functional verification, and
technologies into clinical practice. These
delivery of the definitive restoration. We high-
technologies allow for greater ease, cost
light the benefits of digital technologies,
efficiencies, and improved workflows. When
including precision, predictability, cost and
detailing what is commonly known as the digital
time savings, and improved patient outcomes.
workflow, the process can be defined by six
The chapter also covers specific aspects of the
distinct phases:
digital workflow, such as obtaining IOS scan
1. Preliminary digital data acquisition.
F. Edher 2. Treatment planning in software.
Digital Dentistry Institute, BC Dental Study Club, 3. Surgical execution with guidance (and
University of British Columbia, immediate load provisional prosthetics).
Vancouver, BC, Canada
4. Definitive data acquisition.
S. Rawal (*) 5. Functional verification.
Implant Support Services, Aspen Dental,
Chicago, IL, USA 6. Delivery of definitive restoration.
The Digital Dentistry Institute, Orlando, FL, USA
S. Jivraj
Anacapa Dental Art Institute, Oxnard, CA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 101
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_4
102
4.1 Preliminary Digital Data
Acquisition
Preliminary digital data acquisition is the entry
point into an entire ecosystem of digital work-
flows that result in precision, predictability, and
cost and time savings that in turn create more
comprehensive affordable solutions for patients.
This phase consists of:
1. Obtaining iOS scan data.
2. CBCT imaging.
3. Facial scans.
4. Adjunctive photography or videography if
needed.
Intraoral scanning is one of these
technologies that has significantly increased
the exactness of measurement for the digital
planning of patient cases. It has streamlined
both the gathering of diagnostics and the
predictability of results. However, intraoral
scanners and digital impression systems are
much more than just data acquisition. The
application of intraoral scanning and the digital
workflow is also highly impactful in dental
Fig. 4.1 (a) Facial scan.
a b
(b) Facial scan
combined with intraoral
scan
F. Edher et al.
implant therapies, especially fixed full-­ arch
modalities, enabling the clinician to execute
prosthodontically driven treatment plans with a
reduced number of procedures. The information
collected by intraoral scanners can all be
managed through software tools, permitting
the technician to create virtual master models
that contain all essential information [1].
Highly valuable ingredients to successful
outcomes then begin with a distinct coordination
between the surgical and the prosthodontic treat-
ment. The initial evaluation of the patient includ-
ing the digital acquisition of facial aesthetics,
digital iOS scans with digital intraoral jaw rela-
tionship records, and any adjunctive photo-
graphic images are then merged in a software
with radiographic analysis utilizing three-­
dimensional CBCT scanning.
All data including facial scans and intraoral
digital impressions are then transferred to CAD/
CAM software (Fig. 4.1a, b) which allows for
digital smile design. This is the process of identi-
fying the position of teeth and supporting struc-
tures based on aesthetics and function in relation
to the existing facial and intraoral soft tissue and
bone anatomy [2].
4 Digital Workflows in Full Arch Implant Prosthodontics
4.2 Treatment Planning
in Software
Providing clinicians with comprehensive
software tools to transform the smiles of their
patients, digital applications are wholly changing
the dental profession. The impact of technology
on the delivery of care has enabled clinicians to
be increasingly more analytical and meticulous
in planning and rigidly focused on the predict-
ability of outcomes.
There is no question that the impact of digital
technology in a dental practice has grown signifi-
cantly. Marinello states that virtually all current
clinical and technical prosthodontic procedures
can be supported by new digital processes and
that communication between dentist, surgeon,
dental technician, and patient has become mark-
edly faster and more efficient. Most clinicians
who have embraced the complete digital regi-
ment also realize increased profitability as a
result of streamlined efficiency. The technology
has touched planning, designing, and manufac-
turing of surgical guides, provisionals, as well as
fixed and removable definitive restorations. In
some cases, the digital technology drives every
phase of the treatment plan from diagnosis to
delivery.
Fig. 4.2 Data manipulated in digital planning software
103
Patients also benefit substantially from the
digital revolution. Along with less time spent in
the dental chair, procedures are less invasive, and
costs to the doctor are generally passed to the
patients, resulting in availability of care to a
wider range of patient populations. Patients feel
they have some participation in the planning of
their treatment, positively influencing the dentist-­
patient relationship, the acceptance of care, and
satisfaction with the results.
Designing a smile that a patient can preview in
advance of treatment has become a critical tool in
case acceptance, and full-arch therapy is no
exception. Clinicians recognize that emotional
factors impact treatment planning and, with the
assistance of software, can now incorporate intra-
oral scanning with 2D images and videography to
overlay a restorative plan on a patient’s photo-
graph, providing a glimpse of what can be
expected from treatment (Fig. 4.2) [3]. From the
2D proposed design, utilizing intraoral scanning
to create stereolithic files and cone beam CT, the
design can be translated to a three-dimensional
design in various software, which can then be
shared with the patient (Fig. 4.3). Patient confi-
dence and satisfaction are both increased when
the scanning and design software invite them
more intimately into the planning process.
104
Fig. 4.3 Digital mockup
4.3 Surgical Execution: Guided
Implant Placement
Once the proposed design is approved by the
patient, the same data can be imported into dental
implant planning software to determine the posi-
tion of dental implants. This is beneficial because
digitally planning the treatment for the placement
of dental implants is most effective when the
planning is prosthetically driven [4]. This allows
three-dimensional precision in placement of the
implants which in turn makes prosthetic fabrica-
tion much easier. The implant-placing clinician
then incorporates the appropriate files from the
planning software into the guided modality of
choice. Three types of guided implant placement
are currently used in dentistry: static guided sur-
gery with a printed resin or laser sintered metal
guide, dynamic camera-based navigation appli-
cations, and robot-assisted dental implant
placement.
The onset of virtual planning has significantly
advanced freehand surgical procedures, but the
concept of guided surgery, which led to camera
navigation and eventually robotic guidance, has
enhanced the processes utilized for precise place-
ment of implants. It has also significantly reduced
the risk of damage to vital anatomical structures
F. Edher et al.
such as nerves and neighbouring teeth.
Additionally, guided implant placement opti-
mizes implant position in relation to the pros-
thetic requirements by engaging more bone,
leading to primary stability for immediate load-
ing [5]. Indeed, as the accuracy of surgical
implant placement has been shown to greatly
influence prosthetic results, the precision afforded
by a range of digitally based guidance technolo-
gies has been credited with enabling restoratively
optimized dental implant procedures [6–9].
Stereolithographic static guides are perhaps the
prevalent form of surgical guidance for implants
[10]. Their clinical use, however, can be limited
by both manufacturing and positioning errors, as
well as by fracture or fabrication time, thus
potentially increasing time to treat a patient.
Moreover, static guides do not permit real-time
changes to the treatment plan in response to sur-
gical conditions while still providing guidance to
the clinician [11–15].
Unlike the fixed protocols dictated by static
stereolithographic resin or laser-sintered metal
surgical guides, digital capabilities have emerged
that allow dynamic intraoperative adjustments
[16–18]. The first available dynamic systems pro-
vided “navigation,” characterized by real-time
visual feedback. With navigation, the operator
4 Digital Workflows in Full Arch Implant Prosthodontics
manually matches the current position of a drill
intraorally with the plan model derived from cone
beam computed tomography (CBCT) scans of the
patient, and this is viewed on a monitor [18].
Navigation systems provide information on drill
deviation with respect to position or depth; how-
ever, unlike with static guides, there is no physical
prevention against excursions from the prescribed
treatment plan. Therefore, navigation may still be
considered an augmented “freehand” approach
that is dependent ultimately on the fine motor skill
of the operator (Fig. 4.4) [17, 18]. As mentioned,
guided dental implant placement has been evolv-
ing since the development of physical static
guides as far back as 2004 (which are still viable
in practice today although with less flexibility
than the current navigational and robotic options)
[19]. According to Block and Emery, who are pio-
neers in the use of dynamic navigation, control of
the depth and angulation of implants became
more predictably accurate, surgeons could more
consistently avoid the inferior alveolar nerve, and
flap mobilization could be minimized to promote
a less invasive procedure for the patient [20]. The
use of navigation assists the case collaboration
between the surgical and restorative clinicians in
integrating the virtual plan to the orchestration of
the treatment, thereby enabling the achievement
of a high level of patient-specific results. Dynamic
navigation has been widely adopted because it is a
flexible, time- and cost-effective workflow; how-
ever, as Block and Emery further indicate, the cli-
nician must undergo a learning curve to gain
proficiency and will need to factor in training and
simulation [20].
A new class of surgical dental technology,
robotic-assisted dental surgery (RADS), offers
intriguing novel functionalities. One of these is
the concept that, in addition to providing the audi-
tory and visual inputs of navigation, RADS is
Fig. 4.4 Navigation-guided surgery
105
capable of providing physical guidance through
haptic feedback. Robotic haptics function by pro-
viding directional and proportional guidance
forces and constraining instrumentation trajectory
in accordance with the prescribed surgical plan.
Robotic surgical guidance has been in a state of
continual refinement since its introduction in
2017. Because it is still in its infancy, numerous
multi-centre evidence-based studies will be
required to produce the anticipated superior data
outcomes. Robotic guidance brought the term
“haptic” into the surgical vocabulary. Haptic
refers to physical guidance in addition to visual
and auditory guidance during implant surgery; the
software program utilizes a CBCT scan of the
patient and allows the 3D planning of ideal
implant positioning based on bone availability,
biomechanical load, and the design of the defini-
tive prostheses. The robotic assistance then pro-
vides the surgeon with physical guidance of the
drills to the desired position, angulation, and
depth. When the orientation is accurate to the
plan, there is no robotic (haptic) resistance; if the
drills deviate, the robot will constrain the tool axis
to the planned orientation. Haptic refers to the
surgeon experiencing a vibrating resistance to the
normal sensations of drilling or implanting [21].
While static, navigational, and robotic guides
all provide valuable digital assistance in achiev-
ing aesthetic, functional outcomes, the future of
robotic guidance promises to achieve the highest
degree of accuracy. Static guides run the risk of
fracture and can impede the clinician’s visibility
as well as access for irrigation to the osteotomy
site; moreover, it is impossible to adjust the actual
plan during the surgical procedure and still per-
form a guided surgery. Intraoperative navigation
allows for clinician adjustments and provides
real-time visual information through a display,
although there tends to be a more rigid adherence
to the digital plan. Furthermore, the procedure
that is performed is essentially freehand with no
physical boundary. Haptic guidance currently
promises to provide the best adherence to the
plan as it originates in the minds of the
clinicians.
One case that highlights the application of
preliminary digital data acquisition, treatment
106
planning in software, and surgical execution
through guidance is presented below.
A male patient presented with classic
ectodermal dysplasia, the congenital anomaly
caused by a single abnormal gene or pair of
abnormal genes [22]. The typical malformation
of the alveolar ridge, bone deficiency, and
absence of tooth buds were evident (Fig. 4.5).
Maxillofacial rehabilitation of adults inflicted
with ectodermal dysplasia is most successfully
accomplished through therapeutic protocols uti-
lizing osseointegrated dental implants and
advanced ceramic prosthodontics to provide aes-
Fig. 4.5 Intraoral view, patient with ectodermal dysplasia
Fig. 4.6 Digital planning of patient in Fig. 4.5
F. Edher et al.
thetically pleasing smiles [23]. The treatment
plan for this patient was for implementation of a
definitive prosthesis in the maxillary arch built on
four implants—two in the anterior aesthetic zone
and two posterior tilted implants placed adjacent
to the anterior wall of the sinus (Fig. 4.6).
A fully integrated digital design was created
focusing on the patient’s desired outcomes of
creating a highly aesthetic, natural-looking smile
with ideal form and function as close to a natural
dentition as possible. The smile design created
using 3Shape design software and surface scan-
ning images were merged with STL and CBCT
files to engineer a virtual surgical plan, and then
a pre-manufactured screw-retained fixed provi-
sional restoration was fabricated (milled PMMA
manufactured on Zirkonzahn 5 axis mills) that
would function as the basis for the desired result
(Figs. 4.7 and 4.8). Robotic guidance was
employed to ensure the surgeon could make real-­
time plan adjustments if the bone or soft tissue
contraindicated the treatment plan. The provi-
sional was already prepared with one of the ante-
rior abutments embedded to facilitate alignment
with the remaining implants (Fig. 4.9). The
patient eventually was restored in both the max-
illa and mandible with four implants in each arch
4 Digital Workflows in Full Arch Implant Prosthodontics
to create a functional, aesthetic smile that was
expected to be enduring (Fig. 4.10).
The above case mentions immediate loading
during the surgical execution phase with a full-­
arch fixed provisional prosthesis. In the mid-­
1990s, implantology science was substantially
streamlined through experimentation with imme-
diate loading of dental implants. A significant
development was the shifting of focus to a con-
version prosthesis, fabricated to serve as a proto-
type of the definitive prosthesis. This innovative
approach aided in the stabilization of implants in
healing bone and enabled patients to have both
Fig. 4.7 Digital planning for surgical guide
Fig. 4.8 Digital planning for provisional
107
immediate aesthetic gratification and a more nat-
ural return to function after surgery (Fig. 4.11).
The refinement of the immediately loaded
conversion prosthesis and the development of
protocols to ensure longevity had far-reaching
impact even beyond increased patient accep-
tance. The establishment of occlusion for the
final restoration was always a primary concern,
and patients wearing a conversion prosthesis for
a minimum of 3 months afforded the clinician an
opportunity to evaluate and record a highly pre-
cise occlusal relationship. Models of the existing
conversion prosthesis could be articulated against
the cast of the opposing dentition. The master
cast with the conversion prosthesis in place was
also articulated against the same opposing denti-
tion model (Fig. 4.12). The stone cast of the con-
version prosthesis then served as an ideal
prototype for the final prosthesis [24].
The advantages of digital workflows have also
impacted the immediate conversion protocols and
possibilities. Utilizing guided implant placement,
the clinician and lab team can accurately predict
the final position of where the implants would be
placed, allowing for more predictable methods for
fabricating the provisional prosthesis.
Using virtual planning software, a mucosa-­
borne static guide can be planned for the accurate
placement of fixation pins. The same fixation pin
108
Fig. 4.9 Provisional prepared with provisional abutment
embedded
Fig. 4.10 Implant-supported restorations for patient in
Fig. 4.5
Fig. 4.11 Provisional prosthesis in maxilla
Fig. 4.12 Cross-mounting of provisional prosthesis to
transfer incisal edge position, occlusal plane, and occlusal
relationships
F. Edher et al.
position can be integrated into the design of addi-
tional bone reduction and implant placement
static guides, in addition to a prefabricated provi-
sional prosthesis with access holes premade to
allow for intraoral pickup of the temporary cylin-
ders after implant placement. The prefabricate
provisional prosthesis can reduce the time needed
during the chairside conversion as it is designed
without flanges and a convex intaglio surface.
This multi-component system depends on the
accurate positioning of the fixation pins to ensure
all other elements are correctly positioned based
on the planning (Figs. 4.13, 4.14, and 4.15) [25].
Fig. 4.13 Digitally generated surgical guide
Fig. 4.14 Digitally generated bone reduction guide
4 Digital Workflows in Full Arch Implant Prosthodontics 109

Fig. 4.16 Intraoral view of bone reduction guide with

adjusted bone

Fig. 4.15 Digitally generated provisional

A challenge when depending on fixation pins

to seat different components is in correctly
­repositioning the fixation pins. Stackable guided
systems overcome this challenge as the guide is
designed to have a base component that is posi-
tioned and secured with fixation pins, onto which
other components can be attached. For instance, a
soft tissue-supported guide can initially be used Fig. 4.17 Intraoral view of implant placement guide
to position the base and place the fixation pins.
Afterwards, the soft tissue-supported guide can
be detached from the base, and a bone reduction
guide placed. This can be followed by removing
the bone reduction guide and placing an osteot-
omy guide that connects to the base, and finally a
prefabricated provisional prosthesis can be posi-
tioned in place onto the base guide with premade
holes to allow for chairside conversion and
pickup of the abutments to the prosthesis
(Figs. 4.16, 4.17, and 4.18) [26, 27].
However, a major limitation of the stackable
guide system is intrinsic in its multiple templates Fig. 4.18 Intraoral view of digitally designed and milled
secured through the same anchor pin base sites and provisional
the related errors that may accumulate during their
positioning. Static guided surgery accuracy is Dynamic guidance can also be utilized to
related to type of support, with tooth-supported create workflows for effective immediate
template more accurate than tissue-supported. conversion. Pozzi et al. describe a method where
Bone-supported template are the least accurate dynamic guided protocols are utilized to place
and had the highest degree of surgical invasiveness the dental implants based on virtual planning but
because of the need to raise a large full-­thickness also to create prosthetic guide pin preparations in
flap to seat the guide on the bone surface [28]. the bone. These prosthetic guide pins are digi-
110
tally designed as attachments of the prefabricated
prosthesis to be aligned and fit three to four cor-
responding bone recipient sites that are planned
as “mini-implants”, allowing for the accurate
positioning of a pre-fabricated prosthesis
designed with inserts that fit into the guide pin
preparations [28].
The above described methods all utilize a
prefabricated provisional prosthesis with holes
pre-­designed based on the planned position of the
dental implants. The pickup and conversion pro-
cess is still required intraorally to allow for the
fabrication of a fixed provisional prosthesis.
However, as guided implant placement accuracy
improves, there have been reports of pre-­
fabricated bars and provisionals being made
using 3D-printed models with the planned
implant positions, to allow for the immediate
insertion of a full-arch implant-supported provi-
sional prosthesis immediately after implant
placement. The risks associated with this work-
flow are that if there are any discrepancies
between the implant planning and the final posi-
tion of the implants, the pre-fabricated prosthesis
will not fit or will not achieve a passive fit [29].
4.4 Definitive Data Acquisition
The traditional treatment plan commences with
extremely comprehensive analyses of the
patient’s face, converting multi-angular photo-
graphs into computer-generated results that con-
sider midline, lip lines, and even the distance
between the eyes and mouth [3]. In addition to
drawing very specific guidelines into the restor-
ative plan for the clinician, contemporary
software affords the patient a preview of the
­ 4.21). When the accuracy of this technique was
result, which often may be the chief motivational
factor for acceptance of treatment (Fig. 4.19).
As discussed, an exciting innovation occurs
when these digital technologies are utilized in
initial diagnosis, treatment planning, and surgical
execution of full-arch fixed implant therapies as
the digitally designed smile can then be utilized
in the definitive phase of therapy. Software allow
for the provisional prosthetics to be merged with
new digital data and translated to harmonize the
F. Edher et al.
position of the teeth with the patient’s face [3].
Software of this nature aids in positioning maxil-
lary central incisors, the occlusal plane, and tooth
size and shape. Most importantly, because the
final prosthesis can be an exact fabrication of the
interim prosthesis, the patient is able to visualize
the aesthetics and approve the comfort and func-
tion of the prosthesis during the preliminary ther-
apy so that this can be easily translated to the
definitive therapy with high patient satisfaction.
The provisional prosthesis is therefore critical to
utilizing digital workflows that allow for more
efficient definitive data acquisition for the fabri-
cation of the final prosthesis.
One of the most common techniques in
definitive data acquisition is the double digital
scanning technique, which involves the
superimposition of the digital impression of the
provisional prosthesis to the digital impression of
the scan bodies. The provisional prosthesis digital
impression captures the prosthetic setup. The scan
bodies digital impression registers the implant
abutment positions and allows for capturing the
soft tissue and ridge. Superimposing these two
digital files requires maintaining stable common
reference points between the two scans. In some
cases, attached and stable mucosa such as on the
hard palate can be utilized as the common
reference. In situations where there is not enough
stable soft tissue to reliably superimpose and
merge the two digital scans, reference markers
can be utilized.
Several reference markers have been described
by clinicians. The most commonly used are fidu-
cial markers attached to the soft tissue on the pal-
ate or on keratinized soft tissue on the buccal
aspect of the mandibular ridge (Figs. 4.20 and
assessed, the superimposition showed that the 3D
implant deviations between the digital and con-
ventional stone casts were less than 90 μm. Based
on these findings, the digital scans led to a poten-
tially clinically acceptable virtual cast, which
made a complete digital workflow feasible.
This could decrease treatment time by making
the maxillomandibular interocclusal records
unnecessary and going from impression directly
4 Digital Workflows in Full Arch Implant Prosthodontics
Fig. 4.19 Digital software used to convey anticipated changes to patient
Fig. 4.20 Reference markers with provisional in situ for
scanning
Fig. 4.21 Reference markers in place with scan bodies
to prosthesis prototype try-in, followed by the
fabrication of the final prosthesis [30].
111
A similar method can be utilized at the time of
implant placement and immediate provisional-
ization if fixation anchor pins are utilized for the
guided system. The double digital scanning tech-
nique and the anchor pins allow for superimposi-
tion of the STL files from the two digital scans
regardless of the presence of keratinized mucosa
in the mandible. The anchor pins serve as fiducial
markers and facilitate the superimposition of the
two STL files. This leads to one master STL file
that is used for the CAD/CAM fabrication of the
PMMA prototype prosthesis in a complete digital
workflow [30].
An additional method utilizing scannable
impression pins has been described that allows to
have stable landmarks for the superimposition of
the multiple STL files from digital scans but does
not rely on landmarks placed on the soft tissue.
The scannable impression pin is hand tightened
on the multi-abutment which is a stable and
reproducible landmark on the ridge. This allows
for intraoral scanning at the time of the implant
placement or at any other time, making this tech-
nique possible in all clinical scenarios. The main
benefit of intraoral scanning after tissue healing
is the better adaptation of the definitive prosthesis
to the underlying tissue. Another advantage of
the complete digital workflow, including the
present workflow, is that it allows for complete
112 F. Edher et al.

new digital teeth setup, if required, using patient’s

existing interim prosthesis as a reference [31].
The main advantage of all these efficient
double digital scan protocols is that all the
required information for the fabrication of the
definitive prosthesis is acquired from the
immediately loaded provisional prosthesis. The
technique also allows for making
maxillomandibular records simultaneously with
the impression since all the diagnostic information
is provided within the provisional prosthesis.
Additional advantages of the current technique Fig. 4.22 Stereophotogrammetry markers in situ maxilla
are all related to the digital workflow. Firstly, it
may improve patient experience, removing the
need for conventional impressions and long
clinical procedures. Complete digital workflow
reduces lab time by eliminating certain
conventional lab procedures, such as fabricating
stone models, mounting, and articulating. It also
removed the need for teeth setups in wax and pro-
cessing the prostheses. These time efficiencies in
both clinical and laboratory procedures may be a
financial benefit for all parties involved, includ-
ing the patient [31].
Another technology that has gained in
prevalence in recent years is the use of
Fig. 4.23 Stereophotogrammetry markers in situ
stereophotogrammetry in fixed-full arch mandible
applications. Stereophotogrammetry is a
method of making precise measurements by
using reference points within photographs the combination of both stereophotogrammetry
without any contact with the measured object. and intraoral scanning enhances the overall
It was first proposed as a way to determine accuracy of capturing both hard and soft tissue,
misfit between dental implants and their making it an optimal solution (Figs. 4.22 and
frameworks and later found to be a suitable 4.23).
substitute for traditional impressions. Today,
technical advances have led to commercially
available stereophotogrammetry systems with 4.5 Functional Verification
high accuracy for both partially and completely
edentulous patients. This high level of accuracy Even though the digitally fabricated prototypes
can now lead to eliminating the need for a presented with accurate fit, a verification remains
verification jig after a final impression, making the standard process of the full-arch implant
the process more efficient while also retaining workflow reconstructions. This can be done in
all of the benefits mentioned for the double different ways such as intraoral splinting of abut-
digital scanning technique. However, one of the ments and then connecting analogues prior to the
limitations of stereophotogrammetry is that it pouring of a jig cast or similarly back-pouring the
still requires an intraoral scan to be taken for conversion prosthesis after connecting analogues.
accurately capturing the soft tissue. In this way, A digital alternative to verification is using the
4 Digital Workflows in Full Arch Implant Prosthodontics 113

STL data from a digital impression to fabricate a arch restorations in the coming years. New inno-
digitally designed milled or printed verification vations in resin technology along with
jig through a complete digital workflow. As men- advancements in hardware technology will allow
tioned previously, exciting innovations in stereo- clinicians to utilize 3D printing across all phases
photogrammetry may eliminate the need for of the fixed full-arch digital workflow including
verification of the spatial positioning of the diagnostics, provisionalization, and ultimately,
implants or abutments for full arch fixed therapy. definitive restorations.
However, today there is much more One case that highlights the application of the
accomplished with this verification step than just digital workflow through to definitive digital
verifying the spatial relationship of the implant acquisition, functional verification, and definitive
positions. In addition to this information, the phase of therapy is presented below.
verification also includes verifying tooth posi- A patient presents for treatment with existing
tion, vertical dimension of occlusion, jaw rela- maxillary posterior implants, previously osseoin-
tionship, form, and function, and this is tegrated but unrestored, and a periodontally fail-
accomplished by utilizing a prototype that is ing anterior dentition (Fig. 4.24). An intraoral
either milled or printed prior to fabrication of the scan of both the implants (using scan bodies) and
definitive prosthesis. The accuracy of fit of the the anterior teeth provided the laboratory with the
generated prosthesis prototype and a definitive necessary digital files to design posterior teeth
prosthesis is crucial for long-term success [32, that would harmonize with the anterior teeth
33]. Therefore, if a misfit of the PMMA proto- (Fig. 4.25). The same file was then sent for mill-
type prosthesis is found, the prototype can be ing or 3D printing to create the full-arch provi-
sectioned and re-luted intraorally, and the sional restoration. It is essential that the laboratory
adjusted prototype can be rescanned in the lab
and copy milled into the final prosthesis. As
always, the accuracy of fit of the prototype pros-
thesis is directly correlated to the accuracy of the
full-arch digital impression, and the complete
digital workflow without the need for a physical
cast removed the errors introduced with 3D print-
ing master casts and inserting implant analogues
which may incorporate additional errors [34].
Many patients today choose implant-­
supported dental solutions as, along with almost
instant gratification, they also provide psycho- Fig. 4.24 Patient with periodontally failing dentition and
posterior implants unrestored
logical security, increased self-confidence, more
secure chewing ability, and improved phonetics
and aesthetics [35]. Both the milling and print-
ing of prostheses have evolved, and current tech- 5
12
4 13
nology includes software that can simultaneously
create the substructure, veneer, and soft-tissue
replication in a single process. These manufac-
tured prostheses, if based on accurate clinical
recording and careful laboratory digitizing, can
deliver a true-to-nature smile that requires no
clinical adjustments [36]. Of note are innova-
tions in additive manufacturing or 3D printing
that will continue to make great strides as an Fig. 4.25 Intraoral scan and digital files for laboratory
optimal manufacturing solution for fixed full- restorative design
114
Fig. 4.26 Milled provisional ready to load additional
implants
Fig. 4.27 Occlusal view of milled provisional
Fig. 4.28 Anterior teeth extracted and anterior implants
placed
accurately digitizes the records in order to exactly
replicate what was presented clinically (Figs. 4.26
and 4.27) [35].
At the patient’s second visit, anterior teeth
were extracted, and additional anterior implants
placed (Fig. 4.28). Abutments were connected,
and then temporary cylinders were installed. The
provisional was screwed into the posterior
F. Edher et al.
Fig. 4.29 Implant supported provisional placed
implants, and the anterior implants were con-
nected to the digitally produced provisional pros-
thesis (conversion prosthesis protocol—the
immediate loading of a non-removable interim
prosthesis) (Fig. 4.29) [37]. The immediate load-
ing of a fixed transitional prosthesis allows for
adequate tissue protection and significantly ele-
vates the patient’s level of function and self-­
esteem immediately post-operatively [37].
After the appropriate healing time, intraoral
scanning of the provisional teeth, all sides, and
surfaces and in occlusion with the opposing den-
tition took place. The provisional prosthesis was
then unscrewed, and a material-based impression
was made of the implant positions. Along with
this one physical analogue step, a digital impres-
sion of the implants, both anterior and posterior,
using scan bodies was taken, and during the same
appointment, the master cast was fabricated and
mounted using the existing provisional, and then
scanning of the provisional on the master cast in
occlusion was accomplished using the intraoral
scanner. This entire body of data acquisition
which was made in one clinical visit provides the
body of information required for the laboratory
to produce the definitive prosthesis.
This is a case in which the entire treatment
plan from the collection of diagnostics to the
delivery of the definitive prosthesis was driven by
reliance on digital technology and resulted in an
effective functional and aesthetic solution that
was pleasing to the patient in a minimal number
of visits.
Digital implant dentistry workflows have
transformed the way in which care is delivered
from dentist to patient. Through the six phases of
the digital workflow, namely, preliminary digital
4 Digital Workflows in Full Arch Implant Prosthodontics
data acquisition, treatment planning in software,
surgical execution with guidance (and immediate
load provisional prosthetics), definitive data
acquisition, functional verification, and delivery
of definitive restorations, therapies have been
enhanced to meet the needs of patients in the
most optimal ways possible.
Acknowledgements Figures 4.20 and 4.21 provided by
Dr. Armand Bedrossian D.D.S.
References
1. Carlo M, Lorenzo S, Paolo B, Giovanni Z. Implant
digital impression in the esthetic area. J Prosthodont.
2019;28:536–40.
2. Coachman C, Calamita MA, Coachman FG,
Coachman RG, Sesma N. Facially generated and
cephalometric guided 3D digital design for complete
mouth implant rehabilitation: a clinical report. J
Prosthet Dent. 2017;117:577–86.
3. Coachman C, Calamita MA, Coachman FG, et al.
Facially generated and cephalometric guided
3D digital design for complete mouth implant
rehabilitation: a clinical report. J Prosthet Dent.
2017;117(5):577–86.
4. Horowitz J, Zuabi O, Machtei EE. Accuracy of a
computerized tomography-guided template-assisted
implant placement system: an in vitro study. Clin Oral
Implants Res. 2009;20(10):1156–62.
5. Witter G, Adeyemo WL, Schicho K, et al. Navigated
flapless transmucosal implant placement in the
mandible: a pilot study in 20 patients. Int J Oral
Maxillofac Implants. 2007;22(5):801–7.
6. Katsoulis J, Pazera P, Mericske-Stern R. Prosthetically
driven, computer-guided implant planning for the
edentulous maxilla: a model study. Clin Implant Dent
Relat Res. 2009;11(3):238–45.
7. Kosinski T. Proper preparation for prosthetically
driven implants: CBCT diagnosing and surgical pro-
tocol. Dent Today. 2017;36(6):56–9.
8. Younes F, Cosyn J, De Bruyckere T, et al. A random-
ized controlled study on the accuracy of free-handed,
pilot-drill guided and fully guided implant surgery
in partially edentulous patients. J Clin Periodontol.
2018;45(6):721–32.
9. Dano D, Stiteler M, Giordano R. Prosthetically driven
computer-guided implant placement and restoration
using CEREC: a case report. Compend Contin Educ
Dent. 2018;39(5):311–7.
10. Tahmaseb A, Wu V, Wismeijer D, et al. The accuracy
of static computer-aided implant surgery: a systematic
review and meta-analysis. Clin Oral Implants Res.
2018;29(suppl 16):416–35.
115
11. Sigcho López DA, García I, Da Silva SG,
Cruz LD. Potential deviation factors affecting
stereolithographic surgical guides: a systematic
review. Implant Dent. 2019;28(1):68–73.
12. de Almeida EO, Pellizzer EP, Goiatto MC, et al.
Computer-guided surgery in implantology: review of
basic concepts. J Craniofac Surg. 2010;21(6):1917–21.
13. D’Haese J, Ackhurst J, Wismeijer D, et al. Current
state of the art of computer-guided implant surgery.
Periodontol 2000. 2017;73(1):121–33.
14. Happe A, Fehmer V, Herklotz I, et al. Possibilities and
limitations of computer-assisted implant planning and
guided surgery in the anterior region. Int J Comput
Dent. 2018;21(2):147–62.
15. Kola MZ, Shah AH, Khalil HS, et al. Surgical
templates for dental implant positioning; current
knowledge and clinical perspectives. Niger J Surg.
2015;21(1):1–5.
16. Block MS, Emery RW, Lank K, Ryan J. Implant
placement accuracy using dynamic navigation. Int J
Oral Maxillofac Implants. 2017;32(1):92–9.
17. Stefanelli LV, DeGroot BS, Lipton DI, Mandelaris
GA. Accuracy of a dynamic dental implant navigation
system in a private practice. Int J Oral Maxillofac
Implants. 2019;34(1):205–13.
18. Mandelaris GA, Stefanelli LV, DeGroot BS. Dynamic
navigation for surgical implant placement: overview
of technology, key concepts, and a case report.
Compend Contin Educ Dent. 2018;39(9):614–21.
19. Marra R, Acocella A, Rispoli A, et al. Full-mouth
rehabilitation with immediate loading of implants
with computer-guided flap-less surgery: a 3-year
multicenter clinical evaluation with oral health impact
profile. Implant Dent. 2013;22(5):444–52.
20. Block MS, Emery RW. Static or dynamic navigation
for implant placement—choosing the method of
guidance. J Oral Maxillofac Surg. 2016;74(2):269–77.
21. Srivastava R, Jyoti B, Kushwaha S, Priyadarshi
PK. Computer aided navigation for predictable
dental implantology: a review. Natl J Integr Res Med.
2019;10(3):63–7.
22. Freire-Maia N. Ectodermal dysplasia. Hum Hered.
1971;21:309–12.
23. Petropoulos VC, Balshi TJ, Wolfinger GJ, Balshi
SF. Ectodermal dysplasia: an 11-year follow-up of
siblings with 2 implant treatment approaches. Implant
Dent. 2014;23(4):387–93.
24. Balshi TJ, Wolfinger GJ, Alfano SG, et al. Fabricating
an accurate implant master cast: a technique report. J
Prosthodont. 2015;24(8):654–60.
25. Makarov N, et al. Computer-assisted implant
placement and full-arch immediate loading with
digitally prefabricated provisional prostheses without
cast: a prospective pilot cohort study. Int J Implant
Dentistry. 2021;7:80. https://doi.org/10.1186/
s40729-­021-­00369-­0.
26. Baruffaldi A. A suggested protocol to increase the
accuracy of prosthetic phases in case of full-arch
model-free fully guided computer-aided implant
placement and immediate loading. Oral Maxillofac
116
Surg. 2020;24:343–51. https://doi.org/10.1007/
s10006-­020-­00849-­4.
27. Yang JW, et al. Digital workflow for full-arch
immediate implant placement using a stackable
surgical guide fabricated using SLM technology. J
Prosthodont. 2021;30:645–50.
28. Pozzi A, Hansson L, Carosi P, Arcuri L. Dynamic
navigation guided surgery and prosthetics for
immediate loading of complete-arch restoration. J
Esthet Restor Dent. 2021;33:224–36. https://doi.
org/10.1111/jerd.12710.
29. Lanis A, Alvarez del Canto O, Barriga P, Polido WD,
Morton D. Computer-guided implant surgery and full-­
arch immediate loading with prefabricated—metal
frame-work—provisional prosthesis created from a
3D printed model. J Esthet Restor Dent. 2019;31:199–
208. https://doi.org/10.1111/jerd.12458.
30. Papaspyridakos P, et al. Double full-arch implant
rehabilitation with monolithic zirconia. J Prosthodont.
2020;29:460–5.
31. Marinis A, et al. Digital workflow for double complete
arch zirconia prostheses utilizing a novel scan body. J
Prosthodont. 2022;31:4–8.
F. Edher et al.
32. Chochlidakis K, Romeo D, Ercoli C, Papaspyridakos
P. Complete digital workflow for prosthesis prototype
fabrication with the double digital scanning (DDS)
technique: a prospective study on 16 edentulous
maxillae. J Prosthodont. 2022;31:761–5. https://doi.
org/10.1111/jopr.13569.
33. Sinada N, Papaspyridakos P. CAD/CAM
verification for implant rehabilitation. J Prosthodont.
2021;30:651–5.
34. Papaspyridakos P, et al. Complete digital workflow
for full-arch implant rehabilitation. J Prosthodont.
2021;30:548–52.
35. Balshi TJ, Balshi SF. A new digital solution for
implant supported restorations. Inside Dental Technol.
2017;8(3):40–6.
36. Marchak CB. CAD/CAM-guided implant surgery
and fabrication of an immediately loaded prosthesis
for a partially edentulous patient. J Prosthet Dent.
2007;97(6):389–94.
37. Stephen P, Thomas B, Daniel S. Modifications of
existing prosthesis with osseointegrated implants. J
Prosthet Dent. 1986;56(1):61–5.
 3D Printing Protocols in Full-Arch
Reconstruction: A Complete
Workflow
Keith Klaus and Saj Jivraj
Abstract
The application of computer-aided design and
computer-aided manufacturing (CADCAM)
to full-arch implant rehabilitation has spawned
new digital workflows for prosthetic design
and manufacture. Technologies such as cone
beam computed tomography (CBCT), photo-
grammetry, intraoral scanning, facial scan-
ning, and 3D printing may eliminate many of
the steps used in traditional analog workflows.
As the treatment planning for full-arch implant
rehabilitation is highly complex, new work-
flows must allow clinicians to treat the patient
more efficiently and effectively; otherwise,
the workflows will not be utilized. Regardless
of the workflow chosen, the overall goal is to
manufacture a part that may be used during
treatment. 3D printing allows the clinician to
manufacture study models, surgical guides,
prosthetic try-ins, provisionals, etc. This chap-
ter outlines the use of 3D printing in full-arch
implant treatment to reduce cost, reduce time,
and allow for a more streamlined manufactur-
ing process.
K. Klaus (*)
Private Practice, Flowood, MS, USA
S. Jivraj
Anacapa Dental Art Institute, Oxnard, CA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_5
5
5.1 3D Printing in Dentistry
The combination of highly accurate manufac-
turing and a wide range of materials makes 3D
printing suitable to dentistry [1]. Charles Hull
first filed the patent for a 3D printer in 1986
[2], originally for rapid prototyping. Since
then, the technology has progressed tremen-
dously. Making its way into medical and dental
applications, 3D printing has become accepted
by surgeons and restorative dentists across the
globe. Many practitioners are reaping the ben-
efits of a more cost-­effective and time-saving
process over traditional methods [3]. Being an
additive manufacturing process, 3D printing
involves layering resin materials one by one
until the part is completed. With subtractive
techniques, such as milling, material is
removed from a block by a bur rotating at high
speeds. The milling process is then limited to
the diameter, shape, and length of the bur being
used. 3D printing reduces the amount of wasted
material, generates less noise, and cuts down
on labor costs as compared to subtractive man-
ufacturing. 3D printing is also much faster than
milling [4]. For dental applications, the main
differentiating factor is the material properties
of the printable resin compared to a solid pre-
formed puck.
The advent of 3D printing continues to yield
more efficient and cost-effective manufacturing
of dental prosthetics. Where subtractive manufac-
117
118
turing techniques such as milling have dominated
the realm of full arch provisional prosthetics,
additive techniques with 3D printers and their
newly upgraded resins are gaining in popularity at
a rapid rate. The most common additive technol-
ogy in 3D printing for dentistry is stereolithogra-
phy with vat polymerization, whereby resin is
contained in a vat, and a light source under the vat
polymerizes the resin in incremental layers. The
light source may be a laser source (SLA) or digital
light processing (DLP). If a print is to be used as
a definitive prosthesis, the 3D-printed materials
must exhibit the following characteristics as pub-
lished by Schweiger et al.:
1. The material must have the ability to with-
stand high mechanical stress and the chemical
processes inside the oral cavity.
2. The material must not release harmful chemi-
cals while also having smooth surface con-
tours to prohibit bacterial deposits.
3. The production must be practical, cost-­
effective, and precise at the micrometer
level [5].
5.2 3D Printing Resins
Recent improvements in resins and printing
technologies have introduced materials suit-
able to implant-supported prosthetics. These
new age resins are highly accurate in marginal
fit. They also offer esthetics that rival their
milled resin counterparts. A study conducted
by Park et al. [4] showed that a printed pros-
thesis had a smaller internal gap than a milled
prosthesis, given that ideal parameters were
utilized for the print. This finding is likely due
to the fact that a milled product is limited to
the bur size and shape being used. The new-
age 3D printers along with their esthetic and
functional resins has allowed the ability to 3D
print surgical study models, surgical guides,
try-in prosthetics, and provisional prosthetics
for full-arch rehabilitations. Perhaps, the only
K. Klaus and S. Jivraj
downside to 3D printing resins compared to
milling resins is the lack of current clinical tri-
als [6].
5.3 Surgical Study Models
Surgeons benefit greatly from having presurgical
study models printed, sterilized, and available for
reference during surgery. The data gets seg-
mented from CBCT imaging and saved as an .
STL file. This file then is easily printed on a 3D
printer and may be used for planning the full-arch
surgery, as landmarks are easily recognized.
These resins are available in a variety of colors.
5.4 Radiopaque Resin for Try-In
prosthesis
Complete edentulous cases require using the
dual scan technique [7] in order to properly align
data to make a surgical guide. As there are no
teeth present to serve as common references
between a digital mesh file of the jaw and the
CBCT scan of the jaw, an appliance is required
that may relate the two files together. Partial
edentulous cases and cases with a lot of metal
restorations may also benefit from a dual-scan
technique. The dual-scan technique involves cre-
ating a removable appliance, often a denture,
with radiopaque fiducial markers. The intaglio of
the appliance must be relined with a radiopaque
material such as Blu-Mousse® PVS bite registra-
tion material. The fiducial markers are often
radiopaque glass beads and may be attached to
the denture through stickers or resin adhesive.
The patient receives a CBCT scan with the
altered prosthesis in the mouth, and a separate
CBCT scan on just the prosthesis is taken. The
files are now able to be accurately aligned and
may be used for surgical guide design. New radi-
opaque resins allow for a printed try-in denture
to become the fiducial as the radiopaque align-
ment object, much like a barium sulphate dupli-
5 3D Printing Protocols in Full-Arch Reconstruction: A Complete Workflow
Fig. 5.1 Radiopaque try-in visible on a CBCT
cate denture [8]. The CBCT is taken with the
radiopaque try-in fully seated on the respective
arch, as shown in Fig. 5.1. There is no need to
take a second CBCT as the resin is easily detect-
able, and the design is already in the CADCAM
software to make the alignment predictable. The
reline is also not necessary so long as there is
intimate contact with the gingiva by the intaglio
of the try-in prosthetic. This benefit reduced cost
and removes a step in the workflow. Another
benefit is the ability to digitally design and 3D
print the try-in denture, lowering costs associ-
ated with lab processing fees.
5.5 Surgical Guide Resin
3D printing surgical guides allow for more
complex guide manufacturing while also reduc-
ing cost to manufacture compared to milling
surgical guides. Once again, burr size limits the
ability to mill certain shapes. With 3D printing,
higher-­resolution parts are easily achieved. In
regard to surgical guides, the appliances may
119
have a more intimate fit while also allowing for
more definition for parts and pieces such as
guide sleeves and transverse pin sleeves. Most
surgical guide resins are autoclavable and
therefore integrate well into aseptic surgical
techniques.
5.6 Hybrid Ceramic Resin
Printing resin manufacturers have begun to
develop hybrid resins incorporating ceramic filler
to improve material properties. These new hybrid
ceramic resins are significantly stronger than the
earlier resins that were marketed purely for pro-
visional restorations. Many of these ceramic res-
ins have obtained approval for final restorations.
The improvement in material properties, namely,
fracture toughness, has allowed for the produc-
tion of same-day immediate load full-arch pros-
thetics. Figures 5.2 and 5.3 show an immediate
load mandibular full-arch prosthesis printed on a
SprintRay 55S Pro (Pro 55S, Sprintray, Los
Angeles, USA) in OnX Tough resin (OnX Tough,
120
Fig. 5.2 Printed mandibular immediate provisional
Fig. 5.3 Complete denture opposing printed mandibular
immediate prosthesis
SprintRay, Los Angeles, USA) hybrid ceramic
resin. Print time often is under 30 min, and it
takes even less time to cure, stain, and glaze.
Studies are needed to compare the material prop-
erties of these hybrid ceramic printed prosthetics
to their milled PMMA counterparts.
5.7 Pretreatment Planning
for a Successful Digital
Alignment
The clinician must follow proper surgical plan-
ning beginning with prosthetic design. Patients
undergoing full-arch treatment present as com-
K. Klaus and S. Jivraj
pletely dentate, partially dentate, or completely
edentulous. Regardless of the protocol used for
provisionalization, a proper and complete surgi-
cal and prosthetic workup is mandatory. The
prosthesis is almost always designed in
CADCAM software prior to surgery. There are
numerous digital workflows available; however,
most workflows require the alignment of the pre-
and post-surgical plans in order to digitally trans-
fer the prosthetic design so that it may be
manufactured. This alignment will use a common
reference point from the pre- and post-surgical
scans. Reference points are qualified into two
groups: hard and soft reference points. Hard ref-
erence points most commonly are existing teeth,
implants, temporary anchorage devices (TADs),
or composite resin. Soft tissue reference points
are almost always keratinized gingiva due to their
lack of movement. Using soft tissue reference
points can be extremely difficult to use on day of
surgery due to bleeding and inflammation.
Intraoral scanners have difficulty scanning a
bloody field. The rugae of the palate make a nice
point for reference; however, the mandible lacks
this anatomy. For these reasons, the most predict-
able common reference points will be hard refer-
ence points. Figures 5.4 and 5.5 show alignment
using hard and soft tissue reference points,
respectively. It is important to note that the blue
mapping corresponds to 0 deviation between
scans. The alignment was done in Exocad
CADCAM software (Exocad GmbH, Darmstadt,
Germany). Following alignment, the technician
completes the digital design, making changes to
tooth position if needed. It is important to ensure
a convex intaglio surface. Once the design is
complete, the prosthesis design file is sent to the
3D printer for printing. It is imperative that the
surgical and prosthetic team understand which
landmarks will be used as reference before sur-
gery; otherwise, alignment may be extremely dif-
ficult and the outcome will suffer.
5 3D Printing Protocols in Full-Arch Reconstruction: A Complete Workflow 121

Fig. 5.4 Digital alignment using soft tissue references in EXOCAD

Fig. 5.5 Digital Alignment of photogrammetry data using hard reference points pre- and post-op

5.8 Edentulous and Dentate
Workflows
Workflows for dentate and edentulous cases are
handled differently. If a patient is dentate, there is
opportunity to leave several teeth in order to align
using hard reference points. When possible, it is
recommended to keep teeth that may help in pre-
serving the vertical dimension of occlusion
(VDO). For these reasons, dentate workflows may
be easier from an alignment and design perspec-
tive. An edentulous case will obviously require
something other than teeth for alignment. In these
edentulous cases, utilizing a reference denture
may prove very beneficial. The reference denture
may either be a patient’s existing denture or a
printed denture out of try-in resin. Much like an
analogue conversion, the multiunit abutments
(MUAs) are fitted with healing caps. The reference
denture is then relieved so that it seats completely
over the healing caps. A wash impression is com-
pleted, and an intraoral scanner is used to scan the
relined reference denture in 360°. The opposing
arch is then scanned. The relined denture is then
reinserted in the mouth, and the bite registration is
recorded via intraoral scanner. The relined denture
captures both the soft tissues and hard reference
points in the MUA healing caps. The single 360
reference denture scan may be split in the
CADCAM software for use in prosthetic design,
yielding both tooth position and a gingiva scan. A
very important benefit of using the reference den-
ture workflow allows for the operated jaw record
to be scanned outside the mouth, making the scan
much easier. The restorative dentist is also able to
evaluate the proposed tooth position, VDO, mid-
line, etc. of the reference denture prior to design-
ing the day of surgery immediate prosthesis.
122
5.9 Photogrammetry
Being introduced by Jemt and Lie in 1994, pho-
togrammetry’s use in full-arch implant rehabilita-
tions has given practitioners a new tool for digital
acquisition of implant positions. Through the
decades, the technology has improved vastly.
Jemt and Lie only described the use of the tech-
nology for extraoral use. At the time, their appli-
cation was to use photogrammetry to analyze
implant framework distortion [9]. Today, we are
able to obtain implant position records intraorally
in a matter of minutes, greatly reducing chair-­
time. Photogrammetry allows for a precise
implant location, essentially eliminating the need
for a physical impression. It has been well docu-
mented that intraoral scanning alone introduces
inaccuracies when scanning across the full arch.
While many methods are utilized to reduce this
error, the most accurate workflows still very
much depend on the operator and are widely
deemed as unsuitable. Photogrammetry has
proven to accurately record implant positions
while also improving patient and dentist satisfac-
tion. Work time is also reported to be reduced
[10, 11]. The technology uses fiducials that are
seated on the implant multiunit abutment (MUA)
much like scan bodies. The photogrammetry
device then scans these fiducials and records the
data in an extensible markup language (XML)
file. This data acquisition does not include any
surface topography. The implant position data
stored in the .XML file is used to export a geom-
etry consistent with an existing implant compo-
nent such as MUAs, healing caps, cylinders, etc.
These geometries are then aligned to an intraoral
scan, thus combining the datasets. The CADCAM
software may then complete the prosthetic digital
design using the intraoral scan data for the jaw
scans and using the photogrammetry data for the
implant positions. Utilizing photogrammetry in
this manner allows for the design and manufac-
ture of an implant supported fixed dental prosthe-
sis (FDP) with a passive fit. To verify accuracy,
K. Klaus and S. Jivraj
Sinada and Papaspyridakos described a process
to digitally design and mill a verification jig uti-
lizing the photogrammetry datasets [12].
Photogrammetry will continue to grow in accep-
tance as companies are quickly bringing the
devices to the full-arch market.
5.10 Printed Conversion
Prosthesis
There are numerous advantages to immediate
loading a fixed provisional prosthesis, the con-
version prosthesis [13]. A traditional conversion
prosthesis begins as a denture, either an existing
denture if adequate or an immediate denture if
the patient is dentate. This denture is then con-
verted to the fixed provisional by being bonded to
implant temporary cylinders using acrylic resin.
The process requires premade holes in the den-
ture whereby the cylinders may fit with a gap in
which to flow acrylic resin. This method of fabri-
cation is not without its complications. Some
common complications of manual conversions
include poor bonding to the denture base and
contamination of the acrylic resin used for bond-
ing [14]. In a printed conversion workflow, the
prosthesis is designed and manufactured after
implants have been placed. The designed pros-
thesis is then either sent to a printer or a milling
machine. Many practitioners follow a model
whereby a milled polymethylmethacrylate
(PMMA) provisional is delivered the day of or
day after implant insertion. As milling takes lon-
ger and costs more to manufacture compared to
printing, the ability to print the immediate pros-
thesis would cut down on time and cost. Since
there are no predrilled holes, strength is improved
in a conversion prosthesis that is monolithic and
not attached to cylinders with acrylic resin. With
either method of manufacturing, the restorative
dentist has the opportunity to make alterations to
the prosthetic design following surgery. An alter-
native to milling the provisional is 3D printing.
5 3D Printing Protocols in Full-Arch Reconstruction: A Complete Workflow
As discussed previously, 3D printing has vast
cost and time savings when compared to milling
PMMA. Until recently, the available printed res-
ins were prone to fracture and therefore not
dependable to withstand the occlusal forces dur-
ing the healing phase of full-arch implant ther-
apy. Current resins are approaching the strength
of milled PMMA.
5.11 Prototype Provisional
Prosthesis
Following the healing period, the converted pros-
thesis often requires revision prior to proceeding
to the final restoration. It is imperative to revisit
tooth position, shape, shade, and gingival con-
tact. The following records are acquired for pre-
dictable prosthetic design:
1. 360-degree prosthesis scan if there were
chairside alterations to the intaglio
2. Gingiva scans
3. Opposing jaw scans
4. Bite registration scans
5. Photogrammetry
6. Photography
7. CBCT
These records may be obtained in one visit,
thus combining many of the traditional analogue
full arch workflow appointments. The lab takes
this data and creates a new prototype provisional
prosthesis. At this phase in treatment, a printed
prototype prosthesis has significant benefits.
Reducing the manufacturing time and overall
cost affords the restorative dentist to offer multi-
ple prototypes. Once the prototype prosthesis is
approved by the patient, the lab only needs to
copymill the design in the material of choice. The
ability to copymill the design exactly provides a
distinct advantage, as patients may be quick to
notice even slight changes between the provi-
sional and final prostheses.
123
Fig. 5.6 Before photos showing rampant decay
5.12 Case Presentation
The following patient presented to our clinic
requesting solutions to her dental complaints
concerning rampant caries. She was experiencing
pain when eating and becoming socially reclu-
sive due to her chronic dental conditions. The
patient had a medical history including Sjogren’s
syndrome, pre-diabetes, rheumatoid arthritis, and
obesity. The vast majority of recently placed
direct composite restorations were experiencing
recurrent decay, visualized in Fig. 5.6. Multiple
options were presented including full-mouth
rehabilitation with full coverage restorations,
combination full coverage restorations with
implant restorations, and full-mouth fixed
implant FDPs. The patient ultimately decided to
proceed with full-arch fixed implant prosthetics
for her full-mouth rehabilitation.
Preliminary diagnostics were recorded
including CBCT, photographs, and intraoral
scanning. 2D and 3D mockups were completed
using EXOCAD software. The plan for the max-
illa was to follow a sequenced treatment begin-
ning with preparation of select natural teeth to
retain a tooth-supported full-arch provisional.
This approach reduced risks to the implants by
not immediately loading. Once the teeth were
prepared, an intraoral scan was completed and
used to create a surgical guide that indexed to
124 K. Klaus and S. Jivraj

the natural tooth preparations as well as a

printed provisional to be retained by the natural
teeth. On the day of surgery, the unprepped teeth
were atraumatically extracted. A tooth-sup-
ported surgical guide was utilized to complete
the osteotomies. Immediate implants were
placed. The gap between implant and buccal
plate was grafted according to the dual-zone
protocol as described by Tarnow et al. [15] with
healing abutments supporting the keratinized
gingiva. Implants were added in sites 2 and 15
and cover screws placed. The provisional was
cemented to the natural teeth, and the patient Fig. 5.7 MUA caps placed and ready for intraoral
was dismissed. scanning
The second surgical appointment involved
immediately loading the mandible with a printed
prosthesis (Figs. 5.7, 5.8, 5.9, 5.10, and 5.11).
Using EXOPLAN, the lower jaw scan was modi-
fied by digitally extracting teeth for future
implant placement. The remaining teeth were
used to support a surgical guide. The planned
teeth were extracted atraumatically and osteoto-
mies completed. All implants were placed with
appropriate insertion torque for immediate load-
ing. Photogrammetry records were completed
with the iCAM 4D (iCam4D, iMetric4D Imaging,
Courgenay, Switzerland). The records were
aligned to intraoral scans, and the provisional
prosthesis was designed in EXOCAD. Rather
than extract the guide supporting teeth, a root
submergence technique (RST) as described by Fig. 5.8 Photogrammetry scan bodies in place
Salama et al. was followed [16]. The provisional
was printed in OnX on a SprintRay Pro 55S. The
prosthesis was finished and delivered [17]. The
patient was then dismissed.
The patient was allowed to heal for 4 months,
at which time a third surgical procedure was
completed. At this surgery the teeth supporting
the maxillary provisional would undergo
RST. The posterior implants were uncovered.
MUAs were seated and torqued. Photogrammetry
scans were again utilized to record implant posi-
tion. After aligning to the intraoral scan,
EXOCAD was used to design the implant-­
supported provisional. The provisional design Fig. 5.9 Mandibular printed immediate fixed provisional
was printed out of nanoceramic OnX resin by inserted
5 3D Printing Protocols in Full-Arch Reconstruction: A Complete Workflow
Fig. 5.10 Panoramic view from CBCT radiograph fol-
lowing second surgery
Fig. 5.11 Maxillary tooth-supported provisional oppos-
ing lower implant-supported provisional
Fig. 5.12 Intraoral photo showing gingival margin height
discrepancy
SprintRay. At this point in treatment, all implants
had integrated successfully.
The patient was satisfied with the provision-
als; however, the gingival zeniths had discrep-
ancy (Fig. 5.12). Site #7 specifically had a
125
Fig. 5.13 Photogrammetry scan bodies in place for
revised MUA selection
Fig. 5.14 Rendering from Exocad showing new design
with less buccal contour
Fig. 5.15 Intraoral photo showing improved marginal
height discrepancy
margin that was too apical. The multi-unit abut-
ment was changed from a straight to a 17°. A
new photogrammetry scan was taken to quickly
obtain the new implant location (Fig. 5.13). This
record was brought into EXOCAD, and a new
prototype restoration was designed with reduced
buccal contour (Fig. 5.14). The 2-week follow-
up revealed a more coronal position of the gingi-
val tissue (Fig. 5.15). CBCT was taken to
126
Fig. 5.16 CBCT analyzing distance from printed provi-
sional to the coronal extent of the RST tooth root
Fig. 5.17 Implant-supported printed provisionals
evaluate the apical tissues of the teeth treated
with RST. The CBCT was also used to evaluate
the distance from the ovate pontics to the coronal
portion of these teeth that underwent RST
(Fig. 5.16). The patient was sent home to con-
tinue to evaluate the provisionals (Fig. 5.17).
K. Klaus and S. Jivraj
Fig. 5.18 Tissue healing following removal of prelimi-
nary fixed provisional
Fig. 5.19 Tissue healing following revised provisional
Following a few months, the provisionals were
removed to assess soft tissue contours (Figs. 5.13
and 5.14). Once the patient was satisfied with the
prototype restorations, the final definitive zirco-
nia prosthetics were fabricated and inserted
(Figs. 5.18 and 5.19).
5 3D Printing Protocols in Full-Arch Reconstruction: A Complete Workflow 127

References stereophotogrammetric technique for rehabilitation

with immediate loading of complete-arch, implant-­
supported prostheses: a randomized controlled pilot
1. Tian Y, et al. A review of 3D printing in dentistry:
clinical trial. J Prosthet Dent. 2017;118(5):596–603.
technologies, affecting factors, and applications.
https://doi.org/10.1016/j.prosdent.2016.12.01.
Scanning. 2021;2021:9950131.
11. Gómez-Polo M, et al. Stereophotogrammetric impres-
2. Hull CW. Apparatus for production of three-­
sion making for polyoxymethylene, milled immedi-
dimensional objects by stereolithography. U.S. patent
ate partial fixed dental prostheses. J Prosthet Dent.
4,575,330, 8 Aug 1984.
2018;119(4):506–10.
3. Vasamsetty P, et al. 3D printing in dentistry—
12. Sinada N, Papaspyridakos P. Digitally designed and
exploring the new horizons. Mater Today Proc.
milled verification jigs generated from photogramme-
2020;26:838–41.
try data acquisition: a clinical report. J Prosthodont.
4. Park GS, Kim SK, Heo SJ, Koak JY, Seo DG. Effects
2021;30(8):651–5. https://doi.org/10.1111/
of printing parameters on the fit of implant-­
jopr.13409. Epub 2021 Aug 9. PMID: 34296484.
supported 3D printing resin prosthetics. Materials
13. Balshi TJ, Wolfinger GJ. Conversion prosthesis:
(Basel). 2019;12(16):2533. https://doi.org/10.3390/
a transitional fixed implant-supported prosthesis
ma12162533. PMID: 31395801; PMCID:
for an edentulous arch--a technical note. Int J Oral
PMC6720497.
Maxillofac Implants. 1996;11(1):106–11. PMID:
5. Schweiger J, Edelhoff D, Güth JF. 3D printing in
8820130.
digital prosthetic dentistry: an overview of recent
14. Swamidass R, Goodacre CJ. Conversion of digital
developments in additive manufacturing. J Clin
dentures for immediate loading of complete arch
Med. 2021;10(9):2010. https://doi.org/10.3390/
implant prostheses. J Prosthodont. 2021;30(S2):143–
jcm10092010. PMID: 34067212; PMCID:
9. https://doi.org/10.1111/jopr.13323. PMID:
PMC8125828.
33988279.
6. Della Bona A, et al. 3D printing restorative materi-
15. Tarnow DP, Chu SJ, Salama MA, Stappert CF,
als using a stereolithographic technique: a systematic
Salama H, Garber DA, Sarnachiaro GO, Sarnachiaro
review. Dent Mater. 2021;37(2):336–50.
E, Gotta SL, Saito H. Flapless postextraction socket
7. Verstreken K, Van Cleynenbreugel J, Martens K,
implant placement in the esthetic zone: part 1. The
Marchal G, van Steenberghe D, Suetens P. An image-­
effect of bone grafting and/or provisional restoration
guided planning system for endosseous oral implants.
on facial-palatal ridge dimensional change—a retro-
IEEE Trans Med Imaging. 1998;17(5):842–52.
spective cohort study. Int J Periodontics Restorative
https://doi.org/10.1109/42.736056.
Dent. 2014;34(3):323–31. https://doi.org/10.11607/
8. Basten CHJ, Kois JC. The use of barium sulfate for
prd.1821. PMID: 24804283.
implant templates. J Prosthet Dent. 1996;76(4):451–4.
16. Salama M, et al. Advantages of the root submergence
9. Jemt T, Lie A. Accuracy of implant-supported prosthe-
technique for pontic site development in esthetic
ses in the edentulous jaw: analysis of precision of fit
implant therapy. Int J Periodontics Restorative Dent.
between cast gold-alloy frameworks and master casts
2007;27(6):521–7.
by means of a three-dimensional photogrammetric
17. Peñarrocha-Oltra D, Agustín-Panadero R, Pradíes G,
technique. Clin Oral Implants Res. 1995;6(3):172–80.
Gomar-Vercher S, Peñarrocha-Diago M. Maxillary
https://doi.org/10.1034/j.1600-­0501.1995.060306.x.
full-arch immediately loaded implant-supported fixed
PMID: 7578793.
prosthesis designed and produced by photogrammetry
10. Peñarrocha-Diago M, Balaguer-Martí JC, Peñarrocha-­
and digital printing: a clinical report. J Prosthodont.
Oltra D, Balaguer-Martínez JF, Peñarrocha-Diago
2017;26(1):75–81. https://doi.org/10.1111/
M, Agustín-Panadero R. A combined digital and
jopr.12364. Epub 2015 Dec 14. PMID: 26662261.
 The Zygoma Anatomy-Guided
Approach (ZAGA) for Preventing
6
Complications Using Zygomatic
Implants

Carlos Aparicio

Abstract The results of using the combination of the

ZAGA concept together with the new ZAGA
The previously described systems for zygo-
implant designs consistently show:
matic implant placement, such as the origi-
nal surgical procedure, the slot technique or
–– Less traumatic osteotomy.
the extra-sinus technique, promote a spe-
–– Better implant stability.
cific surgical technique that should be uni-
–– Better bone-to-implant contact together with
versally applied to all patients. However,
better bone sealing around the implant neck.
different morphologies of the edentulous
Additionally, the rate of late sinus complica-
maxilla can be identified, both between and
tions dramatically decreases, and more ana-
within individuals. Using the same type of
tomic rehabilitation is achieved.
osteotomy in all situations will often result
in bulky prosthetic constructions, poor
hygiene, possible sinus complications and/
6.1 Introduction
or soft tissue dehiscence.
We present the ZAGA protocol for
The clinical scenario of the severely atrophic
decision-­making before performing zygo-
maxilla is represented by a very thin bone sepa-
matic osteotomy. The ZAGA concept aims to
rating the nose/maxillary sinus from the overly-
promote patient-specific therapy by adapting
ing soft tissue. An eventual osteotomy through
the type of osteotomy to the patient’s anatomy.
this minimal bone layer would barely achieve
Surgical treatment of the implant bed is guided
sufficient bone-to-implant contact to initially sta-
by the patient’s anatomy according to specific
bilize the implant (Fig. 6.1). Under these condi-
prosthetic, biomechanical and anatomical cri-
tions, it would be difficult to achieve and maintain
teria. In most cases, the so-called late compli-
secondary stability—osseointegration—capable
cations are refrained from.
of sealing the zygomatic implant (ZI) at the level
of its neck. It would then increase the risk of
development of late rhino/sinus-oral communica-
C. Aparicio (*)
International Teaching Scholar Indiana University
tion. In a recent retrospective study of up to 22
School of Dentistry, Indianapolis, IN, USA years of duration, Vrielinck et al. [1] analysed the
Director of Zygomatic Unit at Hepler Bone Clinic,
survival and complications associated with a total
ZAGA Center, Barcelona, Spain of 940 implants placed in 302 adult patients with
e-mail: carlos.aparicio@zagacenters.com atrophic maxilla. The survival rate of the ZI was

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 129
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_6
130
Fig. 6.1 (a, b) Radiographic CBCT images processed
with DTX Studio Implant planning software. The 3D and
2D images illustrate the plan for the path of the implant
(a) in the position of the right second premolar and (b) in
89.9%, and the mean time between implant
placement and failure was 4.8 years. The imme-
diate loading protocol presented a superior sur-
vival rate compared to the delayed loading
protocol. Among infectious biological complica-
tions, sinusitis was the most reported (n = 138)
and occurred over a mean follow-up period of 4.5
years.
Bone may resorb with function and time in
patients with minimal crestal bone around the entry
point of the zygomatic implant. Thus, Becktor
et al. in 2005 [2] speculated that the lack of bone
support would end in transverse mobility of the
C. Aparicio
the position of the left second premolar. The condition of
extreme maxillary atrophy makes it impossible to place
regular implants and dramatically reduces the chances of
success of an eventual sinus graft
long coronal part of the ZI that would facilitate oro-
sinus communication (Fig. 6.2), which is consis-
tent with finite element analysis studies by
Freedman in 2013 [3] and 2015 [4] showing
increased tensile forces on the zygoma in situations
where alveolar implant support is not achieved.
There is no empirical evidence as to what is
the minimum amount of residual bone capable of
supporting in the long term the different mastica-
tory loads applied from the zygomatic implant to
the bone-implant junction of the sinus floor. In
fact, the circumstances affecting bone-to-implant
contact, quality, and maintenance at the entrance
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic…
Fig. 6.2 CBCT radiographic image showing a total occu-
pation of the left maxillary sinus. The image also shows an
implant entering the sinuses through the palatal area. The
white circle highlights the lack of bone implant sealing at
the level of the palatal entrance. Note also the perpendicu-
lar angle of attack of the implant in the zygomatic zone
level can differ drastically from patient to patient.
Possible variables would be:
–– The difference between the final diameter of
the drill and the diameter of the implant
–– The accuracy of implant insertion
–– The quality of the anchorage/stability of the
zygomatic implant allowing or not
micromovements
–– The quality of the soft tissue attachment
–– The biotype of the soft tissue around the
implant/abutment head
–– The type of oral hygiene maintenance
–– The history of periodontitis
–– Excessive probing of the implant sulcus
–– Habits such as smoking, etc.
To achieve a long-lasting successful outcome
in zygomatic implant surgery, attention must be
paid to the prevention of late complications, par-
ticularly oral-antral or nasal communications or
soft tissue recession/infection (Fig. 6.3).
131
Fig. 6.3 Intraoral clinical image showing mucosal reces-
sion around a rough surface implant. Note the signs of
tissue infection associated with the recession
6.2 Technique Evolution
6.2.1 Original Technique
In the early 1990s, several reports were published
on the possibility of anchoring attachments to the
zygomatic bone for both nasofacial [5] and dental
prostheses [6]. Subsequently, Brånemark et al.
published in 2004 [7] the first long-term follow-
­up study on the placement of zygomatic implants,
sometimes simultaneously with on-lay bone
grafts. It was after this study that zygomatic
implants were considered within the scientific
implant dentistry. During this study, 28 patients
received 52 zygomatic implants and 106 conven-
tional fixations. Additional bone grafting was
considered necessary in 17 patients. All patients
were followed closely for 5–10 years. The surgi-
cal procedure for zygomatic implant placement
consisted of a “window” antrostomy in the upper
lateral quadrant of the anterior maxillary wall
(Fig. 6.4). The sinus mucosa was then reflected,
and “no special effort was made to keep it intact”.
It was thus established that the implant had to
have an intra-sinusal path. According to
Brånemark, “the direction of fixation of the
zygoma was selected to provide optimal stability
132
Fig. 6.4 Typical “emotional window” osteotomy of the
original surgical technique. The implant placement
required a second osteotomy since the final position of the
implant, indicated by the probe, does not correspond to
the position of the first osteotomy
against prosthetic requirements”. In different
words, to maintain the path inside the sinuses, the
implant path had a more or less palatal entry
depending on whether the curvature of the maxil-
lary wall was more or less pronounced. This long-
term study by Brånemark reported three ZI failures
and a 94.2% survival rate. The 5-year prosthetic
rehabilitation success rate was 96%. At least 96
conventional implants ranging from 10 to 20 mm
in length were placed. The success rate of the ini-
tially placed conventional implants was approxi-
mately 71%. In 2 patients out of 28, 1 of the 2 ZIs
placed was disconnected from the prosthesis due
to suppuration at the palatal entrance of the
zygoma attachment combined with a sinus infec-
tion. Four patients had recurrent sinusitis during
the follow-up time (Fig. 6.1). The treatment of
these six cases was the same: an antrostomy of the
inferior meatus was performed, and the results
were satisfactory. Four other patients had radio-
graphically diagnosed sinusitis with occupied but
clinically asymptomatic maxillary sinuses. No
treatment was considered necessary in these cases.
Depending on the criteria we apply, the per-
centage of cases presenting sinusitis, as defined
by Lanza Kennedy in 1997 [8], would be 21%,
while if we also apply the radiological criteria of
Lund Mackay 1993 [9], the percentage of rhino-
sinusitis in the original PI Brånemark study
would amount to 35.7%.
Due to the palatal position of the zygomatic
fixations, it was necessary to thin the palatal flap
C. Aparicio
Fig. 6.5 Slot osteotomy performed before implant place-
ment. As in the “window” osteotomy, there is a mismatch
between the final position of the implant and the previous
osteotomy that decreases the implant-bone contact
and remove the fatty tissue to refrain from soft
tissue inflammation around the definitive abut-
ments. Despite the palatal emergence of the pros-
thesis, no patient discomfort or speech difficulties
were recorded.
6.2.2 The Slot Technique
In 2000, Stella and Warner [10] described the
sinus slot technique in a technical note with
the objectives of offering a solution to the
prosthodontic shortcomings of the original
Branemark technique and reducing postopera-
tive pain.
To this end, the authors proposed elevating a
reduced flap only to the inferior aspect of the
infraorbital nerve and to the mid-inferior aspect
of the zygomatic process of the maxilla. Unlike
the original technique, they did not uncover the
angle formed by the frontal and temporal pro-
cesses of the zygomatic bone, since, in theory, the
groove provided them with the direction of the
implant (Fig. 6.5).
Second, a reduced groove-shaped antrostomy
was proposed instead of a window osteotomy.
The groove was performed in the planned direc-
tion before implant placement. They reasoned
that in an already highly resorbed maxilla, a sinus
window, as in the original technique, may further
compromise the remaining precarious alveolar
bone support.
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic…
Stella and Warner [10] also proposed a crestal
entry for the zygomatic implant to achieve more
anatomical prostheses. Local anaesthesia and
intravenous sedation were also introduced.
Although the slot technique improves mini-
mizing antrostomy and prosthesis design, the
method was also not without drawbacks. For
instance, the authors did not provide any specific
criteria for adopting variations within this process
that would refrain from oro-antral communication
when penetrating the sinuses through a too thin
alveolar ridge, nor did they define possible varia-
tions in implant trajectory in different anatomic
situations. Moreover, since the “slot” antrostomy
is performed before implant placement, it does
not always correspond to the implant shape. For
the same reason, the slot may not even be neces-
sary in the presence of concavities in the maxil-
lary wall. In other words, the ability to seal the
maxillary wall with the implant is limited.
6.2.3 Exteriorized Technique
The next step in the evolution of the technique
occurred in 2005, when Aparicio’s group pre-
sented a 1-year follow-up of a new technique for
a b
Fig. 6.6 (a) In the clinical image, we can see how the
bone remnant at the alveolar level has been used to pre-
pare the entrance of the Straumann ZAGA Round type
implant through it and not through the palatal bone. Due
to the pronounced concavity of the maxillary wall, the
path of the implant proceeds outside the wall until it enters
the zygomatic bone. The white circle highlights the pres-
ervation of the alveolar bone to support the soft tissue
133
zygomatic implant placement at the EuroPerio
meeting in Madrid, Spain. This new technique,
indicated in cases of maxillary wall concavity,
used an external approach to the maxilla to place
zygomatic implants (Fig. 6.6). The 1-year study
for this new technique was first published in
English literature by Ouazzani from Aparicio’s
group in 2006 [11]. Migliorança et al. in 2006
[12] published a similar approach to Aparicio’s
group in Portuguese, which they called the exter-
nalized technique. In a 3-year prospective study
in 2008, Aparicio et al. [13] reported the results
of extra-sinus placement of zygomatic implants
in 20 consecutive patients recruited from October
2004 to October 2005. The minimum follow-up
period was at least 3 years. Thirty-six zygomatic
implants were used, with smooth, turned titanium
surfaces according to the initial zygomatic fixture
design (Nobel Biocare AB, Göteborg, Sweden).
According to the authors, the indication for using
the extra-sinus approach was the presence of buc-
cal concavities in the lateral wall of the maxillary
sinus, which would cause an eventual intra-sinus
trajectory of the zygomatic implants to lead to the
placement of the implant head at a distance
greater than 10 mm from the centre of the alveo-
lar ridge. In these cases of a very concave maxil-
connective fibres and thus refrain from recession. (b) The
clinical image shows a Straumann ZAGA Round implant
in the most anterior zone where the alveolar bone has been
preserved. The posterior area belongs to a ZAGA 4 type
without remaining alveolar bone, so a Straumann ZAGA
Flat design has been chosen. The white circle highlights
the preservation of the alveolar bone, and the arrows indi-
cate the close bone-to-implant contact achieved
134
lary wall, the implant trajectory was prepared by
drilling the alveolar crest sufficiently from its
palatal side, pointing towards the zygomatic arch,
and without making a previous window opening
in the maxillary sinus. Prioritization was given to
the anatomical prosthesis on the palatal entry,
enabling the implant entry to occur at the maxil-
lary ridge. And depending on the concavity of the
wall, the implant would have an “aerial path”
(Fig. 6.6). On the condition of passing through a
ridge sufficient in volume and architecture, the
integrity of the sinus membrane was preserved,
and the creation of a “window” or “slot” prior to
surgery was eliminated.
Maló et al. in 2008 [14] introduced a modified
approach called the extra-maxillary technique
that would suit all anatomies. However, it
involved systematic contouring of the alveolar
ridge to achieve exclusive anchorage into the
zygoma bone. So when patients presented with
an over-contoured anterior-maxillary sinus wall,
the sinus membrane was inevitably perforated
because it was in the direct pathway of the drill
direction. Of the 18 patients who underwent a
1-year follow-up, 4 suffered sinus infections rep-
resenting 22% of sinusitis. Further study on the
extra sinus technique was published by
Migliorança’s group in 2011 [15]. The authors
reported a 98.7% survival rate for zygomatic
implants, only two of them showed soft tissue
recession, and no patients experienced sinusitis.
Incomprehensibly, the success criteria used were
the same as for regular implants including mar-
ginal bone height and probing depth.
6.3 The ZAGA Concept
ZAGA is a philosophy and concept for the reha-
bilitation of the atrophic maxilla described by
Aparicio in 2011 [16] and 2012 [17]. ZAGA is
the acronym for “zygoma anatomy-guided
approach”, which is a descriptive name that iden-
tifies a new technique and distinguishes it from
previously published techniques intended to be
universally applied to all patients. The ZAGA
concept differs in that it seeks a specific treat-
ment for each patient. This is so in multiple
C. Aparicio
aspects such as the type of incision according to
the biotype and amount of soft tissue:
–– The surgical protocol of positioning and
design of the osteotomy
–– The type of drilling with lateral or perpendicu-
lar cut depending on the type of osteotomy
projected
–– The procedures and individualized recom-
mendations to better preserve the bone and
soft tissue in the ZICZ
–– Various instruments such as drills to facilitate
the surgery
–– The choice of implant design that is chosen
for each site
There is a tendency to confuse the ZAGA ana-
tomical classification with the “ZAGA concept”
which is a philosophy that promotes first recog-
nizing the type of anatomy of the patient in need
of oral rehabilitation and then providing this
patient with a specific therapy. In other words,
instead of forcing the patient’s anatomy to adapt
to a particular process and/or implant, the use of
the ZAGA concept matches its strategies and
tools according to the patient’s anatomy.
Indeed, the use of the same type of technique
in all anatomical situations described in the origi-
nal and other protocols often results in bulky
prosthetic constructions, impaired hygiene, even-
tual sinus complications, and/or soft tissue dehis-
cence. The zygoma anatomy-guided approach
(ZAGA), on the other hand, aims to promote
patient-specific therapy. Surgical treatment of the
implant site is guided by the anatomy of that
patient and that site, not by a universal “magic
recipe”.
Consequently, the implant trajectory can be
intra-sinus, extra-sinus, or intermediate, using
the maxillary wall as an additional source of
anchorage (Fig. 6.7). In fact, its aim is to maxi-
mize the primary stability of a prosthesis-guided
zygomatic implant, which implies a conserva-
tive osteotomy. At the same time, the ZAGA
concept aims to prevent potential late complica-
tions of the procedure, such as oral-antral fistula
and soft tissue recession/infection, by following
the steps detailed in Table 6.1. Overall, the
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic…
Fig. 6.7 Some clinicians mistakenly identify the ZAGA
concept with the placement of externalized implants. The
ZAGA concept proposes the adaptation of the path of the
implant, and the osteotomy, to the patient’s anatomy. The
series of clinical images that we present here shows the
Table 6.1 Key steps and protocols in the ZAGA
concept
– The identification of the patient’s anatomy
– The determination of an implant trajectory guided by
the prosthesis according to specific criteria that
determine the location of the zygomatic implant
critical zone (ZICZ), the antrostomy z(AZ), and the
zygomatic anchor zone (ZAZ)
– The selection of the appropriate minimally invasive
osteotomy design for the residual anatomy preventing
channel or tunnel complications
– The selection of appropriate implant design for the
type of osteotomy chosen
– The appropriate procedures in each case to maintain
the bone and soft tissue refraining from complications
– The use of a systematic method to define success or
failure in each rehabilitation
ZAGA concept provides clinicians with the
decision criteria necessary to obtain a satisfac-
tory and predictable outcome over time. It
establishes protocols for determining the key
landmarks that will define the zygomatic
implant trajectory or ZAGA zones, which will
be explained in the next chapter. In this way, an
individualized, patient- and site-­specific implant
trajectory is determined.
6.3.1 The ZAGA Classification
To better understand the influence of anatomy
on a prosthetically driven implant trajectory,
Aparicio described the “ZAGA classification”
135
different paths that the zygomatic implant can have
according to the ZAGA philosophy. Note how the choice
of implant design varies also in relation to the type of
path. Essentially, ZAGA is a patient-specific therapy
in 2011 [16]. He identified five basic skeletal
forms of the alveolar crest complex, maxillary
wall-­zygomatic buttress complex, and implant
path. The classification represents the anatomi-
cal differences on the trajectory of an implant
placed from the posterior premolar/molar area
during its alveolar and anterior maxillary wall
zygomatic path. Indeed, the ZAGA classifica-
tion was intended to describe anatomic differ-
ences on the double posterior zygomatic implant
trajectory (Fig. 6.8). However, it did not refer to
an eventual anterior zygomatic implant
passageway.
Currently, the indications for zygomatic
implants have been broadened since they are
used not only in cases of lack of bone in the pos-
terior maxilla but also in clinical cases of
extreme anterior and posterior maxillary atro-
phy [18, 19]. Then, four implants anchored in
the zygomatic bone ZI are placed (Fig. 6.9). In
these new situations, the indication for reaching
the zygomatic bone using an intra-nasal implant
path, in the same manner as an intra-sinus path
that was prescribed on the original technique,
cannot be extrapolated. The reduction of sub-
nasal bone volume frequently forces the surgeon
to choose an extra-nasal/extra-sinus implant tra-
jectory, preventing future complications like
nasal or sinus fistula by avoiding nasal or sinus
penetration. The frequent scenario in a four-
zygomatic implant indication is then a very
resorbed maxilla where before establishing the
136
Fig. 6.8 In the figure we can appreciate the different
schemes that represent the ZAGA classification for zygo-
matic implants whose head has a posterior position at pre-
Fig. 6.9 Clinical occlusal image showing the final posi-
tion of four zygomatic implants, two anterior and two pos-
terior. This technique is known as quad zygoma and is
now sufficiently documented to be used routinely in cases
of extreme maxillary atrophy. Customarily, the path and
anatomical particularities found in the anterior region dif-
fer from those found in the posterior region. In this case,
two Straumann ZAGA Round implants were placed in the
anterior area classified as ZAGA 3 and two Straumann
ZAGA Flat implants were placed in the posterior areas
corresponding to a ZAGA type 4 anatomy
osteotomy, the surgeon must analyse the remain-
ing anatomy (Fig. 6.10) to visualize balance and
prevent possible late complications, such as fis-
tula or soft tissue dehiscence/infection, related
to nasal/sinus perforation or an eventual extra-
maxillary zygomatic implant position respec-
tively [20].
6.3.1.1 Group ZAGA Type 0
–– The maxillary wall is flat or convex.
–– Providing a minimum of 4 mm high × 6 mm
wide in an adequate architecture, a circular
C. Aparicio
molar/molar level. The percentages show the frequency of
this situation
osteotomy is performed through the remain-
ing alveolar crest. The implant neck is located
on the alveolar crest to minimize the risk of
late soft tissue complications.
–– A threaded circular implant section is used to
seal the tunnel-shaped osteotomy.
–– The antrostomy is placed immediately across
the alveolar crest.
–– Sinus lining integrity at the crestal level is not
preserved.
–– The implant body reaches the zygomatic bone
using an intra-sinus path.
–– The implant comes in contact with bone at
the alveolar crest and zygomatic bone and
sometimes at the lateral sinus wall
(Fig. 6.11).
6.3.1.2 Group ZAGA Type 1
–– The maxillary wall is slightly concave.
–– Providing a minimum of 3–4 mm high × at
least 5 mm wide in an adequate architecture,
a circular osteotomy is performed through
the remaining alveolar crest. The implant
neck is mostly located on the alveolar crest
to minimize the risk of late soft tissue
complications.
–– A threaded circular implant section is used to
seal the tunnel-shaped osteotomy.
–– To properly reach the zygomatic bone, the
drill performed the osteotomy slightly through
the maxillary wall.
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic… 137

Fig. 6.10 ZAGA anatomical classification and frequency nose relationship of the anterior implant rather than the
percentages for zygomatic implants originating in the implant/sinuses of the posterior
anterior zone. The main difference will be in the implant/

Fig. 6.11 Intraoperative clinical image showing the drill Fig. 6.12 Intraoperative clinical image showing prepara-
in charge of widening the osteotomy entrance to accom- tion for zygomatic implant placement in a ZAGA type 1
modate the implant neck. Note that an “emotional” oste- maxilla. There is enough alveolar bone for an alveolar
otomy, neither in window nor in slot, has not been tunnel osteotomy. The maxilla is slightly convex so part of
performed previously. The line drawn with a pencil on the the implant body is exteriorized
external face of the wall (white arrows), as well as the
position of the retractor and the knowledge of the anat-
6.3.1.3 Group ZAGA Type 2
omy, will guide the surgeon in the initial osteotomy. The
entire path of the implant will be intra-sinus –– The maxillary wall is concave.
–– The alveolar architecture is not enough to
–– The antrostomy is placed immediately across allocate the implant neck. The final osteotomy
the alveolar crest. has a channel section with floor and lateral
–– Sinus lining integrity at the crestal level is not walls but no roof. The implant head is partially
preserved. located on the alveolar crest.
–– Although the implant can be seen through the –– An implant section in the shape of a flat arc of
wall, most of the implant body has an intra-­ the circumference is preferably used to seal
sinus path. the channel type of osteotomy.
–– The implant comes into contact with bone at –– In an anterior placement, the drill avoids nasal
the alveolar crest, lateral sinus wall, and zygo- floor perforation to reach the zygomatic bone.
matic bone (Fig. 6.12). The osteotomy is performed through the ante-
138
Fig. 6.13 Intraoperative clinical image showing prepara-
tion for zygomatic implant placement in a ZAGA type 2
maxilla. The remaining alveolar bone is more sparse than
in types 0 and 1. Although a tunnel preparation can be
attempted (white circle), it is more advisable to refrain
from perforating the membrane in this area by using a
channel osteotomy from the beginning
rior maxillary wall, displacing the initial alve-
olar drilling towards the buccal area.
–– The antrostomy is placed as far as possible
from the crest level.
–– Sinus lining integrity at the crestal level is
preserved.
–– The implant can be seen through the maxillary
wall, and most of the body has an extra-sinus
path.
–– The implant comes into contact with bone at
the alveolar crest, lateral sinus wall, and zygo-
matic bone (Fig. 6.13).
6.3.1.4 Group ZAGA Type 3
–– The maxillary wall is very concave.
–– The alveolar architecture is enough to allocate
the implant neck in diameter. Then a circular
osteotomy is performed through the remain-
ing alveolar crest.
–– The implant neck is located on the alveolar
crest.
–– The drill will perform a circular osteotomy
following a trajectory that goes from the pala-
tal to the buccal alveolar bone. The drill
“flies” over the most concave part of the ante-
C. Aparicio
Fig. 6.14 The patient had a knife-edge anterior ridge. It
was decided to remove the two affected canines. We did
not remove the residual alveolar bone. Note (white arrow)
the implant crossing the alveolus of the canine. The mid-
dle part of the implant body is floating without osseous
contact
rior sinus wall to penetrate the zygomatic
bone.1
–– A threaded circular implant section is used to
seal the tunnel-shaped osteotomy.
–– The antrostomy is placed as far as possible
from the crest level.
–– Sinus lining integrity at the crestal level is
preserved.
–– Most of the implant body has an anterior
extra-sinus path.
–– The middle part of the implant body is not
touching the most concave part of the wall.
–– The implant comes in contact with bone in the
coronal alveolar and apical zygomatic bone
(Fig. 6.14).
6.3.1.5 Group ZAGA Type 4
–– The maxilla and the alveolar bone show
extreme vertical and horizontal atrophy. In a
quad case, the reduction of sub-nasal bone
volume forces the surgeon to an extra-nasal/
extra-sinus implant pathway.
–– The alveolar architecture is not enough to
allocate the implant neck. The final osteotomy
1
For classification procedures, borderline situations where
a pronounced maxillary wall concave curvature is con-
comitant with a zygomatic implant neck diameter too
close to the remaining alveolar thickness that is not capa-
ble of completely covering the implant neck, but most of
it is buried into the alveolar bone, were also classified as
ZAGA A-3.
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic…
Fig. 6.15 Intraoperative occlusal image showing a typi-
cal ZAGA type 4 situation in the posterior areas. Two
Straumann ZAGA Flat implants have been selected to
close the channel osteotomies
has a channel section with floor and lateral
walls but no roof.
–– The implant head is located partially buccally
of the alveolar crest.
–– The antrostomy is placed as far as possible
from the crest.
–– The osteotomy aims to “sink” the implant as
much as possible while respecting sinus lining
integrity at the crestal level.
–– The drill has arrived at the apical zygomatic
entrance following a path outside the sinus
wall.
–– Most of the implant body has an extra-sinus/
extra-maxillary path. Just the apical zygo-
matic part of the implant is totally surrounded
by bone.
–– The implant comes in contact with bone in the
zygomatic bone and part of the lateral sinus
wall (Fig. 6.15).
6.3.2 The ZAGA Minimally Invasive
Osteotomy
In the ZAGA concept, two osteotomies are not
used as in the previous techniques. In the original
or slot technique, the first osteotomy had a visu-
alization purpose, for example, the window oste-
otomy or the slot osteotomy. This “emotional”
osteotomy was performed before a second oste-
otomy necessary for implant placement and is
generally not necessary because, due to the sinu-
ous anatomy of the maxillary-zygoma complex,
the window or the slot does not allow visualiza-
139
Fig. 6.16 The white arrows show the detail of the “emo-
tional” osteotomy in “window” performed by the surgeon
before the osteotomy necessary to place the implants. The
circles indicate that the apical zones of the implants are
designed to achieve maximum stability by incorporating a
rough surface, threads, and tapered profile, which have
been left in the air outside the bone. In other words, the
window osteotomy has rendered the implant less
effective
tion of the apical drilling point (Fig. 6.16). On the
contrary, the ZAGA concept performs only one
osteotomy: the one necessary to place the implant
and it does it by under-preparing the bone at all
levels. In this way, the osteotomy, according to
the ZAGA concept, achieves greater stability and
better sealing of the implant by increasing the
contact of the implant with the bone. That is why
it is known as minimally invasive ZAGA
osteotomy.
To preserve the integrity of the sinus and
refrain from soft tissue complications, implant
osteotomy can be performed as a tunnel or chan-
nel depending on the architecture of the residual
alveolar bone forming the sinus floor and the
contours of the maxillary lateral wall. Bone-to-­
implant contact or support should be achieved
throughout its path, especially at the alveolar
level, for better load distribution in both tunnel
and channel osteotomy techniques.
As a general rule, the volume and architecture
of the alveolar/basal process and the curvature of
the anterior maxillary wall will define the coronal
position of the implant. In other words, if an intui-
140 C. Aparicio

tively adequate thickness of circumferential alve-

olar bone support can be found at the neck of the
zygomatic implant (i.e., greater than 4 mm in
height and 6–7 mm in width) when exploring the
residual ridge, the first choice should be a tunnel-­
type osteotomy through that bone. The ZAGA
concept proposes to call this circular-shaped oste-
otomy, performed through sufficient bone, a “tun-
nel osteotomy”. The reason is that at the coronal
bony entry, it has a floor, side walls, a more or less
complete roof, and an exit on the opposite side.
ZAGA concept recommends opting for the “tun-
nel osteotomy” whenever possible, regardless of
the curvature of the maxillary wall. The rationale Fig. 6.17 The white arrows show the tunnel-shaped oste-
otomies performed in the remaining alveolar bone. Note
is as follows: a ZI, with an adequate threaded neck that the direction of attack comes from palatine obliquely
profile, surrounded by sufficient bone at the coro- since the amount of bone we would find in a direction
nal entry and stabilized by an adequate apical perpendicular to the ridge would be insufficient to stabi-
zygomatic and coronal prosthetic anchorage, will lize an implant. It has been possible to preserve the integ-
rity of the membrane by moving the antrostomy away
achieve osseointegration at the neck level. This from the coronal critical zone
will be able to seal the sinus entrance in the long
term. A tunnel can be achieved depending on the
existing architecture of the remaining alveolar
bone at the chosen entry point. This type of oste-
otomy is typical of ZAGA type 0, 1, and 3 situa-
tions of the maxillary wall accompanied by
adequate thickness and geometry of the alveolar
bone support circumferential to the implant neck
(Fig. 6.17). The tunnel osteotomy, by definition,
has a circular profile entrance that must be sealed
by a round section implant.
When the alveolar bone thickness/architecture
is inadequate to achieve at least 3–4 mm of circu-
lar bone-to-implant contact, implant placement
following the ZAGA concept is shifted buccally
to refrain from late oro-antral communication or Fig. 6.18 Both osteotomies have the shape of a channel.
sinus infection. In these cases, the position of the In both, the amount of residual alveolar bone is extremely
antrostomy is moved as far as possible from the small. Therefore, it was decided to move the entry buc-
cally. The transparency of the membrane (arrow) indicates
level of the ridge to maintain the integrity of the that we have to stop the depth of the preparation in order
sinus membrane at this point. The osteotomy is not to tear the membrane
performed by preparing, in the remaining alveo-
lar bone and in the maxillary wall, a space in the times also in the lateral maxillary wall and zygo-
form of a channel capable of accommodating matic buttress. The depth limit for excavation of
most of the circumference of the implant the channel is the integrity of the membrane at
(Fig. 6.18). This type of osteotomy, unable to this level. Like a waterway or channel, the sulcus
provide complete coverage of the implant’s mid- has a floor and lateral walls with more or less
body and neck, is referred to by the ZAGA con- height but no ceiling. The indications for the two
cept as a “channel osteotomy”. This groove is types of ZAGA osteotomy are described in
prepared in the coronal alveolar bone and some- Table 6.2 (Fig. 6.19).
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic…
Table 6.2 The ZAGA osteotomy types. Description and
indications
ZAGA tunnel osteotomy:
1. Intra-sinus path: adequate residual alveolar bone
volume below the maxillary sinus (e.g., in ZAGA 0
and 1)
 (a) Osteotomy has an entry point to the maxillary
sinus through sufficient alveolar bone which is
used to embrace the implant neck
 (b) Osteotomy direction is determined by the
anatomy of the zygoma and the number of
implants to be placed, independently of maxillary
wall curvature
 (c) Antrostomy is placed at the sinus side of the
tunnel osteotomy
 (d) Additional facial (window) antrostomy or sinus
lift is not recommended (e.g., in ZAGA 0)
 (e) Straumann ZAGA® Round implant section is
recommended
2. Extra-sinus path: residual alveolar bone below the
maxillary sinus has a triangular architecture,
inadequate to host a regular implant, and is
concomitant with pronounced maxillary wall
concave curvature (e.g., in ZAGA 3 and some 2
types)
 (a) Osteotomy has its entry and exit points within the
residual alveolar bone
 (b) Osteotomy direction is determined by the
anatomy of the zygoma and the number of
implants to be placed, independently of maxillary
wall curvature
 (c) Antrostomy location is determined by the number
of implants to be placed and the curvature of the
zygomatic buttress
 (d) Straumann ZAGA® Round implant section is
recommended
ZAGA Channel Osteotomy
Advanced alveolar bone atrophy. Alveolar bone has
inadequate volume and architecture to host the neck of
the ZI (e.g., in ZAGA 4 and some 2 types)
– Osteotomy is buccally offset through the residual of
the alveolar bone and maxillary wall
– Osteotomy direction is determined by the anatomy of
the zygoma and the number of implants to be placed,
independently of maxillary wall curvature
– Antrostomy location is placed as far as possible from
the ZICZ, in relation to the number of implants to be
placed and the zygoma buttress curvature
– Straumann ZAGA® Flat implant section is
recommended
The results of the so-called ZAGA concept
were described in 2014 by Aparicio et al. [21] in
a controlled study. In the aforementioned com-
parative study, long-term results (survival rate,
implant stability, sinus conditions, prosthesis
141
design, soft tissue sealing, etc.) were reported.
For comparison, a cohort group of 22 consecutive
patients treated with the original classical zygo-
matic technique and followed for at least 10 years
was used as a control [22]. Their results were
compared with those obtained in another cohort
group of 80 consecutive patients treated with the
ZAGA protocols and with a mean follow-up of
4.62 years. All patients included in the test group
had at least 3 years of prosthetic follow-up,
including a presurgical comparison and a final
CT scan. Of note, both groups of patients received
the same implant design: the original Brånemark
zygomatic fixation with a threaded machined sur-
face (Nobel Biocare AB, Gothenburg, Sweden).
The results showed that both classic and ZAGA
procedures achieved similar positive clinical
results with respect to implant survival and
implant stability. However, patients treated with
the ZAGA concept had immediate rehabilitations
minimizing very significantly the risk of pathol-
ogy associated with the maxillary sinuses com-
pared to the original technique. In addition, less
bulky, more comfortable, and easier-to-clean
prostheses were achieved.
Recently, Clarós et al. [23] published a study
on the prevalence of maxillary sinus alterations
after zygomatic surgery. The study also com-
pared the differences in sinus alterations between
the intra-sinus and ZAGA approaches.
The retrospective study included 200 patients
restored with zygomatic implants with a follow-
­up of at least 5 years after surgery. The surgeries
were performed between 2004 and 2014 at differ-
ent centres. Patients were divided into two radio-
logical groups according to the type of surgical
procedure: the first group, Group 1, original
zygomatic intra-sinus surgical technique (OI-­
ST), included 40 patients with 80 implants placed
with the classic intra-sinus approach, including
those placed through sufficient bone of the floor
of the maxillary sinus, and the slot technique.
The second group, Group 2, included 160 patients
treated with 320 zygomatic implants placed
according to the ZAGA concept. To facilitate an
unbiased radiological classification, patients with
ZAGA type 0 were excluded from the ZAGA
Group.
142
Fig. 6.19 Diagram representative of the importance of
implant design. Both for a tunnel osteotomy and a channel
osteotomy, the threads will be necessary to transmit the
All patients included in the study underwent at
least one CT scan preoperatively and another at
least 5 years postoperatively.
The results showed a statistically significant
increase in radiographic evidence of sinusitis in
patients after zygomatic implant surgery. This
indicated that zygomatic surgery may cause sinus
alterations. A significant increase in the preva-
lence of sinus symptoms was also found in the
OI-ST with respect to the ZAGA concept.
6.3.3 The ZAGA Flat and ZAGA
Round Zygomatic Implants:
The Story of a Breakthrough
Because a typical zygomatic implant trajectory
involves the atrophic alveolar bone, maxillary
wall, and zygomatic bone, it presents greater
peculiarities than an implant trajectory in a con-
ventional implant indication. However, although
numerous implant designs can be used in residual
C. Aparicio
masticatory forces to the bone in order to achieve and
maintain the osseointegration and, therefore, the bone at
the ZICZ level
alveolar bone, there are few, if any, implant
designs that suit the needs of zygomatic implant
patients with severely atrophic jaws.
This section describes the origins of the
“adapted to the anatomy” new portfolio of zygo-
matic implants designed by Carlos Aparicio. The
Straumann company is currently the universal
distributor of the ZAGA® Round and ZAGA®
Flat zygomatic implant designs. These implants
feature several unique distinct attributes, which
makes them a major step forward for the growing
field of zygomatic implant rehabilitation. The
invention, design, industrial technology transfer,
and commercialization are all textbook examples
from beginning to end.
6.3.3.1 The Clinical Points to Solve
Created with the clinical needs of the end user in
mind, this portfolio represents, for commercial
reasons, a reduction of the original larger portfo-
lio. The goal was to make it possible for the sur-
geon to manage different unsolved problems.
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic…
–– The management of an eventual limitation of
the surface area suitable for anchorage in the
zygomatic bone, especially when performing
quadruple surgeries
–– The problem of overly wide implant transport-
ers that often interfere with the bony ridge, so
valuable for soft tissue maintenance
–– The interference of wide implant transporters
with anterior hard bone or another implant
when placing implants in the opposite quad-
rant of a compromised maxilla
–– Difficulty in obtaining primary stability in
certain zygomatic bones with low quantity or
quality
–– Difficulty in anchoring and stabilizing soft tis-
sues at the ridge level
–– The need for a threaded design to maintain
crestal alveolar bone
–– High soft tissue stress when placing
implants extra-maxillary in ZAGA types 2
and 4
–– Bacterial adhesion to the rough surfaces of the
implant
Backed by its scientific approach and building
on its legacy of innovation, the Straumann
Company assumed the choice of the final pro-
tected design and universal distribution of ZAGA
Round and ZAGA Flat zygomatic implants. The
correct use and indication for the rehabilitation of
zygomatic implants together with various pat-
terns to prevent long-term complications repre-
sent the main goal of this achievement. Thus, the
final design of the Straumann-ZAGA zygomatic
implant includes:
–– Use of commercially pure Grade 4 titanium
with no aluminium vanadium alloys
–– A narrower apex diameter of 3.4 mm, which is
achieved because the implants are fabricated
from special cold-worked grade 4 titanium,
which in bench experiments has been shown
to increase fatigue strength
143
–– A tapered apex portion to improve primary
stability and accommodate minimally inva-
sive ZAGA osteotomies
–– Turned implant body and head to refrain as
much as possible from bacterial adhesion
–– Rough surface apex to accelerate secondary
stability away from possible contamination
–– A 55° angular correction in the implant plat-
form that optimizes prosthetic versatility
–– A model, ZAGA Flat, with a flat midsection to
reduce soft tissue stress when placed extra-­
maxillary and prevent dehiscence
–– One model, ZAGA Round, with a round mid-
section to accommodate a tunnel-type osteot-
omy if intra-sinus placement is used
–– Macro- and micro-threads in the neck to stabi-
lize the bone at that level and prevent oro-­
antral communication
–– A transporter with the same outer diameter as
the implant to facilitate implant placement and
preserve the osseous ridge
Modifications in the design of any implant
should be technically, clinically, and scientifi-
cally validated. Fortunately, after a long and
successful period of preclinical and mechanical
testing, human donor placement, and non-­
interventional clinical trials, the Zygoma Round
and Flat implants were launched by Straumann
in October 2020. The added use of the
Straumann ZAGA Round and ZAGA Flat
implants used in conjunction with the ZAGA
concept contributes greatly to avoiding imme-
diate or late complications while maintaining
excellent rehabilitation stability. Understanding
the reasons, strategies, and engineering of the
zygomatic implant design changes imple-
mented in the new Straumann ZAGA Round
and ZAGA Flat designs will help the clinician
to optimize their use (Fig. 6.20). The relation-
ships between the changes, their indication, and
their effect are explained in Table 6.3 taken
from Aparicio et al. [24].
144 C. Aparicio

Fig. 6.20 Representative diagram of the different diameters in the two ZAGA zygomatic implant designs distributed
by Straumann

Table 6.3 Influence of implant design on ZAGA minimally invasive osteotomy goals (from Aparicio et al. [24])
Goal Implant feature Results
Place the implant head at Implant axis 55° correction Easier ideal prosthetic positioning
the optimal dental Implant-to-­abutment junction is not located at
position using a the zygomatic implant critical zone (ZICZ).
prosthetically driven This eliminates the possibility of bone
implant trajectory resorption due to eventual bacterial leakage
Achieve optimal Reduced apical diameter The reduction of the apical diameter increases
anterior-posterior the possibility of divergent positioning of the
distribution of the implant shafts, thus improving the final AP
implants distribution
Achieve maximal Apical tapered self-cutting design If a conservative osteotomy is performed, the
implant primary stability difference between the diameter of the last drill
and the progressive section of the implant
achieves greater primary stability
Preserve as much bone as Threads and/or micro-threads are Threads, together with implant stability,
possible at the maxillary incorporated at the implant head/neck facilitate osseointegration and bone stability
wall and alveolar bone level
Maximize bone-to- The tapered apical design experiences Increased BIC along the entire length of the
implant contact (BIC) an increased diameter at the level of the implant
along the length of the implant neck. The drilling protocol
whole implant. This shows a difference between the implant
includes the alveolar, diameter and the last drill diameter
maxillary wall, and (0.5 mm at the apical level, increasing
zygomatic bone to 1.4 mm at the implant neck/head)
Achieve complete Two types of implant section, round The clinician may decide which design would
sealing of the osteotomy and flat better adapt to the performed osteotomy
by the implant body
Protect sinus integrity at Implant-to-­abutment connection is not No bacterial leakage and subsequent bone
the implant head/neck located at the ZICZ resorption are expected at the ZICZ
level to prevent late Threads and/or micro-threads at the Threads, together with stability and alveolar
sinus-oral head neck level bone contact, will enhance the possibility of
communication osseointegration
Machined surface at implant head and If a soft tissue recession occurs, machine-
body surfaced implants will maintain surrounding
soft tissue health better than a rough-­surfaced
implant
Prevent soft tissue A design presenting a flat surface is By facing the flat surface against the soft tissue,
dehiscence available any eventual compression of its vessels is
diminished, thus decreasing the possibility for
dehiscence
6 The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic… 145

6.4 Conclusions 7. Brånemark P-I, Gröndahl K, Ohrnell L-O, Nilsson

P, Petruson B, Svensson B, et al. Zygoma fixture in
the management of advanced atrophy of the max-
The main differences between the documented illa: technique and long-term results. Scand J Plast
techniques for the rehabilitation of the atrophic Reconstr Surg Hand Surg. 2004;38:70–85.
maxilla using zygomatic implant-anchored pros- 8. Lanza DC, Kennedy DW. Adult rhinosinusitis defined.
Otolaryngol Head Neck Surg. 1997;117:S1–7.
theses have been reviewed. Unlike previous tech- 9. Lund VJ, Mackay IS. Staging in rhinosinusitis.
niques that use two osteotomies to place the Rhinology. 1993;31(4):183–4.
zygomatic implant, placement following the 10. Stella JP, Warner MR. Sinus slot technique for sim-
ZAGA concept requires only one osteotomy that plification and improved orientation of zygomaticus
dental implants: a technical note. Int J Oral Maxillofac
is performed by infra-preparation of the residual Implants. 2000;15(6):889–93.
bone. This is why it is known as minimally inva- 11. Ouazzani W, Arevalo J, Sennerby L, Lundgren S,
sive ZAGA osteotomy. Comparative studies Aparicio C. Zygomatic implants. A new surgical
between the original technique and the ZAGA approach. J Clin Periodontol. 2006;33(Suppl, second
part):128.
concept show clear advantages in the ZAGA phi- 12. Migliorança R, Ilg JP, Serrano AS, Souza RP,
losophy since immediate, less aggressive, and Zamperlini MS. Sinus exteriorization of the zygoma
bulky rehabilitations are achieved. The percent- fixtures: a new surgical protocol. Implant News.
age of long-term sinus problems decreases dra- 2006;3:30–5.
13. Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela
matically with using the ZAGA concept. The R, Pascual A, et al. Extra sinus zygomatic implants:
results obtained in clinical studies performed fol- three-year experience from a new surgical approach
lowing the minimally invasive ZAGA concept for patients with pronounced buccal concavities in
together with the new implant designs are clearly the edentulous maxilla. Clin Implant Dent Relat Res.
2010;12:55–61. E-Pub 2008.
superior in terms of reduction of complications to 14. Maló P, de Nobre M, A, Lopes I. A new approach to
those found with zygomatic implants and tradi- rehabilitate the severely atrophic maxilla using extra
tional techniques. maxillary anchored implants in immediate function: a
pilot study. J Prosthet Dent. 2008;100(5):354–66.
15. Migliorança RM, Coppedê A, Dias Rezende RCL, de
Mayo T. Restoration of the edentulous maxilla using
References extra sinus zygomatic implants combined with ante-
rior conventional implants: a retrospective study. Int J
1. Vrielinck L, Moreno Rabie C, Coucke W, Jacobs R, Oral Maxillofac Implants. 2011;26(3):665–72.
Politis C. Retrospective cohort assessment of survival 16. Aparicio C. A proposed classification for zygomatic
and complications of zygomatic implants in atrophic implant patients based on the zygoma anatomy guided
maxillae. Clin Oral Implants Res. 2023;34(2):148– approach (ZAGA): a cross-sectional survey. Eur J
56. https://doi.org/10.1111/clr.14027. Oral Implantol. 2011;4:269–75.
2. Becktor JP, Isaksson S, Abrahamsson P, Sennerby 17. Aparicio C. Zygomatic implants: the anatomy-­
L. Evaluation of 31 zygomatic implants and 74 regu- guided approach. 1st ed. New Malden: Quintessence
lar dental implants used in 16 patients for prosthetic Publishing Company; 2012.
reconstruction of the atrophic maxilla with cross-­ 18. Duarte LR, Filho HN, Francischone CE, Peredo LG,
arch fixed bridges. Clin Implant Dent Relat Res. Brånemark P-I. The establishment of a protocol for
2005;7:159–65. the total rehabilitation of atrophic maxillae employ-
3. Freedman M, Ring M, Stassen LFA. Effect of alve- ing four zygomatic fixtures in an immediate loading
olar bone support on zygomatic implants: a finite system--a 30-month clinical and radiographic follow-
element analysis study. Int J Oral Maxillofac Surg. ­up. Clin Implant Dent Relat Res. 2007;9:186–96.
2013;42:671–6. 19. Davo R, Pons O, Rojas J, Carpio E. Immediate func-
4. Freedman M, Ring M, Stassen LFA. Effect of alveolar tion of four zygomatic implants:1-year report of a pro-
bone support on zygomatic implants in an extra-sinus spective study. Eur J Oral Implantol. 2010;3:323–34.
position--a finite element analysis study. Int J Oral 20. Aparicio C, Polido WP, Chow J, David L, Davo R,
Maxillofac Surg. 2015;44:785–90. De Moraes EJ, Fibishenko A, Ando M, Mclellan G,
5. Jensen OT, Brownd C, Blacker J. Nasofacial prosthe- Nicolopoulos C, Pikos MA, Zarrinkelk H, Balshi
ses supported by osseointegrated implants. Int J Oral TJ, Peñarrocha M. Identification of the pathway and
Maxillofac Implants. 1992;7(2):203–11. appropriate use of four zygomatic implants in the
6. Aparicio C, Brånemark PI, Keller EE, Olive atrophic maxilla: a cross-sectional study. Int J Oral
J. Reconstruction of the premaxilla with autogenous Maxillofac Implants. 2021;36:807–17. https://doi.
iliac bone-in combination with osseointegrated org/10.11607/jomi.8603.
implants. Int J Oral Maxillofac Implants 1993: 8: 21. Aparicio C, Manresa C, Francisco K, Aparicio A,
61–67. Nunes J, Claros P, et al. Zygomatic implants placed
146
using the zygomatic anatomy-guided approach versus
the classical technique: a proposed system to report
rhinosinusitis diagnosis. Clin Implant Dent Relat Res.
2014;16:627–42.
22. Aparicio C, Manresa C, Francisco K, Ouazzani W,
Claros P, Potau JM, et al. The long-term use of zygo-
matic implants: a 10-year clinical and radiographic
report. Clin Implant Dent Relat Res. 2014;16:447–59.
23. Clarós P, Końska N, Clarós-Pujol D, Sentís J, Clarós
A, Peñarrocha-Diago M, Aparicio C. Prevalence of
C. Aparicio
maxillary sinus alterations after zygomatic surgery.
A comparative study between intra-sinus and ZAGA
approaches. J Dent Oral Maxillofac Surg. 2021;3(1).
https://doi.org/10.31579/2643-­6612/0018.
24. Aparicio C, Polido W, Chow J, Davó R, Al Nawas
B. Round and flat zygomatic implants: effectiveness
after a 1-year follow-up non-interventional study. Int
J Implant Dent. 2022;8:13. https://doi.org/10.1186/
s40729-­022-­00412-­8.
 Pterygoid Implants as Alternative
to Bone Augmentation in Implant
Dentistry
Vishtasb Broumand and Jayson Kirchhofer
Abstract
The ultimate dental implant challenge is
reconstruction of the severely resorbed max-
illa especially in patients with long-term eden-
tulism or multiple previous failed attempts at
dental implant placement and full-arch
implant rehabilitation. Before implant den-
tistry, complete dentures, which are limited by
poor retention and lack of support that the
alveolar ridge offers in atrophic maxillae,
were the only option for these patients.
Pterygoid implants are now a valid and valu-
able resource for the rehabilitation of the pos-
terior atrophic maxilla. This chapter will cover
pterygoid implant surgical and presurgical
planning, surgical procedures, and protocols,
including multiple techniques commonly uti-
lized to place and restore these implants
comprehensively.
V. Broumand (*) · J. Kirchhofer
Oral and Maxillofacial Surgery Private Practice,
Desert Ridge Oral Surgery Institute,
Phoenix, AZ, USA
Department of Oral and Maxillofacial Surgery,
University of Arizona College of Medicine at Banner
University Medical Center Phoenix,
Phoenix, AZ, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_7
7
7.1 Introduction
Placement of dental implants in patients with ver-
tical and horizontal deficiencies of the maxilla, or
with tumour or trauma-related defects, is often
limited by the extensive pneumatization of the
sinus cavities and, furthermore, by the poor qual-
ity and inadequate quantity of remaining bone
(Fig. 7.1). Many surgical procedures have been
developed to rebuild the atrophic maxilla for sub-
sequent dental implant placement, such as alloge-
neic bone grafting with mesh, autogenous iliac
crest block grafting, Le Fort I osteotomies with
interpositional grafts, and sinus augmentation
procedures. None of these procedures yield
immediate results with long periods of healing,
multiple required surgical procedures, and
increased financial burdens/hurtles. Furthermore,
complications and failures of these reconstructive
efforts are common (Fig. 7.2) [1].
In more contemporary literature, in order to
avoid extensive bone grafting procedures, ptery-
goid and angled implants with or without zygo-
matic implants have been recommended for the
dental rehabilitation and reconstruction of this
group of patients, even though the palatal and
posterior resorptive pattern of the edentulous
maxillae may also limit the horizontal bony vol-
ume necessary to successfully place angled
endosseous implants (Fig. 7.3) [2–4].
Severe atrophy of the maxilla can be due to
various factors such as tumour resection, general-
147
148 V. Broumand and J. Kirchhofer

a b

Fig. 7.1 Example of a severely atrophic maxilla (a). Sagittal and panoramic view demonstrating the maintenance of
dense bone at the pterygomaxillary junction despite a severely resorbed maxillary alveolus (b, c)

ity for patients with an atrophic edentulous max-

­tubero-­pterygoid or, more commonly, a pterygoid
Fig. 7.2 Coronal CBCT slice demonstrating a large oro-
antral fistula of the left maxilla caused by multiple failed
sinus augmentation bone grafting procedures
ized aggressive periodontitis and other infections,
and genetic disorders or syndromes. Fabrication
of a prosthesis with adequate retention and stabil-
illa presents a significant challenge for even the
most skilled surgeon. Treatment concepts with
pterygoid implants have evolved as an alternative
for bone augmentation procedures.
Placement of an implant through the maxil-
lary tuberosity and into the pterygoid plate at the
pterygomaxillary junction is called a
implant. Though close in anatomical proximity,
they are not the same as tuberosity implants
which obtain their stability solely from the poor-­
quality bone of the tuberosity. Pterygoid implants
were first proposed by Linkow in 1975 [1, 5] as
an alternative to rehabilitate the atrophic maxilla
avoiding the need for further surgeries, such as
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry 149

a b

c d

Fig. 7.3 Pterygoid implants in conjunction with (a) traditional AOX; (b) trans-nasal and trans-palatal implants; (c)
hybrid zygomatic implants and traditional nasomaxillary implants; (d) quadruple zygomatic implants

sinus lifts or alternative ridge augmentation with
bone grafting [6, 7]. The first pterygoid implant
was placed by Tulasne in 1985 [5]. In 1992,
Tulasne and Tessier first described the technique
and initially described a success rate of 80%.
Tulasne later reported a success rate of 92% in
1999. Nonetheless, during the past years, several
studies have reported a much higher success rate,
ranging from 90.7% to 99% success as reported
by Balshi and Araujo [8–14].
Dental implant placement in the posterior
maxilla poses a challenge due to the quality and
quantity of bone, the anatomy of the maxillary
sinus, and difficulty of access. To overcome these
challenges, several surgical procedures such as
sinus lifts, ridge augmentation, tilted implants,
short implants, and zygomatic implants have
been used by many clinicians, though not all
patients are candidates for such techniques. All of
these procedures have their own limitations, and
the pterygomaxillary junction provides an excel-
lent source of D1 cortical bone for placement of
implants in the rehabilitation of the posterior
maxilla [15]. Pterygoid implants serve to reduce
the anterior-posterior (AP) cantilever for full-­
arch hybrid prostheses and are commonly used as
rescue implants in cases of failed hybrid 4-implant
supported cases.
Placement of pterygoid implants involves an
osteotomy starting in the tuberosity region with a
mesiocranial oblique trajectory proceeding poste-
riorly toward the pyramidal process of the palatine
bone. It is subsequently advanced superiorly
between both the medial and lateral pterygoid
plates of the pterygoid process destined for the
pterygoid, or scaphoid, fossa of the sphenoid bone.
Placement of pterygoid implants can present
some challenges compared to conventional den-
tal implants as it is a blind procedure hinged
solely on the surgeon’s knowledge of the anat-
omy. Surgical access is limited, and serious inju-
ries can occur if, unintentionally, other vital
structures are encountered/injured. The descend-
ing palatine artery or maxillary artery may be
severed if the implant is placed too far apical. An
implant can also invade the pterygomaxillary
fossa and the pterygoid plexus of veins leading to
significant haemorrhage [16]. The pterygoid
plexus is a valve-free venous plexus located in
the infratemporal fossa, is continuous with the
cavernous sinus, and eventually becomes the
maxillary vein as it drains inferiorly. There is
only a risk of bleeding to the plexus if, during
surgery, the implant extends too far laterally as
the pterygoid plexus is found lateral to the ptery-
goid implant target area (Fig. 7.4).
150 V. Broumand and J. Kirchhofer

Cavernous venous
sinus
Emissary vein connecting
pterygoid venous plexus
to cavernous sinus
Inferior
ophthalamic vein Superficial
temporal vein

Maxillary vein

Pterygoid
venous plexus
Deep facial
vein

Retromandibular
Facial vein vein

External jugular vein

Internal jugular vein

Fig. 7.4 The pterygoid plexus is found lateral to the lateral pterygoid plate. Significant haemorrhage may be encoun-
tered if the pterygoid implant osteotomy is created with an excessively lateral angulation

3rd part of Maxillary A

2nd part of Maxillary A

Upper head of lateral

Neck of mandible (cut)
Pterygoid Muscle

1st part of Maxillary A

Lower head of lateral Maxillary Artery

Pterygoid Muscle

External carotid artery

Fig. 7.5 The internal maxillary artery may be encountered if the osteotomy is extended too far superiorly leading to
potentially life-threatening haemorrhage

It is imperative to have a thorough knowledge
of the regional anatomy because nearby vital
structures can be injured during the blind place-
ment of these technique sensitive implants. The
pterygomaxillary fissure connects the infratem-
poral fossa to pterygopalatine fossa and is a con-
duit for the internal maxillary artery which
traverses the pterygomaxillary fissure 18.7 mm
above the pterygomaxillary suture (according to
Uchida) (Fig. 7.5) [17, 18].
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry
a extremely difficult in the severely atrophic premax-
b phic maxilla, especially in patients with conven-
Fig. 7.6 (a, b) The greater palatine canal and descending
palatine artery have a variable anatomic location and
should always be evaluated with preoperative imaging. (a)
Schematic of the palatal anatomy with the greater palatine
foramen exiting at the third molar (most common varia-
tion). (b) Axial CT image demonstrating the location of
the greater (red) and lesser (green) palatine arteries and
their close proximity to the pterygomaxillary complex
When placing a pterygoid implant, it is essen-
tial to pay attention to its proximity to the greater
palatine canal and neurovascular bundle as it also
houses the descending palatine artery, one of the
terminal branches of the maxillary artery [19].
Unfortunately, the location of the greater palatine
foramen is quite variable: 16.3% at the second
maxillary molar site, 6.8% between the second
and third molar, 63.9% at the third molar, and
2.2% distal to the third molar site (Fig. 7.6) [20].
7.2 Indications
Treatment concepts with zygomatic implants have
evolved as an alternative for challenging bone aug-
mentation procedures. The combination of conven-
tional implants and zygomatic implants, namely, a
“hybrid zygoma,” has been used successfully for
restoration of the moderately atrophic maxilla [21–
27]. Placement of anterior conventional implants
without large grafting procedures may prove to be
151
illa. In such situations, quadruple zygomatic
implants can be used for the dental rehabilitation of
the edentulous maxilla in combination with the use
of pterygoid implants [28–31].
Pterygoid implant placement procedures,
which do not require any adjunctive procedures
such as grafting, have become a logical choice
for dental rehabilitation of the moderately atro-
tional implants in the premaxilla or failed sinus
grafting procedures in the posterior maxilla [32].
When placed with zygomatic implants, a pter-
ygoid implant, in combination with conventional
implants in the premaxilla, can counteract the
long lever arm created by zygomatic implants
and prevent prosthetic screw loosening as well as
increase the odds of long-term success of the
zygomatic implants. When successfully placed,
pterygoid implants diminish the posterior pros-
thetic cantilever significantly.
One of the most important reasons and advan-
tages for the use of pterygoid implants is the
elimination of the need to perform sinus lift sur-
geries or bone grafts. This can also significantly
decrease the patient morbidity and shorten the
treatment time, as these implants can be used for
immediate loading with a fixed prosthesis
(Fig. 7.7). They are also quite useful in conjunc-
tion with zygomatic implants to reduce the poste-
rior cantilever associated with zygomatic
implants. Unlike maxillary tuberosity implants,
pterygoid implants anchor in dense cortical bone
of the pterygomaxillary junction, allowing a bet-
ter primary stabilization which is known to be a
critical factor for long-term success [33–35].
Pterygoid Implants are only manufactured by a
few dental implant companies. They are relatively
long and specifically designed with the characteris-
tics of the pterygomaxillary region in mind.
Pterygoid implants range in length from 18 to
26 mm and generally have a sharp, self-­tapping
apex to ensure a secure anchorage when inserted in
the pterygoid fossa [32]. Some manufacturers fab-
ricate the implant with a coronal portion that has a
wide thread profile in order to provide compression
in the region of the tuberosity where the bone is
often porous and of poor quality and low density.
152 V. Broumand and J. Kirchhofer

a b

Fig. 7.7 (a–c) Patient with immediately loaded pterygoid pterygoid implants. (a) Digital design of day-of-surgery
and zygomatic implants on day of surgery. Note the com- temporary prosthesis; (b) temporary resin prosthesis
plete reduction of posterior cantilever by utilization of occlusal; and (c) smiling photos shortly after delivery

7.3 Contraindications 7.4 Pertinent Clinical Anatomy

Contraindications to placement of pterygoid
implants are limited mouth opening which
leads to decreased access, lack of a maxillary
tuberosity, recent LeFort or pterygomaxillary
fracture, and presence of impacted maxillary
third molars.
of the Pterygomaxillary
Region
Support for the pterygoid implants is derived from
the maxillary tuberosity, the pyramidal process of
the palatine bone, and the pterygoid process of the
sphenoid bone. The tuberosity of the maxilla has
been shown to be soft, type III or type IV bone.
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry 153

The anatomy of the pyramidal process of the suture can often dictate changes in implant tra-
palatine bone often dictates the trajectory of the jectory vertically and horizontally depending
implant as it can alter the shape and size of the on the form and size of the pyramidal process
pterygomaxillary suture. The variations in this of the palatine bone as seen in Figs. 7.8 and 7.9.

Fig. 7.8 (a) Palatine bone—the a

anatomy of the pyramidal process of
the palatine bone often dictates the
trajectory of the implant; (b) the
pterygoid fossa is the apical aiming
point for pterygoid implants

a b

Fig. 7.9 Sphenoid bone, (a) inferior view; (b) anterior view. The desired trajectory for the pterygoid implant is between
the medial and lateral pterygoid plates within the pterygoid fossa
154
7.5 Preoperative Planning
A thorough clinical examination in the planning
process for pterygoid implants, although manda-
tory, is incomplete without a proper radiologic
evaluation as three-dimensional assessment must
be considered. In order to properly evaluate a
patient for all angled implants, and especially
zygomatic or pterygoid implants, a panoramic
radiograph gives distorted and incomplete infor-
mation. One must be able to thoroughly evaluate
a b
Fig. 7.10 (a–c) Three-dimensional evaluation of the
pterygomaxillary complex via CT imaging is of utmost
importance when planning pterygoid implants. (a)
V. Broumand and J. Kirchhofer
the size and shape of the maxillary sinuses, health
of the sinuses, the height of the maxillary tuberos-
ity and the pterygomaxillary process, width of the
pterygomaxillary process, mediolateral thickness
and anterior posterior length, and the position of
the nasal floor [36]. The examination of choice is
three-dimensional computed tomography (CT)
scans which also allow for construction of surgi-
cal guides as well as stereolithographic models to
facilitate the orientation of pterygoid and zygo-
matic implants during the surgery (Fig. 7.10) [37].
Sagittal, (b) axial, and (c) coronal cuts are used to under-
stand the complex anatomy which may be variable from
patient to patient
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry 155

7.6 The Surgical Approaches ity bone. The pyramidal process of the palatine
for Pterygoid Implants bone is the second bone to be encountered. The
drill or osteotome should hit this like a “brick
After local anaesthetic administration, a full-­ wall.” Once the sharp spade drill hits dense bone,
thickness flap extending to the posterior border of then the operator should switch to the Noris
the tuberosity is developed. A small amount of 2 mm sharp osteotome. Using this sharp osteo-
bone reduction is performed with a large head tome and a mallet, gently tap until you feel a
bone rongeur followed by a straight handpiece dense bone wall and then continue tapping until
flame shape tungsten bur in order to (a) achieve you hear an increase in sound frequency. In order
an optimal platform for implant placement, (b) to avoid fracturing the pterygomaxillary com-
create a flat bone surface, and (c) create pros- plex, it is recommended to drill with a 2 mm twist
thetic space for the future screw-retained hybrid drill to 18 mm or until perforating through the
prosthesis. Pterygoid implant positioning should pterygomaxillary complex and into the pterygoid
be carefully studied using helical or cone-beam fossa. The length of the implant may differ
computer tomography (CBCT) imaging of the depending on the entry point of the implant, i.e.,
patient. Careful planning is important as these second vs. third molar site (Fig. 7.12). Next, a
implants require a bucco-palatal and a mesio-­ Noris 3 mm osteotome is used to gently tap to
distal angulation [38, 39]. There are two depth. If the bone is super dense, use the 2.8 mm
­commonly employed techniques used to place twist drill to widen osteotomy prior to placing the
pterygoid implants, both of which will be dis- pterygoid implant by hand.
cussed here. Regardless of surgical technique
used, the implant is preferably placed by hand
with a minimal torque value of 30 N cm for 7.6.2 Description of the Technique:
immediate loading. With this technique, the goal Pterygoid Implants with Drill
is insertion of implants in the pterygomaxillary Guided Technique (Fig. 7.13)
junction using the residual alveolar-basal bone as
anchorage of a standard implant antero-­inferiorly. Clinically, the anatomy of the tuberosity, the
The two techniques used are placement of ptery- length from the planned starting point to the end
goid implants with either the osteotome guided of the tuberosity, and the relative position of the
technique or the drill guided technique. sinus are used as landmarks for the starting drill.
Operator’s experience and haptic awareness are
extremely important in this step as the place-
7.6.1 Description of the Technique: ment of pterygoid implants allows no direct
Pterygoid Implants vision to the end point. Implant placement fol-
with Osteotome Guided lows standard procedures, but some techniques
Technique (Fig. 7.11) are used to increase primary stability, in particu-
lar underpreparation, osseodensification, and
Clinically, the anatomy of the tuberosity, the bi-corticalization.
length from the planned starting point to the end For the pterygoid implants, the implant bed
of the tuberosity, and the relative position of the preparation follows the following sequence. The
sinus are all used as landmarks for the initial first needle-type drill and the second 2.0 mm
entry point of the sharp pilot drill or osteotome. diameter pilot drill from a Helix long implant kit
One must advance the sharp pilot “spade”-shaped (Neodent) are used clockwise, full length, until
drill through the soft tuberosity until dense bone perforation of the pterygomaxillary process is
is encountered. An osteotome is used first by achieved. This allows the bi-corticalization of the
some surgeons. When using the sharp osteotome, implants. The three following drills used (2.0,
it may migrate in the soft bone, and the operator 2.35, and 3.75 mm) are Neodent Helix Long or
can often push entirely through this soft tuberos- Noris Medical Pterygoid with counter-clockwise
156
a b
d e
Fig. 7.11 Osteotome guided technique—(a) axial view
of the maxilla demonstrating the appropriate bucco-­
palatal angulation of the osteotomy; (b) sagittal view
demonstrating the appropriate mesio-distal angulation of
the osteotomy. (c) The osteotome technique is first initi-
ated using the 2 mm pterygoid osteotome which is
advanced through the tuberosity and continued until hit-
ting the “brick wall” of the palatine bone. (d) The white-­
banded 2.3 mm twist drill is then used to perforate through
a b
Fig. 7.12 (a) Proper angulation for an implant entering
at the second molar site. (b) Proper angulation for an
implant entering at the third molar site. (c) Note the sig-
V. Broumand and J. Kirchhofer
c
f g
the dense palatine bone to the desired osteotomy depth.
(e) The 3 mm osteotome is then used to gently expand the
osteotomy. (f) The red-banded 2.8 mm twist drill is then
used to open dense apical portion of the osteotomy. (g)
The pterygoid implant is gently hand tightened into the
osteotomy taking extreme care to follow the same angula-
tion used for the previous steps. Any alteration in angula-
tion may lead to fracture of the pterygomaxillary junction
and loss of the ability to place a subsequent implant
c
nificantly greater length required when entering from the
second molar site compared to the third molar site
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry
a b
d e
Fig. 7.13 Drill guided technique—(a) axial view of the
maxilla demonstrating the appropriate bucco-palatal
angulation of the osteotomy; (b) sagittal view demonstrat-
ing the appropriate mesio-distal angulation of the osteot-
omy from the third molar entry point. (c) The drill guided
technique is first initiated using the 2 mm twist drill which
is advanced through the tuberosity and continued through
the “brick wall” of the palatine bone. (d) The 2.35 mm
twist drill is then used to further widen the dense palatine
bone to the depth of the osteotomy. (e) The 3.75 mm twist
rotation of the final drill in order to increase bone
density of the tuberosity via osseodensification.
Together, these two techniques result in the high
primary stability of pterygoid implants.
The implant enters in the region of the former
maxillary second or third molar and follows an
oblique mesio-cranial direction proceeding pos-
teriorly towards the pyramidal process of the
palatine bone. It subsequently proceeds superi-
orly/cranially between both wings of the ptery-
goid process and finds its encroachment in the
pterygoid, or scaphoid, fossa of the sphenoid
157
c
f
drill is then used to gently expand the inferior aspect of
the osteotomy. Note that this drill is not carried to the full
depth and is stopped approximately 3–5 mm short of the
planned implant length. (f) The pterygoid implant is gen-
tly hand tightened into the osteotomy taking extreme care
to follow the same angulation used for the previous steps.
Any alteration in angulation may lead to fracture of the
pterygomaxillary junction and loss of the ability to place
a subsequent implant
bone [38, 39]. All pterygoid implants should
anchor with 50 + N cm torque, and the most com-
mon length is 18 mm when utilizing the third
molar entry point. After implant placement, a
multi-unit-type abutment is placed on each
implant, generally an angled 17° or 30° abutment
(Fig. 7.14). The flap is then sutured in place as
described by de Sousa [40]. A previous remov-
able provisional denture can be converted to a
fixed, screw-retained full acrylic FP-3 prosthesis
following the denture conversion technique
described by Misch [41].
158
Fig. 7.14 30° neodent multi-unit abutment in place on
pterygoid implant site 16
7.7 Prosthetic Considerations
In most cases, we consider an immediate-load
protocol, although a delayed load protocol is also
possible [42–44]. The immediate one-stage pro-
tocol requires the immediate cross-arch splinting
of the zygomatic and/or pterygoid implants at the
time of surgery. The patient’s existing or new
denture is converted to a hybrid bridge. The den-
ture is altered to accommodate the multi-unit
abutments with temporary cylinders in order to
splint the zygomatic or pterygoid implants. The
patient’s existing denture is then converted into a
fixed provisional bridge using the same direct or
indirect conversion technique described for the
conversion protocol used when immediate load-
ing is considered. During the first month of the
healing stage, the patient is seen every week to
adjust the occlusion as it must remain equally
balanced across the entire arch. After healing of
the bone and soft tissues, approximately 6 months
later, abutment level final impressions of the
zygomatic and/or pterygoid implants are obtained
for the fabrication of a definitive fixed hybrid
with a titanium bar [45–47].
Once the final restorations are delivered, it is
recommended to use a waterpik water flosser
twice daily, especially at bedtime. It is also rec-
ommended to brush twice daily with a soft man-
ual toothbrush using a non-abrasive,
non-whitening toothpaste. Recall appointments
are advised at 3 months, 6 months, and 1 year
after delivery of the final appliance. At the yearly
V. Broumand and J. Kirchhofer
appointment, the appliance is removed to clean
the underside of the hybrid restoration and the
multi-unit abutments, especially for patients that
have difficulty maintaining hygiene. Periapical
and panoramic radiographs are taken each year at
the recall appointment for 3 years following
insertion, and then once every 3 years, or as
deemed necessary thereafter.
From a prosthetic standpoint, pterygoid
implants minimize the time to rehabilitation by
avoiding secondary grafting, bypass the need of
a distal cantilever, and make it possible to place
second molars in the final full-arch prosthesis.
Even though they are placed in the pterygomax-
illary region at an angle, once osseointegrated,
these pterygomaxillary implants resist all axial
and nonaxial forces better than any other
implants placed in the maxilla. As illustrated in
our cases, patients tolerate the distal position of
the implant, showing no difficulty in speech or
swallowing. Patients also demonstrate no diffi-
culty in maintenance of oral hygiene. The suc-
cess rate of these implants and restorations is
highest when they meet criteria for an immedi-
ate prosthetic load with adequate vertical
restorative space to avoid prosthetic or screw
fracture [48].
7.8 Clinical Cases
7.8.1 Case #1: Trans-nasal
and Trans-palatal Implants
in Conjunction with Pterygoid
Implants (Fig. 7.15)
The case shown here illustrates maxillary reha-
bilitation using a combination of trans-palatal,
trans-nasal, and pterygoid Neodent implants for
an implant supported maxillary hybrid bridge in
a 67-year-old male with terminal maxillary denti-
tion. Due to the significant amount of preopera-
tive bone loss as well as the alveolar ridge
reduction required prosthetically by his high
smile line, insufficient bone remained for tradi-
tional AOX implant placement. Note the signifi-
cant increase in anterior-posterior spread gained
by the addition of the pterygoid implants.
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry
a c
b d
Fig. 7.15 (a, b) A 67-year-old male presenting with ter-
minal maxillary dentition and failing previous restorations
and mobile anterior teeth. Due to the significant amount of
preoperative bone loss as well as the alveolar ridge reduc-
tion required prosthetically by his high smile line, insuf-
ficient bone remained for traditional AOX implant
placement. Trans-nasal and trans-palatal implants were
used in conjunction with pterygoid implants to restore an
atrophic maxilla after the removal of remaining terminal
7.8.2 Case #2: Hybrid Zygoma
in Conjunction with Pterygoid
Implants (Fig. 7.16)
The case shown here illustrates maxillary arch
rehabilitation using a combination of two zygo-
matic and three traditional implants in the ante-
rior maxilla in combination with pterygoid
implants. This 40-year-old male presented with
terminal maxillary dentition, Angle’s class-III
malocclusion, and a constricted maxillary arch.
The patient was told by other providers that he
was not a candidate for full-arch implants due to
the atrophic nature of his alveolar bone in con-
junction with his constricted and hypoplastic
maxilla. A hybrid zygomatic and traditional
implant approach, along with pterygoid implants,
was utilized to restore the maxillary arch. The
patient is currently in the process of restoring his
mandibular dentition.
159
maxillary teeth. Note the significant increase in anterior-­
posterior spread gained by the addition of the pterygoid
implants. (a) Preoperative panoramic imaging, (b) post-
operative panoramic imaging on the day of surgery with
multi-unit abutments and scanning caps in place. (c, d)
Another example of trans-nasal and trans-palatal implants
used in conjunction with pterygoid implants
7.8.3 Case #3: Quadruple
Zygomatic Implants
in Conjunction with Pterygoid
Implants (Fig. 7.17)
The case shown here illustrates full mouth
rehabilitation using a combination of four
zygomatic and two pterygoid implants in the
maxilla and implant retained lower hybrid
Zirconia bridges with four dental implants uti-
lizing an immediate load protocol in a 61-year-
old male who presented with terminal maxillary
and mandibular dentition. Due to the long his-
tory of partial edentulism, significant bone loss
had led to a severely atrophic maxilla with
inadequate bone volume for traditional, trans-
nasal, or trans-palatal implant placement. He
was treated with quadruple zygomatic implants
in conjunction with pterygoid implants to fully
restore his dentition.
160 V. Broumand and J. Kirchhofer

a b

c d

Fig. 7.16 (a–d) A 40-year-old male presenting with ter-
minal maxillary dentition, Angle’s class-III malocclusion,
and a constricted maxillary arch. The patient was told by
other providers that he was not a candidate for full-arch
implants due to the atrophic nature of his alveolar bone in
conjunction with his constricted and hypoplastic maxilla.
A hybrid zygomatic and traditional implant approach,
along with pterygoid implants, was utilized to restore the
maxillary arch. The patient is currently in the process of
restoring his mandibular dentition. (a) Preoperative pan-
oramic imaging; (b) preoperative intraoral photograph;
(c) postoperative panoramic imaging; (d) smile photo-
graph of temporary maxillary prosthesis

a b

c d

Fig. 7.17 (a–d) A 61-year-old male presenting with ter-
minal maxillary and mandibular dentition. Due to the long
history of partial edentulism, significant bone loss had led
to a severely atrophic maxilla with inadequate bone vol-
ume for traditional, trans-nasal, or trans-palatal implant
placement. He was treated with quadruple zygomatic
implants in conjunction with pterygoid implants to fully
restore his dentition. (a) Preoperative panoramic imaging,
(b) preoperative intraoral photograph; (c) panoramic
imaging following delivery of final prostheses; (d) intra-
oral photograph following delivery of milled zirconia final
prostheses
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry 161

7.9 Complications undertaking surgery for the placement of ptery-

goid implants (Fig. 7.18).
It is important for the treating surgeon to have a The overall frequency of complications with
clear knowledge of the intricate anatomy of the pterygoid implants is variable and includes
maxilla and the pterygomaxillary complex prior implant failure, haemorrhage, trismus, tuberos-

Pterygomaxillary fissure
(Laterally)

Greater wing of sphenoid

(Superiorly)

Perpendicular plate of palatine bone

(Medially)
Pterygoid process
(Posteriorly)

Pyramidal process of palatine bone

(Inferiorly)

Posterior surface of maxilla

(Anteriorly)

Maxillary artery

Pterygoid vein
plexus

Fig. 7.18 The (a) bony and (b) vascular anatomy of the pterygomaxillary region
162 V. Broumand and J. Kirchhofer

ity or pterygoid complex fracture, and displace- 7.11 Conclusion

ment into the infratemporal fossa.
Pterygoid implants provide an aid to a graftless
solution in an atrophic maxilla. The pterygomaxil-
7.10 Discussion lary complex, though seemingly distant, provides
anchorage for fixed solutions without any need for
Dental implant placement in the posterior max- bone grafting or sinus lift procedures. Pterygoid
illa poses a challenge due to the poor quality and implants provide strong cortical anchorage even in
inadequate quantity of bone, the anatomy of the the atrophic maxilla. Studies have shown them to
maxillary sinus, and difficulty of access. To be an alternative treatment option for patients with
overcome these challenges, several surgical pro- highly atrophic maxillae without the need for
cedures such as sinus lifts, ridge augmentation, extensive augmentation procedures. The availabil-
tilted implants, short implants, and zygomatic ity of dense cortical bone for engagement of the
implants have been used by many clinicians, implant encourages its use. Pterygoid implants
although not all patients are candidates for such have high success rates, similar bone loss levels to
techniques. All of these procedures have their those of conventional implants, minimal compli-
own limitations, and the pterygomaxillary junc- cations, and good acceptance by patients [6, 7, 51].
tion provides us an excellent source of D1 corti- Additionally, when anterior implants fail or are
cal bone for placement of implants for not feasible, addition of pterygoid implants seems
rehabilitation of the posterior maxilla [15, 49]. to be a valid primary or rescue solution for the full-
Pterygoid implants serve to reduce the antero-­ arch rehabilitation with immediate loading of the
posterior cantilever significantly and are com- atrophic maxilla, avoiding more invasive and time-
monly used as rescue implants in cases of failed consuming procedures like the sinus lifts and large
hybrids. bone grafts. In some cases, quadruple zygomatic
Treatment concepts with pterygoid implants implants can be avoided if adequate pterygoid
have evolved as an alternative for challenging anchorage is obtained as they provide additional
bone augmentation procedures. In some cases, a support with increased composite torque value
combination of conventional implants and zygo- and, more importantly, improved A-P spread for
matic or pterygoid implants has been used suc- prosthetics, eliminating large cantilevers [33, 34,
cessfully for restoration of the moderately atrophic 52, 53]. Pterygoid implant use can significantly
maxilla [21–27]. Placement of anterior conven- eliminate the posterior cantilever and, thus, can
tional implants without large grafting procedures decrease screw and restoration fractures which
may prove extremely difficult in the severely atro- ultimately can lead to failure of full-arch implant
phic premaxilla. In such situations, quadruple supported prosthesis [54]
zygomatic implants with or without pterygoid Surgical demonstration of Osteotomy and
implants can be used for the dental rehabilitation drill guided pterygoid implant methods
of the edentulous maxilla [28–31, 50]. (Figs. 7.19 and 7.20).
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry 163

a b c d

e f g h

Fig. 7.19 (a–i) Step-by-step surgical demonstration of
pterygoid implant placement utilizing the osteotome
guided method. (a) Demonstration of appropriate angula-
tion using 2.0 mm pterygoid osteotome; (b) initiation of
osteotomy using 2.0 mm pterygoid osteotome with the
third molar entry site; (c) 2.0 mm pterygoid osteotome hit-
ting the “brick wall” stop of palatine bone; (d) 2.0 mm
white-stripe twist drill perforating through the dense pala-
tine bone; (e) 3.0 mm pterygoid osteotome being advanced
to planned osteotomy depth; (f) 2.8 mm twist drill prepar-
ing the apical aspect of the osteotomy; (g) hand placement
of 4.2 × 20 mm Noris implant; (h) implant in place with
ideal depth for adequate restorative space; (i) postopera-
tive panoramic imaging demonstrating improved antero-­
posterior spread by use of pterygoid implants with
quadruple zygomatic implants

a b c d

e f g h

Fig. 7.20 (a–h) Step-by-step surgical demonstration of
pterygoid implant placement utilizing the drill guided
method. (a) 2.0 mm Neodent twist drill; (b) initial oste-
otomy being created with 2.0 mm twist drill; (c) 2.35 mm
twist drill widening osteotomy to depth; (d) 3.75 mm
twist drill widening the coronal aspect of the osteotomy
(stopping short of full depth); (e) placement of
4.0 × 20 mm Neodent Helix GM Long implant; (f) dem-
onstration of adequate torque for immediate loading; (g)
30° Neodent multi-unit abutment torqued in place; (h)
postoperative panoramic image demonstrating ideal
antero-posterior spread by use of pterygoid implants
164 V. Broumand and J. Kirchhofer

References implant site using multislice CT, micro-CT, and cone

beam CT. Clin Oral Implants Res. 2013;26:e1–7.
16. Rodríguez X, et al. Anatomical study of the ptery-
1. Linkow LL. Maxillary implants: a dynamic approach
gomaxillary area for implant placement: cone beam
to oral implantology. North Haven, CT: Glarus
computed tomographic scanning in 100 patients. Int J
Publishing; 1977. p. 109–12.
Oral Maxillofac Implants. 2014;29:1049–52.
2. Fortin Y, Sullivan RM, Rangert BR. The Marius
17. Uchida, et al. Computed tomography and anatomi-
implant bridge: surgical and prosthetic rehabilitation
cal measurements of critical sites for endosseous
for the completely edentulous upper jaw with moder-
implants in the pterygomaxillary region: a cadaveric
ate to severe resorption: a 5-year retrospective clinical
study. Int J Oral Maxillofac Surg. 2017;46:798–804.
study. Clin Implant Dent Relat Res. 2002;4:69–77.
18. Lee SP, Paik KS, Kim MK. Anatomical study of the
3. Krekmanov L, et al. Tilting of posterior mandibular
pyramidal process of the palatine bone in relation to
and maxillary implants for improved prosthesis sup-
implant placement in the posterior maxilla. J Oral
port. Int J Oral Maxillofac Implants. 2000;15:405–14.
Rehabil. 2001;28:125–32.
4. Aparicio C, Perales P, Rangert B. Tilted implants as
19. Balaji VR, Lambodharan R, Manikandan D,
an alternative to maxillary sinus grafting: a clinical,
Deenadayalan S. Pterygoid implant for atrophic pos-
radiologic, and periotest study. Clin Implant Dent
terior maxilla. J Pharm Bioallied Sci. 2017;9:S261–3.
Relat Res. 2001;3(1):39–49.
20. Balshi TJ, Lee HY, Hernandez RE. The use of pter-
5. Tulasne JF. Implant treatment of missing poste-
ygomaxillary implants in the partially edentulous
rior dentition. In: Albrektson T, Zarb G, editors.
patient: a preliminary report. Int J Oral Maxillofac
The Branemark osseointegrated implant. Chicago:
Implants. 1995;10:89–98.
Quintessence; 1989. p. 103–15.
21. Malevez C, Abarca M, Durdu F, Daelemans P. Clinical
6. Fuh LJ, et al. Variations in bone density at dental
outcome of 103 consecutive zygomatic implants: a
implant sites in different regions of the jawbone. J
6–48-month follow-up study. Clin Oral Implants Res.
Oral Rehabil. 2010;37:346–51.
2004;15:18–22.
7. Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation
22. Bedrossian E. Rehabilitation of the edentulous maxilla
of the atrophic posterior maxilla with pterygoid
with the zygoma concept: a 7-year prospective study.
implants: a review. J Oral Implantol. 2012;38:461–6.
Int J Oral Maxillofac Implants. 2010;25:1213–21.
8. Araujo RZ, Santiago Júnior JF, Cardoso CL,
23. Aparicio C, Manresa C, Francisco K, Ouazzani
Benites Condezo AF, Moreira Júnior R, Curi
W, Claros P, Potau JM, et al. The long-term use
MM. Clinical outcomes of pterygoid implants: sys-
of zygomatic implants: a 10-year clinical and
tematic review and meta-analysis. J Craniomaxillofac
radiographic report. Clin Implant Dent Relat Res.
Surg. 2019;47:651–60. https://doi.org/10.1016/j.
2014;16:447–59.
jcms.2019.01.030.
24. Miglioranca RM, Sotto-Maior BS, Senna PM,
9. Bidra AS, Huynh-Ba G. Implants in the pterygoid
Francischone CE, Del Bel Cury AA. Immediate
region: a systematic review of the literature. Int J
occlusal loading of extrasinus zygomatic implants: a
Oral Maxillofac Surg. 2011;40:773–81. https://doi.
prospective cohort study with a follow-up period of
org/10.1016/j.ijom.2011.04.007.
8 years. Int J Oral Maxillofac Surg. 2012;41:1072–6.
10. Balshi SF, Wolfnger GJ, Balshi TJ. Analysis of 164
25. Farzad P, Andersson L, Gunnarsson S, Johansson
titanium oxide-surface implants in completely eden-
B. Rehabilitation of severely resorbed maxillae with
tulous arches for fixed prosthesis anchorage using
zygomatic implants: an evaluation of implant stabil-
the pterygomaxillary region. Int J Oral Maxillofac
ity, tissue conditions, and patients’ opinion before
Implants. 2005;20:946–52.
and after treatment. Int J Oral Maxillofac Implants.
11. Suzuki M, et al. Regional anatomical observation of
2006;21:399–404.
morphology of greater palatine canal and surrounding
26. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt
structures. Bull Tokyo Dent Coll. 2016;57:223–31.
T. A long-term follow-up study of osseointegrated
12. Kato Y, Kizu Y, Tonogi M, Yamane GY. Internal struc-
implants in the treatment of totally edentulous jaws.
ture of zygomatic bone related to zygomatic fixture. J
Int J Oral Maxillofac Implants. 1990;5:347–59.
Oral Maxillofac Surg. 2005;63:1325–9.
27. Bedrossian E, Stumpel L III, Beckely ML, Indresano
13. Peñarrocha M, Carrillo C, Boronat A, Peñarrocha
T. The zygomatic implant: preliminary data on treat-
M. Retrospective study of 68 implants placed in the
ment of severely resorbed maxillae. A clinical report.
pterygomaxillary region using drills and osteotomes.
Int J Oral Maxillofac Implants. 2002;17:861–5.
Int J Oral Maxillofac Implants. 2009;24:720–6.
28. Davo R, Pons O. Prostheses supported by four imme-
14. Valerón JF, Valeron PF. Long-term results
diately loaded zygomatic implants: a 3-year prospec-
in placement of screw-type implants in the
tive study. Eur J Oral Implantol. 2013;6:263–9.
pterygomaxillary-­
­ pyramidal region. Int J Oral
29. Padovan LE, Ribeiro-Junior PD, Sartori IA, Thome G,
Maxillofac Implants. 2007;22:195–200.
Sartori EM, Uhlendorf J. Multiple zygomatic implants
15. Parsa A, Ibrahim N, Hassan B, van der Stelt P,
as an alternative for rehabilitation of extremely atro-
Wismeijer D. Bone quality evaluation at dental
7 Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry
phic maxilla: a case letter with 55 months of follow-
­up. J Oral Implantol. 2015;41(1):97–100.
30. Rajan G, et al. Full mouth implant rehabilitation
of patients with severely atrophic maxilla: Quad
zygomatic implants approach. J Dent Implants.
2014;4(2):182.
31. Louis P, Vega L, Christopher J. Atlas of operative oral
and maxillofacial surgery, vol. 8. Hoboken, NJ: John
Wiley & Sons; 2015. p. 42–7.
32. Agbaje JO, Diederich H. Cortically fixed at once
implants for the treatment of the atrophic maxilla—a
case report. Adv Dent Oral Health. 2019;1:1–5.
33. Penarrocha M, Carrillo C, Bonorat A, Penarrocha
M. Retrospective study of 68 implants placed in the
ptertygomaxillary region using drills and osteotomes.
Int J Oral Maxillofac Implants. 2009;24:720–6.
34. Penarrocha M, Vina JA, Carrillo C, Penarrocha
M. Rehabilitation of reabsorbed maxillae with
implants in buttresses in patients with com-
bination syndrome. J Oral Maxillofac Surg.
2012;70:e322–30.
35. Park YJ, Cho SM. Retrospective chart analysis on sur-
vival rate of fixtures installed at the tuberosity bone
for cases with missing unilateral upper molars: a study
of 7 cases. J Oral Maxillofac Surg. 2010;68:1338–44.
36. Rodrıguez X, Lucas-Taulé E, Elnayef B, Altuna P,
Gargallo-Albiol J, Peñarrocha MD, et al. Anatomical
and radiological approach to pterygoid implants: a
crosssectional study of 202 cone beam computed
tomography examinations. Int J Oral Maxillofac Surg.
2015;45(5):636e640.
37. Grecchi F, Stefanelli LV, Grivetto F, Grecchi E, Siev
R, Mazor Z, Del Fabbro M, Pranno N, Franchina
A, Di Lucia V, et al. A novel guided zygomatic and
pterygoid implant surgery system: a human cadaver
study on accuracy. Int J Environ Res Public Health.
2021;18:6142.
38. Graves SL. The pterygoid plate implant: a solution
for restoring the posterior maxilla. Int J Periodontics
Restorative Dent. 1994;14:512–23.
39. Tulasne J. Osseointegrated fixtures in the pterygoid
region. In: Worthington P, Branemark PI, editors.
Advanced osseointegration surgery, applications
in the maxillofacial region. Berlin: Quintessence
Publishing; 1992. p. 182.
40. Nunes de Sousa BL, Leitão de Almeida B. Pterygoid
implants for the immediate rehabilitation of the atro-
phic maxilla: a case report of a full arch on 4 implants.
Oral Maxillofac Surg Cases. 2020;6(4):100192.
41. 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;62:106–15.
165
42. Bedrossian E, et al. Fixed prosthetic implant restora-
tion of the edentulous maxilla: a systematic pretreat-
ment evaluation method. J Oral Maxillofac Surg.
2008;66:112–22.
43. Uchida Y, Goto M, Katsuki T, Akiyoshi
T. Measurement of the maxilla and zygoma as an aid
in installing zygomatic implants. J Oral Maxillofac
Surg. 2001;59:1193–8.
44. Aparicio C. A proposed classification for zygomatic
implant patient based on the zygoma anatomy guided
approach (ZAGA): a cross-sectional survey. Eur J
Oral Implantol. 2011;4(3):269–75.
45. Bedrossian E, et al. Immediate function with the
zygomatic implant—a graftless solution for the
patient with mild to advanced atrophy of the maxilla.
Int J Oral Maxillofac Surg. 2006;21:1–6.
46. Zhao Y, Skalak R, Branemark PI. Analysis of a
dental prosthesis supported by zygomatic fix-
tures. Gothenberg: The Institute for Applied
Biotechnology. 1997.
47. Balshi TJ. The Biotes conversion prosthesis: a provi-
sional fixed prosthesis supported by osseointegrated
titanium fixtures for restoration of the edentulous
jaws. Quintessence Int. 1985;16:667–77.
48. Bedrossian E, Stumpel LJ. Immediate stabilization
at stage II of zygomatic implants: rationale and tech-
nique. J Prosthet Dent. 2001;86(1):10–4.
49. Fernández H, Gómez-Delgado A, Trujillo-Saldarriaga
S, Varón-Cardona D, Castro-Núñez J. Zygomatic
implants for the management of the severely atrophied
maxilla: a retrospective analysis of 244 implants. J
Oral Maxillofac Surg. 2014;72(5):887–91.
50. Yates JM, Brook IM, Patel RR, Wragg PF, Atkins SA,
El-Awa A, et al. Treatment of the edentulous atrophic
maxilla using zygomatic implants: evaluation of sur-
vival rates over 5-10 years. Int J Oral Maxillofac Surg.
2014;43:237–42.
51. Balshi TJ, Wolfinger GJ, Balshi SF. Analysis of 356
pterygomaxillary implants in edentulous arches for
fixed prosthesis anchorage. Int J Oral Maxillofac
Implants. 1999;14:398–406.
52. Holtzclaw, et al. Computed tomography and ana-
tomical measurements of critical sites for endosseous
implants in the pterygomaxillary region: a cadaveric
study. J Implant Adv Clin Dent. 2018;10(7):6–15.
53. Jensen O, et al. Maxillary V4 – four implant treatment
for maxillary atrophy with dental implants fixed api-
cally at the Vomer-Nasal crest, lateral piriform rim,
and zygoma for immediate function. J Prosthet Dent.
2015;114(6):810–7.
54. Sheridan RA, Decker AM, Plonka AB, Wang H-L. The
role of occlusion in implant therapy: a comprehensive
updated review. Implant Dent. 2016;25(6):829–38.
 Scientific Basis of Immediate
Loading and the Biomechanics
8
of Graftless Solutions

Bobby Hardeep Birdi, Komal Majumdar,

and Saj Jivraj

Abstract thoroughly evaluated for relative contraindi-

The implementation of graftless solutions
requires the clinician to have a clear grasp of
many detailed clinical concepts. Diagnosis is
critical for long-term success of the proce-
dure. There has been a paradigm shift in treat-
ment of the edentulous patient with dental
implants. Today, the graftless approach com-
bines three published variables:
1. Four to six implants to support a full-arch
fixed restoration.
2. Use of tilted implants for graftless
anchorage.
3. Immediate loading to provide immediate
function.
For an optimal outcome, it is imperative
that concepts of immediate loading, biome-
chanics of the restoration design, and manage-
ment of the occlusal scheme be understood.
The patients’ medical history must also be
cations to immediate load.
The clinical application of the graftless
concept has been well accepted, and survival
rates in excess of 98% have been reported in
the literature (Busenlechner et al., Int J Oral
Maxillofac Implants 31:1150–1155, 2016).
The purpose of this chapter is to shed light
on the science and biomechanical aspects of
immediate loading of the edentulous patient
utilizing a graftless approach.
8.1 Defining Immediate Loading
The term immediate loading does not have an
established universal definition. Two variables
exist when one attempts to define immediate
loading:
1. The acceptable interval between implant
placement and prosthetic loading.
2. The type of forces exerted on the implant and
prosthesis [1].

B. H. Birdi The following classification proposed by

University of Minnesota School of Dentistry,
Minneapolis, MN, USA
Private Practice, Vancouver, BC, Canada
K. Majumdar
Om Dental Clinic, Navi Mumbai, India
S. Jivraj (*)
Anacapa Dental Art Institute, Oxnard, CA, USA
Esposito et al. [2] has been the most accepted.
Immediate loading is considered the establish-
ment of occlusal function of implants during the
first week after implant placement, early loading
within 1 week and 2 months and conventional
loading from 2 months onwards; the separate

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 167
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_8
168 B. H. Birdi et al.

consideration of delayed loading was suppressed The interim prosthesis should satisfy the fol-
for being unnecessary. lowing requirements (Figs. 8.1, 8.2, 8.3, and 8.4)
[12–17]:

8.2 General Factors

in Immediate Loading

The main factor to consider in immediate loading

is biomechanical force distribution and how this
relates to natural healing. Thus, implant osseoin-
tegration must be attained despite the forces
experienced during the healing phase; otherwise,
fibrous encapsulation of the dental implants will
result [3]. Implant primary stability, that is, the
ability of the implant to withstand an applied
torque of 35–40 N cm without rotation, is the pre-
requisite to immediate loading [2, 4]. Fig. 8.1 Screw-retained, cross-arch stabilized interim
Given that implant initial stability has been prosthesis to be immediately loaded
attained, the main clinical factor that influences
successful immediate loading treatment is the
design of the immediately delivered interim full-­
arch restoration. The clear majority of these types
of full-arch restorations are screw-retained in
design and cross-arch splinted [5]. Screw-­
retained prostheses have been suggested to have
fewer complications when compared to their
cement-retained counterparts [6, 7]. Thus, it is
suggested that all interim restorations be screw-­
retained and cross-arch stabilized as this is the
most evidence-based design.
There are a number of prosthetic consider- Fig. 8.2 Interim prosthesis with adequate AP spread and
ations that must be understood prior to embark- minimal cantilever
ing upon the immediate load process. Meticulous
attention to detail is required for the process to be
successful. An important prerequisite for predict-
able healing is absence of micro-motion. Brunski
et al. [8] reported that micro-motion of 100 μm
may constitute a threshold value for machined
implant surfaces to osseointegrate adequately.
Favourable loading conditions can be achieved
by splinting the implants together immediately
after placement. Micro-motion at the bone
implant interface is limited, thus facilitating the
healing process [9–11].
Fig. 8.3 Interim prosthesis intra-orally with minimal ver-
tical and horizontal overlap
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
Fig. 8.4 Requirements of immediate loading
1. Provide cross-arch stabilization with a screw-­
retained rigid prosthesis with no cantilevers.
2. No premature occlusal contacts.
3. No interferences in lateral excursion.
4. Minimal vertical and horizontal overlap.
5. An occlusal scheme which protects the
implants most at risk.
8.3 Specific Elements
of Immediate Loading
Immediate loading is considered the establish-
ment of occlusal function of implants during the
first week after implant placement [2]. The tim-
ing of when the prosthesis is delivered after the
surgical placement of the implants is important,
as it relates to the bone healing around the dental
implants, and the continued stability of the
implants in the osseous structure. Glauser et al.
[18] have established that the primary initial sta-
bility that is attained at the time of surgical
implant placement decreases significantly after
1 week. Furthermore, it has been shown that bone
remodelling begins to significantly occur at the
1 week time point [19–22]. This helps to estab-
lish the first week after surgical placement of the
dental implants as the safest time to deliver the
immediate prosthesis. However, it must be stated
169
that on a cellular level, osteoclasts have been
shown to be present on the surface of the cut
native bone surrounding the implant 4 days after
implant placement [19]. Thus, it may be advanta-
geous to place the immediate interim restoration
as soon as possible after the implants have been
surgically placed.
8.4 Occlusion
Agreement on the occlusal scheme to be utilized
in the interim prosthesis has not been established
in the literature [5]. There is no evidence to show
that one occlusal scheme is superior to another,
one type of tooth form is more efficient than
another, or one type of occlusal scheme is pre-
ferred by patients.
Most occlusal schemes advise on avoiding
non-axial loading on implants. If we evaluate the
recommendations critically, we become aware
that axial loading of implants almost never occurs
along the long axis of the implant. Instead, func-
tion occurs on various areas of the prosthesis
with the development of complex bending
moments within the restorative implant compo-
nents and within the surrounding bone.
Factors that affect distribution of occlusal
forces include but are not limited to:
170
(a) Number of implants involved.
(b) Biomechanical design of the implant.
(c) Nature of the bolus of food.
(d) Design and fit of the prosthesis.
(e) Nature of the opposing occlusion.
(f) Deformation of the bone and the prosthesis.
During the immediate load phase, manage-
ment of the occlusion for force distribution and
protection of the existing implants becomes very
critical [5, 23, 24]. Unfortunately, an evidence
base does not exist which guides the clinician in
developing an occlusal scheme. The following
are generalized guidelines when immediate load-
ing in a patient with a class 1 incisor
relationship:
1. Posterior cusps flattened to minimize bending
and torsional forces.
2. Evaluation of the opposing occlusion: if the
full-arch interim prosthesis opposes natural
teeth, it may be feasible to adjust the natural
teeth to minimize steep inclines and lateral
forces.
3. Bilateral simultaneous contact.
4. Shallow protrusive disclusion.
5. Anterior group function.
6. Steep anterior disclusion is not recommended
as this may create destructive deflective forces
which may result in prosthesis fracture.
7. No cantilevers: Although no evidence-based
consensus has been established regarding can-
tilevers, it is the overall recommendation that
distal cantilevers are minimized or eliminated
from the interim prosthesis. Cantilevers have
been found to create greater risk in restoration
fracture and implant failure, when utilized in
the interim restoration [25–28].
8. Definitive contacts on canine to canine with
lighter contacts on posterior teeth. The ratio-
nale for the above is that the further posterior
the tooth, the higher the occlusal forces. The
implants in the posterior part of the mouth are
also in the weakest quality bone. As clini-
cians, our goal in the immediate load phase is
to minimize occlusal load on the implants that
are more posteriorly positioned and in the
poorest-quality bone.
B. H. Birdi et al.
9. Use of a night-time appliance.
From a clinician’s perspective, one aspect
that must be considered is the relationship
between occlusion loading and mechanical
complications. As resin fracture and tooth frac-
ture are the most common types of prosthetic
complication in these types of prostheses [5],
the design and the rigidity of the interim hybrid
prosthesis has been suggested to aid in the
strength and resilience during the healing phase
[29]. Furthermore, increased rigidity of the
interim prosthesis is also suggested to aid in
successful osseointegration by reducing load-
induced implant micro-­movement during heal-
ing [30–32]. The rigidity of the interim
restoration is increased through dimensional
thickness. Appropriate restorative space must be
created by the surgeon to fulfil the biomechani-
cal requirements of the specific restoration
treatment planned.
One of the main methods in which rigidity can
be improved is through reinforcement of the
interim hybrid prosthesis. Patient advantages
include less breakage and a longer-lasting provi-
sional restoration. Clinician advantages include
fewer unscheduled visits and reduced chair time.
One material that has shown to increase flexural
strength is use of a fibre [31]. This material type
has also been suggested to increase fracture
toughness in provisional restorations [5, 30, 32]
(Figs. 8.5, 8.6, 8.7, 8.8, and 8.9).
Fig. 8.5 Fibre reinforcement requires an indirect tech-
nique with impressions and tooth set up
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 171

Fig. 8.6 Putty matrix of tooth position in relation to the temporary cylinders

Fig. 8.7 Fibre tied in a specific manner to provide support for the teeth, processed provisional

Fig. 8.8 Clinical delivery

172
Fig. 8.9 Provisional restoration intra-orally, note minimum vertical overlap of anterior teeth
8.5 Optimal Number of Implants
The number of implants needed to successfully
and routinely rehabilitate an edentulous arch uti-
lizing an immediate loading protocol has been
debated for some time in the literature.
Classically, the use of five mandibular implants
for a full-arch rehabilitation has been advocated.
However, recently, two to three implants have
been advocated for the fixed rehabilitation of a
dental arch utilizing an immediate loading proto-
col [33–35]. With the introduction of full-arch
fixed rehabilitation on four implants [36, 37], the
conceptual requirement of increased implant
numbers for full-arch fixed rehabilitation was
put into question. With continued research being
conducted in this area, it can be stated that the
use of four to six implants for fixed full-arch
rehabilitation utilizing an immediate loading
protocol is evidence based.
When deciding the optimal number of
implants, we must give the term optimal a broader
definition. The clinician should consider not just
the number of implants but where in the jaw they
are placed and the quality of bone in which they
are placed [38]. The magnitude of stresses that
develop in the bone, the implant and the prosthe-
sis, and the relationship of the stresses and strains
to thresholds for damage to the bone and pros-
thetic components should also be given consider-
ation. The treatment plan must be developed
biomechanically.
When looking at the literature in this arena,
three types of study have been completed:
B. H. Birdi et al.
1. Mathematical models.
2. 3D finite element analyses
3. Intra-oral strain gauge studies.
When attempting to predict forces on four,
five, or six implants with the above studies,
extrapolation becomes very difficult. What makes
this problem difficult to solve is the fact that each
implant is connected to both the bone and the
prosthesis; computing the loads (and stresses and
strains) in each part of the structure is a problem
that is not solvable by statics alone but also
requires data on the material properties of the
implants, bone, and prosthesis as well as their
stress-strain behaviours. Prosthesis rigidity, bone
implant stiffness, and deformation of the mandi-
ble also come into consideration. The use of
fewer implants to rehabilitate an edentulous
patient has been established, and the need for
reserve implants is no longer considered
necessary.
8.6 Axial vs. Tilted Implants
The introduction of a tilted implant protocol in
full-arch fixed rehabilitation utilizing immediate
loading put into question the need for universal
axial implant placement. Since that time, these
two implant positioning regimens have been
compared throughout the literature [39–44].
However, it is clear that in many instances tilting
of posterior implants in full-arch rehabilitations
provide significant benefits (Table 8.1) [44].
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
However, concerns about the consistency and
clinical results using tilted implants continue to
be present in the industry. Three general areas of
concern are prevalent:
1. Titled implants exhibit more bone loss.
2. There is increased stress concentration around
tilted implants.
3. Restorations with tilted implants experience
greater prosthetic complications.
It has now been thoroughly established that
the use of tilted implants in an immediate loading
protocol does not induce more bone loss com-
pared to the use of an axially placed implant [47–
49]. Many studies have indicated that the
inclination of implants, in a splinted structure,
aids in decreasing the stress in the arch [40, 50–
52]. There is no evidence to demonstrate a higher
prosthetic complication rate in restorations that
encompass tilted implants [17, 27].
Table 8.1 Benefits of tilted posterior implants [39–49]
1. Implants are placed into more dense and better-­
quality bone.
2. Longer posterior implants can be utilized through
tilting.
3. Tilting posterior implants allows for greater
distribution of the implant connections.
4. Larger anterior-posterior spread of implants
decreases cantilever lengths needed.
5. Marginal bone levels are maintained around tilted
implants.
6. Similar success and survival rates when compared to
axial implants.
7. Vital anatomical structures are avoided by tilting
posterior implants.
8. Tilting posterior implants minimizes the need for
grafting procedures (Fig. 8.10).
Fig. 8.10 Advantages of tilted implants
173
The reasons why splinted restorations utiliz-
ing a tilted implant protocol perform so well
include the following:
1. Rigidity of the prosthesis counteracts the rela-
tively small bending moments applied to the
tilted implants.
2. Enough micro-motion for function is not
enough to prohibit osseointegration.
3. Off-axis loading is stabilized by cross-arch
stability.
8.7 Vertical Cantilever Height:
Crown-Implant Ratio
In patients who have undergone severe resorp-
tion, there is obviously a limited amount of bone
to place the implants and an obvious bulk of pros-
thetic structure and on occasion causing a tre-
mendous prosthesis to implant ratio.
The theory is that in these patients with unfa-
vourable crown-implant ratios, the prosthesis
acts as a lever causing a bending moment and
transmits stress to the peri-implant crestal bone
causing resorption.
Multiple studies have shown that crown-­
implant ratio is not a factor that causes bone loss
providing there is a good fit of the prosthesis to
the implants and we are maintaining cross-arch
stabilization [53–57].
174 B. H. Birdi et al.

8.8 Medical Evaluation Diabetes mellitus presents in two forms. Type

of the Patient 1 (T1DM) is an autoimmune disorder with early
onset in childhood where the body cannot pro-
A systematic review by the Academy of duce insulin. Type 2 (T2DM) is a multifactorial
Osseointegration [58] evaluated the effects of disease with genetic and environmental factors,
various medical conditions and medications on where the pancreas cannot produce insulin, and
bone remodelling. thus the body becomes insulin resistant [61, 62].
This section will highlight certain clinically The four currently recommended diagnostic
relevant medical conditions, patient-related fac- tests for diabetes (Classification of diabetes mel-
tors, the use of certain medications, and their litus. Geneva: World Health Organization; 2019):
recent consensus pertaining to immediate loading
1. Fasting plasma glucose measurement ≥7.0 mmol/L
protocols. Clinician-related factors will also be
(126 mg/dL).
discussed. 2. A 2-hour (2-h) post-load plasma glucose after a 75 g
The medical conditions that may influence oral glucose tolerance test (OGTT) ≥ 11.1 mmol/L
immediate loading include but are not limited (200 mg/dL).
to: 3. HbA1c ≥ 6.5% (48 mmol/mol).
4. A random blood glucose ≥11.1 mmol/L (200 mg/dL)
in the presence of signs and symptoms of diabetes.
1. Diabetes mellitus.
2. Patients on dialysis.
3. Osteoporosis. 8.9.1.1 How Does It Affect the Body?
Diabetes mellitus is associated with poor wound
The medications of interest that may affect healing, neuropathy, structural damage to blood
outcomes of immediate loading include: vessels, poor micro-circulation, arterial hyperten-
sion, and unsatisfactory immune response [63]. It
1. Selective serotonin reuptake inhibitors is also associated with increased dental implant
(SSRIs). failure due to poor osseous healing [64–66].
Patients with diabetes mellitus produce advanced
Patient-related factors: glycation end products (AGEs) [67, 68].

1. Bruxism.
2. Smoking. 8.10 How Does Diabetes Affect
Implants and Immediate
Clinician-related factors: Loading?

1. Experience. One of the preferred criteria for immediate load-

2. Expertise.
8.9 Medical Conditions That May
Impact Immediate Loading
8.9.1 Diabetes Mellitus
Diabetes mellitus is a chronic metabolic disease
classified by the World Health Organization as
the sixth leading cause of death in the world [59,
60].
ing and predictable osseointegration is the
absence of systemic disease [69]. In T2DM
patients, AGEs accumulate permanently in the
vessel walls, altering the phenotype of impor-
tant cells such as macrophages, polymorphonu-
clear cells, fibroblasts, and endothelial cells
[68]. This leads to production of destructive
inflammatory cytokines leading to bone resorp-
tion around immediately loaded implants [68,
70]. The diabetic patients are also associated
with higher risk of osseointegration failure due
to infection [71] and long-term bone and soft
tissue complications [59].
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
However, in controlled diabetics there is opti-
mal osteoblast activity and minimal bone resorp-
tion. It is also associated with lower levels of
AGEs [68, 72].
8.10.1 Does Literature Support
Immediate Loading
of Implants in Uncontrolled
Diabetic Patient?
The placement of dental implants in a diabetic
patient is a topic of substantial debate in
implant dentistry. In diabetic patients the clini-
cian should proceed with caution. Various
studies advocate that implants in patients with
diabetes mellitus should be avoided [73, 74].
Studies also show that with proper glycaemic
control (controlled diabetic), dental implants
can osseointegrate and remain functionally
stable like that in a non-­diabetic individual [75,
76]. Studies likewise show that immediate
loading in a controlled diabetic can be safely
done [77].
When it comes to immediate loading, a recent
systematic review stated that there is no differ-
ence in the survival of immediately loaded dental
implants among non-diabetic individuals when
compared to type 2 diabetic individuals, even
when not controlled [78].
8.10.1.1 Can Immediate Loading
Be Done on Patients
with Uncontrolled Diabetes
Mellitus?
Full-arch immediate loading is an advanced
implant procedure which depends on multiple
factors such as adequate primary stability
(>35 N cm insertion torque), rigid cross-arch sta-
bilization, density of bone, health of the bone
bed, and lastly to an extent on the patient’s inher-
ent healing potential.
Although the current consensus points
towards immediate loading even in uncon-
trolled diabetic individual, the clinician should
follow prudence in proper case selection and
follow certain protocols before and after the
implant procedure.
175
1. HbA1c levels should be evaluated before the
procedure [70].
2. Since diabetic patients are more prone to peri-­
implant infections [79], it becomes imperative
that management of periodontal infection
should be done before implant placement.
3. Pre-operative antibiotic coverage should be
started as it helps in reducing the rate of
implant failure from 13.4% to 2.9% in dia-
betic patients [80].
4. Chlorhexidine mouthwash should also be
started pre-operatively as studies have shown
it helps to reduce the failure rates from 13.5%
to 4.4% [80].
5. In uncontrolled diabetic individuals with con-
comitant obesity and cardiovascular diseases,
immediate loading should be avoided as there
can be greater chances of failure [69].
6. Periodic recalls of the patients after implant
therapy for hygiene maintenance to avoid
chances of peri mucositis and peri-implantitis
in the long term.
7. Accessing the opposing dentition and para-
function. Low occlusal loads in a patient with
a denture as an opposing dentition with no
parafunction will categorize as a low-risk
individual.
8.10.1.2 Alternatives to Immediate
Loading in a Diabetic
Individual
The clinician has various alternate choices if the
patient has uncontrolled diabetes and other
comorbidities that would prevent him/her from
opting for immediate loading.
Complete Denture
This is a very viable option, more so if the patient
presents completely edentulous to the dental
office. This is not the most preferred choice as the
denture can cause uncontrolled loads on the
implants during mastication. A soft tissue liner
can be used to cushion the occlusal loads to a cer-
tain extent. However, this may still not prevent all
the transfer of the loads and can cause failure of
the implants. For the soft liner to be effective, the
minimum thickness of the reliner should be at
least 4 mm.
176 B. H. Birdi et al.

a b

Fig. 8.11 (a) Strategic abutments in place. (b) Teeth supported provisional

a b

Fig. 8.12 (a) Implants integrated. (b) Impression with teeth present

Strategic Abutments tioned in a fixed restoration. Two mandibular

If the patient is partially edentulous and immedi-
ate loading cannot be attempted, the clinician
may use existing teeth as strategic abutments.
These teeth would hold a fixed provisional resto-
ration while implants are placed in the edentu-
lous sites between them. The advantage of this
approach is that the patient has fixed restorations
throughout, and the implants can heal undis-
turbed. The downside of this procedure is that the
strategic abutments are of poor prognosis and
may fail while the implants are integrating.
Should this happen, the patient would be transi-
tioned to a removable prosthesis.
Once osseointegration has been confirmed,
the strategic abutments can either be submerged
if they are periodontally sound or can be
extracted. Impressions can be made of the inte-
grated implants and implant supported provision-
als fabricated for insertion when the strategic
abutments are extracted/submerged.
The following patient was an uncontrolled
diabetic who needed mandibular full-arch resto-
ration. The patients’ request was to be transi-
anterior teeth and two premolars were retained to
be used as strategic abutments (Fig. 8.11a, b).
On implant integration, an open tray impres-
sion was fabricated to make an implant-supported
prosthesis (Fig. 8.12a, b). The lab was instructed
to make an implant-supported prosthesis, remov-
ing the teeth from the cast. Once the provisional
was ready, the anterior teeth were extracted and
the premolars were submerged (Fig. 8.13a, b).
Provisional/Transitional Implants
In this approach single one-piece smaller diame-
ter implants are placed in between or palatal to
the primary implants. These provisional implants
can be used to restore the patient while the pri-
mary implants heal with a submerged approach.
The provisional implants can be removed during
the fabrication of definitive restoration
(Fig. 8.14a, b).
8.10.1.3 Patients on Dialysis
Chronic kidney disease (CKD) is a general term
of heterogenous disorders affecting the structure
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 177

a b

Fig. 8.13 (a) Strategic abutments extracted. (b) Implant supported provisional

a b

Fig. 8.14 (a) Temporary implants. (b) Temporary implants between primary implants

and function of kidneys. It could be due to kidney
damage (albuminuria) or decreased kidney func-
tion (glomerular filtration rate, GFR) < 60 mL/
min per 1.73 m2 for 3 months or more [81–83].
When chronic kidney disease progresses to
end-stage renal disease, dialysis is required for
the patient. Chronic kidney disease can have mul-
tiple aetiologies including genetic [84, 85] or a
by-product of other diseases like type 2 diabetes
[86–90] and hypertension. Apart from numerous
oral signs of the disease, the CKD patients can
have multiple bone disorders [91] which become
extremely relevant in immediate loading. Bone
metabolism is regulated by several factors includ-
ing parathormone (PTH), fibroblast growth factor
23 (FGF23), and dihydroxycholecalciferol
(1,25(OH)2D).
Complications from CKD, including hyper-
phosphatemia, hypocalcaemia, hyperparathy-
roidism, and vitamin D deficiency, may interrupt
the balance of these factors, impacting bone
structural integrity and resulting in CKD-mineral
and bone disorder [92–95].
8.10.1.4 Can Immediate Loading
Be Done on Patients
with CKD and Dialysis?
Most patient will present with an adequate resid-
ual bone for implant placement [96]. Although
there is no data to show that CKD and dialysis
affect implant healing, it is advisable to avoid
immediate loading in patients with chronic kid-
ney disease to avoid any early failures due to poor
bone metabolism. It is preferable for the clinician
to extend the healing time or use a provisional
crown for extended periods prior to the definitive
restoration [92].
In conclusion, it is the authors’ preference to
avoid immediate loading in patients with CKD.
8.11 Osteoporosis
As described by World Health Organization
(WHO), osteoporosis is a ‘progressive systemic
skeletal disease characterized by low bone mass
and micro architectural deterioration of bone
178 B. H. Birdi et al.

t­issue, with a consequent increase in bone fragil- [110] showed that there is a close relation
ity and susceptibility to fracture’. between insertion torque and micro-mobility or
It is a disease that predominantly affects post-­ micro-movements of the implant. As torque
menopausal women and is usually not detected increased, implant micro-mobility progressively
until a fracture occurs. Osteoporosis is linked decreased. This measurement, performed in bone
with bone loss, periodontal disease, and poor of different qualities, demonstrated that peri-­
bone density [97–102]. Genetic predisposition, implant bone density has a decisive influence on
poor calcium and vitamin D intake, smoking, micro-mobility and insertion torque. Both high
alcohol, physical inactivity, and oestrogen defi- torque and increased stability can be achieved in
ciency due to menopause are the possible aetiolo- soft bone. Patients with osteoporosis tend to have
gies and risk factors for developing osteoporosis. softer bone density, thereby reducing the primary
Females are more prone to osteoporosis than stability. This poses a problem in immediate
men. loading in these patients.
Osteoporosis results in loss of bone mineral Another study on bovine bone by Engelke and
density (BMD) throughout the body, including co-workers [111] studied the degree of micro-­
the maxilla and the mandible. The resulting low movements in different bone densities. Their
density in the jawbones leads to increased alveo- study showed a strong relationship between force
lar porosity, microarchitectural deterioration of applied and the movement observed and a signifi-
trabeculae, reduced remodelling rate, reduction cant association between bone quality and degree
in volume of the residual ridge, and decrease in of micromovement. This study showed that the
the cortical thickness following invasion by peri- amount of micro-motions in a type 3 and type 4
odontal pathogens [103]. bone is much higher (150 and 250 μm, respec-
tively) when a force as low as 30 N cm was
exerted on them. Comparatively, the same force
8.11.1 Why Is Osteoporosis produced 100 μm of micro-motions in type 2
a Problem in Immediate bone. This shows that great caution must be taken
Loading? in planning immediate loading in poor density
bone like one sees in osteoporotic patients. CBCT
Osteoporosis is not a contraindication to place planning and assessing the density by measuring
implants [104]. However, immediate loading the Hounsfield values [112] can be of great assis-
requires a set of protocols to be in place like ade- tance in planning such cases. An osteoporotic
quate primary stability, rigid fixation, and splint- patient may show sparse trabecular pattern, even
ing to avoid micro-movements. The bone density in the areas which conventionally show dense
in osteoporotic patient is compromised leading to bone. Figure 8.5a shows the mandibular anterior
inferior primary stability. region of an osteoporotic post-menopausal
Numerous experimental studies on animal patient. Insertion torque of 25 N cm was achieved
models, supported by histologic evidence, have despite under preparing the site (Fig. 8.5b).
shown that immediate loading does not hinder
osseointegration, provided that the micro-­ 8.11.1.1 Can Immediate Loading
movements at the bone-implant interface are kept Be Performed
below a threshold (approximately 100–150 μm) in Osteoporotic Patients?
[105–108]. These movements are known as toler- Any bone disorder can affect osseointegration.
ated micromovements. Any movement above the Osteoporosis is considered as a major public
threshold of 150 μm are called macro-movements health concern [113] and is characterized by
and are detrimental to osseointegration. These decrease in bone mass. Many authors [114–116]
macro-movements can cause fibrous integration have advocated that mutilation of osseointegra-
of the implant, rather than osseous integration tion might occur around implants in osteoporotic
[105–107, 109]. An in vitro study by Trisi et al. animal specimens. However, they advocated that
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
it is possible to immediately load dental implants
in an osteoporotic patient [117]. Moreover, a
proper history of the patient should be taken
before attempting immediate loading in such
cases. Smoking more than ten cigarettes a day,
concomitant obesity, etc. are additional risk fac-
tors. Some patients are prescribed bisphospho-
nates to treat osteoporosis. Consulting their
physicians and evaluating risk benefit should be
taken consideration before commencing with any
surgical procedure.
8.11.2 What Are the Potential
Medical Complications
Associated with Osteoporotic
Patient?
Most of the osteoporotic patients are not treated
with any medications until they develop any
signs or have their first fracture. Once detected,
these patients are usually treated with oral
bisphosphonates (BP). They are potentially
known to reduce complications of osteoporosis
[118]. Intravenous bisphosphonates are reserved
for patients with osteolytic tumours, hypercalce-
mia of malignancy, multiple myeloma, bone
metastases from solid tumours, and other tumours
[118, 119].
The most common oral BPs are alendronate,
risedronate, and ibandronate.
Bisphosphonates act on osteoclast activity and
decrease bone turnover [120], leading to high
concentrations of BPs retained within the bone
for an extended period, which causes
bisphosphonate-­related osteonecrosis of the jaw
a b
Fig. 8.15 (a) Sparse trabecular bone in an area expected to show dense bone. (b) Poor density despite mandibular
anterior region
179
(BRONJ), which has been renamed as medication-­
related osteonecrosis of the jaw (MRONJ).
BRONJ incidence is significantly higher with
IV bisphosphonates, while patients receiving oral
bisphosphonates have minimal risk.
The mechanism by which BPs may cause or
promote the occurrence of osteonecrosis of the
jaws remains uncertain [121]. The potent
BP-mediated inhibition of osteoclastic function
reduces bone resorption. It inhibits normal bone
turnover remodelling, resulting in areas of micro-
damage, accumulation, and a reduction in some
mechanical properties of the bone [122]. The
mandible and maxillary bones usually offer a
high level of resistance to infection by oral micro-
organisms during dental infections or extractions
or when a foreign body (e.g., an implant) is
inserted. This resistance to infections, together
with an ability to heal rapidly, is thought to stem
partly from the high blood flow that characterizes
the mandibular and maxillary bone [123]
(Fig. 8.15).
8.11.3 Precautions for Immediate
Loading in an Osteoporotic
Patient?
A significant challenge in an osteoporotic patient
is achieving adequate primary stability. The clini-
cian should utilize techniques to improve the
insertion torque. This becomes even more rele-
vant in maxilla where inherently it becomes more
difficult to achieve high insertion torque values.
This can be accomplished by bicortical engage-
ment of the implant with the lateral piriform rim
180
Fig. 8.16 Bicortical stabilization
and the nasal floor in the tilted implant protocol
(Fig. 8.16).
The other methods may include underprepar-
ing the osteotomy site, performing stepped oste-
otomy, using tapered implant design, and using
expanders and the more contemporary Densah
burs. The latter are specially designed burs with a
negative rake angle that burnishes the bone along
the walls of the osteotomy. A regular drill
removes the bone and thus bone is lost during
osteotomy which can significantly affect the pri-
mary stability, especially in osteoporotic bone.
From an engineering point of view, this negative
rake angle has a thicker cutting tip that produces
more bone deformation leading to the compres-
sion or compaction autografting, also referred to
as ‘osseodensification’ (Fig. 8.17a, b).
In the process, the bone debris is redistributed
along the flutes of the bur and is pressed into the
osteotomy’s wall which improves the primary
stability [124] because unlike the traditional burs,
Densah burs do not remove, but move, the bone.
They utilize the property of flexibility of cancel-
lous bone, which helps in changing the shape of
the bone without breaking or cracking (Fig. 8.18).
The following key factors should be remem-
bered while using Densah burs:
1. Use the bur in reverse or osseodensification
mode at 800–1200 rpm.
2. Use copious irrigation to prevent overheating
of the bone as Densah burs compact the bone
and make it dense.
3. Do not go flapless while using Densah burs.
4. Do not underprepare lesser than 0.5 mm as the
osteotomy is lined with a layer of cortical
B. H. Birdi et al.
osseodensified bone. A greater underprepara-
tion may lead to a higher chance of implant
failure due to poor vascularity in an osseoden-
sified site (Fig. 8.19).
8.11.4 What Postoperative Care
Should One Take When Doing
Immediate Loading
in an Osteoporotic Patient?
One of the pathogenic factors for osteoporosis
and the occurrence of fractures is vitamin D defi-
ciency [125]. Vitamin D deficiency also nega-
tively affects bone regeneration, including
fracture healing [126] and osseointegration of
implants [127]. While vitamin D supplementa-
tion is mandatory in the pharmacological man-
agement of osteoporosis, few studies are available
that would justify this treatment to support bone
regeneration and, thus, osseointegration [128].
However, a preclinical study [129] demonstrates
that vitamin D supplementation counteracts the
reduced peri-implant bone regeneration caused
by dietary vitamin D deficiency, especially in the
early healing phase. Vitamin D supplementation
is an effective treatment for reduced peri-implant
bone formation because it directly counteracts
the catabolic mechanisms of vitamin D defi-
ciency. Thus, giving vitamin D supplements,
maintaining oral hygiene, and soft food intake to
keep the micro-movements below the threshold
should be an integral part of post-op instructions
for osteoporosis patients.
8.11.4.1 Medications
Depression, a clinical state associated with low
mood, affecting the person’s thoughts, behaviour,
feelings, and sense of well-being, has become a
threatening disease because of its high preva-
lence and associative public health problems
[130, 131].
Serotonin (5-hydroxytryptamine [5-HT]) is a
monoamine neurotransmitter in the brain that
contributes to feelings of well-being and happi-
ness [131]. Lower serotonin levels or obstacles to
its utilization can lead to depression [131].
Selective serotonin reuptake inhibitors (SSRIs)—
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 181

a
go 18.0mm
WEDGE ANGLE + FLANK ANGLE < 90 DEGREES 15.0mm
+υe
12.0mm
a+b < 90 degrees 10.5mm
9.0mm
7.5mm

BONE
POSITIVE RAKE ANGLE
0mm
Lesser Shear NORMAL
deformation of DRILL
bone
WEDGE ANGLE (a)

FLANK ANGLE (b)

THIN TIP OF
THE DRILL
Vc
BONE

Diagram source - mechanical engineering and everything about it

b
WEDGE ANGLE + FLANK ANGLE < 90 DEGREES
go

–υe
a+b > 90 degrees

NEGATIVE RAKE ANGLE

DENSAH
BONE
DRILLS

More Shear
deformation of
WEDGE ANGLE (a)
bone
FLANK ANGLE (b)

THICKER TIP OF
THE DRILL
Vc
BONE

Diagram source - mechanical engineering and everything about it

Fig. 8.17 (a) Positive rake angle in regular drill. (b) Negative rake angle in Densah bur

such as Celexa, Paxil, Lexapro, Prozac, and
Zoloft—are drugs designed to inhibit serotonin
reuptake and boost its levels to treat depression
[132]. Because of their unique effectiveness in
depression treatment, SSRIs have become the
most widely used antidepressants worldwide
[133]. Although serotonin is required for treating
depression, it is also needed for the functioning
of digestive, skeletal, and cardiovascular tissues
[133].
182
Fig. 8.18 Densah burs improve primary stability
Fig. 8.19 Osseodensified site
Serotonin regulates bone metabolism by act-
ing on the bone receptors and serotonin trans-
porters, resulting in complex signal transmission
in osteoblasts and osteoclasts [133]. Thus, SSRIs
block receptors on bone cells resulting in a direct
negative effect on bone formation [134, 135] and
metabolism [133] by increasing osteoclast differ-
entiation [136] and decreasing osteoblast prolif-
eration [133].
8.11.4.2 Can Immediate Loading
Be Done in Patients Taking
SSRIs?
Since the bone in patients taking SSRIs is normal
in structure and quality, it is easy to achieve pri-
mary stability and good rigid fixation to go for
immediate loading. However, SSRIs are associ-
ated with not early but late failures due to
mechanical loading. The failures caused by
mechanical overloading usually occur after the
loading time of 4 and 6 months [137]. So, it
becomes prudent to carefully plan surgical treat-
ment in SSRI users as there is a higher risk to
implant survival [138].
B. H. Birdi et al.
8.12 Patient-Related Factors
8.12.1 Bruxism
Bruxism is defined as a movement disorder of
the masticatory system that is characterized,
among others, by teeth grinding and clench-
ing, during sleep as well as wakefulness [139,
140].
Bruxism is frequently considered a causative
factor for temporomandibular disorders (TMD),
tooth wear (e.g., attrition), loss of periodontal
support, and restoration failure. However, many
conflicting pieces of evidence show that these are
due to bruxism [141–144].
Psychosocial factors like stress and person-
ality are also frequently mentioned in relation
to bruxism. Bruxism seems to be mainly regu-
lated centrally, not peripherally. Implant over-
loading due to bruxism can cause complications
like occlusal surface wear, fracture, loosened
screws or abutment, and implant fracture [145].
In fact, bruxism is considered a contraindica-
tion for implant treatment, although most evi-
dence is usually based on clinical experience
[146].
8.12.1.1 How to Diagnose a Bruxer?
The diagnosis of bruxism includes a complaint
of jaw muscle discomfort, fatigue, stiffness,
occasional headaches, the presence of tooth
wear, tooth sensitivity, muscle hypertrophy,
TMJ clicking or jaw lock, and tongue indenta-
tion. The clinical diagnosis of bruxism is based
on an orofacial examination and the patient and
the partner’s report. Often, the patients are
unaware of sleep bruxism, and even their part-
ner may not know if they are deep sleepers
[147]. This can lead to an incorrect diagnosis by
the clinician [147]. Diagnosis becomes even
more challenging if the patient reports to the
office completely edentulous. The best way to
diagnose bruxism is polysomnographic analysis
[145], although that is considered complicated
by some authors [148] and may not always be
practically possible for all general clinicians in
their day-to-day practice.
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 183

8.12.1.2 What Are the Problems a

of Doing Immediate Loading
in a Bruxer?
The occlusal loads produced by a bruxer are con-
siderably higher and can be termed as overload
than that seen in a normal physiologic chewing
cycle [146]. It is, therefore, not unlikely that
forces applied to implants during bruxism are
even larger than those exerted during mastication
[149], making them more prone to occlusal over-
load and possible subsequent failure [146]. One
of the most critical aspects of immediate loading
is to keep the micromotions below the threshold
value [105–108], as it is not immediate loading
per se but deleterious macro-motions that
increase the risk. Moreover, as the loads gener-
ated by bruxers are considerably higher, there are
higher chances of early failure. The risk of failure
is enhanced due to the absence of periodontal
ligament and decreased proprioception. b

8.12.2 Can Immediate Loading

Be Done in Bruxers?

Immediate loading in bruxers is controversial in

implantology, with multiple studies for both and
against it. One of the problems is that many stud-
ies do not include bruxers in the inclusion crite-
ria; hence, the results cannot be predictable.
Multiple prospective studies show problems
with implants in bruxers. Wannafors et al. [150]
reported a significant relationship between brux-
ism and implant failure after the implants have
been functional for a year. Likewise, Glauser
et al. [151] found a higher percentage of implant
loss in bruxists (41% vs. 12% after 1 year).
Another review by Lazzara [152] and another
study by Misch et al. [153] consider bruxism as
a contraindication for immediate loading.
However, counter studies show that immediate
loading can be easily done in bruxers
[153–157].
In conclusion, immediate loading in bruxers
has inherent biomechanical risks ranging from
breakage of provisional restoration (Fig. 8.20a)
to implant loss (Fig. 8.20b) during the healing
Fig. 8.20 (a) Fracture of provisional. (b) Failure of
implants
period. Multiple studies show that there are also
greater chances of late failures in a bruxer.
Considering that immediate loading by itself
requires strict protocols to be followed, like ade-
quate primary stability, rigid cross-arch fixation,
etc., an inexperienced clinician (<50 implants)
should avoid attempting immediate loading in a
bruxer. An experienced clinician (>50 implants)
may be able to attempt the same as studies show
that they experience less failure as compared to
inexperienced clinicians [158]. However, this
should be tried only after thoroughly clarifying
the risks and pitfalls of the procedure to the
patient. This will avoid any future embarrass-
ments and legal glitches for the clinician.
184
8.12.3 Are There Any Practical
Guidelines When Attempting
Immediate Loading
in a Bruxer?
The following guidelines should be followed to
prevent the chances of over loading in a bruxer:
1. Multiple studies, including this retrospective
study by Naiedermaier [159] and by Brunski
[160], show that a minimum of four implants
is sufficient to restore an entire arch opti-
mally. However, it makes more sense to
increase the number of implants in a bruxer.
This means keeping a low ratio of the pros-
thetic unit to implants (PU/I). Studies have
shown that a low PU/I ratio improves the
long-term prognosis of the implants [161–
166]. This PU/I value works as a ‘safe side’
parameter (Fig. 8.21).
2. Avoid cantilevers in the provisional and final
restorations.
3. Though implant length is more relevant in
immediate loading, an increased length and
width of the implant should be used for long-­
term favourable prognosis and reducing
stress [167, 168].
4. Tarnow et al. recommend metallic reinforce-
ment of the temporary to reduce the bending
loads in the immediate loading protocol.
However, if the number of implants is
increased, the rigid temporary can efficiently
counteract loads of occlusion [169].
5. Rigid metallic splint using the digital proto-
col can act as additional protection to reduce
the micro-motions and keep it below the
threshold value (Fig. 8.13a, b).
Fig. 8.21 Low PU/I ratio
B. H. Birdi et al.
6. Achieve the passivity of the temporary by
doing the one screw test. An active prosthesis
can exert loads on the implant leading to
overloads on the prosthesis and the implants
[167, 168] (Figs. 8.22 and 8.23).
7. Occlusion has to be very carefully evaluated.
If the opposing dentition is implant-­
supported fixed restoration or natural denti-
tion, the following points must be
considered:
(a) Simultaneous bilateral equal intensity
contact points in maximum intercuspa-
tion with shallow anterior guidance
(Fig. 8.24a, b).
(b) Flap cusps for flat linear pathways. No
interference in lateral excursions
(Fig. 8.24c), even if the opposing denti-
tion is a denture (Fig. 8.24d)
(c) Posterior disclusion in protrusion
(Fig. 8.24e).
8. A rigid stabilization splint for nightly use
(night guard) contributes to optimally dis-
tributing and vertically redirecting the forces
that go with nocturnal teeth grinding and
clenching [169–175] (Fig. 8.24f). Some cli-
nicians prefer to put a layer of cold cure resin
over the occlusal surface and keep the inner
core made of a softer material for better
retention and for it to act like a dampening
effect (Fig. 8.24g).
9. Although a night guard is given, the clinician
cannot prevent the patient in engaging in the
habit. Nevertheless, the clinician may be able
to reduce the deleterious loads on the
implants [176].
Fig. 8.22 Avoid cantilevers in immediate loading
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 185

a b

Fig. 8.23 (a) Digital impression. (b) Metal milled bar for rigid splinting

a b

c d

e f

g h

Fig. 8.24 (a, b) Simultaneous bilateral contacts. (c, d) No interferences in lateral excursions. (e) Posterior disclusion
in protrusion. (f) Hard night guard. (g) Soft night guard with layer of resin. (h) Occlusal markings
186
10. The nightguard should be given only for one
arch. Giving night guards on both arches can
increase the vertical dimension and cause
discomfort. The arch selected should be the
stable of the two and should interfere the
least with occlusal excursions (Fig. 8.24h).
8.13 Case Report
Infrequently, a clinician may fail to see the subtle
signs of bruxism and may treat such a patient
with an immediate loading protocol. This is espe-
cially true of patients that are edentulous. No
amount of bone loss can be a predictive marker
for bruxism.
Bruxism may lead to consequences such as
minor screw loosening and fracture of the provi-
sional to failure of the implants in the critical
healing period.
The following case shows the management of
a patient with possible bruxism. The term possi-
ble bruxism is used as the patient had minimum
signs and no symptoms of bruxism. The possibil-
ity of bruxism was taken into consideration, once
he had multiple breakage of the temporary during
the healing phase.
A 65-year-old male patient reported to the
practice. He had been wearing a cast partial den-
ture since a few years and was looking for a fixed
option.
Extra-oral examination in the frontal view
showed that the patient’s horizontal reference
lines (the eyebrow line, the inter pupillary line,
and the commissural line) were almost parallel to
each other and the patient had a straight facial
midline. Because of the extremely low lip line, it
could not be ascertained if both facial and dental
midline coincided (Fig. 8.25a, b).
His sagittal view showed a very minor con-
cave profile (Fig. 8.25c).
His vertical dimension was maintained due to
the cast partial denture (Fig. 8.25d). On ­palpation,
the muscles of mastication were not sore. The
patient did not complain of any joint discomfort.
However, the patient considered himself as hav-
ing a stress taking mentality. He however admit-
ted of grinding not during the examination phase
B. H. Birdi et al.
but after he had multiple fractures of the
temporary.
The patient had a low lip line with more expo-
sure of teeth on the right side and none of the left
side of the face, indicating a minor asymmetry in
the smile (Fig. 8.25e).
The occlusal plane did not show any abnor-
mality. Some old cervical facets were restored
with composite resin and some minor wear was
observed in the incisal edge (which did not seem
pathological/excessive).
However, considering phonetics and aesthet-
ics as the parameter, the maxillary incisal edge
position was correct and could be used as a refer-
ence plane for deciding the restorative space and
the final prosthetic material.
Intraoral examination is conducted after the
dentures were removed, partial edentulism on
both the arches. The extent of horizontal bone
resorption was minimum (Fig. 8.25f, g). There
was minor wear seen on the incisal edges of the
mandibular anterior teeth (Fig. 8.25h).
Radiographic evaluation showed there was
minor pneumatization of the sinus. CBCT evalu-
ation showed adequate bone to place three axial
and two tilted implants in the upper arch
(Fig. 8.25i). The lower arch required three
implants.
The tilted implant protocol was followed and
the lower implants were placed in the same surgi-
cal appointment. Long, wide implants were
placed to ensure high primary stability. Open tray
impressions were made on the multi-unit abut-
ments (MUAs), and a lab fabricated temporary
with PMMA was fabricated. Adequate thickness
of provisional was kept to avoid fractures in the
healing period. The pickup technique was used to
ensure passivity. The one screw test was positive
(Fig. 8.25j–m). The lower arch was restored with
partial denture with soft liner over the implants to
restore function and maintain the posterior sup-
port in the interim healing period.
The patient was asymptomatic for a period of
4 weeks. He then reported with a single tooth
being dislodged to the office which was easily
attached on the temporary. The occlusion was re-­
verified to rule out any heavy occlusal contact
point on the said tooth. Anticipating that the
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 187

a b c

d e

f g

h i

Fig. 8.25 (a) Facial midline. (b) Harmony of horizontal
reference planes. (c) Concave profile. (d) Vertical
dimension-­maintained. (e) Low and asymmetric lip line.
(f) Minimal horizontal resorption. (g) Few teeth remain-
ing. (h) Minor wear on anterior teeth. (i) Radiographic
evaluation. (j) Tilted implant with MUA. (k) Lab fabri-
cated PMMA. (l) Implants placed. (m) Temporary pros-
thesis. (n) Temporary fractured. (o) Old cast to make
temporary. (p) Digital impression. (q) Bite registered
digitally. (r) Verification jig. (s) Teeth setting trial. (t)
Second PMMA temporary fractured. (u) PMMA trial. (v)
One screw test on PMMA. (w) Metal trial with hybrid
design. (x) One screw test on metal trial. (y) Milled tita-
nium framework with individual zirconia crowns. (z)
Milled titanium framework with individual zirconia
crowns
188 B. H. Birdi et al.

j k

l m

n o

Fig. 8.25 (continued)

8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 189

q r

s t

v w

Fig. 8.25 (continued)

190
x y
Fig. 8.25 (continued)
patient may have higher occlusal forces, a night
guard was fabricated at this stage and delivered to
the patient.
The patient then reported to the office after
4 weeks after the first incident with a broken tem-
porary in the midline (Fig. 8.25n). A new tempo-
rary was made at this stage using the older cast
that was preserved in the office (Fig. 8.25o).
The patient was kept on the temporary for
another 3 weeks. The patient had no complaints
at this stage, and the fabrication of final prosthe-
sis was commenced at this stage using the digital
protocol. Digital impression was made with scan
bodies on MUAs (Fig. 8.25p). Despite the digital
protocol, a model was printed and a verification
jig was made to verify the impression (Fig. 8.25r).
Since the occlusion was correct, the bite was also
recorded digitally (Fig. 8.25q). Teeth setting trial
was done as the patient wants some minor
changes in the aesthetics (Fig. 8.25s).
At this stage, the patient again reported to the
office with the second fractured temporary
(Fig. 8.25t).
The old temporary was not repaired, as the
fabrication of the final prosthesis was being done.
B. H. Birdi et al.
PMMA trial was done and verified for aesthetics,
function, phonetics, and passivity (Fig. 8.25u, v).
Once the PMMA trial was done, the same PMMA
trial was given as a third provisional to the
patient.
Milled titanium framework with provisions
for individual zirconia crowns was fabricated.
The passivity was verified again with one screw
test (Fig. 8.25w, x). A full zirconia monolithic
design was avoided to prevent the chances of
fracture of the final prosthesis as higher occlusal
bite forces was anticipated in this case.
The final prosthesis with individual zirconia
crowns was fabricated. The crowns were luted on
the framework by the lab as all the access holes
were palatal and occlusal (Fig. 8.25y, z). The
design chosen provided both aesthetics and long-­
term favourable biomechanical prognosis for this
case.
The prosthesis was verified for passivity and
occlusion. Mutually protective occlusal scheme
was used for the final prosthesis (Fig. 8.26a–e).
Considering that either the patient is a bruxer
or has heavy occlusal bite forces, biomechanical
principles were taken into consideration while
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 191

a b

c d

e f

Fig. 8.26 (a) Passivity of prosthesis. (b) Maximum intercuspation. (c) Protrusion. (d) Lateral excursions. (e) Acceptable
aesthetics. (f) Minimal cantilever. (g) Hard nightguard

fabricating the final prosthesis. No excessive can- 8.14 Smoking

tilevers were given and a milled passive prosthe-
sis was delivered (Fig. 8.26f). A hard night guard
was fabricated to avoid future excessive loads on
the implants (Fig. 8.26g).
Smoking is one of the risk factors for placing den-
tal implants. Most of the studies on immediate
loading tend to exclude patients who are smok-
ers. Lower success rates are reported in smokers
192 B. H. Birdi et al.

than in non-smokers [177]. The rate of failures is
four times higher in patients who smoke more
than 20 cigarettes daily [178].
Smoking negatively affects bone metabolism
by impeding normal function and proliferation of
the alveolar bone marrow mesenchymal stem
cells. A study by Zhao et al. revealed that these
changes were also correlated with osseointegra-
tion disturbances and reduced implant stability
among smokers from the third to sixth week after
surgery [179].
8.14.1 What Are the Problems
of Doing Immediate Loading
in a Smoker?
As discussed, one of the essential criteria for
immediate loading is high primary stability or
insertion torque. The implants are loaded within
1 week under physiological loads to keep the
micro-movements below the threshold of
150 μm—the higher the primary stability, the
lesser the micro-motions. However, as described
by Raghvendra et al. [180], there is a dip in the
primary stability between the second and fifth
week, supported by other studies [181–183].
However, the problem with smokers is that the
trough span (dip in stability) for the non-smoker
group was relatively shorter, lasting for only
1 week, whereas that for the heavy smoker group
lasted for approximately 10 weeks [184]. Longer
trough spans mean more micro-movements,
which could lead to failure in immediate loading
protocols.
8.14.2 Can We Perform Immediate
Loading in Smokers?
Although multiple studies recommend against
placing implants in smokers, some suggest
immediate loading can be done predictably in
heavy smokers, provided certain criteria are met.
A study shows that immediate loading in edentu-
lous arches of heavy smokers seems successful
when the primary implant stability is high, full-­
arch splinting is secure, and also, a soft diet mini-
mizes the initial forces [185].
Of course, these patients should be made
aware of the possible risks involved, including
chances of infection, delayed healing, and loss of
the implant. If possible, the patient should be
advised to stop smoking 2 weeks before and
4–6 weeks after the surgery, which could help in
the early healing period and reduce the failure
chances. The study mentioned earlier [185] also
concluded that better results are obtained if the
abutment implant connection is not removed.
Using MUAs would significantly help in such a
scenario.
8.15 Case Report
The following case shows the management of a
case of a heavy smoker (15–20 cigarettes a day)
with the immediate loading protocol.
A 48-year-old male patient reported to the
practice. He complained of pain and mobility of
teeth and wanted a fixed replacement option.
Extraoral examination in the frontal view
showed that the patient’s horizontal reference
lines (the eyebrow line, the inter pupillary line,
and the commissural line) were parallel to each
other and the patient’s dental and facial midline
coincided (Fig. 8.27a, b).
The sagittal view showed a straight profile
with no loss of lip support (Fig. 8.27c). His verti-
cal dimension seemed to be maintained. The
patient had an average lip line with 3–4 mm of
teeth visible, although the maxillary incisal edge
position seemed to be shifted coronally
(Fig. 8.27d).

Fig. 8.27 (a) Facial and dental midline coinciding. (b) Harmony in all three horizontal lines. (c) Straight sagittal pro-
file. (d) Maxillary incisal edge shifted. (e, f) Terminal dentition. (g) Radiographic evaluation. (h) Maxillary flap raise.
(i) Implants placed. (j) Pickup technique, passivity ensured. (k) Implant level open-tray impression. (l) MUA level
open-tray impression. (m) Jig trial—upper. (n) Jig trial—lower. (o) Jaw relation. (p) Teeth setting trial. (q) PMMA trial.
(r) PMMA trial. (s, t) Milled titanium framework with individual zirconia crowns. (u, v) Maximum intercuspation. (w)
Protrusion. (x) Lateral excursion. (y, z) Oral hygiene instructions
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 193

a b c

d e

f g

h i

j k
194 B. H. Birdi et al.

l m

n o

p q

r s

Fig. 8.27 (continued)

Intraoral examination showed aggressive peri-
odontitis with grade III mobility in almost the
entire dentition. The occlusal plane was not nor-
mal with migration of various teeth. Oral prophy-
laxis was done with antibiotic prophylaxis for a
period of 5 days before the surgery. This ensured
reduction in inflammation during the procedure.
The patient was asked to stop or reduce smoking
for 2 weeks before the surgery (Fig. 8.27e, f).
Radiographic evaluation showed there was
minor pneumatization of the sinus. CBCT evalu-
ation showed severe atrophy but adequate bone to
place three axial and two tilted implants in the
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 195

t u

v w

x y

Fig. 8.27 (continued)

maxillary arch. The mandibular arch required axial implants were placed in the mandibular jaw.
axial implants placement (Fig. 8.27g). Long, wide implants were placed to ensure high
The flap was raised and the tilted implant pro- primary stability (Fig. 8.27h, i).
tocol was followed for the maxillary arch, and
196
Open tray impressions were made and a lab-­
fabricated acrylic temporaries were fabricated for
both the jaws. Adequate thickness of provisional
was kept to avoid fractures in the healing period.
The pick-up technique was used to ensure passiv-
ity. The one screw test was positive (Fig. 8.27j).
The patient was given hygiene and diet
instructions and was asked to be on soft diet. The
patient was asked to avoid smoking for the next
4–6 weeks. The patient followed the instructions
and had uneventful healing. The process for final
restoration was started after 4 months. The
extended healing period was decided considering
that the patient was a smoker.
Open tray impressions were made (Fig. 8.27k,
l) and jig trials for both the arches were done
(Fig. 8.27m, n).
Jaw relation and teeth setting trial were con-
ducted (Fig. 8.27o, p).
This was followed by PMMA trial. Once pas-
sivity was ensured, all the corrections needed
were communicated to the lab (Fig. 8.27q, r).
Milled titanium framework with provisions
for individual zirconia crowns was fabricated.
The passivity was verified again with one screw
test (Fig. 8.27s, t).
Mutually protected occlusal scheme was
designed (Fig. 8.27u–x).
Oral hygiene instructions were given to the
patient to avoid chances of peri-implantitis,
because not only was the patient a smoker but
also had aggressive periodontitis as the causative
factors for loss of dentition in first place
(Fig. 8.27y, z).
Stable bone levels were observed during the
delivery of the final prosthesis (Fig. 8.28).
Fig. 8.28 Stable bone levels
B. H. Birdi et al.
8.16 Clinician Related
Immediate loading protocol is an advanced surgi-
cal and prosthetic modality of treatment that a
clinician can offer a patient. This involves a num-
ber of factors that come into play right from cor-
rect case selection, surgical and prosthetic
planning to their correct execution. The entire
modality can be stressful (especially if done in
the free hand approach) for both the patient and
the clinician.
It has been in author’s experience that imme-
diate loading protocol should be attempted by
clinician who is a bit experienced as there is a
learning curve to these procedures. This is sup-
ported by studies that show that there is a strong
correlation between experience of the surgeon
and the success of the procedure [158, 185].
An inexperienced surgeon may not be able to
get high stability especially in the maxilla, may
not create adequate restorative space, may end up
perforating the buccal plate, and lastly may not
get passivity of the framework. Unlike in the con-
ventional approach, where the implants can be
submerged, that freedom is not available in the
immediate loading protocols. This can lead to
severe embarrassment for the clinician if he fails
to deliver to the patient what was initially
promised.
Lastly, early failures in the protocol in the ini-
tial few cases may dishearten the clinician who
may stop adopting this technique completely,
depriving his patients from such a life-changing
treatment modality.
8.17 Conclusion
The biomechanical aspects of full-arch rehabili-
tation utilizing an immediately loading protocol
are multi-faceted with many dynamic parts to
consider. Careful planning and the amalgamation
of surgical and restorative therapies is essential.
However, it must be emphasized that this proce-
dure, as with all implant therapy, is a restoratively
driven treatment modality. Thus, restorative plan-
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
ning must be completed prior to implant surgery
to allow for proper implant placement, as well as
the creation of adequate restorative space.
Full-arch immediate loading is predictable
when initial implant stability is attained. This is
the main prerequisite for this type of therapy.
The broad distribution of implants which can
involve angled implant placement will be bene-
ficial from both a biomechanical and restorative
standpoint. This prerequisite when combined
with a carefully designed cross-arch stabilized
interim hybrid prosthesis with minimal cantile-
vers will provide the greatest chance for success
of the immediately loaded implants. Attributes
such as reinforcement of the interim hybrid
prosthesis, as well as minimizing excessive res-
toration height, will aid in the force risk of the
prosthesis. Finally, and most importantly, the
occlusion on the interim hybrid prosthesis must
be adjusted to minimize deflective occlusal
forces. This combined with a soft diet during the
healing phase will provide the best chance for
success.
A thorough evaluation of the patient’s medical
history is of equal importance. It is an integral
part of the entire treatment planning for the
immediate loading concept. Immediate loading
should only be suggested and executed when the
patient is medically stable. Contrary to initial
beliefs, immediate loading can be performed in
bruxers, heavy smokers, and uncontrolled diabet-
ics. However, these must be attempted by experi-
enced clinicians who can follow the rigorous
rules required for its success, like high primary
stability, rigid cross-arch stabilization, and thor-
ough instructions about the diet. Patients must be
informed of the risk prior to commencing
treatment.
References
1. Davarpanah M. Immediate loading of dental
implants theory and clinical practice. Quintessence
Int. 2008:x–xi.
2. Esposito M, Grusovin MG, Willings M, Coulthard
P, Worthington HV. The effectiveness of immediate,
early, and conventional loading of dental implants:
a Cochrane systematic review of randomized con-
197
trolled clinical trials. Int J Oral Maxillofac Implants.
2007;22:893–904.
3. Szmukler-Moncler S, Salama H, Reingewirtz Y,
Dubruille JH. Timing of loading and effect of micro-
motion on bone-dental implant interface: review
of experimental literature. J Biomed Mater Res.
1998;43:192–203.
4. Ottoni JM, Oliveira ZF, Mansini R, Cabral
AM. Correlation between placement torque and sur-
vival of single-tooth implants. Int J Oral Maxillofac
Implants. 2005;20:769–76.
5. Ghoul WE, Chidiac JJ. Prosthetic requirements for
immediate implant loading: a review. J Prosthodont.
2012;21(2):141–54.
6. Millen C, Brägger U, Wittneben JG. Influence of
prosthesis type and retention mechanism on com-
plications with fixed implant-supported prostheses:
a systematic review applying multivariate analyses.
Int J Oral Maxillofac Implants. 2015;30(1):110–24.
7. Wittneben JG, Millen C, Brägger U. Clinical
performance of screw- versus cement-retained
fixed implant-supported reconstructions--a sys-
tematic review. Int J Oral Maxillofac Implants.
2014;29(Suppl):84–98.
8. Brunski JB. In vivo bone response to biomechani-
cal loading at the bone/dental-implant interface. Adv
Dent Res. 1999;13:99–119.
9. Ericsson I, Randow K, Nilner K, et al. Early func-
tional loading of Branemark dental implants. A 5
year follow up study. Clin Implant Dent Relat Res.
2000;2:70–7.
10. Chow J, Hui E, Li D, et al. Immediate loading of
Branemark system fixtures in the mandible with a
fixed provisional prosthesis. Appl Osseointegration
Res. 2001;2:30–5.
11. Friberg B, Henningsson C, Jemt T. Rehabilitation of
edentulous mandibles by means of turned Branemark
system implants after one stage surgery: a 1 year ret-
rospective study of 152 patients. Clin Implant Dent
Relat Res. 2005;7:1–9.
12. Kinsel RP, Lamb RE, Moneim A. Development
of gingival esthetics in the edentulous patient
with immediately loaded, single-stage, implant-­
supported fixed prostheses: a clinical report. Int J
Oral Maxillofac Implants. 2000;15:711–21.
13. Balshi SF, Allen FD, Wolfinger GJ, et al. A reso-
nance frequency analysis assessment of maxillary
and mandibular immediately loaded implants. Int J
Oral Maxillofac Implants. 2005;20:584–94.
14. Bergkvist G, Simonsson K, Rydberg K, et al. A finite
element analysis of stress distribution in bone tissue
surrounding uncoupled or splinted dental implants.
Clin Implant Dent Relat Res. 2008;10:40–6.
15. Schnitman PA, Wohrle PS, Rubenstein JE, et al. Ten-­
year results for Branemark implants immediately
loaded with fixed prostheses at implant placement.
Int J Oral Maxillofac Implants. 1997;12:495–503.
16. Kinsel RP, Liss M. Retrospective analysis of 56
edentulous dental arches restored with 344 single-­
stage implants using an immediate loading fixed
198
provisional protocol: statistical predictors of
implant failure. Int J Oral Maxillofac Implants.
2007;22:823–30.
17. Suarez-Feito JM, Sicilia A, Angulo J, Banerji S,
Cuesta I, Millar B. Clinical performance of provi-
sional screw-retained metal-free acrylic restorations
in an immediate loading implant protocol: a 242
consecutive patients’ report. Clin Oral Implants Res.
2010;21(12):1360–9.
18. Glauser R, Sennerby L, Meredith N, Rée A,
Lundgren A, Gottlow J, Hämmerle CH. Resonance
frequency analysis of implants subjected to immedi-
ate or early functional occlusal loading. Successful
vs. failing implants. Clin Oral Implants Res.
2004;15(4):428–34.
19. Berglundh T, Abrahamsson I, Lang NP, Lindhe J. De
novo alveolar bone formation adjacent to endosseous
implants. Clin Oral Implants Res. 2003;14:251–62.
20. Salvi GE, Bosshardt DD, Lang NP, Abrahamsson
I, Berglundh T, Lindhe J, Ivanovski S, Donos
N. Temporal sequence of hard and soft tissue healing
around titanium dental implants. Periodontol 2000.
2015;68(1):135–52.
21. Bosshardt DD, Salvi GE, Huynh-Ba G, Ivanovski
S, Donos N, Lang NP. The role of bone debris in
early healing adjacent to hydrophilic and hydropho-
bic implant surfaces in man. Clin Oral Implants Res.
2011;22:357–64.
22. Lang NP, Salvi GE, Huynh-Ba G, Ivanovski S,
Donos N, Bosshardt DD. Early osseointegration to
hydrophilic and hydrophobic implant surfaces in
humans. Clin Oral Implants Res. 2011;22:349–56.
23. Morneburg TR, Proschel PA. In vivo forces on
implants influenced by occlusal scheme and food
consistency. Int J Prosthodont. 2003;16:481–6.
24. Ozgur GO, Kazancioglu HO, Demirtas N, Deger S,
Ak G. Risk factors associated with implant marginal
bone loss: a retrospective 6-year follow-up study.
Implant Dent. 2016;25(1):122–7.
25. Horita S, Sugiura T, Yamamoto K, Murakami K,
Imai Y, Kirita T. Biomechanical analysis of immedi-
ately loaded implants according to the “All-on-Four”
concept. J Prosthodont Res. 2016;61(2):123–32.
pii:1883–1958.
26. Drago C. Cantilever lengths and anterior-posterior
spreads of interim, acrylic resin, full-arch screw-­
retained prostheses and their relationship to pros-
thetic complications. J Prosthodont. 2016;26:502.
27. Drago C. Frequency and type of prosthetic compli-
cations associated with interim, immediately loaded
full-arch prostheses: a 2-year retrospective chart
review. J Prosthodont. 2016;25(6):433–9.
28. 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(2):427–31.
29. Yamaguchi K, Ishiura Y, Tanaka S, Baba K. Influence
of the rigidity of a provisional restoration sup-
ported on four immediately loaded implants in the
edentulous maxilla on biomechanical bone-implant
B. H. Birdi et al.
interactions under simulated bruxism conditions:
a three-dimensional finite element analysis. Int J
Prosthodont. 2014;27(5):442–50.
30. Al Twal EQ, Chadwick RG. Fibre reinforce-
ment of two temporary composite bridge mate-
rials--effect upon flexural properties. J Dent.
2012;40(12):1044–51.
31. Kamble VD, Parkhedkar RD. In vitro compara-
tive evaluation of the effect of two different fiber
reinforcements on the fracture toughness of pro-
visional restorative resins. Indian J Dent Res.
2012;23(2):140–4.
32. Zuccari AG, Oshida Y, Moore BK. Reinforcement
of acrylic resins for provisional fixed restorations.
Part I: mechanical properties. Biomed Mater Eng.
1997;7(5):327–43.
33. Heydecke G, Zwahlen M, Nicol A, Nisand D, Payer
M, Renouard F, Grohmann P, Mühlemann S, Joda
T. What is the optimal number of implants for fixed
reconstructions: a systematic review. Clin Oral
Implants Res. 2012;23(Suppl 6):217–28.
34. Mericske-Stern R, Worni A. Optimal number of
oral implants for fixed reconstructions: a review of
the literature. Eur J Oral Implantol. 2014;7(Suppl
2):S133–53.
35. Niedermaier R, Stelzle F, Riemann M, Bolz W,
Schuh P, Wachtel H. Implant-supported imme-
diately loaded fixed full-arch dentures: evalu-
ation of implant survival rates in a case cohort
of up to 7 years. Clin Implant Dent Relat Res.
2016;19:4.
36. Maló P, Rangert B, Nobre M. “All-on-Four”
immediate-­function concept with Brånemark System
implants for completely edentulous mandibles: a ret-
rospective clinical study. Clin Implant Dent Relat
Res. 2003;5(Suppl 1):S2–9.
37. Maló P, Rangert B, Nobre M. All-on-4 immediate-­
function concept with Brånemark System implants
for completely edentulous maxillae: a 1-year retro-
spective clinical study. Clin Implant Dent Relat Res.
2005;7(Suppl 1):S88–94.
38. Sagat G, Yalcin S, Gultekin BA, Mijiritsky
E. Influence of arch shape and implant position on
stress distribution around implants supporting fixed
full-arch prosthesis in edentulous maxilla. Implant
Dent. 2010;19(6):498–508.
39. Francetti L, Cavalli N, Villa T, La Barbera L, Taschieri
S, Corbella S, Del Fabbro M. Biomechanical in vitro
evaluation of two full-arch rehabilitations sup-
ported by four or five implants. Int J Oral Maxillofac
Implants. 2015;30(2):419–26.
40. Kim KS, Kim YL, Bae JM, Cho HW. Biomechanical
comparison of axial and tilted implants for mandibu-
lar full-arch fixed prostheses. Int J Oral Maxillofac
Implants. 2011;26(5):976–84.
41. Bellini CM, D. Romero comparison of tilted versus
nontilted implant-supported prosthetic design for
the restoration of the edentulous mandible: a bio-
mechanical study. Int J Oral Maxillofac Implants.
2000;24(3):511–7.
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
42. Fazi G, Tellini S, Vangi D, Branchi R. Three-­
dimensional finite element analysis of differ-
ent implant configurations for a mandibular
fixed prosthesis. Int J Oral Maxillofac Implants.
2011;26(4):752–9.
43. Bevilacqua M, Tealdo T, Menini M, Pera F,
Mossolov A, Drago C, Pera P. The influence of
cantilever length and implant inclination on stress
distribution in maxillary implant-supported fixed
dentures. J Prosthet Dent. 2011;105(1):5–13.
44. Chan MH, Holmes C. Contemporary “All-on-4”
concept. Dent Clin N Am. 2015;59(2):421–70.
45. Krekmanov L, Khan M, Rangert B, et al. Tilting
of posterior mandibular and maxillary implants for
improved prosthesis support. Int J Oral Maxillofac
Implants. 2000;15:405–14.
46. Butera C, Galindo DF, Jensen O. Mandibular all-­
on-­four therapy using angled implants: a three year
clinical study of 857 implants in 219 jaws. Dent Clin
N Am. 2011;55:795–811.
47. Testori T, Del Fabbro M, Capellini M, et al.
Immediate occlusal loading and tilted implants
for the rehabilitation of the atrophic edentu-
lous maxilla: 1-year interim results of a multi-
center prospective study. Clin Oral Implants Res.
2008;19:227–32.
48. Francetti L, Agliardi E, Testori T, Romeo D,
Taschieri S, Del Fabbro M. Immediate rehabilita-
tion of the mandible with fixed full prosthesis sup-
ported by axial and tilted implants: interim results of
a single cohort prospective study. Clin Implant Dent
Relat Res. 2008;10(4):255–63.
49. Calandriello R, M. Tomatis simplified treatment
of the atrophic posterior maxilla via immediate/
early function and tilted implants: a prospective
1-year clinical study. Clin Implant Dent Relat Res.
2000;7:1–12.
50. Saleh Saber F, Ghasemi S, Koodaryan R, Babaloo
A, Abolfazli N. The comparison of stress distribu-
tion with different implant numbers and inclination
angles in all-on four and conventional methods in
maxilla: a finite element analysis. J Dent Res Dent
Clin Dent Prospects. 2015;9(4):246–53.
51. 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(4):440–5.
52. Martini AP, Freitas AC Jr, Rocha EP, de Almeida
EO, Anchieta RB, Kina S, Fasolo GB. Straight and
angulated abutments in platform switching: influ-
ence of loading on bone stress by three dimen-
sional finite element analysis. J Craniofac Surg.
2012;23(2):415–8.
53. Phillips K, Wong KM. Vertical space requirement
for the fixed-detachable, implant-supported prosthe-
sis. Compend Contin Educ Dent. 2002;23(8):750–2,
754, 756.
54. Tallgren A. The reduction in face height of eden-
tulous and partially edentulous subjects during
long term denture wear: a longitudinal roentgeno-
199
graphic cephalometric study. Acta Odontol Scand.
1966;24:195–239.
55. Nunes M, Almeida RF, Felino AC, Malo P, de Araújo
Nobre M. The influence of crown-to-implant ratio
on short implant marginal bone loss. Int J Oral
Maxillofac Implants. 2016;31(5):1156–63.
56. Nissan J, Ghelfan O, Gross O, Priel I, Gross M,
Chaushu G. The effect of crown/implant ratio
and crown height space on stress distribution in
unsplinted implant supporting restorations. J Oral
Maxillofac Surg. 2011;69(7):1934–9.
57. Birdi H, Schulte J, Kovacs A, Weed M, Chuang
SK. Crown-to-implant ratios of short-length
implants. J Oral Implantol. 2010;36(6):425–33.
58. Aghaloo T, Pi- Anfruns J, Moshaverinia A, Sim D,
Hadaya D. The effects of systemic diseases and
medications on implant osseointegration. A sys-
tematic review. Int J Oral Maxillofac Implants.
2019;34:s35–49.
59. Kowal P, Chatterji S, Naidoo N, et al. Data resource
profile: the World Health Organization Study on
global AGEing and adult health (SAGE). Int J
Epidemiol. 2012;41:1639–49.
60. Organisation WH. World health statistics 2016:
monitoring health for the SDGs sustainable devel-
opment goals. Geneva: World Health Organisation;
2016.
61. Tuomi T. Type 1 and type 2 diabetes: what do they
have in common? Diabetes. 2005;54(Suppl 2):s40–5.
62. Salsali A, Nathan M. A review of types 1 and 2 dia-
betes mellitus and their treatment with insulin. Am J
Ther. 2006;13:349–61.
63. Strain WD, Paldánius PM. Diabetes, cardiovascular
disease and micro circulation. Cardiovasc Diabetol.
2018;17:57.
64. Naujokat H, Kunzendorf B, Wiltfang J. Dental
implants and diabetes mellitus – a systematic review.
Int J Implant Dent. 2016;2:5.
65. Dubey RK, Gupta DK, Singh AK. Dental implant
survival in diabetic patients; review and recommen-
dations. Natl J Mazxillofac Surg. 2013;4:142–50.
66. Moraschini V, Barboza ES, Peixoto GA. The impact
of diabetes on dental implant failure. A systematic
review and meta-analysis. Int J Oral Maxillofac
Surg. 2016;45:1237–45.
67. Aguilar-Salvatierra A, Calvo-Guirado JL, González-­
Jaranay M, et al. Peri implant evaluation of imme-
diately loaded implants placed in the aesthetic zone
in patients with diabetes mellitus type 2: a two year
study. Clin Oral Implants Res. 2016;27:156–61.
68. Al Amri MD, Kellesarian SV, Al-Kheraif AA, et al.
Effect of oral hygiene maintenance on HbA1c lev-
els and peri implant parameters around immediately
loaded dental implants placed in type-2 diabetic
patients; 2 years follow-up. Clin Oral Impants Res.
2016;27:1439–43.
69. Javed F, Romanos GE. Impact of diabetes melli-
tus and glycaemic control on the osseointegartion
of dental implants: a systematic literature review. J
Periodontol. 2009;80:1719–30.
200
70. Tawil G, Younan R, Azar P, Sleilati G. Conventional
and advanced implant treatment in the type II dia-
betic patient: surgical protocol and long term
clinical results. Int J Oral Maxillofac Implants.
2008;23(4):744–52.
71. Al Maskari AY, Al Maskari MY, Al-Sudairy
S. Oral manifestations and complications of diabe-
tes mellitus: a review. Sultan Qaboos Univ Med J.
2011;11:179–86.
72. Ghiraldini B, Conte A, Casarin RC, et al. Influence
of glycaemic control on peri implant bone healing:
12 month outcomes of local release of bone related
factors and implant stabilization in type 2 diabetes.
Clin Implant Dent Relat Res. 2016;18:801–9.
73. Delamaire M, Maugendre D, Moreno M, Le
Goff MC, Allanic H, Genetet B. Impaired leuco-
cyte functions in diabetic patients. Diabet Med.
1997;14:29–34.
74. Ebersole J, Holt SC, Hansard R, Novak
MJ. Microbiological and immunological char-
acteristics of periodontal disease in Hispanic
Americans with type 2 diabetes. J Periodontol.
2008;79:637–46.
75. Fenner N, Hammerle CH, Sailer I, Jung
RE. Long term clinical, technical and aesthetic
outcomes of all ceramic vs titanium abutments
on implant supported single tooth reconstruc-
tions after at least 5 years. Clin Oral Implants
Res. 2016;27(6):716–23.
76. Hoeksema AR, Visser A, Raghoebar GM, Vissink A,
Meijer H. Influence of age on clinical performance
of mandibular two implant over dentures: a 10 year
prospective comparative study. Clin Implant Dent
Relat Res. 2016;18(4):745–51.
77. Al Amri MD, Alfarraj Aldosari AM, Al Johany SS,
et al. Comparison of clinical and radiographic sta-
tus around immediately loaded versus convention-
ally loaded implants placed in patients with type 2
diabetes: 12 and 24 month follow up results. J Oral
Rehabil. 2017;44:220–8.
78. Andrade CAS, Paz JLC, De Melo GS, Mahrouseh
N, Jauário A, Capeletti LR. Survival rate and peri
implant evaluation of immediately loaded dental
implants in individuals with type 2 diabetes melli-
tus: a systematic review and meta analysis. Clin Oral
Investig. 2022;26(2):1797–810.
79. Chrcanovic BR, Albektsson T, Wennerberg
A. Diabetes and oral implant failure: a systematic
review. J Dent Res. 2014;93:859–67.
80. Morris HF, Ochi S, Winkler S. Implant survival
in patients with type 2 diabetes: placement to 36
months. Ann Periodontol. 2000;5:157–65.
81. National Kidney Foundation. K/DOQI clinical prac-
tice guidelines for chronic kidney disease: evalua-
tion, classification, and stratification. Am J Kidney
Dis. 2002;39(2 suppl 1):S1–266.
82. Vassalotti JA, Stevens LA, Levey AS. Testing for
chronic kidney disease: a position statement from
the National Kidney Foundation. Am J Kidney Dis.
2007;50:169–80.
B. H. Birdi et al.
83. Stevens LA, Levey AS. Current status and future
perspectives for CKD testing. Am J Kidney Dis.
2009;53(Suppl 3):S17–26.
84. Kao WH, Klag MJ, Meoni LA, et al. MYH9
is associated with nondiabetic end-stage renal
disease in African Americans. Nat Genet.
2008;40(10):1185–92.
85. Kanji Z, Powe CE, Wenger JB, et al. Genetic
variation in APOL1 associates with younger age
at hemodialysis initiation. J Am Soc Nephrol.
2011;22(11):2091–7.
86. Albert DA, Ward A, Allweiss P, et al. Diabetes and
oral disease: implications for health professionals.
Ann N Y Acad Sci. 2012;1255:1–15.
87. Habib Khan Y, Sarriff A, Hayat Khan A, et al.
Infective endocarditis and chronic kidney disease:
how to deal with complications. Malays J Med Sci.
2015;22(4):73–5.
88. American DA. Diagnosis and classification of
diabetes mellitus. Diabetes Care. 2012;35(Suppl
1):S64–71.
89. Taylor GW. Bidirectional interrelationships between
diabetes and periodontal diseases: an epidemiologic
perspective. Ann Periodontol. 2001;6(1):99–112.
90. Wu YY, Xiao E, Graves DT. Diabetes mellitus
related bone metabolism and periodontal disease. Int
J Oral Sci. 2015;7(2):63–72.
91. Kidney Disease: Improving Global Outcomes
(KDIGO) CKD-MBD Work Group. KDIGO clinical
practice guideline for the diagnosis, evaluation, pre-
vention, and treatment of Chronic Kidney Disease-­
Mineral and Bone Disorder (CKD-MBD). Kidney
Int Suppl. 2009;113:S1–S130.
92. Yuan Q, Xiong QC, Gupta M, López-Pintor RM,
Chen XL, Seriwatanachai D, Densmore M, Man Y,
Gong P. Dental implant treatment for renal failure
patients on dialysis: a clinical guideline. Int J Oral
Sci. 2017;9(3):125–32. https://doi.org/10.1038/
ijos.2017.23. Epub 2017 Jun 23.
93. Wu Q, Lai X, Zhu Z, et al. Evidence for chronic
kidney disease-mineral and bone disorder associ-
ated with metabolic pathway changes. Medicine
(Baltimore). 2015;94(32):e1273.
94. Moe S, Drueke T, Cunningham J, et al. Definition,
evaluation, and classification of renal osteodys-
trophy: a position statement from Kidney Disease:
Improving Global Outcomes (KDIGO). Kidney Int.
2006;69(11):1945–53.
95. Miller PD. Chronic kidney disease and the skeleton.
Bone Res. 2014;2:14044.
96. Zhao D, Chen X, Yue L, et al. Assessment of residual
alveolar bone volume in hemodialysis patients using
CBCT. Clin Oral Investig. 2015;19(7):1619–24.
97. Jeffcoat M. The association between osteoporosis
and oral bone loss. J Periodontol. 2005;76:2125–32.
98. Persson RE, Hollender LG, Powell LV, MacEntee
MI, Wyatt CC, et al. Assessment of periodon-
tal conditions and systemic disease in older sub-
jects. I. Focus on osteoporosis. J Clin Periodontol.
2002;29:796–802.
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
99. Geurs NC, Lewis CE, Jeffcoat MK. Osteoporosis
and periodontal disease progression. Periodontol
2000. 2003;32:105–10.
100. Krall EA. The periodontal-systemic connection:
implications for treatment of patients with osteo-
porosis and periodontal disease. Ann Periodontol.
2001;6:209–13.
101. Jagelaviciene E, Kubilius R. The relationship
between general osteoporosis of the organism
and periodontal diseases. Medicina (Kaunas).
2006;42:613–8.
102. Mohammad AR, Brunsvold M, Bauer R. The
strength of association between systemic postmeno-
pausal osteoporosis and periodontal disease. Int J
Prosthodont. 1996;9:479–83.
103. Marya CM. Effect of osteoporosis on oral health.
Arch Med. 2015;8:2.
104. Wagner F, Schuder K, Hof M, Heurer S, Seemann R,
et al. Does osteoporosis influence the marginal peri
implant bone level in female patients? A cross sec-
tional study in matched collective. Clin Implant Dent
Relat Res. 2017;19(4):616–23.
105. Szmukhler- Moncler S, Salama H, Reingewirtz
Y, Dubruille JH. Timing of loading and effect of
micro motion on bone implant interface. Review
of experimental literature. J Biomed Mater Res.
1998;43:192–203.
106. Brunski JB. Influence of bio mechanical factors
at the bone – biomaterial interface. In: Davies JE,
editor. The bone biomaterial interface. Toronto:
University of Toronto; 1991. p. 391–405.
107. Brunski JB. Avoid pitfalls of over loading and micro
motion of intra osseous implants. Dent Implantol
Updat. 1993;4(10):77–81.
108. Szmukhler- Moncler S, Piattelli A, Favero GA,
Dubruille JH. Considerations preliminary to the
application of early and immediate loading proto-
cols in dental implantology. Clin Oral Implants Res.
2000;11:12–25.
109. Brunski JB. Biomechanical factors affecting
the bone dental implant interface. Clin Master.
1992;10(3):153–201.
110. Trisi P, Perfetti G, Baldoni E, Berardi D,
Colagiovanni M, Scogna G. Implant micro motion
is related to peak insertion torque and bone density.
Clin Oral Implants Res. 2009;20:467–71.
111. Engelke W, Decco OA, Rau MJ, Massoni
MC, Schwrzwäller W. In vitro evaluation of
horizontal implant movement in bone speci-
men with contact endoscopy. Implant Dent.
2004;13:88–94.
112. Todisco M, Trisi P. Bone mineral density and bone
histo morphometry are statistically related. Int J Oral
Maxillofac Implants. 2005;20:898–904.
113. Riggs BL, Melton LJ. Involutional osteoporosis. N
Eng J Med. 1986;314(26):1676–86.
114. Lugero GG, de Falco CV, Guzzo ML, Koning B Jr,
Jorgetti V. Histomorphometric evaluation of tita-
nium implants in osteoporotic rabbits. Implant Dent.
2000;9(4):303–9.
201
115. Yamazaki M, Tokugawa Y, Motohshi M, Ohno
K, Michi K, et al. Bone reactions to titanium
screw implants in overiectomized animals. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
1999;87(4):411–8.
116. Hara T, Hayashi K, Nakashima Y, Kanemaru T,
Iwamoto Y. The effect of hydroxyapatite coating
on the bonding of bone to titanium implants in the
femora of ovariectomised rats. J Bone Joint Surg Br.
1999;81(4):705–9.
117. Liddeow G, Klineberg I. Patient related risk factors
for implant therapy. A critique of perinent literature.
Aust Dent. 2011;56(4):417–26.
118. Greenspan SL, Harris ST, Bone H, Miller PD,
Orwoll ES, et al. Bisphosphonates: safety and effi-
cacy in the treatment and prevention of osteoporosis.
Am Fam Physician. 2000;61:2731–6.
119. Coleman RE. Risks and benefits of bisphosphonates.
Br J Cancer. 2008;98:1736–40.
120. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff
SL. Osteonecrosis of the jaws associated with the
use of bisphosphonates: a review of 63 cases. J Oral
Maxillofac Surg. 2004;62:527–34.
121. Mashiba T, Hirano T, Turner CH, Forwood MR,
Johnston CC, et al. Suppressed bone turnover by
bisphosphonates increases microdamage accumula-
tion and reduces some biomechanical properties in
dog rib. J Bone Miner Res. 2000;15:613–20.
122. Bodic F, Hamel L, Lerouxel E, Baslé MF,
Chappard D. Bone loss and teeth. Joint Bone Spine.
2005;72:215–21.
123. Huwais S, Meyer EG. A novel osseous densifica-
tion approach in implant osteotomy preparation to
improve biomechanical primary stability, bone min-
eral density and bone-implant contact. Int J Oral
Maxillofac Implants. 2017;32:27–36.
124. Roux C, Bischoff-Ferrari HA, Papapoulos SE, de
Papp AE, West JA, Bouillon R. New insights into the
role of vitamin D and calcium in osteoporosis man-
agement: an expert roundtable discussion. Curr Med
Res Opin. 2008;24:1363–70.
125. Brinker MR, O’Connor DP, Monla YT, Earthman
TP. Metabolic and endocrine abnormalities in
patients with non-unions. J Orthop Trauma.
2007;21:557–70.
126. Kelly J, Lin A, Wang CJ, Park S, Nishimura
I. Vitamin D and bone physiology: demonstration of
vitamin D deficiency in an implant osseointegration
rat model. J Prosthodont. 2009;18:473–8.
127. Fu L, Tang T, Hao Y, Dai K. Effect of 1,25- dihy-
droxy vitamin D3 on fracture healing and bone
remodelling in ovariectomised rat femora. Bone.
2009;44:893–8.
128. Dvorak G, Fügl A, Watzek G, Pokorny P, Gruber
R. Impact of dietary vitamin D on osseointegration
in the ovariectomized rat. Clin Oral Implant Res.
2011;23:1308–13.
129. Murray CJ, Lopez AD. Global mortality, disability,
and the contribution of risk factors: global burden of
disease study. Lancet. 1997;349:1436–42.
202
130. Krishnan V, Nestler EJ. The molecular neurobiology
of depression. Nature. 2008;455:894–902.
131. Liu B, Anderson G, Mittmann N, To T, Axcell T,
Shear N. Use of selective serotonin-reuptake inhibi-
tors or tricyclic antidepressants and risk of hip frac-
tures in elderly people. Lancet. 1998;351:1303–7.
132. Tsapakis E, Gamie Z, Tran G, Adshead S, Lampard
A, Mantalaris A, et al. The adverse skeletal effects
of selective serotonin reuptake inhibitors. Eur
Psychiatry. 2012;27:156–69.
133. Diem SJ, Blackwell TL, Stone KL, Yaffe K, Haney
EM, Bliziotes MM, et al. Use of antidepressants
and rates of hip bone loss in older women: the
study of osteoporotic fractures. Arch Intern Med.
2007;167:1240–5.
134. Yadav VK, Ryu JH, Suda N, Tanaka KF, Gingrich
JA, Schütz G, et al. Lrp5 controls bone formation by
inhibiting serotonin synthesis in the duodenum. Cell.
2008;135:825–37.
135. Battaglino R, Fu J, Späte U, Ersoy U, Joe M,
Sedaghat L, et al. Serotonin regulates osteoclast dif-
ferentiation through its transporter. J Bone Miner
Res. 2004;19:1420–31.
136. Esposito M, Hirsch JM, Lekholm U, Thomsen
P. Biological factors contributing to failures of
osseointegrated oral implants (II): etiopathogenesis.
Eur J Oral Sci. 1998;106:721–64.
137. Wu X, Al-Abedalla K, Rastikerdar E, Abi Nader S,
Daniel NG, Nicolau B, Tamimi F. Selective sero-
tonin reuptake inhibitors and the risk of osseointe-
grated implant failure: a cohort study. J Dent Res.
2014;93(11):1054–61.
138. Thorpy MJ. Parasomnias. In: Thorpy MJ, edi-
tor. International classification of sleep disorders.
Diagnostic coding manual. Rochester, MN: Allen
Press; 1990. p. 142–85.
139. Okeson JP. Orofacial pain: guidelines for assess-
ment, diagnosis and management. Chicago, IL:
Quintessence Publishing Co., Inc.; 1996.
140. Lavigne GJ, Rompré PH, Montplaisir JY, Lobbezzoo
F. Motor activity in sleep bruxism with concomitant
jaw muscle pain: a retrospective pilot study. Eur J
Oral Sci. 1997;105:92–5.
141. Lobbezzo F, Lavigne GJ. Do bruxism and temporo-
mandibular disorders have a cause and effect rela-
tionship? J Orofac Pain. 1997;11:15–23.
142. John MT, Frank H, Lobbezoo F, Drangsholt M,
Dette KE. No association between incisal tooth wear
and temporomandibular disorders. J Prosthet Dent.
2002;87:197–203.
143. Lavigne GJ, Kato T, Kolta A, Sessle
BJ. Neurobiological mechanisms involved in sleep
bruxism. Crit Rev Oral Biol Med. 2003;14:30–46.
144. Tosun T, Karabuda C, Cuhadaroglu C. Evaluation
of sleep bruxism by polysomnographic analysis in
patients with dental implants. Int J Oral Maxillofac
Implants. 2003;18:286–92.
145. Lobbezoo F, Brouwers JE, Cune MS, et al. Dental
implants in patients with bruxing habits. J Oral
Rehabil. 2006;33:152–9.
B. H. Birdi et al.
146. Lavigne GJ, Manzini C. Bruxism. In: Kryger MH,
Roth T, Dement WC, editors. Principles and prac-
tice of sleep medicine. 3rd ed. Philadelphia, PA:
Saunders; 1999. p. 773–85.
147. Johansson A, Omar R, Carlsson GE. Bruxism and
prosthetic treatment: a critical review. J Prosthodont
Res. 2011;55:127–36.
148. Meyer G, Fanghanel J, Proff P. Morphofunctional
aspects of dental implants. Ann Anat.
2012;194:190–4.
149. Wannafors K, Johansson B, Hallman M, Strandkvist
T. A prospective randomised study of 1- and 2- stage
sinus inlay bone grafts: 1 year follow up. Int J Oral
Maxillofac Implants. 2000;15:625–32.
150. Glauser R, Rée A, Lundgren AK, Gottlow J,
Hämmerle CHF, Schärer P. Immediate loading of
Branemark implants applied in various jawbone
regions: a prospective, 1 year clinical study. Clin
Implant Dent Relat Res. 2001;3:204–13.
151. Lazzara RJ, Testori T, Meltzer A, Misch C, Porter
S, del Castillo R, Goené RJ. Immediate occlusal
loading (IOL) of dental implants: predictable results
through DIEM guidelines. Pract Proced Aesthet
Dent. 2004;16(4):3–15. PMID: 15279236.
152. Misch CE, Hahn J, Judy KW, Lemons JE, Linkow
LI, Lozada JL, Mills E, Misch CM, Salama H,
Sharawy M, Testori T, Wang H-L. Workshop guide-
lines on immediate loading in implant dentistry. J
Oral Implantol. 2004;30(5):283–8.
153. Cannizzaro G, Leone M. Restoration of partially
edentulous patients using dental implants with a
microtextured surface: a prospective comparison of
delayed and immediate full occlusal loading. Int J
Oral Maxillofac Implants. 2003;18:512–22.
154. Jaffin RA, Kumar A, Berman CL. Immediate load-
ing of dental implants in the completely edentulous
maxilla: a clinical report. Int J Oral Maxillofac
Implants. 2004;19:721–30.
155. Bergkvist G, Sahlholm S, Karlsson U, Nilner K,
Lindh C. Immediately loaded implants supporting
fixed prostheses in the edentulous maxilla: a pre-
liminary clinical and radiologic report. Int J Oral
Maxillofac Implants. 2005;20:399–405.
156. Ibanez JC, Tahhan MJ, Zamar JA, Menendez AB,
Juaneda AM, Zamar NJ, Monqaut JL. Immediate
occlusal loading of double acid-etched surface tita-
nium implants in 41 consecutive full-arch cases in
the mandible and maxilla: 6- to 74-month results. J
Periodontol. 2005;76:1972–81.
157. Lambert PM, Morris HF, Ochi S. Positive effect
of surgical experience with implants on second
stage implant survival. J Oral Maxillofac Surg.
1997;55(Suppl):12–8.
158. Niedermaier R, Stelzle F, Riemann M, et al. Implant
supported immediately loaded full arch dentures:
evaluation of implant survival rates in a case cohort
up to 7 years. Clin Implant Dent Res. 2017;19:4–19.
159. Brunski JB. Biomechanical aspects of the optimal
number of implants to carry a cross-arch full restora-
8 Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions
tion. Eur J Oral Implantol. 2014;7 Suppl 2:S111–31.
PMID: 24977245.
160. Misch CE, Dietsh-Misch F. Diagnostic casts, preim-
plant prosthodontics, treatment prosthesis and surgi-
cal templates. In: Misch CE, editor. Contemporary
implant dentistry, vol. 8. St. Louis: CV Mosby;
1999. p. 135–49.
161. Misch CE. Occlusal considerations for implant
supported prosthesis. In: Misch CE, editor.
Contemporary implant dentistry. St. Louis: CV
Mosby; 1993. p. 705–33.
162. Misch CE, Bidez MN. Implant protected occlu-
sion, a biomechanical rationale. Compendium.
1994;15:1330–43.
163. Rangert B-R, Sullivan R-M, Jemt T-M. Load fac-
tor control for implants in the posterior partially
edentulous segment. Int J Oral Maxillofac Implants.
1997;12:360–70.
164. Rangert B, Jemt T, Jöurnéus L. Forces and moments
on Brånemark implants. Int J Oral Maxillofac
Implants. 1989;4:241–7.
165. Rangert B, Krogh PHJ, Langer B, Van Roekel
N. Bending overload and implant fracture. A ret-
rospective clinical analysis. Int J Oral Maxillofac
Implants. 1995;10:326–34.
166. Carr AB, Brunski JB, Hurley E. Effects of fabrica-
tion, finishing and polishing procedures on pre-
load in prostheses using conventional gold and
plastic cylinders. Int J Oral Maxillofac Implants.
1996;11:589–98.
167. Ness EM, Nicholls JI, Rubenstein JE, et al. Accuracy
of the acrylic resin pattern for the implant-retained
prosthesis. Int J Prosthodont. 1992;5:542–9.
168. El Askary AS, Meffert RM, Griffin T. Why
do dental implants fail? Part I. Implant Dent.
1999;8:173–85.
169. Misch CE. The effect of bruxism on treatment plan-
ning for dental implants. Dent Today. 2002;21:76–81.
170. Tarnow DP, Emtiaz S, Classi A. Immediate load-
ing of threaded implants at stage 1 surgery in eden-
tulous arches. Ten consecutive case reports with
1- to 5-year data. Int J Oral Maxillofac Implants.
1997;12:319–24.
171. Hurson S. Practical guidelines to prevent screw loos-
ening. Int J Dent. 1995;3:22–5.
172. McCoy G. Recognizing and managing parafunction
and maintenance of the oral implant patient. Implant
Dent. 2002;11:19–27.
173. McCoy G. Occlusion and implants. Dent Today.
1997;16:108–11.
203
174. Perel ML. Parafunction habits, nightguards, and root
form implants. Implant Dent. 1994;3:261–3.
175. English CE. Biomechanical concerns with fixed
partial dentures involving implants. Implant Dent.
1993;5:713–62.
176. Cakarer S, Selvi F, Can T, Kirli I, Palancioglu
A, Keskin B, Yaltirik M, Keskin C. Investigation
of the risk factors associated with the sur-
vival rate of dental implants. Implant Dent.
2014;23(3):328–33.
177. Naseri R, Yaghini J, Feizi A. Levels of smoking and
dental implants failure: a systematic review and
meta-analysis. J Clin Periodontol. 2020;47:518–28.
178. Zhao X, Zhu B, Duan Y, Wang X, Li D. The effect
of smoking behaviour on alveolar Bone marrow
mesenchymal stem cells of clinical implant patient.
Biomed Res Int. 2018;2018:7672695.
179. Raghavendra S, Wood MC, Taylor TD. Early wound
healing around endosseous implants: a review
of the literature. Int J Oral Maxillofac Implants.
2005;20(3):425–31.
180. Schliephake H, Sewing A, Aref A. Resonance fre-
quency measurements of implant stability in the
dog mandible: experimental comparison with his-
tomorphometric data. Int J Oral Maxillofac Surg.
2006;35(10):941–6.
181. Bischof M, Nedir R, Szmukler-Moncler S, Bernard
JP, Samson J. Implant stability measurement of
delayed and immediately loaded implants during
healing. A clinical resonance-frequency analysis
study with sandblasted-and-etched ITI implants.
Clin Oral Implants Res. 2004;15(5):529–39.
182. Huwiler MA, Pjetursson BE, Bosshardt DD, Salvi
GE, Lang NP. Resonance frequency analysis in rela-
tion to jawbone characteristics and during early heal-
ing of implant installation. Clin Oral Implants Res.
2007;18(3):275–80.
183. Sun C, Zhao J, Jianghao C, Hong T. Effect of heavy
smoking on dental implants placed in male patients
posterior mandibles: a prospective clinical study. J
Oral Implantol. 2016;42(6):477–83.
184. Romanos GE, Nentwig G-H. Immediate loading
using cross-arch fixed restorations in heavy smokers:
nine consecutive case reports for edentulous arches.
Int J Oral Maxillofac Implants. 2008;23(3):513–9.
185. Melo MD, Shafie H, Obeid G. Implant survival
rates for oral and maxillofacial surgery residents: a
retrospective clinical review with analysis of resi-
dent level of training on implant survival. J Oral
Maxillofac Surg. 2006;64:1185–9.
 FP1 Concepts in Rehabilitating
the Edentulous Patient
with Implant-Supported
Restorations
Martin Wanendeya and Saj Jivraj
Abstract
Treatment planning of edentulous patients
with fixed restorations on dental implants has
undergone a paradigm shift since the introduc-
tion of graftless solutions. Minimally invasive
full-arch implant dentistry adheres to concept
of preserving and maintaining bone. Full-arch
solutions should not adhere to a specific phi-
losophy but rather to the defect the patient
presents with. The patient may be missing
teeth, gingiva, or bone, or all. Based on the
defect, the clinician will plan the appropriate
type of restoration. This chapter will discuss
digital and analogue workflows for full-arch
implant rehabilitation where the patient pres-
ents with teeth or presents with very minimal
resorption.
M. Wanendeya (*)
Ten Dental, London, UK
e-mail: martin@tendental.com
S. Jivraj
Anacapa Dental Art Institute, Oxnard, CA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_9
9
9.1 What Is an FP1?
More and more patients are seeking full-arch
solutions due to a combination of factors. These
include an ageing population whose dentitions
are failing and needing replacement; an aware-
ness by both dentists and patients of the option to
have fixed teeth as opposed to dentures; and den-
tal implant companies marketing full-arch solu-
tions to dentists and sometimes to patients
directly.
However, in all the marketing and training
available, the main solution that is featured is an
FP3 solution.
Carl Misch [1] first proposed the classification
system that we use today to classify the pink and
white balance for partial and full-arch implant-­
supported restorations.
Misch proposed three groups: FP1, FP2, and
FP3. FP1 is the replacement of only the white tis-
sues, i.e., only the teeth, in the implant restora-
tion. FP2 replaces the crown and a portion of the
root with white material and very little (if any)
pink. FP3 is the prosthetic replacement of both
the pink and white tissue, i.e., the teeth and the
gums, when providing an implant restoration
(Fig. 9.1).
In this chapter we will be focusing on the FP1
approach to full-arch implant dentistry.
205
206 M. Wanendeya and S. Jivraj

FP-1 FP-2 FP-3

12 mm 12 mm

4 mm 18 mm 4 mm 18 mm
10 mm 10 mm

FP-1 FP-2 FP-3

Fig. 9.1 Misch Classification

One of the questions that is often asked is how
to assess an individual patient and decide on
whether the most appropriate method of replace-
ment is FP1 or FP3. It is important to recognise that
the FP1 classification is a prosthetic classification
and implant dentistry is a prosthetically guided dis-
cipline where we begin with the end in mind.
Something that has changed in recent years
regarding the provision of full-arch implantology
is what clinicians are replacing. Traditionally, it
was dentures being replaced, as well as terminal
dentitions where dentures and implants were the
only solution available.
Today, there is far more data about the success
rates of implants [2] and therefore more options
available to the professional team. Now, there
must be a discussion with the patient regarding
whether it is prudent to keep terminal teeth until
they have lost all their supporting hard and soft
tissue structures or use the remaining bone for
implant placement. Opting for implant treatment
at this slightly earlier stage often allows an easier
transition to an implant supported prosthesis,
known to some as the “tertiary dentition”.
In addition, many patients have had extensive
crown and bridgework in the past, so as this starts
to fail, it is important for the clinician to decide
the best time for and type of intervention.
As stated, many of the solutions and the
courses currently available to dentists focus on
FP3 solutions. This is not helped by a perception
within the profession that:
1. Very few patients are suitable for an FP1
restoration.
2. FP1 is difficult to conduct.
3. FP1 requires extensive hard and soft tissue
reconstruction.
4. FP1 is not stable due to soft tissue recession.
It is, therefore, important for practitioners to
be able to accurately assess whether a case is
suitable for FP1 restoration.
9.1.1 Stage 1: Data Capture
An FP1 case should be planned in the same way
that all full-arch treatments are planned—using a
facially driven approach. Only once the facially
guided wax up is produced should the type of res-
toration (FP1 or FP3) be determined.
Facially driven planning [3] uses both photo-
graphs and video clips to look at the position of
the three components of a patient’s smile [4]
(Fig. 9.2a–c):
• The teeth.
• The lip framework.
• The gingival scaffold.
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
a b
Fig. 9.2 Smile photo showing lips, teeth, and gingival
margins. (a) Smile photo showing lips, teeth, and gingival
margins. (b) Smile photo showing lips, teeth, and gingival
Fig. 9.3 Extra oral
photos with the RAW
protocol
With this information in mind, a diagnostic
wax-up can be proposed with the teeth in the
ideal position, using guidelines that were origi-
nally designed for denture tooth setup [3, 5].
It is important that the photographs show
the patient smiling, with lips at rest as well as
with maximum lip movement. Some patients
will naturally resist showing their full smile,
and in these cases, video can be used to docu-
ment the full range of lip movement. On some
patients, there can be up to 2.5 mm more tooth
display during a video, when they are not con-
sciously restricting their lip movement [6]
(Fig. 9.3).
There are several factors that one can use to
guide the decision-making process when estab-
lishing if a patient is suitable for an FP1
­prosthesis. To ensure all areas are sufficiently
covered, it’s important to carefully gather the
required information for accurate diagnosis and
207
c
margins. (c) Smile photo showing lips, teeth, and gingival
margins
treatment planning. This requires the following
images:
1. Facial photographs should include images of
[7]:
(a) Full face lateral with patient lips at rest.
(b) Full face lateral with patient smiling.
(c) Full face lateral with patient laughing/
grimacing.
(d) Close-up frontal smiling.
(e) Close-up lateral with patient smiling
(Fig. 9.4).
2. Intraoral photographs should include:
(a) Upper teeth only with contrastor in place.
(b) Upper and lower occlusal photographs.
(c) Lateral photographs showing the left and
right occlusion.
3. An OPG radiograph.
4. Intraoral scan or impression.
5. Cone beam CT scan.
208 M. Wanendeya and S. Jivraj

Fig. 9.4 Extra oral photos with the RAW protocol. (a) Extra oral photos with the RAW protocol. (b) Intraoral lateral
photo. (c) Lateral intra-oral view of presenting situation. (d) Smile photo. (e) Upper and lower occlusal photos
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.4 (continued)
9.1.2 Stage 2: Facially Driven Digital
Wax-Up
This information is then refined and used to cre-
ate a facially driven, digital wax-up [3]. As part
of this process, the following lines and curves
should be drawn on the facial photograph to
determine the position of the teeth, starting with
the central incisors (Fig. 9.5a–d):
1. The interpupillary line.
2. The midline.
3. The smile curve.
From these lines the smile is evaluated and the
ideal tooth position determined, starting with the
position of the central incisors [8]. The rest of the
tooth shapes can be designed from here using the
golden proportion [9], and the rest of the tooth
shapes can be drawn, again guided by the facial
features (Fig. 9.6a, b).
Using the proposed tooth shapes and facial
photographs, a digital wax-up should be pro-
duced. There are several software packages on
209
the market that facilitate this process, which
include, but are not limited to, Smilecould,
Digital Smile Design Lab, 3Shape Smile Design,
Exocad, and Meshmixer.
The steps from here are as follows
(Fig. 9.7a, b):
• Begin with an STL of the starting position of
the teeth.
• Superimpose the two-dimensional ideal tooth
shapes onto a two-dimensional version of this
STL.
• Use the two-dimensional tooth shapes to posi-
tion three-dimensional teeth onto the original
STL.
• Copy and modify any functional aspects as
needed, increasing the vertical dimension if
required.
• Make a new wax-up where the gingival mar-
gins and incisal edges of the proposed teeth
can be seen separately without the palate
present.
• Consider whether the papilla is curved [10]
and if the positions of the papilla in the arch
210 M. Wanendeya and S. Jivraj

a b c

Fig. 9.5 (a) Upper arch photo with contrastor. (b) Interpupillary line. (c) Midline and interpupillary line. (d) Smile
curve, midline, and interpupillary line

a b

Fig. 9.6 (a) Tooth proportions, arch form, smile curve, midline and interpupillary line. (b) Midline, smile curve, and
central incisor tooth forms in place

Fig. 9.7 Midline, smile curve, and upper tooth forms incisors in place
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
are ideal. Some software packages, such as
Smilecloud (Dentcof, Romania), allow the
papilla levels to be raised and lowered on the
teeth, meaning these can be tailored to each
individual case.
Once the facially driven wax-up has been gen-
erated, the next stage of the diagnostic process
can begin.
9.1.3 Stage 3: Superimposition
of the Initial Situation,
the Digital Wax-Up,
and the CT Scan
The final steps to confirm the restorative design
involve superimposition of these three elements
to check the position of the proposed gingival
margin and the bone. This process has been
described by several authors for single teeth [11]
and multiple teeth [12].
The process involves looking at the relation-
ship of the bone to the gingival margin of the pro-
posed tooth and checking the distance in both the
buccal and apical dimensions.
The planning is then broken down into three
steps:
1. Choosing individual implant positions.
2. Evaluating pontic sites.
3. An overall view of the case.
a b
Fig. 9.8 (a) Smilecloud view showing smile curve and tooth form. (b) Simplant view with implants, abutments
showing
211
9.1.3.1 Choosing Individual Implant
Positions
When planning for the three-dimensional implant
placement, one needs to ensure the correct emer-
gence profile for each tooth. This is achieved by
considering the multi-unit abutment as part of the
emergence profile shape. The implant depth is
vital to allow the correct emergence profile, as
well as the correct critical and subcritical con-
tours [13–15], so this must be incorporated within
the planning stage (Fig. 9.8a, b).
To ensure the correct emergence profile, the
gingival margin of the proposed tooth needs to
be 2–3 mm above the collar of the abutment.
The abutment should ideally have a concave
profile from the implant with adequate room
for soft tissue, and this tends to be achieved
with abutment collar heights of 2 mm or more.
So, depending on the system used and the abut-
ment selected, the implant head will be 5 mm
below the gingival margin on the proposed
tooth. If this height is less, the emergence of
the abutment tooth will need to be more acute
(Fig. 9.9).
The width of the proposed multi-unit abutment
should also be a taken into consideration—software
that allows the clinician to see both the implant and
abutment position are helpful for this. A very wide
abutment will make it difficult to create the emer-
gence profile of a narrow tooth. However, if only a
wider multi-unit abutment (greater than 4.5 mm) is
available to the clinician, the implants should be
212 M. Wanendeya and S. Jivraj

Emergence angle around

Emergence angle less than
45 degrees. Low risk of
45 degrees. Risk of food Ideal emergence angle for soft Ideal emergence angle. This
food impaction. It may be
impaction. Implant should tissue volume around the implant implant maybe a little deeper
more difficult to get ideal
be placed deeper to avoid and aesthetics and that the ideal position, but is still
anterior aesthetics due to
this restorable with good aesthetics
lack of soft tissue space

Fig. 9.9 Abutment height and emergence profile

4.8 mm
a b
Ø 3.6 mm

23 2.5

2.5

6.2 mm
5 mm

1.5 mm
4.0 mm

Fig. 9.10 (a) Narrow and wide multi-unit abutments> uni-abutment and multi-base abutments (Dentsply Sirona,
Charlotte NC, USA. (b) Narrow multiunit abutments (Neodent)

ideally positioned to avoid narrow teeth such as lat-
eral incisors and small premolars (Fig. 9.10).
Depending on the material being considered
for the final bridge, the distance between implants
needs to be optimised too.
For instance, when using a monolithic zirco-
nia final bridge, manufacturer guidelines [16]
for many materials state that there should be no
more than two pontics between abutments and
that there should be no more than a 1-unit poste-
rior cantilever. This, along with the bone avail-
ability, bone anatomy, and opposing dentitions,
will guide the practitioner as to where the ideal
implant positions within the arch should be.
Due to anatomical constraints, if the
implants can only be positioned in sites to be
restored using a bridge with larger abutment
span, a titanium-­reinforced zirconia bridge can
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.11 (a) Metal
reinforcement for final a b
bridge. (b) Metal
reinforcement for final
bridge. Prosthetic shell
for WeldOne protocol
be used in this case, as the titanium will pro-
vide adequate support for the zirconia
(Fig. 9.11a, b).
9.1.3.2 Evaluating Pontic Sites
Pontics are an important part of the biology and
aesthetics of a case and should not be ignored. In
planning the pontic, a distance of 4 mm [17] from
the gingival margin to the bone is considered
ideal to allow adequate soft tissue to form
between the pontic and the bone.
9.1.3.3 An Overall View of the Case
In order to evaluate the access options and there-
fore the feasibility of an FP1 prosthesis, the clini-
cian must bear in mind that a minimum of four
and maximum of eight implants are needed—and
each implant site and pontic site need to be
assessed individually.
At the end of this process, an overview of the
case with implant positions, pontic sites, and
both the provisional and final bridge size should
be planned.
9.1.4 Stage 4: Periodontal
and Prosthetic Planning
Once the implant positions are decided, each
implant and pontic sites need to be optimised.
The clinician must bear in mind that after extrac-
tion, the hard and soft tissue around the extrac-
tion socket will remodel [18], and where the
aesthetics outcome is critical, some form of pres-
ervation or augmentation procedure will be
needed.
Healed sites and extraction sockets need to be
evaluated while bearing in mind the inevitable
213
changes in volume that will occur without any
intervention:
• Is there adequate hard tissue following implant
placement to maintain aesthetics?
• Is there adequate hard tissue for an aesthetic
and self-cleansing pontic site?
• Is there adequate soft tissue for aesthetics after
implant placement?
• Is there adequate soft tissue for pontic
aesthetics?
On each implant and pontic site, decisions
will need to be made and strategies implemented
to either:
1. Maintain the current hard and soft tissue vol-
ume around extraction sockets.
2. Augment the soft tissue around pontic sites.
3. Manipulate and augment the soft tissue, and
suture this around the prosthesis at either the
implant or pontic site.
4. Augment any hard tissue.
9.1.4.1 Maintain the Current Hard
and Soft Tissue in an Extraction
Socket
There are three methods that can be used in an
extraction socket to maintain the buccal volume
following extraction:
1. Combination therapy [19]—where a connective
tissue graft is used in conjunction with biomate-
rials within the socket to maintain volume.
2. Partial extraction therapy [20]—the most well-
known variant is socket shield where a small
portion of the buccal root is left in place after
extraction to maintain the buccal bundle bone.
214
3. Immediate dentoalveolar restoration [21]—
where tuberosity bone and soft tissue can be
used to preserve alveolar bone, as well as
repair larger bone and smaller soft tissue
defects at the time of implant placement.
4. The IVAN [22] technique—which can be used
to repair single-site hard and soft tissue defects.
9.1.4.2 Augment the Soft Tissue
around Pontic Sites
There are many different methods of soft tissue
augmentation, and this has been the subject of
many books, lectures, and manuals, especially
when studied concomitant with immediate load-
ing. These concepts include:
1. The Vista [23] technique, which can be used
to tunnel soft tissue into pontic areas to
increase the width and, to a limited extent, the
height of soft tissue.
2. If a flap is raised, a connective tissue graft can
be placed on the inside aspect of the flap in
order to increase the width at the pontic site.
9.1.4.3 Augment the Hard Tissue
In sites where no implants are being placed, many
methods of bone augmentation are possible with
either particulate and autogenous bone, or combi-
nations of these with or without resorbable mem-
branes (which provide varying resorption times).
9.1.4.4 Manipulate and Augment
the Soft Tissue to the Prosthesis
at Either the Implant or
Pontic Site
This technique fabricates the ideal contours on
the provisional restoration prior to surgery and
then during surgery by adapting the soft tissue
contour to the provisional restoration with
sutures. Pozzi et al. [24] used a xerographic col-
lagen matrix in their description of the digitally
assisted soft tissue (DASS) technique, but the
authors’ preferences were to use a connective tis-
sue graft in a technique described by Carvalho as
“prosthetically guided healing”.
As part of this assessment, different donor
sites can be considered—the most useful will
M. Wanendeya and S. Jivraj
often be the palate and the tuberosity.
Occasionally, the ramus can be used instead.
If, after the assessment, there are too many
areas with defects that cannot be augmented or
sites that cannot be preserved to give an aesthetic
result, then the adoption of an FP3 approach—
with the necessary amount of bone removal—
may give a more predictable aesthetic result for
the patient.
An FP1 implant bridge is indicated where
there are four to six implant sites, adequate soft
tissue for augmentation, and a likely aesthetic
outcome. In this situation, the next stages of plan-
ning should begin.
9.1.5 Stage 5: Implant Planning
Once a treatment plan has been determined,
including the implant positions and the treatment
of each implant and pontic site, the next stage is
to intimately intertwine the FP1 process. This
involves:
1. Placing the implants accurately.
2. Making a provisional restoration.
There are many methods that can be used for
this, and for the purpose of this textbook we will
focus on two (Fig. 9.12a, b):
1. The multifunctional guide [25].
2. The WeldOne Shell [26].
Both of these methods of transfer are made in
the shape of the facially driven wax-up. The tooth
position, shape, and occlusion are then trans-
ferred from the wax-up to the provisional
restoration.
9.1.5.1 The Multifunctional Guide
The multifunctional or Galluci guide, as described
in his article, allows the fabrication of a guide
that functions as:
1. A surgical guide to allow implant placement
within the prosthetic envelope.
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 215

a b

Fig. 9.12 (a) Multifunctional guide. (b) Multifunctional guide

a Ideal pontic shape to adapt the soft tissue around b

Correct interproximal contours
Hole to aid implant position
Palatal rest so that the guide can be positioned correctly

Correct pontic design

Palatal rest so that the guide
can be positioned correctly

c d

Diagnostic wax up Diagnostic wax up

Multifunctional guide Multifunctional guide

Fig. 9.13 (a) Multifunctional guide. (b) Multifunctional guide. (c) Multifunctional guide and diagnostic wax-up. (d)
Multifunctional guide and diagnostic wax-up

2. A surgical guide to allow placement of the multifunctional guide is then picked up in the
implant at the correct depth, considering the mouth and adapted to make a provisional restora-
multi-unit abutment. tion. During this process, a steel or titanium wire
3. A guide to look at the soft tissue profiles of is placed into the prosthesis to reinforce it.
the pontic sites and allow planning of any
hard or soft tissue augmentation procedures. 9.1.5.2 Pontic Design
for the Multifunctional Guide
The emergence profiles of the pontic are built Many authors have proposed different pontic
into the Gallucci guide to allow the correct pros- designs. To achieve a truly cleansable and aes-
thetic profile for the pontic, resulting in a multi- thetic provisional and final bridge, an ovate pon-
functional guide. tic design should be used. The pontics are
This performs as both a surgical guide and a designed in the Gallucci guide to ensure the ideal
basis for the provisional prosthesis. Once the contour for hard tissue to adapt to and soft tissue
implants are placed, abutments are selected and to be sutured around the provisional restoration
placed, and temporary cylinders are attached, the (Fig. 9.13a, b).
216
Tooth shape and Prosthetic space for
a gingival margin follow the wire reinforcement
the diagnostic wax up
Fig. 9.14 (a) Prosthetic shell. (b) Prosthetic shell and welded framework
9.1.5.3 The WeldOne Shell
This approach was developed by Marco Degidi
and Paulo Malo, who pre-fabricated a composite
shell restoration (using Bredent composite)
which was adapted at the time of surgery.
With digital technology, a composite shell
(NextDent) can be designed and printed based on
the diagnostic wax-up. This shell is used to trans-
fer the shape and level of the gingival margins of
all the teeth from the wax-up, as well as the occlu-
sal contacts that have been designed (Fig. 9.14).
When using this method, implants are placed
either freehand or using a separate guide, and
once the abutments are placed, a specially
designed cylinder is fitted onto these. This cylin-
der is thicker than most multi-unit temporary cyl-
inders to allow it to resist the pressure and
temperature generated by resistance welding. A
titanium wire is bent to allow contact with mul-
tiple welding cylinders, and this wire is then
welded intraorally using resistance welding. The
framework is then sandblasted, anodised, primed,
and picked up in the composite shell with dual-­
cure composite. The emergence profiles of both
the abutments and pontic sites are fabricated by
the dental technician.
The main differences between the two tech-
niques are as follows.
Multifunctional/Gallucci
guide WeldOne Shell
Pontics fabricated before Pontics fabricated after
surgery pick up
Reinforcement wire not Reinforcement wire
attached to the cylinders attached to the cylinders
Occlusal anatomy removed Occlusal anatomy
during wire placement maintained
M. Wanendeya and S. Jivraj
Prosthetic space for
b Intra Orally welded
wire reinforcement
the wire reinforcement
9.1.5.4 Guided Surgery
Guided surgery can be used to place the
implants, and studies show that implants placed
using a tooth supported guide can be placed to
within 0.22 ± 0.07 mm (with a 2 mm sleeve to
bone distance) of the planned implant position
[27]. The advantage of using a guide is that the
clinician can get closer to the ideal implant
position that has been planned with the abut-
ment in mind. Pilot guides offer an alternative
that still allows the clinician to control the ini-
tial osteotomy and then complete the drilling
protocol and the implant placement with
precision.
9.1.5.5 Stackable Guides
Stackable guides allow the use of two or more
guides, fabricated using the same planning soft-
ware and implemented with pins, screws, or
sometimes magnets to transfer information from
one stage to another. These fixation/pins/mag-
nets sometimes require a separate guide [28].
The different guides may include (Fig. 9.15a, b):
• A “surgical” guide is supported by either the
teeth or mucosa and is used to place implants.
• A “bone reduction” guide can be used to shape
the osseous anatomy.
• A “prosthetic” guide can be used to position
the provisional prosthesis in the correct posi-
tion before pickup.
9.1.5.6 Freehand Placement
Freehand placement is possible. If the hard and
soft tissue contours of the socket match the con-
tours of the proposed provisional restoration, the
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
a b
Fig. 9.15 (a) Stack guide from Pinaud Planification. (b) Stack Guide from SMOP
Fig. 9.16 Implant position showing prosthesis, place-
ment depth, and multiunit abutment
ideal position and depth of the implant are easier
to visualise (Fig. 9.16).
It is important to remember that the implant
will need to be placed 5 mm (depending on the
abutment height) below the gingival margin of
the proposed tooth to allow an ideal emergence
profile.
9.1.5.7 Fabrication of the Provisional
Restoration
The fabrication method of the provisional resto-
ration when using a Gallucci guide or WeldOne
Shell has been described in the paragraphs pre-
ceding this.
The occlusal principles that are used for other
methods of full-arch restoration are the same as
for an FP1 prosthesis.
The occlusal scheme used in all full-arch res-
torations should ensure even contact in centric
relation (CR) and posterior disclusion on lateral
guidance.
217
The patient should be placed on a soft diet for
12 weeks post-surgery, provided with a bite guard
for the opposing arch and reviewed after 2 weeks.
Any non-resorbable sutures should be removed at
this point. Any resorbable sutures can be left in
place for a longer period and removed as needed.
9.1.6 Stage 6: Fabricating the Final
Restoration
9.1.6.1 The Digital Workflow
The fabrication of the final restoration can be
completed using both analogue and digital work-
flows. This technique works best with a well-­
adjusted provisional restoration that has been
aesthetically and functionally tested and approved
by the patient. If this is not the case, a second
provisional restoration will be needed with any
changes made, and only once this has been
approved should the final restoration be fabri-
cated using the triple-scan technique and digital
workflow.
The digital workflow is often utilised over
three separate appointments:
1. Digital impression using the triple-scan
technique.
2. Try-in and verification.
3. Fit final prosthesis.
Appointment 1: Digital Impression Using
the Triple-Scan Technique
The triple-scan technique involves taking three
scans and using digital technology to marry them
up in the software. The workflow is different for
the various brands of scanner, but the principle is
218
the same. This technique has been described in
the literature [29] (Fig. 9.17a–c):
1. Scan the prosthesis in the mouth, the oppos-
ing arch, and the bite.
2. Connect scan bodies to the abutments and
scan the scan bodies.
3. Scan the prosthesis outside the mouth, espe-
cially the fit surface so that the emergence
profiles and pontic shapes can be copied from
the provisional to the final restoration.
When these three scans are combined, they
give the essential information needed to move
onto the next stages. These involve working on:
• The shape of the prosthesis including tooth
shapes, tooth positions, pontic shapes, and the
emergence profile.
• The vertical dimension and opposing arch.
• The abutment positions.
The next stage of this workflow is to make a
try-in and to verify the digital information. A try-
­in is needed as the information from the initial
scan is merged within the software and this can
lead to positional changes.
Another reason that the design may need to
change between the provisional and the final res-
toration is due to the material choice for the final
prosthetic. The dental technician may need to
make minor changes during the CAD process,
and these changes may have aesthetic and func-
tional implications.
If monolithic zirconia is being used for the
final restoration, the design parameters, including
the minimum layer and connector thickness [16],
need to be incorporated into the PMMA try-in.
a b
Fig. 9.17 (a) Scan of the provisional restoration. (b) Elos scan bodies in place. (c) Scan of the provisional restoration
M. Wanendeya and S. Jivraj
This CAD and then CAM process may mean
that the try-in is bulkier in some areas than the
provisional restoration. It is important at this
stage for the patient to test the try-in and the den-
tist to assess all aspects.
Appointment 2: Try-in and Verification
From the information that has been sent to the
laboratory, the dental technician will design and
manufacture the following:
1. Digital model with analogue models.
2. Printed/milled PMMA try-in with link
abutments.
3. A printed verification device.
During the next appointment, the provisional
restoration should be removed and the PMMA
try-in placed in the mouth so the fit and occlu-
sion can be assessed. If the thickness of the res-
toration has increased between the provisional
and the try-in, then phonetics should be checked
as well.
It is important that the pontic sites engage the
soft tissue in a way that creates a mucosal seal
and prevents food impaction in these areas. If
there are pontic sites where there is no engage-
ment between the try-in and the soft tissue, com-
posite should be added to engage the soft tissue
in these areas and create a mucosal seal.
The quality and accuracy of the digital model
may vary from laboratory to laboratory for many
reasons [30], so it is important to check the preci-
sion of the model each time.
This can be done in two ways (Fig. 9.18a, b):
1. Pickup method.
2. Printed verification jig.
c
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 219

a b

Fig. 9.18 (a) 3D-printed verification device. (b) 3D-printed verification device linked with composite

a b

Fig. 9.19 (a) Temporary cylinders in place over abutments. (b) 3D verification jig picked up

a b c

Fig. 9.20 (a) 3D verification poured into stone index. (b) Stone index. (c) Final bridge verified on stone index

Pickup Method 2. If the printed model is not accurate, one or

The first method [31] involves using a printed
verification device that has a small amount of
space to accommodate the multi-unit pickup
­cylinders. These are attached in the mouth as the
device is placed and everything is picked up with
dual-cure composite or pattern resin (Figs. 9.19a,
b and 9.20a–c).
This device can be used in several ways:
1. To verify the accuracy of the printed model in
one of the clinically accepted ways [32].
more of the analogue teeth can be reposi-
tioned in the model to make this accurate.
3. A plaster cast can be poured with analogue
teeth in place from the verification device, and
this can be used as the working cast. This can
be scanned and incorporated into the CAD for
the design of the final bridge.
Printed Verification Jig
Sinada and Papaspyridakos [33] describe a
method where a digitally designed and milled
220
PMMA jig is made using data acquired from
photogrammetry. This is designed to fit directly
onto the multi-unit abutments and assessed with a
screw resistance test, before a stone index is cast.
The final prosthesis is cemented to link abut-
ments on this stone index.
It is necessary to note that there is still some
debate about the accuracy of digital impressions
from an intraoral scanner for full-arch implant
dentistry [34]. Some of the more recent papers
have concluded that the accuracy of full-arch
digital impressions taken with an IOS is within a
clinically acceptable range [35]. However, not all
the reviews in the literature support this conclu-
sion, and not all the intraoral scanners used in the
studies perform as accurately as one another [36].
This should be considered when utilising a digi-
tal approach.
In addition, the first method mentioned for
fabrication with the stone index gives dentists a
hybrid approach where the CAD can be per-
formed digitally and the model made using an
analogue workflow. This is later digitised to make
the final restoration and used to support the
cementation of the link abutments. This hybrid
technique may be preferable for some clinicians.
Not all dentists and laboratories will have the
necessary equipment for digital input, but it is
possible to use an analogue workflow for fabrica-
tion of the final restoration instead.
9.1.6.2 Using an Analogue Workflow
As the prosthesis will be made with milling
equipment, the final part of the process involves
scanning and digitising the verified model that
has been created so far.
In this workflow, the following impressions
are initially taken at the first restorative
appointment:
1. Impression of the prosthesis in the mouth.
2. Impression of the opposing arch.
3. Bite registration.
4. Facebow registration.
5. Abutment level impression with open-tray
impression copings unsplinted.
M. Wanendeya and S. Jivraj
From these impressions the laboratory will
then produce:
1. Mounted upper and lower models in
occlusion.
2. Screw-retained bite block to record the verti-
cal dimension. The vertical dimension from
the existing prosthesis can be copied if the
mounted models are cross-mounted before
the screw-retained bite block is made.
3. An unsplinted verification jig.
At the second appointment, the dentist will
then:
1. Check and adjust the screw-retained bite
block to ensure the correct vertical dimension
of occlusion.
2. Capture the implant positions, by removing
the provisional restoration and joining the
verification jig with the pattern resin, which is
then also removed once everything is joined.
3. Capture the soft tissue. This is best done as
soon as the provisional is removed, so if the
provisional restoration has been out for a long
time, it may be worth replacing the provi-
sional for 5 min to allow the soft tissue to
settle. All contours can then be captured accu-
rately before any major soft tissue change
occurs, which is inevitable with the restora-
tion not in place [37].
This information is then digitised in the labo-
ratory, and a printed/milled PMMA try-in with
link abutments is manufactured.
At the following appointment, the try-in is
checked and verified. As in the digital workflow,
the design may need to change between the pro-
visional and the final restoration due to the mate-
rial choice for the final restoration.
Once any necessary adjustments have been
made, it is re-tried in the mouth. More material
may need to be added to the fit surface if the try-
­in does not engage with the soft tissue in the same
way as the provisional restoration.
Once the final restoration is approved, it is
then sent for manufacturing.
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 221

7. Seal the screw channels with thread tape. 8. CLEARFILTM CERAMIC PRIMER PLUS and 9. Apply the ceramic primer on the hybrid
Panavia V5 paste from Kuraray Noritake. base.

Panavia V5 paste is available in 5 different Let it air dry or gently dry with oil free
colors. The opaque paste is self-curing and the compressed air.
other four are double curing.

10. Apply the ceramic primer 11. Apply the bonding cement paste with a 12. Place the restoration on the hybrid bases
restoration. brush, covered with cement and amount on the model
making sure that all surfaces on the hybrid
bases are covered with cement. and apply pressure.
Let it air dry or gently dry with oil free com-
pressed air. Remove the excess cemet that has been
pushed out between the hybrid bases and the
restoration.

Fig. 9.21 Elos bonding protocol

9.1.6.3 Laboratory Bonding Protocol
Although many studies are showing good
medium-term success rates for monolithic zirco-
nia restorations [38], one of the issues reported is
the debond of the link abutments [39]. A careful
and researched bonding protocol for the link
abutments should be followed [40], including use
of well-researched and documented materials
(Fig. 9.21).
9.1.7 Stage 7: Fitting the Final
Restoration
The final restoration is fitted at the next appoint-
ment. During the fit of the final restoration, it is
important that the pontic sites engage the soft tis-
sue in a way that creates a mucosal seal and pre-
vents food impaction in these areas [41].
The static and dynamic occlusion should be
checked, with an OPG radiograph taken to con-
firm fit.
The screw access holes should be filled with
PTFE and flowable composite or glass ionomer,
and subsequent review and maintenance appoint-
ments should be scheduled.
9.1.7.1 Patient Cleaning
and Maintenance
One of the ways in which the cleaning around
an FP1 bridge differs from an FP3 bridge is
that it requires minimal maintenance by the
patient.
The recommended cleaning regime should
involve cleaning with an electric toothbrush,
and in areas where there is food impacted
around the papilla, use of an interdental brush
is recommended. It is not necessary for the
patient to clean underneath the pontic areas if a
mucosal seal has been achieved. However, in
cases where this has not taken place, superfloss
or X- floss can be used, with the understanding
that a mucosal seal will not develop in these
areas.
222 M. Wanendeya and S. Jivraj

Case 1 The planning for the facially driven wax-up

Patient 1 was started with the interpupillary line to
Age 84 determine the horizontal plane and the midline.
MH patient is on warfarin The central incisors were positioned in the cor-
Patient Expectation rect position from a facial perspective (), and a
The patient attended the practice having been tooth shape was selected from the two-­
referred in looking for a solution to her failing dimensional library (Figs. 9.29, 9.30, 9.31 and
dentition. She was told after the previous consul- 9.32).
tation that her upper teeth would need extensive The OPG provided by the referring dentist
rehabilitation. She had considered looking at a showed a failing upper dentition (Fig. 9.33).
solution where we would maintain some of the
remaining teeth and place implants into the
spaces. Still, due to the cost and timeframe, she
opted for a solution where the remaining upper
teeth would be removed and replaced with an
implant-supported restoration.
History of Presenting Complaint
The patient has a heavily restored dentition,
with most of the upper teeth root treated, crowned,
and restored. However, many of the remained
crowns have decay underneath them, and the bridge
on the upper right-hand side has failed due to decay.
Extraoral (Figs. 9.22, 9.23, 9.24 and 9.25) and
intraoral (Figs. 9.26, 9.27 and 9.28) photographs
were taken as part of the initial assessment.
These photographs showed that the patient
had a very high smile line with very significant
gingival display (Figs. 9.22, 9.23, 9.24 and 9.25).
There were no abnormal findings with the
extraoral and intraoral examinations.
The current occlusal scheme of canine guid-
ance on the left and right side and protrusion on Fig. 9.22 Extraoral front-facing smile photo taken with
the UL1 was adequate, and we chose to conform head level and teeth visible. This will be used in the smile
to this while conducting this rehabilitation. design

Fig. 9.23 Photos taken as part of the RAW protocol

9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 223

An intra-oral scan was taken, and the STL was

uploaded to Smilecloud alongside the photo-
graphs. Teeth were selected from the Smilecloud
library, and a functional wax-up was prepared
(Figs. 9.34, 9.35, 9.36, 9.37, 9.38 and 9.39).
The extraoral and intraoral photographs were
taken and processed using Smilecloud to ideally
position the teeth based on the face and, from
there, generate a facially driven diagnostic wax-
­up (Figs. 9.35, 9.36, 9.37, 9.38 and 9.39).
During this planning, particular care was
Fig. 9.24 The 12 o’clock view taken to note the position of the transition line
(Fig. 9.40).
Treatment Options
Options discussed with the patient were either:

1. Keep and try and restore as many teeth as pos-

sible and place implants in the spaces.
2. Extract the remaining upper teeth, conduct
osteoplasty beyond the transitions zone, place
four implants within the premaxilla, and
accept a shortened dental arch with final res-
torations extending from UL5 to UR5
Fig. 9.25 Smile photo (Fig. 9.41).
3. Extract the remaining upper teeth, conduct
osteoplasty beyond the transitions zone, place
two implants within the premaxilla and two
zygomatic implants, and have final restora-
tions extending from UL6 to UR6.
4. Extract the upper teeth, and conduct the
needed augmentation and preservation to
restore the patient with an FP1 bridge held
with six implants (Fig. 9.42).

The facially driven diagnostic wax-up

Fig. 9.26 Frontal photo retracted view
(Fig. 9.43) was then adjusted using the virtual

Fig. 9.27 Lateral photo

retracted view
224
Fig. 9.28 Upper occlusal photo showing failing upper
dentition
Fig. 9.29 Extraoral photo combined with intraoral photo.
The interpupillary line and midline have been added to
this
Fig. 9.30 Proposed tooth shaped superimposed over
Fig. 9.8. The positions of the teeth are determined using
facial landmarks
Fig. 9.31 Alternative tooth shapes. These are from the original DSD Keynote
M. Wanendeya and S. Jivraj
articulator (Fig. 9.39). This wax was then altered
digitally to make a prosthetic shell (Figs. 9.44,
9.45, 9.46, 9.47, 9.48, 9.49, 9.50, 9.51 and 9.52).
This prosthetic shell was then printed in
NextDent C&B MFH (Micro Filled Hybrid)
(NextDent B.V. Soesterberg, the Netherlands)
(Figs. 9.47, 9.48, 9.49, 9.50, 9.51 and 9.52).
The following digital files were then imported
into SMOP software:
1. Initial model (STL 01).
2. CT scan.
3. Diagnostic wax-up (STL 02).
4. Prosthetic shell (STL 03).
These files are linked in a way that allows
them to be imported with their coordinates allow-
ing all the positions of STL 01, 02, and 03 in the
design to be linked together, and if STL 01 is
matched with the CT scan, the wax-up and shell
positions are known as well.
At this stage, a site-by-site assessment is con-
ducted on all the potential areas where implants
can be placed. The same criteria for assessing
individual sites for immediate implants are
applied to each site to ensure adequate primary
stability after either extraction or partial
extraction.
The sites chosen in this case are the UL1,
UL3, or UL4 and the UL6 on the left-hand side,
and UR1, UR3, or UR4 and UR6. Once the
implant positions were chosen, the stackable
guide was built, and to do this, the following
steps were taken.
1. Anchor pins are placed away from either
implants or tooth roots.
2. Teeth that are not implant sites (UR2 and
UL2) are left on the initial model (STL 01a).
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 225

Fig. 9.32 Facial landmarks and ideal proportions shown on facial, intraoral, and smile photos. Design by Smilecloud
(Smilecloud, Timisoara, Romania)

Fig. 9.36 Intraoral scan of teeth at initial presentation

Fig. 9.33 Initial panoral radiograph supplied by referring

dentist

Fig. 9.37 Facially driven digital wax-up

Fig. 9.34 Frontal view

Fig. 9.38 Facially driven digital wax-up with incisal

edge. Not needed

Fig. 9.35 Intraoral scan of teeth at initial presentation

merged with frontal view
226 M. Wanendeya and S. Jivraj

Fig. 9.43 Digital wax-up. Design by Smilecloud

(Dentcof, Romania) Screenshot from Exocad (Exocad
GmbH, Darmstadt, Germany)
Fig. 9.39 Digital articulation in Exocad (Exocad GmbH,
Darmstadt, Germany). Design by Smilecloud (Dentcof,
Romania)

Fig. 9.44 Digital wax-up adjusted in Exocad to make a

prosthetic shell. Design by Steve Campbell at Nexus
Dental Laboratory

Fig. 9.40 Transition line visible on high smile.

Screenshot from Exocad (Exocad GmbH, Darmstadt,
Germany)

Fig. 9.41 Proposed implant positions showing a shorter

AP spread if bone reduction was conducted Fig. 9.45 An alternative view of the prosthetic shell

Fig. 9.42 Proposed implant positions showing a good

AP spread if no bone reduction conducted
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 227

Fig. 9.47 The prosthetic shell 3D printed in NextDent

C&B MFH (Micro Filled Hybrid) (NextDent
B.V. Soesterberg, The Netherlands)

Fig. 9.46 An alternative view of the prosthetic shell

Fig. 9.48 Adequate

prosthetic space is left
for the welded
framework

Fig. 9.49 The tooth shapes on the prosthetic shell are

derived from the facially driven wax-up
Fig. 9.50 Surgical guide. Planning for this case has been
conducted with SMOP (Swissmeda A,G Baar,
Switzerland)
228
Fig. 9.51 Location pins on the surgical guide. These will
be used to give a reference point between the surgical and
the prosthetic guide
Fig. 9.52 The prosthetic guide. This will be used to seat
the prosthetic shell in the correct position before the
welded framework is picked up
Fig. 9.53 Upper photo retracted with contrastor in place
Two different guides are made:
1. One that has allowed placement of the
anchor pins and the implants (STL 01a)
(Fig. 9.53).
2. One that has the position of the prosthetic
shell (STL 03) and the anchor pins
(Fig. 9.29).
This information was then sent to the labora-
tory, and the following were printed:
M. Wanendeya and S. Jivraj
Fig. 9.54 On the day of surgery, frontal view
Fig. 9.55 On the day of surgery, occlusal view
Fig. 9.56 Serial exactions are conducted and the teeth left
in place are to support the surgical guide. Partial extraction
therapy will be conducted before implants are placed
1. The surgical guide (Fig. 9.53).
2. The prosthetic guide (Fig. 9.29).
3. The prosthetic shell printed from composite.
Before the day of surgery, the patient stopped
the anticoagulants as advised by her general
medical practitioner.
Surgery (Figs. 9.54, 9.55, 9.56, 9.57, 9.58,
9.59, 9.60, 9.61, 9.62, 9.63, 9.64, 9.65, 9.66,
9.67, 9.68, 9.69 and 9.70).
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.57 Surgical guide in place
Fig. 9.58 Surgical guide in place
Fig. 9.59 Implants in place
Fig. 9.60 Implants in place. UR6 has been placed as an
immediate implant into the palatal socket. Note the UL3
root has been sectioned
229
Fig. 9.61 Pontic shield prepared for UL3
Fig. 9.62 Narrow multi-unit abutments have been
placed, followed by the corresponding welding sleeves
(Dentsply Sirona, Charlotte NC, USA)
Fig. 9.63 A 2 mm titanium wire has been bent and then
welded to the welding sleeves to form a passive metal sub-
structure that will be used to make the provisional
restoration
The implants were placed on the day of sur-
gery, and the restorative protocol first described
by Dr. Marco Degidi (Weldone) was conducted.
• The posterior teeth were extracted.
• The anterior teeth were decoronated apart
from the lateral incisors (Figs. 9.56 and 9.57).
• The UL2, UL1, UR1, and UR3, were prepared
for PET (Fig. 9.38).
230 M. Wanendeya and S. Jivraj

Fig. 9.64 Intraoral view of titanium wire bent around the
temporary cylinders
Fig. 9.67 During the pickup, the framework is secured
on one implant and seated, and then picked up with
combo.lign (Bredent, Senden, Germany) dual-cure com-
posite inside the printed composite shell. An extra-long
screw that is usually used for impression posts has been
used to allow the framework to be removed easily

Fig. 9.65 The prosthetic shell is tried in the mouth and

then checked if it seats without interference

Fig. 9.68 Frontal view of acrylic pick up

Fig. 9.66 The titanium frame will be picked up inside the

printed shell

Fig. 9.69 The metal framework and printed shell imme-

• 6 Ankylos C/X (Dentsply Sirona) implants diately after pickup
were placed in the UL6, UL3, UL1, UR1,
UR3, and UR6 positions using the surgical
guide, and the primary stability of greater than • A 2 mm titanium wire was attached to the
25 Ncm was achieved in all sites. welding sleeves, and the wire was intraorally
• After placement of the implants, six straight welded to form a metal framework linking the
balance base narrow (Dentsply Sirona) multi-­ abutments (Fig. 9.63).
unit abutments were placed. • The titanium wire is removed and trimmed to
• Welding sleeves were attached to the multi-­unit fit into the shell and checked outside the
abutments and torqued to 15 Ncm (Fig. 9.62). mouth.
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.70 Soft tissue grafting and socket preservation. A
combination of techniques has been used. For the UL2
and UR2, rotated pedicle grafts have been used. Socket
preservation has been conducted using a xenograft (Bioss,
Geistlich Pharma Ag, Lucerne, Switzerland); PRFG has
been used to contain some of the granules of xenograft
Fig. 9.71 The provisional bridge is finalised. Work by
Jamie Brain CDT from JB Denture Clinic
• The printed shell is tried in the mouth to check
that it can be seated without interference
(Fig. 9.65).
• The titanium wire is sandblasted and anodised
in preparation for intraoral pickup (Fig. 9.66).
• The printed shell is primed in preparation for
the pickup, and a hole is made in the area
where a single screw will be used to hold the
titanium wire in place during the pickup.
• The titanium wire is picked up inside the shell
with dual-cure composite.
• Once the shell is picked up, this is given
(Fig. 9.69) to the technician to finish and pol-
ish. As part of the finishing, the correct sub-
gingival shape and emergence profile of the
bridge abutments and the correct shape of the
pontics are fabricated (Fig. 9.71).
• While the technician was working on the
bridge, soft tissue augmentation was con-
231
Fig. 9.72 The provisional restoration matches the
wax-up
Fig. 9.73 The provisional restoration in place.
Cyanoacrylate (tissue glue) has been used to aid haemo-
stasis on the palate
Fig. 9.74 The provisional restoration in place
ducted. Inverted pedicle grafts were placed on
the UL2 and UR2 as these teeth need vertical
augmentation. PRGF was placed in the sockets
of the UR6 and UL6. Xenograft was placed on
the sockets of the remaining teeth (Fig. 9.70).
• The provisional bridge is fabricated with the
correct pontic shapes and emergence profiles
(Fig. 9.72), and the provisional bridge is a
direct copy of the diagnostic wax-up.
• This is torqued to 15 Ncm, and the bite is
checked and adjusted, the occlusal scheme
chosen in canine guidance on lateral excur-
sions and protrusive on the upper central
(Figs. 9.73 and 9.74).
232 M. Wanendeya and S. Jivraj

Final Restoration
After a period of healing of 12 weeks, the
patient returned for a review (Figs. 9.75, 9.76,
9.77, 9.78 and 9.79). At this point, the implant
integration was checked, and the restoration pro-
cess was started.

Fig. 9.79 Occlusal view

Fig. 9.75 The patient at the 4-week review

Fig. 9.80 Radiograph taken after placement and before

final restoration

Fig. 9.76 Frontal view showing occlusion

Fig. 9.81 Provisional restoration in place

A panoral radiograph was taken at this stage

Fig. 9.77 Lateral view
(Fig. 9.80). The restoration process involves
copying the soft tissue and occlusal contours
while ensuring the final restoration will have ade-
quate thickness and cross-sectional area to pre-
vent the zirconia from fracturing. Therefore, the
material change will mean thickness changes
from the provisional to the final restoration.
The provisional bridge (Fig. 9.81) is removed
(Fig. 9.82), and having removed the provisional
bridge, the soft tissue is checked, and the implant
integration is checked (Fig. 9.83). At this point,
Fig. 9.78 Lateral view
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.82 Provisional restoration removed
Fig. 9.83 Provisional restoration removed
Fig. 9.84 Elos scan bodies are connected to the multi-­
unit abutment in place (Elos Medtech, Gorlose, Denmark)
Elos scan abutments are placed on the abutments
and talked by hand (Figs. 9.84, 9.85 and 9.86).
These were scanned with a Trios scanner, and
three scans were taken.
1. A scan of this bridge provisional bridge in
place (Fig. 9.87).
2. A scan of the opposing arch.
3. A scan of the bite (Fig. 9.88).
4. A scan of the scan bodies on the multi-unit
abutments.
233
Fig. 9.85 Elos scan bodies in place. Please note this
image is taken after two of the scan bodies have been
removed
Fig. 9.86 Screenshot with Elos scan bodies in place.
Scan taken with Trios Scanner (3Shape, Copenhagen,
Denmark)
Fig. 9.87 Screenshot with Elos scan bodies and provi-
sional superimposed. Taken with the triple-scan tech-
nique. Screenshot taken from Trios 3 scanner (3Shape,
Copenhagen Denmark)
These were sent off to the laboratory (Uniqa
Dental Lab), a model was printed with model
analogues (Elos Medtech), and a verification jig
was made.
234
Fig. 9.88 Screenshot showing provisional restoration in
occlusion. The tripe scan technique allows the capture of
the abutment position, vertical dimension, shape of the
provisional restoration, and soft tissue contours in the
scans. Screenshot taken from Trios 3 scanner (3Shape,
Copenhagen Denmark)
Fig. 9.89 Milled PMMA try-in with link abutments
Fig. 9.90 Digital model with verification jig in place
The lab was then instructed to make a PMMA
try-in (Fig. 9.89) using the link abutments from
the library, which was then tried in along with the
verification jig made on the printed model
(Fig. 9.90).
Due to the inaccuracy of the printed models, it
is essential not to take the printed model or the
M. Wanendeya and S. Jivraj
Fig. 9.91 Verification jig in place
Fig. 9.92 Soft tissue contours before try-in inserted
Fig. 9.93 Facial photo with try-in in place
verification jig as absolute verification of the
implant position (Fig. 9.91). The provisional
bridge is removed (Fig. 9.92). The try-in is used
for an aesthetic evaluation. The patient is contin-
uously put through the DSD process during this
aesthetic evaluation, with the interpupillary line
in the midline checked (Figs. 9.93, 9.94, 9.95,
9.96 and 9.97).
Instructions were given to the laboratory for
any final modifications to the final prosthesis,
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.94 The try-in is put through the same digital smile
design process. Final bridge design by Alina Roscoe at
Uniqa dental laboratory
Fig. 9.95 Laboratory communication to request changes
to the shape of the try-in
Fig. 9.96 Laboratory communication to request changes
to the shape of the try-in
such as changes to the gingival margin, changes
in tissue pressure, and spacing between the inter-
dental areas.
The laboratory then imports these photo-
graphs, which are taken with the try-in in the
235
Fig. 9.97 Laboratory communication to request changes
to the shape of the try-in
mouth, and these are taken and then from and
then put through the 3Shape design software
(Figs. 9.98, 9.99, 9.100, 9.101, 9.102 and
9.103).
The PMMA try-in is copied to form the final
bridge, with special care taken to allow for the
adequate thickness of the zirconia to be used.
This final restoration is then milled in the relevant
zirconia, hand-finished, stained with Miyo, and
sent to the practice (Figs. 9.104, 9.105, 9.106,
9.107, 9.108, 9.109, 9.110 and 9.111).
The final bridge is then picked up inside the
mouth to pacify it, using the KAL (Kulzer abut-
ment luting) technique. Once picked up inside
the mouth and the occlusion checked, it is sent
back to the laboratory for the final processing
stages, and the link abutments are cemented.
The process of replication from the wax-up to
the shell temporary to the final restoration is
shown in Fig. 9.112.
The final bridge is fitted in the mouth, and a
facial photograph (Fig. 9.113) and the final radio-
graphs are taken (Figs. 9.114, 9.115, 9.116, 9.117,
9.118, 9.119, 9.120, 9.121, 9.122 and 9.123).
Case 2
The patient presented with a failing upper denti-
tion. The UR1, UR3, and UL2 were intact.
However, the UL1 and UR2 are fractured at the
gum level (Fig. 9.124a).
A radiographic examination showed minor
vertical bone deficiency in the posterior quad-
rants (Fig. 9.124b).
236 M. Wanendeya and S. Jivraj

Fig. 9.98 The photos

with the try in are
imported back into the
milling and design
software (3Shape dental
system, 3Shape,
Copenhagen, Denmark)

Fig. 9.99 The Final

bridge is superimposed
onto the two-­
dimensional photograph

Fig. 9.100 The design of the final bridge

Fig. 9.101 The design of the final bridge
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 237

Fig. 9.102 The design of the final bridge

Fig. 9.105 Milled zirconia bridge after removal from the

milling machine

Fig. 9.103 The design of the final bridge. Final bridge

design by Alina Roscoe at Uniqa dental laboratory

Fig. 9.106 Milled zirconia bridge after removal from the

milling machine

Fig. 9.107 Staining process with Miyo Stain kit (Jensen

Dental, North Haven, Connecticut). Final stain and finish-
ing by Khristo Ivanov by at Uniqa dental laboratory
Fig. 9.104 The final zirconia bridge ready to be milled
238 M. Wanendeya and S. Jivraj

Fig. 9.111 Final bridge

Fig. 9.108 Staining process with Miyo Stain kit

Fig. 9.112 Printed model of diagnostic wax-up. Printed

shell based on the wax-up. Final zirconia bridge. All of
these show the same tooth shape and position that has
been designed from the facially driven wax-up

Fig. 9.109 After sintering and before final staining (this

needs to be checked)

Fig. 9.113 Smile photo of patient with final bridge in

Fig. 9.110 Final bridge place
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 239

Fig. 9.116 Final restoration in place

Fig. 9.114 After removal of the provisional restoration

Fig. 9.117 OPG of the final restoration in place

Fig. 9.115 Final restoration in place

Fig. 9.118 Final bridge

in place
240 M. Wanendeya and S. Jivraj

Fig. 9.119 Before and after photos side by side Fig. 9.123 Smile at the start of treatment

Fig. 9.120 Start photo and screenshot of STL b

Fig. 9.124 (a) Smile photo. (b) Initial panoral

radiograph

Fig. 9.121 Final photo and screenshot of wax up The patient presented with moderate tooth
wear on the lower arch and a missing tooth on the
lower right side.
Lateral views show an edge-to-edge pint with
incisal wear and chipping on both the left- and
the right-hand side (Figs. 9.124, 9.125, 9.126,
9.127, 9.128, 9.129 and 9.130).
As part of the process of rehabilitation and
assessment, a digital impression was taken and
sent to the laboratory (Fig. 9.131). A facially
driven diagnostic wax-up was made from this
Fig. 9.122 Smile with bridge in place
digital impression.
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.125 Left lateral view retracted view
Fig. 9.126 Right lateral view retracted view
Fig. 9.127 Upper occlusal photo showing failing upper
dentition
Fig. 9.128 Lower occlusal photo
241
Fig. 9.129 Upper photo retracted with contrastor in
place
Fig. 9.130 Frontal view of remaining teeth in occlusion
Fig. 9.131 Digital models for diagnostic work up
The diagnostic wax-up was combined with a
CT scan and the initial situation described earlier
in this chapter. A multifunctional guide was made
with implants planned on the UL1, UL4, UL6,
UR1, UR4, and UR6 areas (Figs. 9.132, 9.133,
9.134, 9.135, 9.136, 9.137, 9.138, 9.139, 9.140,
9.141 and 9.142).
The implants were positioned using Simplant
to the correct depth to allow the correct emer-
gence profiles with the necessary multi-unit abut-
ment (Fig. 9.140).
242 M. Wanendeya and S. Jivraj

Fig. 9.132 Upper STL file of presenting situation (STL Fig. 9.136 STL 01 merged with STL 03
01). This is prepared in Simplant (Dentsply Sirona,
Charlotte NC, USA)

Fig. 9.137 STL 03 and CT scan

Fig. 9.133 STL 01 merged with CT scan

Fig. 9.138 CT scan showing planned implant position

Fig. 9.134 STL 01 merged with CT scan merged with
facially driven wax-up (STL 02)

Fig. 9.139 Multifunctional guide with planned implants

and abutments in place. The multifunctional guide is
Fig. 9.135 STL 02 merged with multifunctional guide printed with NextDent C&B MFH (Micro Filled Hybrid)
(STL 03) (NextDent B.V. Soesterberg, the Netherlands)
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 243

During the assessment process, the depth of

Fig. 9.140 Multifunctional guide with planned implants
and abutments in place
implant placement was planned to allow the cor-
rect emergence of the multi-unit abutments and
the correct emergence profile around each of the
abutments and each of the pontics (Fig. 9.141).
On the day of surgery, partial extraction ther-
apy was conducted on the remaining anterior
teeth (Fig. 9.143). A remote palatal incision was
conducted on the maxilla’s upper left and right-­
hand sides (Fig. 9.144).
The multifunctional guide was dried in as it
was tried in the bony contours adjusted to allow
the necessary 2 mm between the base of the pon-

Fig. 9.141 Planned implants and abutments in place. The depth of placement and the emergence profile can be planned

Fig. 9.142 Multifunctional guide in Exocad (Exocad GmbH, Darmstadt, Germany)

244
Fig. 9.143 Day of surgery. Partial extraction therapy
(PET) is being conducted on the remaining teeth and roots
Fig. 9.144 PET completed on UL1 and UR1. Incisions
in the posterior sextants
Fig. 9.145 Multifunctional guide in place. This is being
used to ensure that any osseous contouring is conducted
where needed and to create the correct shape of the ridge
tic and the bone for an adequately designed pon-
tic (Fig. 9.145).
Six implants were placed in the correct posi-
tions with the aid of a pilot guide, multi-unit
abutments were placed (Fig. 9.146), and tempo-
rary cylinders were attached to the implants and
picked up in the multifunctional guide
(Figs. 9.147 and 9.148).
M. Wanendeya and S. Jivraj
Fig. 9.146 Implants and abutments in place. Uni abut-
ments from the EV system (Dentsply Sirona, Charlotte
NC, USA)
Fig. 9.147 Pick-up cylinders in place
Fig. 9.148 Multifunctional guide picked up with combo.
lign (Bredent, Senden, Germany)
Soft tissue was taken from the tuberosity
area and placed in and around the upper poste-
rior segments and the UL3 (Fig. 9.149). A pro-
visional restoration was fabricated by the
technician (Fig. 9.150). Suturing was con-
ducted around the provisional restoration
(Figs. 9.151 and 9.152). A panoral radiograph
was taken of the implants in place after sur-
gery (Fig. 9.153).
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.149 Soft tissue harvested from the tuberosity
Fig. 9.150 The provisional bridge is finalised. Work by
Jamie Brain CDT from JB Denture Clinic
Fig. 9.151 The provisional restoration in place
Fig. 9.152 The provisional restoration in place
245
Fig. 9.153 Radiograph taken after placement
Fig. 9.154 Provisional restoration at 12 weeks
Fig. 9.155 Provisional restoration removed
After 12 weeks of healing, the patient returned
for the impression appointment (Fig. 9.154). At
this appointment, the provisional bridge was
checked (Fig. 9.155) and removed (Fig. 9.156),
and the pontic areas were checked to ensure ade-
quate hygiene and engagement of the pontic into
the soft tissue.
Scan bodies for multi-unit abutments were
placed onto the abutment and torqued by hand
(Fig. 9.157).
Temporary cylinders were placed onto the
abutments (Fig. 9.158), scanned with a Primescan,
and sent to the laboratory along with the copy of
the scan bodies (Fig. 9.157) and scans of the pro-
246 M. Wanendeya and S. Jivraj

visional bridge inside and outside the mouth.

Unfortunately, one of the abutments was loose
and needed to be torqued again to 25 Ncm. This
movement meant that the initial impression
would not be accurate, meaning a second impres-
sion appointment would be required.
The lab designed a 3D-printed pickup jig
(Fig. 9.159) to be used at the next appointment
and a PMMA try-in with the correct link abut-
ments (Figs. 9.160 and 9.161).
Fig. 9.156 Provisional restoration removed
This try-in will have the same emergence pro-
files and pontic shapes from the provisional
­restoration but will have the dimensions neces-
sary for the zirconia (Figs. 9.160 and 9.161).
At the second impression appointment, the
try-in was placed inside the mouth (Fig. 9.162).
The pick-up jig was put into the mouth along
with the temporary cylinders (Figs. 9.163 and
9.164). These were secured with composite and
sent to the laboratory alongside new scans using
the triple-scan technique (Figs. 9.165, 9.166 and
9.167).
Fig. 9.157 Elos scan bodies are connected to the multi-­
Scan of the provisional inside the mouth
unit abutment in place (Elos Medtech, Gorlose, Denmark).
The triple-scan technique is being used (scan 1).
Scan of the provisional outside the mouth
(scan 2) (Fig. 9.167).
Scan of the scan bodies attached to the abut-
ments (scan 3).
The final prosthesis was designed (Fig. 9.168),
milled (Fig. 9.169), and processed (Fig. 9.170) in
the laboratory, and Miyo staining was applied
(Fig. 9.171).
It is important to note that there will be a dif-
ference in the soft tissue profile which means
ignoring the shape of the soft tissue on the scan
that the laboratory receives and using the shapes
copied from the provisional to make the final res-
toration (Figs. 9.172 and 9.173).
Fig. 9.158 Pickup cylinders in place

Fig. 9.159 3D-printed

pickup jig has been
designed to fit around
the pickup cylinders
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.160 Design of the try-in. This is designed as a
copy of the provisional restoration
Fig. 9.161 Design on the try-in
Fig. 9.162 PMMA try-in is checked in the mouth
247
Fig. 9.163 Pickup jig in place. This is designed to ensure
very small (0.5 mm) space between the jig and the cylin-
der and is placed in the mouth so that it sits passively.
Printed in NextDent SG (surgical guide) (NextDent
B.V. Soesterberg, the Netherlands)
Fig. 9.164 Dual-cure low shrinkage composite is placed
into the spaces and the jig is picked up
248
Fig. 9.165 At this appointment, the triple-scan technique
is used to capture the occlusion, vertical dimension, abut-
ment position, soft tissue contour, and the shape of either
Fig. 9.166 The captured files on the Primescan
Once the processing was complete, the final
bridge was placed onto the stone index created by
pouring a model from the pickup jig (Fig. 9.174),
and the link apartments were cemented
(Figs. 9.175 and 9.176).
The bridge was placed inside the mouth, and
the screws were torqued to 15 Ncm (Figs. 9.177,
9.178 and 9.179), and a final panoral radiograph
was taken to verify the fit of the final prosthesis
(Fig. 9.180).
We can see the patient’s smile before treat-
ment (Fig. 9.181) and after treatment (Fig. 9.182),
M. Wanendeya and S. Jivraj
provisional restoration or the try-in. The scanner used
here is the Primescan (Dentsply Sirona, Charlotte NC,
USA)
where the smile line has changed after having
more confidence in their smile.
Case 3
Treatment planning should be based on a thor-
ough diagnosis to culminate in an appropriate
treatment plan for the patients presenting clinical
situation. Unfortunately, the All-on-4™ concept
has been used as a panacea for full-arch implant
reconstruction, and often patients are treated dog-
matically with this treatment protocol. Often, the
bone is removed needlessly to satisfy a certain
treatment philosophy.
Minimally invasive full-arch implant den-
tistry adheres to the concept of preserving and
maintaining bone. Bone reduction is virtually
eliminated, and the patient maintains their own
gingiva. Although four implants are considered
standard, the placement of additional implants
is considered advantageous. As a practicing cli-
nician, implant failure is always a concern, and
should one of four implants fails, the definitive
restoration need to be remade at the restorative
dentist’s cost. If more than four implants have
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 249

Fig. 9.167 The provisional restoration is scanned inside and outside the mouth

Fig. 9.170 Staining process with Miyo Stain kit (Jensen

Fig. 9.168 Design of the final restoration. Final bridge Dental, North Haven, Connecticut). (Photo by Khristo
design by Alina Roscoe at Uniqa dental laboratory Ivanov)

Fig. 9.171 Final zirconia bridge

Fig. 9.169 Zirconia framework after milling and hand
finishing. Final stain and finishing by Khristo Ivanov by at
Uniqa dental laboratory. (Photo by Khristo Ivanov)
250 M. Wanendeya and S. Jivraj

Fig. 9.172 Design of undersurface of proposed zirconia

restoration showing convex contours and its relationship
to the tissue

Fig. 9.175 Final zirconia bridge on the plaster base

Fig. 9.173 Cross section of the final restoration design. We

can check this to ensure we have adequate cross-­sectional
Fig. 9.176 Final zirconia bridge on the plaster base
thickness of the zirconia framework, and the soft tissue pro-
file of the final is copied from the provisional restoration

Fig. 9.177 About to seat the final

Fig. 9.174 The pickup jig is used to cast a plaster base.

This will be used to verify the digital model and to cement
the zirconia framework to the link abutments Fig. 9.178 Final bridge in place
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.179 Final bridge in place
Fig. 9.180 OPG of final zirconia bridge in place
Fig. 9.181 Smile at the start of treatment
Fig. 9.182 Smile at the end of treatment. Please note that
the increased confidence has meant the patient gingival
display has increased significantly
been placed, then there are reserve implants to
work with. These additional implants also help
in distributing stress over a wider area. The cli-
251
nician must be cognisant that for wider stress
distribution and biomechanical integrity of the
restoration, the implants must satisfy the
requirement of a favourable anteroposterior
spread.
In many clinical situations, there is an abun-
dance of bone where more than four implants can
be placed, and bone reduction may not be
required.
It is the authors’ opinion that more than four
implants are required when:
1. There is an abundance of bone and biome-
chanically cantilevers can be avoided.
2. The patient presents with a dentition that
exhibits signs and symptoms of excessive
force.
3. Patient has uncontrolled metabolic disease
which compromises healing.
4. Poor-quality bone.
The advantages and considerations of placing
more implants and preserving bone include the
following:
1. There is the ability to segment the prosthesis
and complication management becomes eas-
ier for the clinician.
2. If in the future an implant were to fail, there
are enough implants where the patient may
not have to undergo surgery again.
3. The thought process that making an impres-
sion on four implants is easier than making an
impression on five or six does not hold merit.
Today with advancements in digital technolo-
gies, analogue impression making may soon
become obsolete at multi-unit abutment level.
4. When placing implants, the clinician must
begin with the end in mind visualising the
definitive restoration. Zirconia requires spe-
cific connector dimensions and requires
appropriate distance between implants.
Zirconia also requires specific thickness for
biomechanical integrity. The implants
together with the multi-unit abutments must
be positioned three-dimensionally to allow for
this.
5. Maintenance of bone in between the implants
can be obtained by banking roots.
252
6. If a catastrophic failure were to occur and all
the implants were lost, then the clinician still
has the opportunity to retreat the patient.
The following patient presentation illustrates
the philosophy of minimally invasive implant
therapy for full-arch implant rehabilitation utilis-
ing digital technologies.
A 62-year-old female presented seeking a
solution to her failing maxillary dentition. Her
teeth had been compromised due to periodontal
disease. She also presented with a previous his-
tory of dental implant failure (Figs. 9.183, 9.184
and 9.185).
On clinical and radiographic examination, her
maxillary dentition was deemed to be of poor
prognosis. She had inadequate amount of bone in
Fig. 9.183 Preoperative radiographs
Fig. 9.184 Buccal view of patient showing minor crowd-
ing and deep vertical overlap
M. Wanendeya and S. Jivraj
the upper left quadrant due to bone loss and
pneumatisation of the maxillary sinus. The
patient was treatment planned for maxillary full-­
arch implant rehabilitation with sinus bone aug-
mentation in her upper left quadrant.
The patient’s concerns were the following:
1. She did not want to wear a removable appli-
ance at any point during the treatment
process.
2. She wanted the teeth to look and feel like her
own.
3. She wanted teeth back to the second molar.
Considerations in implementing care were the
following:
Fig. 9.185 Smile view of patient showing display of gin-
giva when smiling
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 253

1. History of periodontal disease and previous

implant failure.
2. History of diabetes.
3. Preservation of bone.
4. Being able to provide implant bridgework
which resembles her existing dentition with-
out pink ceramics.
5. Transitioning the patient with fixed restora-
tion during the entire treatment process.
Fig. 9.187 Printed tooth-supported surgical guides
The above considerations required a more
cautious approach in treatment planning and exe-
cution. Immediate loading of the implants was
eliminated in favour of healing and conventional
load. Immediate loading of implants should only
be done after a thorough evaluation of the risk
factors involved and not performed
dogmatically.
Treatment Plan and Sequence

1. Intraoral scans were completed (Trios 3Shape

technologies) and shell provisionals were
milled (ProArt CAD Ivoclar Vivadent), utilis-
ing key strategic teeth which would anchor Fig. 9.188 Day of surgery: strategic teeth have been
extracted, implants placed, and bone allograft placed in
the restoration while implants were integrat- extraction sockets. Shell provisionals relined
ing (Figs. 9.186 and 9.187).
2. Sinus lift and bone augmentation were com-
pleted on patient’s upper left quadrant.
Extraction of strategic teeth and placement of
dental implants were conducted. Strategic
teeth would be prepared to hold a provisional
restoration so implants would not be loaded.
This decision was made due to a history of
failed implants and history of diabetes
(Figs. 9.188 and 9.189).

Fig. 9.189 Postoperative characterized provisional

3. Placement of implants in the upper left

quadrant.
4. On integration implant impressions would be
made to fabricate an implant supported provi-
sional. This would be segmented (Fig. 9.190).
5. Extraction of remaining teeth and grafting of
extraction sites with a bone xenograft to main-
Fig. 9.186 Digitally milled shell provisionals from tain ridge height and width and delivery of
PMMA puck (Ivoclar ProArt) segmented provisionals.
254 M. Wanendeya and S. Jivraj

Fig. 9.190 Strategic teeth have been extracted and milled Fig. 9.192 Occlusal view of milled prototype showing
and implant-supported provisional placed segmentation of prosthesis and anteroposterior spread of
implants

Fig. 9.191 Milled prototype from acrylic puck fabri-

cated in three segments

6. Tissue maturation and stabilisation.

7. Fabrication of prototype to verify aesthetics, Fig. 9.193 Intraoral adjustment of prototype
phonetics, and occlusion (Figs. 9.191, 9.192
and 9.193).
8. Fabrication of segmented zirconia restoration
supported by implants (Figs. 9.194, 9.195,
9.196 and 9.197).
9. Maintenance.

By completing the above sequence, the fol-

lowing objectives were met:

1. Transitioning the patient through fixed provi-

sional restorations at all times.
2. Preservation of bone.
3. Eliminating the risk associated with immedi-
ate loading in a patient that has a history of
previous implant failure.
4. Minimising risk in a patient who has peri-
odontal disease and type 2 diabetes.
5. Placement of more than four implants and
segmentation of the restoration.
6. Utilisation of technology to make treatment
more efficient.
Fig. 9.194 Minimally layered zirconia prosthesis fabri-
cated in three segments (ceramics by Artem Asemov)
Case 4
Often, patients refuse additional grafting proce-
dures, and there is insufficient bone to be able to
place more than four implants in each arch. In these
clinical situations, the patient must be made aware
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 255

of the advantages and disadvantages of such treat-

ment protocols and must be fully aware of the clini-
cal and financial consequences of implant failure.
The following patient presentation illustrates
the philosophy of minimally invasive implant
therapy for full-arch implant rehabilitation utilis-
ing four implants in each arch and digital
technologies.
Fig. 9.195 Minimally layered zirconia prosthesis A 71-year-old female presented seeking a
solution to her failing maxillary and mandibular
dentition. A detail medical and dental evaluation
was performed. Specific concerns in treatment
planning were multiple medications that resulted
in the patient being xerostomic. The patient’s
teeth had been compromised due to caries and
periodontal disease (Figs. 9.198, 9.199, 9.200
and 9.201).
The following diagnoses were made:

1. Caries.
2. Periodontal disease.
3. Lack of posterior support.
Fig. 9.196 Intraoral view of minimally layered zirconia
prosthesis 4. Bimaxillary protrusion.

On clinical and radiographic examination, her

maxillary and mandibular dentition was deemed
to be of poor prognosis.
The following clinical issues required
attention:

1. Lack of bone in the posterior maxilla.

2. Over-eruption of teeth compromising restor-
ative space.
3. Flaring of teeth.
4. High smile line with excessive gingival
display.
Fig. 9.197 Smile view of restoration in situ

Fig. 9.198 Preoperative

clinical view of smile
and retracted intraoral
view
256 M. Wanendeya and S. Jivraj

The patient’s concerns were the following:

1. The patient did not want to wear a removable

appliance at any point during the treatment
process.
2. The patient wanted to address the bimaxillary
protrusion.
(a) The patient refused grafting procedures.

Considerations in implementing care were the

following:

1. Multiple medications causing the patient to be

xerostomic.
2. The patient’s smile line exhibited excessive
gingival display and a short lip. It is the
authors’ opinion that bone reduction and use
of pink prosthetics in these types of clinical
situations are contraindicated (Fig. 9.202).
3. Preservation of bone.
4. Providing an FP1 prosthesis and addressing
Fig. 9.199 Full face the bimaxillary protrusion. This would entail

Fig. 9.200 Peri-apical radiographs

Fig. 9.201 Lateral view

of smile showing
over-eruption and flaring
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Fig. 9.202 White lines
showing anticipated
positioning of maxillary
and mandibular incisal
edge
Fig. 9.203 Milled provisional
palatal placement of dental implants and care-
fully selecting a pre-angled multi-unit abut-
ment to ensure appropriate emergence
profile.
5. Providing an anteroposterior spread that is
optimal. Placement of implants that do not
compromise connector size for the definitive
restorations.
6. Minimal alveolar bone recontouring to lift the
maxillary occlusal plane up and to lower the
mandibular occlusal plane.
7. Transitioning the patient with fixed restora-
tion during the entire treatment process.
The above considerations required a more
cautious approach in treatment planning and
execution.
Treatment Plan and Sequence
1. Intraoral scans were completed (Trios 3Shape
technologies), and shell provisionals were
milled (ProArt CAD Ivoclar Vivadent)
(Fig. 9.203).
257
2. The patient was treated surgically and pros-
thetically in 1 day, utilising laboratory
­fabricated static surgical guides. No guided
surgery was performed per se. The surgical
guides were stabilised on retained teeth and
osteotomies of the anterior implants were
performed. Four implants were placed in the
maxilla and four in the mandible. Multi-unit
abutments were secured and soft tissue clo-
sure was achieved. Deep sedation with pro-
found local anaesthesia was used to remove
all teeth except ones needed for stability of
bone reduction and surgical stent. A tooth-­
supported surgical guide was provided to
ensure accurate three-dimensional placement
of implants in the maxilla. This required care-
ful depth placement so that a pre-angled
multi-unit abutment could be selected with a
minimum collar height. This would allow
correction of the flaring of the teeth as well as
an optimal emergence profile. Alveolectomy
was completed in the mandible to provide
appropriate restorative space and correct the
mandibular incisal edge position. The man-
dibular bone was reduced minimally to create
a platform for implant placement. The patient
was informed that the mandible may require
pink prosthetics. The patient’s provisional
immediate load prosthesis was fabricated on
same day as implant placement. The patient
tolerated the procedure well and healed
uneventfully.
3. A direct technique for immediate loading was
employed. Vertical dimension, centric rela-
tion, and occlusal plane were verified. After
258 M. Wanendeya and S. Jivraj

protection of the surgical sites with rubber

dam, temporary cylinders were first picked up
in the maxillary prosthesis. Patient was guided
into centric relation, and a similar pickup of
temporary cylinders was performed in the
mandibular provisional restoration. The pros-
theses were removed and transferred to the
dental laboratory where the prostheses were
processed and finished. The prostheses were
adjusted to compress the tissue by 2 mm and
to develop the pontic sites from the outset.
Twelve teeth were provided in the maxilla and
ten teeth in the mandible. Occlusion was
adjusted for shimstock hold on anterior teeth
and shimstock drag on the posterior teeth.
Vertical dimension was verified on delivery of
the restoration. Extraction of remaining teeth
and grafting of extraction sites with a bone
xenograft were conducted to maintain ridge
height and width. Moreover, delivery of seg-
mented provisionals was (Figs. 9.204, 9.205,
9.206 and 9.207).

Fig. 9.205 Smile view showing tooth display. Increased

length can be adjusted in provisionals

Fig. 9.206 Milled prototype from acrylic puck fabri-

Fig. 9.204 Immediate load provisional restorations in situ cated in three segments

Fig. 9.207 Lateral view

of provisionals
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
4. Tissue maturation and stabilisation.
5. Post-integration and additional provisional
restoration were fabricated to ensure verifica-
tion of aesthetics, phonetics, and tissue com-
pression (Fig. 9.208).
6. Splinted open-tray impressions, jaw relation
records, and tooth try-ins were performed.
Additional provisional restorations were fab-
Fig. 9.208 Second set of provisionals fabricated
Fig. 9.209 Minimally layered zirconia prosthesis
Fig. 9.211 Lateral view
depicting change in
occlusal plane, flaring
and incisal edge
positions
259
ricated. Aesthetics, phonetics, and soft tissue
contours were further developed in the provi-
sional restoration.
7. Minimally layered zirconia restorations were
fabricated for both maxilla and mandible.
Occlusion was provided on polished zirconia.
Tissue contacting surface was designed in
polished zirconia (Figs. 9.209, 9.210, 9.211
and 9.212).
8. The prosthesis was delivered adjusting the
undersurface to ensure positive pressure.
Dynamic occlusion was adjusted for canine
guidance. Static occlusion was adjusted to
ensure shimstock hold on canines and pre-
Fig. 9.210 Layered restorations in situ
260 M. Wanendeya and S. Jivraj

molars. Shimstock drag on anterior teeth

and no contact on the cantilevers
(Fig. 9.213).
9. Screws were torqued according to the manu-
facturer’s instructions, and access holes were
sealed using Teflon and composite resin.

By completing the above sequence, the fol-

lowing objectives were met:

1. Transitioning the patient through fixed provi-

sional restorations at all times.
2. Preservation of bone and fabrication of an
FP1 prosthesis in the maxilla.
3. Restoration of posterior support.
4. Satisfying the patients’ aesthetic concerns and
solving the issue of bimaxillary protrusion.
5. Utilisation of technology to make treatment
more efficient prosthetically.

Fig. 9.212 Smile view of restoration in situ

Fig. 9.213 Pre- and

postoperative views
following rehabilitation.
(Ceramics by Artem
Asemov)
9 FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations
Acknowledgements from Dr. Wanendaya Thanks
especially to my family (Sarah, Felix, and Jasper) and
friends for the trust and the support I get from you
every day.
Thank you to all the team and Ten Dental, but specific
thanks to the team members directly involved with treat-
ment of patients in this chapter: Violeta Maftei, Valeria
Andrade, Agata Polak, Mihaela Simona, and Maria Ivan.
Thank you to the dental technicians involved in cases
1 and 2: Steve Campbell, Jamie Brain, Alina Rosca,
Khristo Ivanov, James Cox, Hugo Patrao, and Fabio
Trindade.
Thank you to the individuals who have always helped
and supported me through this time: Nigel Jones, Tushar
Patel, Will Murphy and Paul Swanson.
A special thanks to Paulo Carvalho and Nik Sisodia
for their clinical support in getting to this point on our
ever-evolving FP1 journey. I would like to acknowledge
Paulo as the inventor of the “prosthetically driven heal-
ing” technique that has made FP1 so much more accessi-
ble as a treatment modality.
Thank you to Dr. Jonathan Gordon for the surgical
expertise in case 3.
Thank you to Dr. Hessam Siavesh for the surgical
expertise in case 4.
Ceramics in cases 3 and 4 were done by Artem
Asemov, Digital Dental Arts laboratory Ventura, CA.
References
1. Misch CE. Dental implant prosthetics. St. Louis, MO:
Elsevier Mosby; 2015a.
2. Yang Y, Hu H, Zeng M, et al. The survival rates and
risk factors of implants in the early stage: a retrospec-
tive study. BMC Oral Health. 2021;21:293. https://
doi.org/10.1186/s12903-­021-­01651-­8.
3. Coachman C, Calamita MA, Sesma N. Dynamic doc-
umentation of the smile and the 2D/3D digital smile
design process. Int J Periodontics Restorative Dent.
2017;37:183–93.
4. Garber DA, Salama MA. The aesthetic smile: diagnosis
and treatment. Periodontology. 1996;2000(11):18–28.
5. Fradeani M. Aesthetic analysis a systematic
approach to prosthetic treatment, vol. 1. Chicago, IL:
Quintessence Books; 2004.
6. Mahn E, Sampaio CS, Pereira da Silva B, Stanley K,
Valdés AM, Gutierrez J, Coachman C. Comparing the
use of static versus dynamic images to evaluate a smile.
J Prosthet Dent. 2020;123(5):739–46. Epub 2019 Aug
2. https://doi.org/10.1016/j.prosdent.2019.02.023.
7. Duarte S Jr. Quintessence of dental technology.
Chicago: Quintessence; 2010.
8. Fradeani M. Réhabilitation esthétique en pro-
thèse fixée. Tome 1: analyse esthétique. [aesthetic
rehabilitation with fixed prostheses. Volume 1.
­ 2019;45(1):65–72.
Aesthetic analysis]. Paris: Quintessence International;
2006.
261
9. Levin EI. Dental esthetics and the golden proportion.
J Prosthet Dent. 1978;40(3):244–52.
10. Chu SJ, Tarnow DP, Tan JH-P, Stappert CFJ. Papilla
proportions in the maxillary anterior dentition. Int J
Periodont Restor Dentistry. 2009;29(4):385–93.
11. Rojas-Vizcaya F. Biological aspects as a rule for
single implant placement. The 3A-2B rule: a clinical
report. J Prosthodont. 2013;22(7):575–80. Epub 2013
Apr 1. https://doi.org/10.1111/jopr.12039.
12. Rojas Vizcayo F. Rehabilitation of the maxillary arch
with implant-supported fixed restorations guided by
the most apical buccal bone level in the esthetic zone:
a clinical report. J Prosthet Dent. 2012;107(4):213–
20. https://doi.org/10.1016/S0022-­3913(12)00041-­8.
13. González-Martín O, Lee E, Weisgold A, Veltri M,
Su H. Contour management of implant restora-
tions for optimal emergence profiles: guidelines for
immediate and delayed provisional restorations. Int
J Periodontics Restorative Dent. 2020;40(1):61–70.
https://doi.org/10.11607/prd.4422.
14. Su H, Gonzalez-Martin O, Weisgold A, Lee
E. Considerations of implant abutment and crown
contour: critical contour and subcritical contour. Int
J Periodontics Restorative Dent. 2010;30(4):335–43.
15. Esquivel J, Meda RG, Blatz MB. The impact of 3D
implant position on emergence profile design. Int J
Periodontics Restorative Dent. 2021;41(1):79–86.
https://doi.org/10.11607/prd.5126.
16. Ivoclar Zirconia Zircad Prime IFU. https://www.ivo-
clar.com/.
17. Tarnow DP, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of bone on
the presence or absence of the interproximal dental
papilla. J Periodontol. 1992;63:995–6.
18. Araújo MG, Lindhe J. Dimensional ridge alterations
following tooth extraction. An experimental study
in the dog. J Clin Periodontol. 2005;32(2):212–8.
https://doi.org/10.1111/j.1600-­051X.2005.00642.x.
19. Tsuda H, Rungcharassaeng K, Kan JY, Roe P, Lozada
JL, Zimmerman G. Peri-implant tissue response fol-
lowing connective tissue and bone grafting in con-
junction with immediate single-tooth replacement in
the esthetic zone: a case series. Int J Oral Maxillofac
Implants. 2011;26(2):427–36.
20. Gluckman H, Salama M, Du Toit J. Partial extraction
therapies (PET) part 1: maintaining alveolar ridge
contour at pontic and immediate implant sites. Int J
Periodontics Restorative Dent. 2016;36(5):681–7.
https://doi.org/10.11607/prd.2783.
21. da Rosa JC, Rosa AC, da Rosa DM, Zardo
CM. Immediate dentoalveolar restoration of com-
promised sockets: a novel technique. J Esthet Dent.
2013;8(3):432–43.
22. Pohl S, Kurtzman GM. The modified IVAN tech-
nique: hard and soft tissue augmentation at extrac-
tion for delayed implant placement. J Oral Implantol.
https://doi.org/10.1563/
aaid-­joi-­D-­18-­00161.
23. Zadeh HH, Borzabadi-Farahani A, Fotovat M, Kim
SH. Vestibular incision subperiosteal tunnel access
262
(VISTA) for surgically facilitated orthodontic therapy
(SFOT). Contemp Clin Dent. 2019;10(3):548–53.
PMID: 32308335; PMCID: PMC7150560. https://
doi.org/10.4103/ccd.ccd_720_18.
24. Pozzi A, Arcuri L, Block M, Moy P. Digital assisted
soft tissue sculpturing (DASS) technique for imme-
diate loading pink free complete arch implant pros-
thesis. J Prosthodont Res. 2020;65:119. https://doi.
org/10.2186/jpr.JPOR_2019_386.
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(4):524–33.
26. Degidi M, Nardi D, Piattelli A. Immediate load-
ing of the edentulous maxilla with a final restora-
tion supported by an intraoral welded titanium bar:
a case series of 20 consecutive cases. J Periodontol.
2008;79(11):2207–13.
27. Guentsch A, Sukhtankar L, An H, Luepke
PG. Precision and trueness of implant place-
ment with and without static surgical guides: an
in vitro study. J Prosthet Dent. 2021;126(3):398–
404. Epub 2020 Sep 3. https://doi.org/10.1016/j.
prosdent.2020.06.015.
28. Salama M, Pozzi A, Clark W, Tadros M, Hansson L,
Adar P. The “scalloped guide”: a proof-of-concept
technique for a digitally streamlined, pink-free full-­
arch implant protocol. Int J Periodontics Restorative
Dent. 2018;38:791–8. https://doi.org/10.11607/
prd.3778.
29. Monaco C, Ragazzini N, Scheda L, Evangelisti E. A
fully digital approach to replicate functional and
aesthetic parameters in implant-supported full-arch
rehabilitation. J Prosthodont Res. 2018;62(3):383–
5. Epub 2017 Nov 27. https://doi.org/10.1016/j.
jpor.2017.10.005.
30. Etemad-Shahidi Y, Qallandar OB, Evenden J, Alifui-­
Segbaya F, Ahmed KE. Accuracy of 3-dimensionally
printed full-arch dental models: a systematic review.
J Clin Med. 2020;9(10):3357. PMID: 33092047;
PMCID: PMC7589154. https://doi.org/10.3390/
jcm9103357.
31. Mandelli F, Zaetta A, Cucchi A, Mangano FG. Solid
index impression protocol:a hybrid workflow
for high accuracy and passive fit of full-arch
implant-supported restorations. Int J Comput Dent.
2020;23(2):161–81.
32. Kan JY, Rungcharassaeng K, Bohsali K, Goodacre
CJ, Lang BR. Clinical methods for evaluating implant
framework fit. J Prosthet Dent. 1999;81(1):7–13.
https://doi.org/10.1016/s0022-­3913(99)70229-­5.
M. Wanendeya and S. Jivraj
33. Sinada N, Papaspyridakos P. Digitally designed and
milled verification jigs generated from photogramme-
try data acquisition: a clinical report. J Prosthodont.
2021;30:651–5. https://doi.org/10.1111/jopr.13409.
34. Zhang Y-J, Shi J, Qian S, Qiao S-C, Lai
H-C. Accuracy of full-arch digital implant impres-
sions taken using intraoral scanners and related
variables: a systematic review. Int J Oral Implantol.
2021;14:157–79.
35. Revell G, Simon B, Mennito A, Evans ZP, Renne
W, Ludlow M, Vág J. Evaluation of complete-arch
implant scanning with 5 different intraoral scanners in
terms of trueness and operator experience. J Prosthet
Dent. 2022;128(4):632–8. Epub 2021 Apr 6. https://
doi.org/10.1016/j.prosdent.2021.01.013.
36. Amornvit P, Rokaya D, Sanohkan S. Comparison
of accuracy of current ten intraoral scanners.
Biomed Res Int. 2021;2021:2673040. PMID:
34552983; PMCID: PMC8452395. https://doi.
org/10.1155/2021/2673040.
37. Li J, Chen Z, Wang M, Wang HL, Yu H. Dynamic
changes of peri-implant soft tissue after interim res-
toration removal during a digital intraoral scan. J
Prosthet Dent. 2019;122(3):288–94. Epub 2019 Mar
15. https://doi.org/10.1016/j.prosdent.2018.07.020.
38. Pozzi A, Arcuri L, Fabbri G, Singer G, Londono
J. Long-term survival and success of zirconia screw-­
retained implant-supported prostheses for up to 12
years: a retrospective multicenter study. J Prosthet
Dent. 2023;129(1):96–108. Epub 2021 Jun 27. https://
doi.org/10.1016/j.prosdent.2021.04.026.
39. Koenig V, Wulfman C, Bekaert S, Dupont N, Le
Goff S, Eldafrawy M, Vanheusden A, Mainjot
A. Clinical behavior of second-generation zirconia
monolithic posterior restorations: two-year results
of a prospective study with ex vivo analyses includ-
ing patients with clinical signs of bruxism. J Dent.
2019;91:103229. Epub 2019 Nov 10. Erratum
in: J Dent. 2021 Aug;111:103694. https://doi.
org/10.1016/j.jdent.2019.103229.
40. Almquist ML, Jensen BR, Ingemann AB, Duus K,
Rangstrup S, Andersen H, Andersen OZ. Influence
of cement gap size, surface preparation, cleaning
agent and ageing on the retention of cemented single
ceramic crowns, supported by Elos Accurate Hybrid
Bases. Elos Medtech; 2021. https://elosdental.com/
files/document_archives/DEV-­02229_Study_cemen-
tation.pdf.
41. Zitzmann NU, Marinello CP, Berglundh T. The ovate
pontic design: a histologic observation in humans. J
Prosthet Dent. 2002;88(4):375–80. PMID: 12447213.
https://doi.org/10.1067/mpr.2002.128758.
 Graftless Surgical Protocol:
Diagnosis to Delivery
10
Ana Ferro, Mariana Nunes, Diogo Santos,
Armando Lopes, Filipe Melo,
and Miguel de Araújo Nobre

Abstract anchorage benefiting from inserting the

implants in better bone quality regions (Maló
The All-on-4® treatment concept was devel-
et al., Clin Implant Dent Relat Res 5:2–9,
oped in the 1990s as a surgical protocol to
2003; Maló et al., Clin Implant Dent Relat Res
rehabilitate the total edentulous in immediate
7:S88–S94, 2005; Krekmanov et al., Int J Oral
function, with implant insertion, abutment and
Maxillofac Implants 15:405–414, 2000;
prosthesis connection being performed on the
Aparicio et al., Clin Implant Dent Relat Res
same day as the surgery. The concept was
3:39–49, 2001). The All-on-4® surgical proto-
developed in order to avoid graft techniques or
col can be performed in both arches (maxilla
any additional surgery (e.g. inferior alveolar
and mandible) either through free-hand flap
nerve lateralisation), resulting in less chair
surgery or guided surgery. These options will
time and less surgical complications (Maló
be further explored later on in this chapter.
et al., Clin Implant Dent Relat Res 5:2–9,
2003). By placing four implants acting as
‘cornerstones’—two anterior implants in an
10.1 All-on-Four™ Surgical
axial position and two posterior implants tilted
Protocol
distally between 30° and 45°—a more distal
implant position could be reached, reducing
The first cases described for the full-arch restora-
not only cantilever but also improving implant
tion of the mandible included four implants
placed in interforaminal area. The results deter-
A. Ferro (*) · M. Nunes · D. Santos · A. Lopes mined high cumulative survival rates even in
Oral Surgery Department, Maló Clinic, chronical removable denture patients with severe
Lisbon, Portugal resorptions. Immediate implant loading in the
e-mail: aferro@maloclinics.com; mnunes@ mandible was registered at that time stating both
maloclinics.com; dsantos@maloclinics.com; alopes@
maloclinics.com high success and survival rates in part because of
good bone quality [1].
F. Melo
Prosthodontics Department, Maló Clinic, Nevertheless, the reduced bone density com-
Lisbon, Portugal bined with scarce bone availability of the max-
e-mail: fmelo@maloclinics.com illa, particularly critical in the posterior regions,
M. de Araújo Nobre perceived immediate loading as a greater chal-
Research, Development and Education Department, lenge. The use of implant tilting showed to be
Maló Clinic, Lisbon, Portugal effective in the maxilla: by using the sinus or
e-mail: mnobre@maloclinics.com

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 263
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_10
264
nasal fossae corticals for implant anchorage, it
was possible to frequently achieve a high primary
stability that allowed performing immediate
function [2].
The challenge of soft bone leads to the addi-
tion of a new tool to the concept: a novel implant
design [3]. This implant merged three significant
features decisive to what is today All-on-4’s
­success: the implant’s macrodesign (the implant’s
shape and threads) allowed to condense bone
instead of cutting; the new apex design made it
possible to engage the sinus or nasal fossae corti-
cals allowing bicortical anchorage; and because it
is fully threaded from the apex to the implant
head, the whole implant aims to achieve higher
primary stability.[4].
The All-on-4® concept has proven to be very
effective even in more challenging cases where
bone resorption did not allow the placement of
conventional implants by combining standard
and zygomatic implants (All-on-4® Hybrid) or
extremely atrophic cases with two zygomatic
implants placed bilaterally (All-on-4®
Extramaxillary) [5].
This surgical protocol gained visibility thanks
not only to the symbiosis between biological,
anatomical and mechanical aspects, but also to
the short-, medium- and long-term results [1–3,
6–10].
10.2 Treatment Planning
The treatment planning of the All-on-4® surgical
protocol starts with a review of the patients’ med-
ical history, followed by detailed clinical and
A. Ferro et al.
radiographic examinations, intra- and extra-oral
photographs and impressions. With these ele-
ments the surgeon should be able to determine
the degree of difficulty of the All-on-4®
rehabilitation.
10.2.1 Radiographic Evaluation
The quantity and quality of bone between maxil-
lary sinuses are the key to choosing the surgical
All-on-4® approach: All-on-4® Standard, Hybrid
or Extramaxilla. In the mandible, the anatomical
limits are given by the inferior dental nerves
(Figs. 10.1, 10.2, and 10.3).
Both orthopantomography and cone beam
computerised tomography (CBCT) are manda-
tory in this process.
In the maxilla, the criteria to perform an
All-on-4® Standard consider the patients’ bone
volume/ridge between the canines to be at least
5 mm in width and ≥10 mm in height. Considering
the All-on-4® Standard in the mandible, the crite-
ria include the patients’ bone volume/ridge in the
interforaminal region to be 5 mm in width and
≥8 mm in height. Furthermore, a Standard case is
anticipated to have the implant prosthetic emer-
gence between the second premolar and first
molar [11].
In addition to bone availability, an aesthetic
study is performed taking into account parame-
ters such as the lip support (extra-oral soft tissue
support), the smile line, the prosthetic space and
the occlusal vertical dimension changes
(Figs. 10.4 and 10.5).
Fig. 10.1 Preoperative orthopantomography
10 Graftless Surgical Protocol: Diagnosis to Delivery 265

Fig. 10.2 Preoperative cone beam computerised tomography

266 A. Ferro et al.

Fig. 10.3 Type of rehabilitation procedure according to the available bone volume from a conventional full-arch reha-
bilitation with six implants to an All-on-4® double-zygoma protocol

10.3.1 Surgical Protocol: Step by

Step

Before anaesthesia, two facial points are marked

to check the onset of occlusion vertical dimen-
sion (OVD), one in the nose and the other in the
chin, determining the vertical dimension baseline
(Fig. 10.10). With this value it will be possible to
achieve the optimal OVD for the immediate pros-
thesis placement.
Subsequently and under local anaesthesia, the
surgery starts with a crestal incision slightly
­palatal (3 mm), allowing us to preserve kera-
tinised tissue in the buccal flap. Two vertical
releasing incisions in the first molar region are
made (Fig. 10.11). A mucoperiosteal (full thick-
ness) flap is then raised until the anatomical lim-
its (a) the nasal cavity floor in the anterior region
of the maxilla and (b) the anterior wall of the
sinus, laterally (Fig. 10.12).
In the mandible, similar principles apply but
the crestal incision is performed dividing the
existent keratinised tissue and the anatomical
Fig. 10.4 Lip support evaluation limits being the mental foramens bilaterally
(Fig. 10.13). No releasing incisions are per-
formed, except in situations of severe resorption
in which an incision in the midline can be exe-
10.3 All-on-4 Standard: Non-­ cuted to provide more flexibility to the flap.
guided Surgery To create a regular ridge for implant place-
ment and accounting in advance with all aesthetic
As mentioned earlier, the All-on-4® surgical pro- parameters, a bone reduction is performed either
tocol can be performed either with free-hand or with the rongeur, round bur or piezoelectric
guided surgery (Figs. 10.6, 10.7, 10.8, and 10.9) device (Figs. 10.14 and 10.15). The rongeur
[8, 12].
10 Graftless Surgical Protocol: Diagnosis to Delivery 267

Fig. 10.5 Smile line evaluation

Fig. 10.8 Implant planning software image of the max-

illa with planned implants in position

Fig. 10.6 Implant planning software image of the

maxilla

Fig. 10.9 Implant planning software image of the man-

dible with planned implants in position

Fig. 10.7 Implant planning software image of the

mandible
Fig. 10.10 Measuring occlusion vertical dimension
268
Fig. 10.11 Incision on maxilla
Fig. 10.12 Flap raising
Fig. 10.13 Incision on mandible
allows the surgeon to collect autogenous bone
and use it in some bone defects if needed.
Before the implant placement, the surgeon
needs to
1. Place the All-on-4® guide: A midline osteot-
omy with the 2 mm drill, perpendicular to
A. Ferro et al.
Fig. 10.14 Bone reduction with rongeur
Fig. 10.15 Bone reduction with round bur
bipupilar line and checked through the pin-­
guide placement in order to correctly set the
All-on-4® guide (Figs. 10.16 and 10.17). The
All-on-4® guide is flexible and can be adapted
to all jaw sizes and shapes. It also features
10 mm-long straight laser marks displayed
with a 7 mm inter-mark distance, providing
the surgeon with the possibility of placing 6
straight implants or, if not possible, to cor-
rectly angulate the posterior implants between
30° and 45° (Figs. 10.18 and 10.19).
2. Identify the anatomical structures: In order to
identify/map the anterior sinus wall, a curve
probe is introduced inside the sinus through a
small window opening made with a round bur
(Figs. 10.20 and 10.21). In the mandible, the
mental foramen can be easily identified
through careful flap elevation, and bone avail-
ability can be determined after checking the
inferior alveolar nerve’s loop by inserting a
periodontal probe in the foramen (Fig. 10.22).
10 Graftless Surgical Protocol: Diagnosis to Delivery 269

Fig. 10.16 Beginning the osteotomy to place the Fig. 10.19 Placement of the All-on-4® guide in the
All-on-4® guide mandible

Fig. 10.17 Osteotomy with the 2 mm drill to place the Fig. 10.20 Opening the access of the anterior sinus wall
All-on-4® guide of the maxilla

Fig. 10.18 Placement of the All-on-4® guide in the Fig. 10.21 Probing the anterior sinus wall of the
maxilla maxilla
270
Fig. 10.22 Probing the mental foramen in order to evalu-
ate the alveolar nerves’ loop
10.3.2 Implant Placement
In the All-on-4® surgical protocol, the implant
placement follows the same rule for both maxilla
and mandible’s rehabilitation: the surgeon should
first place the posterior tilted implants, thus
determining the space available for the anterior
implants with no risk of inter-implant
interference.
The drilling protocol was simplified to the use
of three drills, aiming for under-preparation of
the implant site, thereby managing drill depth
(increasing or decreasing the preparation of the
last two drills) according to bone density. As
stated before, the implant design allows bone
expansion, acting as an osteotome/final drill, pro-
viding maximum stability.
The preparation starts either with the round
bur or precision drill, followed by the 2 mm twist
drill used full length, creating the implant’s site
preparation. The 2 mm twist drill is the most
important drill since it will provide the necessary
information about the implants’ length and also
the bone density. Based on the bone density
information, the surgeon proceeds according to
the type of bone density in order to place a Ø4mm
regular platform (RP) implant: (a) in soft bone,
the surgeon should use the 2 mm twist drill until
the desired implants’ length (Figs. 10.23 and
10.24) and subsequent drills (2.4–2.8 mm step
drill and 3.2–3.6 mm step drill) only on the corti-
cal aspect (Figs. 10.25, 10.26, 10.27, and 10.28);
(b) in medium bone, both 2 mm twist drill and
2.4–2.8 mm step drill are used until the desired
A. Ferro et al.
implants’ length with the 3.2–3.6 mm step drill
just on the cortical aspect; and (c) in dense bone,
all the drills are used to full length of the implants’
size.
The implant is then placed, aiming to achieve
an insertion torque of at least 30 N cm in the final
seating. The final seating of the implant’s head
must be at bone level (Figs. 10.29 and 10.30).
In the maxilla, the posterior implants are
tilted, following the anterior sinus wall up to 45°.
Once the implants are placed in the correct
apical-­coronal position, a mechanical bone mill
should be used to remove the bone around the
head of the implant before placing the angled
abutments. Implant angulation is then reduced
after placing the 30° multi-unit angled abutments
at 15 N cm, providing short or no cantilever with
an emergence between the first molar and second
premolar (Figs. 10.31 and 10.32). The angled
abutments should be connected with the All-on-4®
guide in place to orient prosthetically the screw
exit of the future immediate provisional prosthe-
sis (Figs. 10.33 and 10.34).
The anterior implants’ preparation follows the
same drilling protocol (Figs. 10.35, 10.36, 10.37,
10.38, 10.39, 10.40, 10.41, 10.42, 10.43, and
10.44). If the bone density is considered soft, the
implant’s apex should engage the nasal cortical,
thus achieving bicortical anchorage in order to
create appropriate stability. These implants
should be oriented by means of a pin guide alter-
natively to the All-on-4® guide. Usually, straight
multi-unit abutments are connected at 35 N cm to
the anterior implants.
Before suturing, if needed, palatal soft tissue
must be removed to avoid abutment covering or
excess soft tissue which may cause multi-unit
impression copings interference and hence
prosthesis misadaptation. Buccal soft tissue
should not be reduced; otherwise, it can result
in insufficient keratinised tissue around the
abutments.
In the mandible, given the sparse quantity of
keratinised tissue, soft tissue should not be
reduced, but apically positioned instead.
After suturing, open tray multi-unit impres-
sion copings are screwed to the abutments and
splinted by means of steel wire and pattern resin
10 Graftless Surgical Protocol: Diagnosis to Delivery 271

Fig. 10.23 Initiating drill sequence after using precision Fig. 10.26 2.4–2.8 mm step drill in the mandible
drill in the maxilla: 2 mm twist drill (first drill)

Fig. 10.24 Initiating drill sequence after using precision Fig. 10.27 3.2–3.6 mm step drill in the maxilla
drill in the mandible: 2 mm twist drill (first drill)

Fig. 10.25 2.4–2.8 mm step drill in the maxilla Fig. 10.28 3.2–3.6 mm step drill in the mandible
272 A. Ferro et al.

Fig. 10.29 Posterior implant placement in the maxilla. Fig. 10.32 Bone mill to remove bone around the head of
Note the implant’s angulation to provide a more posterior the mandibular distal implant
emergence

Fig. 10.30 Posterior implant placement in the mandible. Fig. 10.33 Connecting the angulated abutment to the
Note the implant’s angulation to provide a more posterior maxillary implant with the help of All-on-4® guide
emergence

Fig. 10.31 Bone mill usage to remove bone around the Fig. 10.34 Connecting the angulated abutment to the
head of the maxillary distal implant mandibular implant with the help of All-on-4® guide
10 Graftless Surgical Protocol: Diagnosis to Delivery 273

Fig. 10.35 Drilling protocol and anterior implant place- Fig. 10.38 Using the 2 mm twist drill (first drill) for the
ment. Initiating drill sequence using the precision drill in anterior mandibular implant
the maxilla

Fig. 10.36 Drilling protocol and anterior implant place- Fig. 10.39 Using the 2.4–2.8 mm step drill in the
ment. Initiating drill sequence using the precision drill in maxilla
the mandible

Fig. 10.37 Using the 2 mm twist drill (first drill) for the
Fig. 10.40 Using the 2.4–2.8 mm step drill in the
anterior maxillary implant
mandible
274 A. Ferro et al.

(Figs. 10.45 and 10.46). The impression is made same day of surgery achieving immediate func-
only with putty consistency elastomer. tion (Figs. 10.49, 10.50, 10.51, and 10.52).
Once the impressions are concluded, healing
caps are screwed to the abutments to (Figs. 10.47
and 10.48) support the peri-implant mucosa dur-
ing the fabrication of the prosthesis. The immedi-
ate provisional prosthesis is connected on the

Fig. 10.44 Mandibular implants placed at bone level and

abutments connected

Fig. 10.41 Anterior implant placement in the maxilla

Fig. 10.45 Impression coping screwed to the maxillary

abutments and connect for an accurate impression

Fig. 10.42 Anterior implant placement in the mandible

Fig. 10.46 Impression coping screwed to mandibular

abutments and connect for an accurate impression

Fig. 10.43 Maxillary implants placed at bone level and

abutments connected
10 Graftless Surgical Protocol: Diagnosis to Delivery 275

Fig. 10.47 Healing caps connected to the maxillary Fig. 10.50 Immediate provisional mandibular
abutments prosthesis

Fig. 10.48 Healing caps connected to the mandibular Fig. 10.51 Patient smiling with the immediate provi-
abutments sional maxillary prosthesis achieving immediate function

Fig. 10.49 Immediate maxillary provisional prosthesis Fig. 10.52 Patient smiling with the immediate provi-
sional mandibular prosthesis achieving immediate
function
276
10.4 All-on-4 Standard: Guided
Surgery
The implant placement follows the same protocol
of the standard All-on-4® technique, but it is per-
formed with a flapless approach planned previ-
ously in a 3D software.
This protocol can be used if patients have the
following inclusion criteria:
(a) Sufficient bone volume (defined in the previ-
ous point of the All-on-4 protocol).
(b) Enough mouth-opening capability to accom-
modate the surgical tooling (>40 mm).
(c) A low smile line or when bone recontouring
is not necessary.
(d) An almost edentulous jaw (so the remaining
teeth do not interfere with the position and
placement of the implants).
Through guided surgery, a full-arch restora-
tion can be performed with a minimally invasive
approach, reduced postoperative discomfort and
treatment time for the patient.
Prior to the surgical procedure, a well-defined
protocol with five stages has to be followed: (1)
patient examination (previously executed), (2)
preparation of the radiographic guide and CBCT
scan, (3) computer planning, (4) laboratory work
and (5) surgery.
10.4.1 Patient Examination
A preoperative treatment planning appointment
is performed to evaluate the patient’s medical
history, extra-oral aesthetic measures (lip sup-
port, profile, occlusal vertical dimension accord-
ing to the Thompson functional and the Willis
aesthetic methods, smile line, phonetics [8, 12])
and intra-oral features (arch form and relation,
jaw size, molar class, interocclusal space).
Radiographically, both an orthopantomography
and a CBCT are performed in order to accurately
assess the bone’s anatomy (volume and height)
and determine the exact location of the mental
foramen and/or maxillary sinus.
If the patient fulfils the inclusion criteria (suf-
ficient bone volume, low smile line and mouth-­
opening capability over 40 mm) (Fig. 10.53), a
A. Ferro et al.
Fig. 10.53 Evaluation of the mouth-opening capability
full-arch rehabilitation according to the All-on-4®
concept can be performed.
10.4.2 Preparation
of the Radiographic Guide
and CBCT Scan
The first step consists of the evaluation of the
removable prosthesis. If the patient’s prosthesis
does not meet the functional and aesthetic
requirements or it is not an all-acrylic resin, a
new prosthesis must be fabricated, presenting
optimal design with a correct representation of
the teeth position and a perfect fit to the soft tis-
sue (always maintaining the requirements of the
surgical template in mind).
In the new prosthesis, six gutta-percha mark-
ers on the buccal side and three markers on pala-
tal side are made, and a CBCT is done (Figs. 10.54
and 10.55).
The patient is scanned following the double scan
technique: one CBCT scan of the patient with the
prosthesis with gutta-percha markers and another
CBTC scan taken just to the patients’ prosthesis.
10.4.3 Computer Planning
After scanning and using an implant planning
software, both CBCTS are matched and a precise
3D treatment planning of an All-on-4 surgery can
be performed.
10 Graftless Surgical Protocol: Diagnosis to Delivery
Fig. 10.54 Intra-oral view (1/2) with the radiographic
guide during CBCT
Fig. 10.55 Intra-oral view (2/2) with the radiographic
guide during CBCT
Implants and multi-unit non-engaging angled
abutments are selected for the rehabilitation and
placed tridimensionally in the software.
The order file is sent to the manufacturing
company requesting the surgical template
(Figs. 10.56 and 10.57).
The surgical template is used as a guide to
obtain a stone cast and make all the laboratory
work (Figs. 10.58 and 10.59). Before surgery, a
surgical index is made with silicone and also all
prosthetic procedures are performed (Fig. 10.60).
10.4.4 Surgery Protocol
Prior to the insertion of the implants, the surgical
template is stabilised through anchor pins. The
surgical index helps us to position the surgical
277
Fig. 10.56 Implant planning software—maxilla
Fig. 10.57 Surgical template—maxilla
template in place while the anchor pins osteoto-
mies are performed (Figs. 10.61 and 10.62).
The first step is the use of tissue punch to have
access to the bone (Fig. 10.63). The surgery is
performed following the standard free-hand
All-on-4 protocol but with a surgical guide guid-
ing the drilling according to the preplan on a
computer (Figs. 10.64, 10.65, 10.66, 10.67,
10.68, 10.69, 10.70, 10.71, 10.72, and 10.73).
The surgeon has to adopt an under-preparation
protocol of the implant site in order to achieve
good primary stability.
Once the implants are placed, the surgical
template is removed, and the bone mill is used to
remove the bone around the implants’ head.
Angled abutments are connected to the implants
by means of a pre-made guide positioner. With
this guide it is possible to transfer the position
278 A. Ferro et al.

Fig. 10.58 Surgical index and guide to transfer the posi- Fig. 10.61 Stabilisation of surgical template with anchor
tion of the angulated multi-unit abutments (1/2) pins and surgical index (1/2)

Fig. 10.62 Stabilisation of surgical template with anchor

pins and surgical index (2/2)
Fig. 10.59 Surgical index and guide to transfer the posi-
tion of the angulated multi-unit abutments (2/2)

Fig. 10.63 Tissue punch

Fig. 10.60 Pre-surgically the maxillary removable den-

ture is converted into a fixed screw-retained implant-­
supported prosthesis of acrylic resin
10 Graftless Surgical Protocol: Diagnosis to Delivery 279

Fig. 10.64 Anterior implant placement: twist drill 2 mm Fig. 10.67 Anterior implant placement: implant
insertion

Fig. 10.65 Anterior implant placement: twist drill

2.8 mm Fig. 10.68 Posterior implant placement: twist drill 2 mm

Fig. 10.66 Anterior implant placement: twist drill Fig. 10.69 Posterior implant placement: twist drill
3.6 mm 2.8 mm
280 A. Ferro et al.

Fig. 10.70 Posterior implant placement: twist drill Fig. 10.73 Occlusal view after implant placement with-
3.6 mm out the surgical template

Fig. 10.71 Posterior implant placement: implant

insertion Fig. 10.74 Positioning of the non-engaging angulated
abutment with the help of the abutment guide

Fig. 10.72 Occlusal view after implant placement with

the surgical template
Fig. 10.75 Abutments in place

from the model to the mouth, allowing a passive

fit of the provisional prosthesis (Figs. 10.74 and implant-supported prosthesis is connected and
10.75). Following this procedure, a pre-made the occlusal adjustments verified (Figs. 10.76,
denture converted into a fixed all-acrylic resin 10.77, and 10.78).
10 Graftless Surgical Protocol: Diagnosis to Delivery 281

implant placement systems: static guidance and

Fig. 10.76 Frontal view of the provisional prosthesis
Fig. 10.77 Occlusal view of the provisional prosthesis
Fig. 10.78 Patient smiling
prosthesis
10.5 All-on-4 Standard:
Navigated Surgery
To improve accuracy and precision, surgeons
have available guided computer-assisted surgical
dynamic guidance (surgical navigation) [13]. The
main difference between static guidance and sur-
gical navigation is the placement of implants in a
predetermined position without the possibility of
changing the implant position or dimensions
perioperatively, while for the surgical navigation
system, the operator uses a triangulation setup
provided by the computer to guide the implant
placement, allowing changes during the surgery.
Surgical navigation provides accurate spacing
and angulation of the implants, decreasing the
risk of damaging anatomic structures as maxil-
lary sinus or inferior alveolar nerve. Moreover,
virtual implant planning and navigation provides
surgical and prosthetic collaboration for achiev-
ing a successful outcome through an exact and
precise planning. The accuracy of this system is
independent of CAD-CAM stents and the surgi-
cal field can be visualised live at any time.
Additionally, dynamic navigation allows dental
surgeons to scan, plan and execute navigated sur-
gery on the same day and patients with limited
mouth-opening capability can undergo dynamic
navigation.
However, dynamic navigation requires a team
approach and a learning curve for developing
predictability in implant placement. This may be
related to the difficulty in keeping sight of the
display during the surgical procedure.
The present case illustrates the surgical work-
flow in a bimaxillary full-arch rehabilitation
through the All-on-4 concept assisted by dynamic
navigation.
A 69-year-old male, non-smoker, healthy
patient presented with the need for bimaxillary
full-arch rehabilitation. Periodontal compro-
mised teeth with mobility, gingival recessions
and deep pocket depth were diagnosed as not
viable in the mandible and maxilla. After clinical
with the provisional examinations, orthopantomography, cone beam
computerised tomography (CBCT) scan and
intra-oral scanner were performed (Figs. 10.79
and 10.80).
The DTX Studio Implant software was used to
evaluate the baseline clinical situation, access the
bone reduction, study the best surgical and pros-
thetic solution and select the position and size of
282 A. Ferro et al.

of the clip receptor, which contained fiducial

markers, and read by two cameras, providing the
instruments’ tridimensional position and dis-
played in the navigation system. The handpiece
also holds an array that, when combined with the
fiducial markers on the clip receptor, provided
accurate navigation through triangulation.
Three points in three different maxillary teeth
Fig. 10.79 Preoperative orthopantomography were selected as distant as possible in the DTX
Studio Implant software to have the most favour-
able distribution quality and registration refine-
ment. The probe tool was then used to map the
exact same points in the patient’s mouth and reg-
istered by the system (X-Mark) (Fig. 10.84).
After this process, the precision drill was cali-
brated, and the planned bone reduction height
was marked with three horizontal osteotomies
preplanned on the DTX Studio Implant software
(Figs. 10.85 and 10.86). The preparation of the
implant osteotomy was made using the precision
drill, 2.0, 2.4–2.8 and 3.2–3.6 mm drills (Nobel
Biocare AB), always considering the spatial posi-
tion according to the live navigation data. Four
implants were inserted according to the All-on-4
concept, and all achieved 35 N/cm of primary
stability: the posterior implants reaching an
angulation of 30–45° in relation to the occlusal
plane and the anterior implants were inserted in
an axial position. Multi-Unit Plus abutments of
30° 4.5 mm were attached to the posterior
implants; while Multi-Unit straight 2.5 mm abut-
ments were attached to the anterior implants
(Fig. 10.87).
The protocol followed the same sequence for
Fig. 10.80 (a, b) Preoperative intra-oral photographs the mandibular rehabilitation (Figs. 10.88, 10.89,
exhibiting the occlusal aspect of the maxilla on the left- 10.90, and 10.91). All four implants achieved
hand side and mandible on the right-hand side
35 N/cm of primary stability. Multi-Unit Plus
abutments of 30° 4.5 mm and were attached to
the implants (Fig. 10.81). The X-Guide clip the posterior implants; while Multi-Unit Plus
receptor was directly fixated in the maxilla straight 2.5 mm abutments were attached to the
through two screws, and the navigation surgery anterior implants. Two provisional pre-made,
was initiated (Fig. 10.82). high-density, acrylic resin prostheses with ten
The surgical staff followed the prompts in the teeth were connected on the day of surgery,
X-Guide software (X-Nav Technologies, LLC, achieving immediate function (Figs. 10.92 and
Lansdale, PA, USA). Instruments were calibrated 10.93).
(handpiece tracker, chuck, probe tool and the The All-on-4 concept assisted by surgical nav-
preparation drills) as follows (Fig. 10.83): the igation provided a safe and predictable full-arch
overhead blue lights were reflected by the arrays bimaxillary rehabilitation, allowing the implants
10 Graftless Surgical Protocol: Diagnosis to Delivery 283

Fig. 10.81 DTX Studio Implant software image exhibiting planned bone reduction and implants’ position, diameter
and length, following the All-on-4 concept

Fig. 10.82 Perioperative photograph illustrating the fixa-

tion of the X-Guide clip receptor and array in the maxilla

Fig. 10.83 (a–d) Calibration of the handpiece, chuck and probe tool
284 A. Ferro et al.

Fig. 10.83 (continued)

Fig. 10.83 (continued)

10 Graftless Surgical Protocol: Diagnosis to Delivery 285

Fig. 10.83 (continued)

Fig. 10.84 (a, b) X-Mark selection and registration refinement process (maxilla)
 286 A. Ferro et al.

Fig. 10.84 (continued)

Fig. 10.85 Spatial calibration of the precision drill using an array

10 Graftless Surgical Protocol: Diagnosis to Delivery 287

Fig. 10.86 (a, b) Planned bone reduction osteotomy before and after flap elevation (maxilla)
288 A. Ferro et al.

Fig. 10.87 (a–d) Perioperative preparation of implant sites, implant placement using live navigation and intra-oral
view of the All-on-4 maxilla
10 Graftless Surgical Protocol: Diagnosis to Delivery 289

Fig. 10.87 (continued)

Fig. 10.88 Perioperative

photograph illustrating the
fixation of the X-Guide
clip receptor and array in
the mandible
290 A. Ferro et al.

Fig. 10.89 (a, b) X-Mark selection and registration refinement process in the mandible
10 Graftless Surgical Protocol: Diagnosis to Delivery 291

Fig. 10.90 Bone reduction plane osteotomy before flap elevation in the mandible

Fig. 10.91 (a–e) Perioperative implant sites preparation, implant placement using live navigation and intra-oral view
of the All-on-4 mandible
292 A. Ferro et al.

Fig. 10.91 (continued)

10 Graftless Surgical Protocol: Diagnosis to Delivery
a 10.6 Conclusions
b 93.9% at 13 years. The mean marginal bone loss
c 2.32 mm at 15 years. Prosthetic survival rate was
Fig. 10.92 (a–c) Intra-oral perioperative view with the
immediate prosthesis connected in the maxilla and
mandible
Fig. 10.93 Postoperative orthopantomography of reha-
bilitation through the All-on-4 concept using live
navigation
to be inserted with precision considering the
crestal position, angulation and depth.
293
In 2019, two long-term studies were published on
the All-on-4 treatment concept [9, 10], with data
collected in a private practice (Malo Clinic,
Lisbon, Portugal). The retrospective study in the
Maxilla [9] with a follow-up of up to 13 years
involved 1072 patients with 4288 maxillary
implants. The implant success rates reported
were 97.7% at 5 years, 95.6% at 10 years and
was 1.18 mm at 5 years and 1.67 mm at 10 years.
Prosthetic survival rate was reported to be 99.2%.
The retrospective study in the Mandible [10]
with a follow-up to 18 years involved 471 patients
with 1884 mandibular implants. The implant suc-
cess rates reported were 95.9% at 10 years, 93.5%
at 13 years and 91.7% at 18 years. The mean mar-
ginal bone loss was 1.72 mm at 10 years and
reported to be 98.8%.
Considering the high implant and prosthetic
success rates and the low incidence of both bio-
logical and mechanical complications, the
All-on-4 concept can be considered a viable
treatment alternative for full-arch rehabilitation.
In addition, the All-on-4 concept allows flexibil-
ity to be used with recent developments in
implant dentistry such as surgical navigation.
References
1. Maló P, Rangert B, Nobre M. “All-on-4” immediate
function concept with Branemark System implants
for completely edentulous mandibles: a retrospec-
tive clinical study. Clin Implant Dent Relat Res.
2003;5(Suppl 1):2–9.
2. Maló P, Rangert B, Nobre M. “All-on-4” immediate
function concept with Banemark System implants
for completely edentulous maxilla: a 1-year retro-
spective clinical study. Clin Implant Dent Relat Res.
2005;7(Suppl 1):S88–94.
3. Maló P, de Araújo Nobre M, Lopes A, Ferro A,
Gravito I. Complete edentulous rehabilitation using
an immediate function protocol and an implant design
featuring a straight body, anodically oxidized surface,
and narrow tip with engaging threads extending to the
apex of the implant: a 5-year retrospective clinical
study. Int J Oral Maxillofac Implants. 2016;7(1):153.
294
4. Maló P, Nobre M, Lopes A, Rodrigues R. Preliminary
report on the outcome of tilted implants with longer
lengths (20–25 mm) in low-density bone: one-year
follow-up of a prospective cohort study. Clin Implant
Dent Relat Res. 2013;19:217. https://doi.org/10.1111/
cid.12444.
5. Malo P, de Araújo Nobre M, Lopes A, Ferro A, Moss
S. Extramaxillary surgical technique: clinical out-
come of 352 patients rehabilitated with 747 zygo-
matic implants with a follow-up between 6 months
and 7 years. Clin Implant Dent Relat Res. 2013;17
Suppl 1:e153. https://doi.org/10.1111/cid.12147.
6. Patzelt SB, Bahat O, Reynolds MA, Strub JR. The all-­
on-­four treatment concept: a systematic review. Clin
Implant Dent Relat Res. 2014;16(6):836–55. https://
doi.org/10.1111/cid.12068.
7. Soto-Penaloza D, Zaragozi-Alonso R, Penarrocha-­
Diago M, Penarrocha-Diago M. The all-on-four treat-
ment concept: a systematic review. J Clin Exp Dent.
2017;9(3):e474–88.
8. Lopes A, Maló P, de Araújo NM, Sánchez-Fernández
E, Gravito I. The NobelGuide® All-on-4® treatment
concept for rehabilitation of edentulous jaws: 7-year
clinical and 5-year radiographic retrospective. Clin
Implant Dent Relat Res. 2016;19:233. https://doi.
org/10.1111/cid.12456.
A. Ferro et al.
9. Maló P, de Araújo Nobre M, Lopes A, Ferro A, Nunes
M. The All-on-4 concept for full-arch rehabilitation
of the edentulous maxillae: a longitudinal study with
5-13 years of follow-up. Clin Implant Relat Res.
2019;21:538–49.
10. Maló P, de Araújo Nobre M, Lopes A, Ferro A, Botto
J. The All-on-4 treatment concept for the rehabilita-
tion of the completely edentulous mandible: a longi-
tudinal study with 10 to 18 years of follow-up. Clin.
Implant Relat Res. 2019;21:565–77.
11. Maló P, Nobre M, Lopes A. The rehabilitation
of completely edentulous maxillae with different
degrees of resorption with four or more immedi-
ately loaded implants: a 5 year retrospective study
and a new classification. Eur J Oral Implantol.
2011;4(3):227–43.
12. Maló P, Nobre M, Lopes A. The use of computer-­
guided flapless implant surgery and 4 implants
placed in immediate function to support a fixed
denture: preliminary results after a mean fol-
low-up period of 13 months. J Prosthet Dent.
2007;97:S26–34.
13. Lopes A, Nobre M, Santos D. The workflow of a new
dynamic navigation system for the insertion of den-
tal implants in the rehabilitation of edentulous jaws:
report of two cases. J Clin Med. 2020;9:421.
 Surgical–Anatomical
and Prosthetic–Biomechanical
11
ZAGA Criteria to Determine
the Zygomatic Implant Trajectory

Carlos Aparicio, Arnau Aparicio, and John Brunski

Abstract these zones will have in the long-term result of

the rehabilitation. The reader will obtain bio-
In the late 1990s, we learned from the pio-
mechanical notions of the behaviour of an
neers the use of zygomatic implants to anchor
inclined implant versus one with axial direction
dental restorations. Due to the youth of the
to the occlusal plane, as well as the effect of the
technique at that time, the knowledge trans-
masticatory load on the zygoma in different
mitted was rather intuitive. The surgical pre-
surgical situations. Through the use of clear and
scription was applicable to all patients, and no
reasoned criteria the reader will be able to
criteria or protocols had been developed to
understand the parameters used by the ZAGA
adapt the intervention to the different situa-
Concept to determine the implant trajectory
tions that patients might present. The tech-
preventing late complications in a predictable
nique has evolved, and today, thanks to the
way. Finally, the specific ORIS criteria for
ZAGA Concept, we have protocols based on
determining the success or failure of a zygo-
defined criteria that are supported by evidence
matic implant restoration will be described.
to guide us in the decision-making that the
process requires.
In this chapter we will give clear notions of
11.1 Introduction
how to identify the key zones in the path of the
zygomatic implant and the transcendence that
The original protocol published by PI Brånemark
in 2004 [1] for zygomatic oral rehabilitation was
C. Aparicio (*) designed for the placement of one implant in
Indiana University School of Dentistry,
Indianapolis, IN, USA each zygoma following an intra-sinus path
(Fig. 11.1). The starting point was located pala-
Zygomatic Unit at Hepler Bone Clinic, ZAGA
Center, Barcelona, Spain tally to the first molar/second premolar area.
e-mail: carlos.aparicio@zagacenters.com Additionally two to four regular anterior implants
A. Aparicio were placed and connected to the final prosthesis.
ZAGA Center, Private Practice QDT Center, According to PI Brånemark [1], ‘the direction of
Houston, TX, USA zygoma fixation was selected to provide optimal
J. Brunski stability over the prosthetic requirements’. To
Division of Plastic and Reconstructive Surgery, achieve an intra-sinus trajectory in the presence
Department of Surgery, Stanford University, of a concave maxillary wall, the implant head
Stanford, CA, USA
e-mail: brunsj6@stanford.edu was placed on the alveolar palatal side, resulting

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 295
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_11
296
Fig. 11.1 Clinical photograph showing the anterior max-
illary wall where a ‘window’ osteotomy has been per-
formed (white circle). Through the window we visualise
the original twist drill proceeding (green arrows), but we
do not see its tip cutting the bone. In other words, if the
objective of the osteotomy is to control the drilling by
visualising the point where the drill cuts, we can consider
it as an ‘emotional osteotomy’ because although it tries to
do so, it does not achieve its goal
in bulky prostheses (Fig. 11.2). Eventual diffi-
culty in correct phonetics and hygiene mainte-
nance are often associated with this palatally
retained reconstruction.
Several factors related to the proceeding of
zygomatic implants through the palatal aspect of
the alveolar bone into the maxillary sinus can
induce rhinosinusitis and present with clinical or
subclinical oroantral communication from the
peri-implant sulcus. Factors mentioned may
include discrepancy between the osteotomy and
implant diameters; history of periodontitis; inad-
C. Aparicio et al.
Fig. 11.2 Occlusal clinical photograph showing the dis-
tance from the osseous crest (green dashed line) to the
palatal emergence of the implants (white arrows). Since
the original intra-sinus technique was used, the abutments
are not angled but the initial straight ‘standard’ type
Fig. 11.3 The implant has been placed conservatively.
However, it has a straight connection with the abutment.
To correct the angulation and place the emergence of the
prosthetic screw in a crestal position, the abutment–
implant connection must be made in the ZICZ (white cir-
cle). The green arrows indicate the possible points where
bacterial filtration will occur, which will produce chemo-
tactic stimulation for the osteoclasts favouring the late
appearance of an OAC. (Image taken from the Internet)
equate oral hygiene procedures, chemotactic
stimuli due to bacterial leakage at an implant–
abutment junction placed at the ZICZ (Fig. 11.3),
peri-implant osteomyelitis due to hygiene diffi-
culties, etc. The possibility of this event would be
inversely related to the thickness of the sinus
floor in the area where the implant crosses it. The
inflammatory response of the sinus floor mani-
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
fests with a few symptoms. It is sometimes
accompanied by a sensation of perialveolar and/
or facial discomfort, without usually pain when
the implant itself is loaded [2]. Antibiotic therapy
temporarily eliminates the infection, which even-
tually recurs later.
A recent multicentre randomised controlled
study has compared the use of zygomatic
implants placed in immediate loading with the
use of bone augmentation procedures at 1 year
[3] and 3 years [4]. Study results have reported
significantly fewer prosthetic failures, implant
failures and time to functional loading in the
zygomatic implant group. On the other hand, the
authors note a significantly higher number of
complications at 3 years in the case of zygomatic
implants due to an apparent increase in severe
sinusitis over time. The authors do not explain
the reasons for this large number of sinusitis, but
from a detailed reading of the article it appears
that in 78% of the implants the intra-sinus implant
path with additional window osteotomy of the
original technique was used. It would be reason-
able to speculate that the cause of the large num-
ber of late sinusitis could be due to the loss of the
palatal bone seal, for some reason, combined
with the use of threaded implants with rough sur-
face (TiUnite®).
In this chapter, complementary to the previous
one in which the ZAGA Concept [5] was
explained, we will define and explain the criteria
we use to determine the implant trajectory in
order to prevent the aforementioned complica-
tions when zygomatic implants are used. To this
end, and in order to better understand the origin
of potential problems, we will complement the
ZAGA anatomical classification [6] with a
description of the main anatomical areas to which
the implant trajectory relates. Obviously, it will
be important to understand how these implants
behave biomechanically before proceeding with
the design of both the placement/distribution and
the prosthesis itself. This applies especially to the
immediate provisional prosthesis, which is a key
piece in the treatment. Finally, we will explain
the key points that a reader should look for when
reading a report describing the use of zygomatic
297
implants. To do so, we will describe the ORIS
criteria [7], specific to zygomatic implant reha-
bilitation. By using them systematically, we will
be able to determine the degree of success or fail-
ure and compare them with other reports.
11.2 The ZAGA Zones
As explained in the previous chapter, the success
of the ZAGA Concept for the rehabilitation of the
atrophic maxilla through zygomatic implant-­
anchored rehabilitations is based on the identifi-
cation of the anatomical characteristics of the
patient. Specifically, the surgeon must be familiar
with the characteristics, physiology and
function(s) of the structures that the oblique
plane of the planned osteotomy intersects.
With a didactic intent, we are differentiating
three main zones (Fig. 11.4) of the zygomatic
implant trajectory [8]:
–– The ‘zygomatic implant critical zone’ (ZICZ).
–– The ‘antrostomy zone’ (AZ).
–– The ‘zygomatic anchorage zone’ (ZAZ).
11.2.1 The Zygomatic Implant
Critical Zone
The ‘zygomatic implant critical zone’ (ZICZ) is
formed by the complex formed by the maxillary
bone, the soft tissues and the zygomatic implant
at the coronal level where the first contact with
the maxillary bone occurs (Figs. 11.4 and 11.5).
The fundamentals for the correct position of the
ZICZ are especially important in the ZAGA
Concept and will be discussed later. Residual
alveolar bone and soft tissue preservation or even
augmentation at the coronal level of the zygo-
matic implant are critical to prevent late compli-
cations. In fact, maintenance of bone and soft
tissue in the ZICZ should be one of the main
goals of our surgical approach. In this regard, a
series of protocols, tools, interventions and pro-
cedures are proposed to reach appropriate bone
and soft tissue stability on the ZICZ (Table 11.1).
298
Fig. 11.4 The DTX Studio Implant program allows us to
visualise this screenshot where we visualise in the 3D
image the plane through which the implant proceeds. The
2D image on the right represents the cut where the implant
a b
Fig. 11.5 (a) The minimally invasive ZAGA channel-­
type osteotomy has been prepared. The Straumann ZAGA
implant has its tip placed in the ZICZ (white circle). Note
the precise under-preparation of the osteotomy as well as
the preservation of the integrity of the sinus membrane at
this level. The green circle marks the AZ which is as far
away as possible from the ZICZ. The white arrows high-
light the flat surface of the implant on the buccal side
which will contribute to decrease the pressure against the
soft tissue and therefore reduce the possibility of dehis-
cence due to tissue anoxia. (b) The same implant in (a) is
C. Aparicio et al.
proceeds and its relationship with the adjacent structures.
The arrows and circles represent by colour the positions of
the ZICZ (red), the AZ (green) and the ZAZ (yellow)
in its final position ready to disassemble its transporter.
Note the perfect contact and sealing of the implant walls
with the ‘single’ osteotomy. The white arrows highlight
how the flat surface of the Straumann ZAGA Flat is at the
level of the bony envelope. The implant–abutment con-
nection is made above the ZICZ using an abutment of
smaller diameter than the implant platform (platform
shift), so we do not expect bacterial stimulation. The AZ
(green circle) is far from the ZICZ, so no antrum contami-
nation is expected through it. The yellow circle marks the
ZAZ
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
Table 11.1 Rationale for recommended tools and proce-
dures to achieve and maintain adequate bone and soft tis-
sue stability in the ZICZ (From Aparicio C. Soft tissue
management in zygomatic implant rehabilitation In
Advanced Zygomatic Implants: The ZAGA Concept.
Carlos Aparicio Ed. Quintessence Chicago 2023) [9]
• Postpone any intervention until the soft tissue is fully
healed.
• Incision. As a general rule, use a palatal incision,
displacing and augmenting the soft tissue buccally to
the implant platform.
• ZAGA rolling flap. This is recommended for ZAGA
type 4 anatomy with implants that are expected to be
externalised and when the thickness of the palatal soft
tissue permits. For this, we will use a partial-thickness
incision extending from the ridge about 10–12 mm
towards the centre of the palate where it becomes full
thickness. We will then roll the palatal connective
tissue, ideally leaving the periosteum intact, and move
it buccally towards the neck of the abutment.
• ZAGA partial thickness flap (PTF). Its purpose is to
maintain or facilitate soft tissue closure in cases of
sinus floor or palatal discontinuity.
• Perform an adequate osteotomy procedure by placing
the implant head in relation to the ridge according to
the ZAGA Concept.
• se an appropriate implant section and design to match
the osteotomy and maintain the bone in the ZICZ.
• Consider using simple procedures such as L-PRF
alone or in conjunction with bone grafting to enhance/
facilitate healing and sealing of soft and hard tissues
after surgery.
• If dehiscence is anticipated or considered likely and
sufficient connective tissue is available, use the
ZAGA scar graft. A scar graft is a pedicle connective
tissue graft around the neck of the implant, with the
goal of increasing the amount of buccal tissue.
• If dehiscence is anticipated or considered likely and
sufficient connective tissue is not available, use the
buccal fat pad.
• After implant surgery, consider the use of a definitive
abutment with adequate height as important factors in
maintaining the marginal bone level.
• Position the implant–abutment junction as far away
from the ZICZ as possible to maintain the marginal
bone level avoiding bacterial leakage and subsequent
bone resorption. The latter is of particular relevance if
a straight 0° implant head design is used.
• Consider suturing options, including the use of
periosteal incisions or release flaps to obtain
tension-­free primary wound closure.
• Avoid implant micromotion under masticatory load by
using a rigid framework, no extensions, good
masticatory load distribution and soft diet in the
provisional prosthesis.
• Recommend proper hygiene and diagnostic
procedures that do not compromise the hemi-­
desmosomal bond between titanium and soft tissue.
299
11.2.2 The Antrostomy Zone
The antrostomy zone (AZ) is the area where the
drill penetrates into the maxillary sinus cavity
(Figs. 11.4, 11.5 and 11.6). ZAGA recommends a
minimally invasive osteotomy procedure
intended to maximise BIC using an under-­
preparation of the designed implant trajectory.
The recommended minimally invasive ZAGA
osteotomy [10, 11] procedure is adapted to the
implant shape by direct bone drilling in the three
areas where the implant will contact (ZICZ, AZ
and ZAZ). In other words, prior to implant place-
ment no previous ‘window’ or ‘slot’ osteotomy/
antrostomy is performed nor required. Depending
on the maxillary anatomy, the zygomatic antros-
tomy zone will be located either at the internal
side of the remaining alveolar bone (tunnel oste-
otomy in ZAGA types 0 and 1) or apically from
the ZICZ when there is not enough alveolar bone,
and the osteotomy trajectory is buccally offset
(channel osteotomy). As a rule of thumb, the
antrostomy should be located as far away as pos-
sible from the ZICZ. Excluding ZAGA types 0
and 1 when the ZI perforates the sinus floor
(Fig. 11.6a), the AZ is usually located at the
zygomatic process of the maxilla, below the
zygomatico-maxillary suture (Fig. 11.6b). ZAGA
Concept uses anatomic, prosthodontic, numerical
and 3D implant design criteria to determine the
ZICZ position. The location of the antrostomy
will depend on the zygoma buttress curvature and
on the position of the coronal entrance point.
11.2.3 The Zygomatic
Anchorage Zone
The zygomatic anchorage zone (ZAZ) is the sec-
tion of the zygomatic bone where the implant
reaches its maximum primary stability (Figs. 11.4
and 11.5b). The zygomatic bone is variable in
quality and quantity among patients. Nkenke
et al. [12] described it in 2003 as a trabecular
bone with unfavourable characteristics for
implant placement if not properly utilised.
Structural zygomatic stabilisation will be maxi-
mised when four cortices of the maxillary zygo-
300
Fig. 11.6 The diagram shows an example of the design
of a ZAGA tunnel osteotomy (a) and at the bottom a sec-
ond example (b) of the choice of a ZAGA channel oste-
Fig. 11.7 Image taken from the Internet visualising two
zygomatic implants placed with an osteotomy determined
by a wrong positioning for the AZ. The white arrows high-
light how zygomatic bone has been removed in excess and
inaccurately making the apical margins of the implant not
correspond with the diameter of the osteotomy. The
threads of both implants are exposed, potentially losing
initial stability and zygomatic bone mass without achiev-
ing function
matic process and zygomatic bone are penetrated.
Generally speaking, from a biomechanical point
of view we should also try to drill also the antero-
superior cortex of the zygoma to ensure primary
stability of the implant. The maximum anchorage
is achieved by the partial or total irruption of the
implant in the infratemporal fossa, its re-entry in
the zygomatic bone with final exit through the
superior anterior cortex of the zygoma. Since the
patient’s problem is precisely severe maxillary
C. Aparicio et al.
otomy. Both examples are real and show the pre- and
postoperative radiographs, with the planning of the
implant position and the final situation at 3 years
atrophy, we need to maximise primary stability.
To achieve this, the ZAGA Concept uses a tan-
gential zygomatic bone–implant intersection,
increasing the bone–implant contact (BIC). In
parallel to the above, we recommend using the
minimally invasive ZAGA osteotomy because it
does not remove bone in the form of a slot or win-
dow prior to implant placement (Fig. 11.7),
which decreases the BICA and the strength of the
maxilla or zygomatic bone. Obviously, we will
be able to preserve and adapt better to the bone
structure if we add to the type of osteotomy
­mentioned above the use of site-specific implants
and narrow diameter drills such as Straumann-
ZAGA zygomatic implants.
11.3 Biomechanics in the Context
of Tilted Implants
The successful use of tilted implants has been
described as an alternative to maxillary grafting
in cases where patients present advanced maxil-
lary resorption by Mattson et al. 1999 [13] and
Kremanof et al. in 2000 [14]. Aparicio et al. in
2001 [15] defined a ‘tilted’ implant as an implant
‘placed with more than 15° deviation from per-
pendicular to the occlusal plane’. Implants
anchored in the zygomatic bone are tilted.
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
Stress is defined as a force divided by the area
supporting the force, so its dimensions are force/
area; for example, a typical unit for stress in the
metric system is the Pascal (Pa), which equals
1 N/m2, and 1 million Pa equals 1 MPa
(MegaPascal). There can be different types of
strain, such as tensile strain, compressive strain
and shear strain. Strain is the amount of deforma-
tion experienced by a sample of material in the
direction of the applied force, divided by the ini-
tial dimensions of the sample. Stress and strain
are related by the stress–strain relationship of the
material involved. All materials have failure lim-
its described in terms of stress or strain.
When any prosthesis is loaded by masticatory
forces, its supporting implants are also loaded
along with the surrounding bone. Mechanical
principles dictate that these forces will produce
resistance forces within the materials involved,
and these internal resistance forces are related to
stress. Similarly, stress in a material also causes
deformation or strain, and as a general rule, the
greater the stress and strain in any material, the
greater the risk of failure [16].
We cannot determine conclusively when the
stresses and strains that bone can withstand are
too great. This is because different types of bone,
that is, dense cortical bone, trabecular bone,
immature bone healing around an implant, human
bone versus bone of another species, etc., have
different properties [17]. On the other hand, we
must keep in mind the possibility of fatigue fail-
ure of bone, which is a type of material failure
that occurs under cyclic loading conditions.
Fatigue is especially insidious because it occurs
under magnitudes of stress or strain substantially
lower than those that cause failure in a single
cycle. For example, the ultimate tensile strength
of pure titanium is about 760 MPa, but the so-­
called fatigue strength limit for 10 million cycles
is only 300 MPa [18]. The situation is similar in
bone. For example, in the case of the implant
tilted at 25°, the peak peri-implant bone strain
can be substantially greater than the strain in
bone around an axially loaded implant. In some
cases, it is possible that bone may fatigue under
cyclic loading since humans routinely exert about
100 chewing movements per day [19, 20], which
301
means that many thousands of cycles can accu-
mulate in 1 year.
As defined by Aparicio et al. in 2001 [15],
zygomatic implants can clearly be classified as
‘tilted’, which raises the question ‘What is the
functional difference between a vertical versus a
tilted implant, in particular with respect to the
peri-implant bone?’
According to Brunski and Aparicio in 2023
[21], one answer arises from the comparison of
stress–strain states in the peri-implant bone
around vertical implants versus tilted implants in
identical bone and loaded by the same vertical
force. A suitable method to perform this compari-
son is finite element (FE) modelling, where rele-
vant factors (e.g. bone properties, implant
geometry, implant loading, etc.) can be controlled
in a systematic way to allow for a ‘fair’ compari-
son. Figure 11.8 illustrates the results of an FE
study of the intraosseous strain distributions
occurring around a bone-integrated implant
tested in three different orientations with respect
to the occlusal plane. In the FE models presented
here, the implant is made of pure titanium and the
bone is assigned the approximate properties of a
mixture of dense and cancellous bone. The three
implants—straight (Fig. 11.8a), angled 15°
(Fig. 11.8b) and 25° (Fig. 11.8b)—are assumed
to be connected to the bone (‘osseointegrated’)
and loaded by the same downward vertically
directed force. The conclusion is that other fac-
tors being equal, such as the force on the implant,
the size and shape of the implant, the quality and
quantity of surrounding bone, etc., increasing the
inclination of an implant increases the stresses
and strains in the peri-implant bone compared to
the case of a vertical implant.
Early in the development period of tilted
implants, it was stated that one of the advantages
of tilting an implant was that it would ‘make
maximum use of available bone and result in a
simpler, more predictable, less costly and less
time-consuming treatment compared to bone
grafting procedures in the maxillary sinus or aug-
mentation techniques...’ [15].
We could explain the statement ‘making the
most of the available bone’ from a biomechani-
cal point of view with a simple geometrical
302
a b
Fig. 11.8 (a–c) Principal compressive strains in bone
around implants with different inclinations subjected to
the same force. (From Brunski J. B. Biomechanics in the
a b
Fig. 11.9 If the available bone has a thickness of 10 mm
(a), the length of the vertical implant in the bone (b) may
be 10 mm, whereas if the implant is tilted 25° (c), the
length in the bone increases to 11 mm. (From Brunski
example. Let us assume that the thickness of the
sinuses floor in an individual is 10 mm
(Fig. 11.9a). Let us further assume that it is an
edentulous area which, because of its width,
would allow the placement of a vertical implant
(Fig. 11.9b) or an inclined implant (Fig. 11.9c).
A simple geometric calculation indicates that the
length in bone of the vertical implant would be
10 mm, while for the inclined implant with an
angle α = 25°, the length of the implant in bone
would increase to the length of the inclined dot-
ted line in Fig. 11.9a, which is 11 mm. For an
applied inclination of about 35°, the bone-to-
implant contact area (BICA) of the tilted implant
C. Aparicio et al.
c
context of tilted implants. In Advanced Zygomatic
Implants: The ZAGA Concept. Carlos Aparicio Ed.
Quintessence Chicago 2023) [21]
c
J. B, Aparicio C. Biomechanics in the context of tilted
implants. In Advanced Zygomatic Implants: The ZAGA
Concept. Carlos Aparicio Ed. Quintessence Chicago
2023) [21]
may be about 15% greater than that of a vertical
implant.
Thus, from the perspective of making the best
use of available bone, an inclined implant is argu-
ably superior because it has a greater effective
length in bone and (potentially) more bone con-
tact area than the vertical implant.
This provides a better understanding of the
biomechanics of tilted implants related to inser-
tion technique. For example, the angle of attack
of the implant with an intra-sinus path to the
zygomatic bone is more perpendicular, so the
BICA is lower than when the implant is placed
with an extra-sinus path [22].
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
The above provides insight into the biome-
chanics of tilted implants. Regardless of the sur-
gical and prosthetic justification chosen, the same
biomechanical design considerations arise with
zygomatic implants, which are tilted by defini-
tion: How are implants loaded during mastica-
tory function? What is the difference in load
distribution between an implant anchored exclu-
sively in zygomatic bone and one that is also sup-
ported by alveolar bone? What stress levels occur
in the peri-implant alveolar bone? What stress
levels occur in the peri-implant alveolar bone?
What stress levels occur in the peri-implant alve-
olar bone and what stress levels occur in the
zygomatic bone? Under what conditions can the
applied stresses exceed the damage limits? What
are the differences between the loading of an iso-
lated zygomatic implant and one connected to
other implants? What are the differences between
the loading of an isolated zygomatic implant and
one connected to other implants?
Ujigawa [23] used a finite element model to
investigate the distribution of forces along zygo-
matic implants in a model with regular anatomy.
They simulated an occlusal force of 150 N and a
lateral force of 50 N. Their model also incorpo-
rated a 300 N force, applied to the bone and
zygomatic arch, to simulate the action of the
masseter muscle. The study showed large von
Mises stresses in the zygomatic bone and sug-
gested that most of the occlusal force was trans-
mitted to this area.
Stresses in severely resorbed jaws with con-
nected implants (one zygomatic implant and two
regular implants) were not concentrated around
the alveolar bone supporting the zygomatic
implant. Stresses under vertical and lateral loads,
when separate implants were present, tended to
be generated in the zygomatic bone, in the mid-
dle part of the zygomatic implant and at the
implant–abutment junction, thus indicating the
possibility of complications related to marginal
bone, loss around the implants and mechanical
failure of the components.
According to Ujigawa, stress due to occlusal
forces is borne primarily by the zygomatic bone,
is transferred predominantly through the infra-­
zygomatic ridge and is divided between the fron-
303
tal and temporal processes of the zygomatic bone
in different directions. Therefore, zygomatic
implants in combination with at least two con-
ventional implants can restrain rotational loads
and distribute stresses from the fixed prosthesis
to the zygomatic bone, but cannot restrain stresses
at the implant–abutment joint under lateral
loading.
It is interesting to note that the model used in
the Ujigawa study uses a remaining alveolar bone
height of 6.3 mm, which almost negates the indi-
cation for placing zygomatic implants or, in any
case, represents a more favourable situation than
usual with respect to the amount of alveolar bone
available in a severely atrophic maxilla.
Finite element studies performed by
Freedman’s group in 2013 [24] and 2015 [25]
provide answers to the importance of the alveolar
bone in supporting or modifying the masticatory
load on zygomatic implants placed according to
the original or externalised technique. In the 2013
study, the authors created a model of a fixed
bridge supported by two zygomatic implants
placed using the intra-sinus Brånemark original
technique. Subsequently, the model was dupli-
cated and the holes around both implants were
widened as they advanced through the maxillary
bone. The result was a 0.5 mm gap between the
implants and the bone. Forces ranging from 50 to
600 N were used, with the idea that forces up to
600 N would exceed those recorded in vivo.
The maximum stresses observed in the model
with alveolar support were lower than those in
the model without alveolar support, regardless of
the direction in which the force was applied.
Alveolar bone support had the greatest influence
on von Mises peak stresses when occlusally
directed forces were applied. This is clinically
significant as most masticatory forces are occlus-
ally directed.
The results of this study suggest that the sup-
port provided by the alveolar bone is important
for zygomatic implants. The explanation
Freedman suggests is that although the portion of
the implant supporting the alveolar bone is very
small compared to that supporting the zygomatic
bone, the alveolar zone is much closer to the
force being applied to the implant. This would
304
allow the masticatory forces to be distributed
over the entire maxilla and facial skeleton rather
than solely over the zygomatic bone.
In contrast to the results of Ujigawa et al. [23],
only small stresses were observed in the zygo-
matic bone. Instead, the forces were distributed
throughout the maxilla and the entire facial skel-
eton. This suggests that less force is distributed in
the zygomatic bone than suspected when alveolar
support is present. One possible explanation for
the difference in results is that the Ujigawa model
also incorporated a 300 N force applied to the
arch and zygomatic bone to simulate masseter
action. The study showed large von Mises stresses
in the zygomatic bone and suggested that most of
the occlusal force was transmitted to this area.
However, it is difficult to know what proportion
of the stress observed in the zygomatic bone
came from the occlusal force and not from the
masseteric force.
In a second study published in 2015, Freedman
et al. [25] investigated the influence of the maxil-
lary alveolar bone on the stress distribution of
zygomatic implants in extra-sinus position. For
this purpose, they modelled two zygomatic
implants that were placed in an extra-sinus posi-
tion with anchorage in the zygomatic bone and
contact in the alveolar bone. The implants were
connected by means of a fixed bridge. This model
was duplicated and the area of the maxillary alve-
olar bone contacting the implants was eliminated.
Forces ranging from 50 to 600 N were applied to
each model individually in the molar area of the
bridge at varying angles to the occlusal plane. As
before, the magnitudes of the maximum stresses
were systematically higher in the model without
alveolar support, regardless of the direction of the
applied force.
It is interesting to note how apparently the
influence of the alveolar contact is much more
important when the implant is placed with the
original intra-sinus technique than when the extra
maxillary technique is used. In fact, according to
figures published by Freedman’s group, when
there is no alveolar contact in the original tech-
nique, the stress on the zygomatic bone is
enhanced by approximately three times. Whereas
in the externalised technique the forces increase
C. Aparicio et al.
approximately twice as much when there is no
contact. Freedman does not report a previous
reduction of the maxillary wall of the model in
the form of window or slot osteotomy that would
decrease the contact of the implant with the max-
illary wall. Moreover, Corvello demonstrated in
2011 [22] that due to the tangential attack of the
implant the contact area at zygomatic level is
greater in the externalised technique than in the
original intra-sinus. Therefore, the explanation
for the fact that in Freedman’s studies the reduc-
tion of contact in the alveolar area has less effect
in the externalised technique than in the original
one could be in the greater contact area of the
implant with the maxillary wall and the zygo-
matic bone that is achieved with a minimally
invasive osteotomy as preached by the ZAGA
Concept.
11.4 The ZAGA Criteria
to Establish the Zygomatic
Implant Trajectory
In designing the zygomatic implant trajectory,
the surgeon must have to be familiar with the fol-
lowing aspects related to the maxillary anatomy
that will determine both the position of the entry
and exit point of the implant [8, 26]:
• Remnant alveolar bone or basal bone form-
ing the floor of the maxillary sinuses or nose,
in terms of height, width, geometry and
quality.
• Palatine bone proximal to the floor of the
sinuses, in terms of thickness, quality, archi-
tecture or presence of anatomical incisions.
• Maxillary wall in terms of shape of its curva-
ture if present, thickness and/or presence of
anatomical incidences (e.g. alveolar artery).
• The zygoma itself in its morphology and
architecture in general, as well as the thick-
ness of its cortices and the possible prolonga-
tions of the sinuses inside it. It will be
especially important to know the details of the
architecture of the transition zone of the
zygoma with the maxilla, especially if a dou-
ble window osteotomy is planned.
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
In the ZAGA Concept, the type of incision
and the flap are also designed in relation to the
patient’s anatomy. After planning, we will exe-
cute them until we release a flap that allows us to
control the entire surgical area. For this purpose it
is advisable to use a retractor placed in the angle
formed by the temporal and frontal process of the
zygomatic bone. Following situating the retrac-
tor, the choice of the trajectory of the implant, as
well as the points where it interacts with the sub-
ject, is guided by the anatomy of the area follow-
ing three steps:
(a) Identify the ZICZ.
(b) Establish the AZ.
(c) Perform the antrostomy by joining the two
points.
11.4.1 Identify the ZICZ
The initial step in zygomatic implant placement
is to identify and determine the first contact zone
of the implant at the level of the alveolar ridge
(Fig. 11.10). This point is known as the zygo-
matic implant critical zone (ZICZ) [8, 11].
Determining this zone where the implant first
contacts the alveolar bone and subsequently the
soft tissue is a key factor for the success of the
zygomatic surgical procedure. In fact, the choice
of the type of osteotomy to be performed and
Fig. 11.10 Radiographic series showing on the left the
preoperative planning of the implant trajectory in a ZAGA
type 4 situation. Due to the scarce residual alveolar bone
in the ZICZ (red circle) a ZAGA channel osteotomy is
determined. In the centre we visualise how the minimally
305
therefore the prevention of late complications
such as oro-antral communication or soft tissue
recession, as well as the appearance of mechani-
cal, prosthetic and/or aesthetic complications,
largely depends on it. As described by Aparicio
et al. [8, 11], the location of the ZICZ is governed
by prosthetic, biomechanical and anatomical
considerations. Depending on these factors, the
oral preparation may begin in the form of a tunnel
in the bony ridge itself, placing the entry point on
the palatal side of the alveolar ridge; or in cases
of severe resorption such as ZAGA type 4, have
the form of a lateral channel running from the
ridge along the buccal side of the maxillary wall.
11.4.2 Establish the AZ
To achieve rehabilitation of the atrophic maxilla
by means of a prosthesis fixed to zygomatic
implants, the apical part of the implant is
anchored in the zygomatic bone with the aim of
achieving primary stability, refraining from dam-
aging adjacent structures such as the orbit, the
infraorbital nerve, the infratemporal fossa or the
zygomatic bone itself. Once the ZICZ has been
determined, the next step will be to proceed to
determine the point where the drill will penetrate
the antrum: the antrostomy zone (AZ). In the
ZAGA Concept, the position of the AZ is deter-
mined according to the patient’s anatomy, and
invasive ZAGA osteotomy has maintained the integrity of
the membrane in the ZICZ (white arrows) despite the
small amount of bone. On the right, the tomographic sec-
tion over the implant shows the excellent situation of the
sinus 3 years later
306
Fig. 11.11 The tomographic section over the implant
shows the result of a ZAGA tunnel osteotomy. The red
arrows indicate the position of the ZICZ and entry of the
implant into the residual alveolar bone. The green arrows
indicate the point of the AZ, just on the other side of the
tunnel
Fig. 11.12 The composition shows in the upper perime-
ter the tomographic slices corresponding to the plans for
the zygomatic implants in second premolar/first molar
positions. In the centre the clinical image with the ZAGA
Flat implants placed in minimally invasive ZAGA channel
C. Aparicio et al.
more specifically according to the type of oste-
otomy previously chosen. If, due to the amount
of bone remaining at the alveolar level, a tunnel-­
type osteotomy has been chosen, the antrostomy
will be approximately 5 mm away on the other
side of the alveolar perforation (Fig. 11.11).
If, on the other hand, due to the scarcity of
bone, an externalised channel osteotomy is cho-
sen, the site of the antrostomy (AZ) will be
located far away from the near ZICZ or in the
zygomatic bone (Fig. 11.12).
The decision of the location of the entry zone,
trajectory and length of the implant at the level of
the zygomatic bone will be determined according
to the following criteria: numerical, relative to
the number of implants to be placed; implant
design in terms of its pattern and especially its
thickness; and anatomical/structural relative to
the architecture of the zygomatic bone and its
relationship/transition with the maxillary wall.
As explained more fully in Chap. 5 of The
ZAGA Concept book [11], in the cases of ZAGA
2, 3 and 4, the point of penetration of the drill bit
into the antral cavity corresponds to the point of
osteotomies. The double arrows highlight the distance
between the AZ and the ZICZ. In the lower perimeter the
radiological images taken 3 years after placement show
the state of the maxillary sinuses. The white arrows point
to the AZs
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic… 307

penetration of the drill bit into the antral cavity

approximately to the point of entry into the zygo-
matic bone through its inferior facial cortex
(close to the maxillo-zygomatico suture). In
ZAGA 0 and some ZAGA type 1 cases, the entry
point into the antral cavity is located just across
the perforation of the remaining alveolar bone. In
these cases, the apical entry point into the zygo-
matic bone is located on its inner side and does
not correspond to the AZ.
In order to achieve the longest possible
intraosseous path, taking advantage of its sinuous
shape and looking for an entry point in the zygo-
matic bone that crosses as many cortices as pos-
sible is recommended [12]. While seeking the
maximum possible anchorage, the zygomatic
osteotomy must ensure that the zygoma itself
does not fracture. To this end, we must refrain
from tangential drilling too close to the facial Fig. 11.13 The tomographic section shows the trajectory
cortex, leaving little bone thickness between the of the implant and the state of the adjacent structures. The
implant and the outer surface of the cortex. We double green arrow indicates that in order to refrain from
unwanted fractures or unproductive removal of the zygo-
should also refrain from using exaggerated matic bone, the AZ should be placed at an approximate
implant diameters that require major and unnec- distance of at least 5 mm from the external zone of the
essary osteotomies that facilitate total or partial superior external cortex of the zygoma
fracture of the zygoma (Fig. 11.13). This consid-
eration will be especially important when placing
two zygomatic implants in the same zygoma. 11.5 Interim Prostheses

In zygomatic implant treatment, the immediate

11.4.3 Perform the Antrostomy
The final implant trajectory is determined by
joining the coronal and apical points previously
determined in steps A and B. To do so, a sequen-
tial osteotomy joining the points previously
determined in steps A and B is performed. To
under-prepare the bone of the trajectory, the
future diameter of the planned implant is consid-
ered. Ideally the obtained bed will be fully sealed
with an implant whose design corresponds to the
morphology of the prepared osteotomy. As we
have already pointed out, the ZAGA Concept
uses only one osteotomy. Therefore, there is no
need to waste bone from the patient’s maxillary
wall by performing an ‘emotional’ osteotomy, in
the form of a ‘window’ or ‘slot’, prior to the oste-
otomy really necessary for the implant
placement.
provisional prosthesis design and function is
extremely important. First of all because a well-­
made immediate prosthesis reinforces the initial
stability of the loaded implants by rigidly splint-
ing all the implants and thus refraining excessive
micromovement. In addition, provisional pros-
theses serve multiple functions such as providing
acceptable aesthetics as well as masticatory and
phonetic function during the healing process. As
a provisional prosthesis, it will also be useful as a
test to check the position, occlusion and ­aesthetics
of the teeth as well as the soft tissue substitutes
[27, 28].
As mentioned above, the prosthesis utilises
one of the key principles of orthopaedics to pro-
vide supplemental rigidity to allow for neo-­
vascularisation and subsequent bone healing.
Thus, in orthopaedics, a cast, a metal plate or, in
the case of implants, a fixed prosthesis that rig-
308
idly splints all implants will prevent their relative
movement and allow healing. In the case of zygo-
matic implants, this concept of rigid splinting to
refrain or control micromovement is even more
important than in regular implants. Even if pri-
mary or secondary stability has been achieved in
its apical anchorage zone, an eventual excessive
micromovement would be facilitated by three
possible factors: the first is the great lever length
of a very long implant supported only at its apical
end; the second is that the anatomical variations
of the zygomatic bone are very large and in cer-
tain cases with less density or quantity of cortical
bone it can increase its elasticity, favouring the
movement of the implant; and thirdly, the even-
tual placement of the implant without total con-
tact with the alveolar or palatal bone remnant.
The ZAGA Concept pays special attention to
the importance of the contact of the externally
placed implant with the alveolar bone remnant in
addition to the zygomatic anchorage. Regardless
of whether the implant is placed through the
­palatal bone or externalised, it is essential that the
implant has intimate contact with the alveolar or
palatal bone. In fact, Becktor et al. in 2005 [29],
using the original technique in 16 consecutive
patients, had infectious complications in several
of their patients due to oro sinus communica-
tions. The authors attributed the origin of the
bone destruction to uncontrolled coronal peri-­
implant micromovement.
The construction of the provisional prosthesis
begins at surgery. During implant placement, the
surgeon must ensure that the implant is correctly
tilted towards the antagonist dentition. Ideally the
surgeon will have a prosthetic guide to relate the
emergence of the implants to the antagonist den-
tition and provide the implant head with an
appropriate abutment type in length and angula-
tion (Fig. 11.14).
For the choice of the abutment length it will be
important to have photographs of the patient in
the operating room in different smile intensities
without prosthesis as well as analyse the quantity
and biotype of the soft tissue surrounding the
implant to estimate its final height after healing.
C. Aparicio et al.
Fig. 11.14 Occlusal view of a prosthetic guide for check-
ing the direction of the prosthetic screw
Table 11.2 General rules for a full-arch immediate
prosthesis
• Maximum accuracy in impression taking, whether
digital or analogue
• Rigid initial splinting of all implants with transverse
stabilisation of the arch
• Dentition/occlusal surface/shortened to the limit
marked by the emergence of the distal implants
• Flat or convex but never concave prosthetic mucosal
interface
• Use of Henry Beyron’s principles for an optimal
occlusion adapted to an implant-anchored prosthetic
situation [28]
• Soft diet for 3 months
The immediate screw-retained immediate
prosthesis on zygomatic implants does not have
specific components. For an implant-anchored
provisional prosthesis, the general rules detailed
in Table 11.2 are recommended. The structure
should be rigid and accurately constructed for
better load distribution. If the prosthesis is not
sufficiently rigid, deformation and deflection of
the zygomatic implant can lead to poor distribu-
tion of masticatory loads and facilitate micro-
movements that impede osseointegration,
peri-implant bone loss or screw loosening.
To optimise force distribution, rigid stabilisa-
tion will be of the full arch and will include all
implants (Fig. 11.15). It will be essential to
reduce or eliminate buccal/distal lever arms.
Forces that cause bending moments are known to
be the most unfavourable.
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
Fig. 11.15 Frontal/gingival view of a temporary prosthe-
sis. Note the good AP distribution of the implants and the
perfect design of the mucosal prosthesis interface that will
allow the patient to maintain hygiene. (Image courtesy of
Dr. Fadi Yasmine)
11.6 The ORIS Criteria to Evaluate
the Results of the Zygoma
Anchored Oral
Rehabilitation
There is a tendency to validate, and subsequently
use, the same diagnostic methods to assess the
condition of teeth and oral implants. Similarly,
there is a tendency to consider and evaluate a
zygomatic implant in the same way as a conven-
tional implant. However, zygomatic implants dif-
fer from traditional implants in their
biomechanics, clinical procedures, anatomical
sites to which they relate and possible complica-
tions. In other words, zygomatic implants are dif-
ferent from normal implants and to consistently
evaluate the success of treatment with zygomatic
implants the same parameters cannot be used as
when evaluating conventional implants.
Moreover, the current zygomatic approach is rel-
atively new, especially if the head of the zygo-
matic implant is located in an extra maxillary
area with interrupted alveolar bone around its
perimeter. To compare in fine and thus improve
the quality of the evaluation procedure, specific
success criteria for zygomatic implants have been
proposed in the literature [7, 26, 30]. In the afore-
mentioned works, ORIS is the acronym for off-
set, rhinosinusitis, infection and stability. ORIS is
also a term of Latin origins with a broad meaning
covering the face, the mouth, pronunciation,
309
speech and facial expression. It was chosen as a
mnemonic tool because it somehow covers all
four specific criteria expressing the long-term
status of a single zygomatic implant.
• Offset: Evaluation of prosthetic success based
on the final position of the zygomatic implant
with respect to the centre of the alveolar ridge.
• Rhino-sinuses status: Adopting clinical and
radiological criteria widely accepted in the
ENT literature. Specifically, the Lanza–
Kennedy clinical test [31] and the modified
Lund–Mackay radiological test [32] are
used to compare the sinus status by analys-
ing the pre-­ surgical and post-surgical
CBCT.
• Infection-related soft tissue dehiscence: An
evaluation of signs of infection or soft tissue
dehiscence on a grading scale based on the
reference photographs obtained.
• Stability report: Accepting as success criteria
a certain mobility without signs of rotational
dis-osseointegration or apical pain.
Based on these criteria, five possible condi-
tions may be assessed when evaluating zygo-
matic implants [7]:
• Success condition I: represents the optimal
stage.
• Success condition II: represents an alteration
of routine without clinical impact.
• Success condition III: represents a borderline
situation with alterations that are clinically
manifested but are still possible to success-
fully treat.
• Success condition IV: would represent the sur-
viving implant that supports the prosthesis but
has not been measured according to the pro-
posed criteria
• Success condition V: reflects implant failure.
Specific criteria to describe success/survival
of zygomatic implants are necessary, both to
write and read scientific literature related to
zygomatic implant–based oral rehabilitations.
Given that the success criteria we use to evaluate
conventional implants (i.e. assessment of mar-
310
ginal bone height over time) cannot be used, the
implementation of ORIS success criteria as a
follow-up tool is key to assessing the long-term
multi-aspect success of the treatment.
11.7 Conclusions
The ZAGA Concept is a natural evolution of the 4.
original zygomatic implant process originated by
Branemark.
Unlike the previously described systems that
promote a surgical technique that is applied to all
5.
patients in a similar manner, the ZAGA Concept
promotes a patient-specific therapy that is tai-
lored to each patient’s anatomy. It provides 6.
patients with advanced maxillary atrophy the
opportunity to regain masticatory and aesthetic
function achieving more anatomical prostheses 7.
while minimising the risk of oroantral communi-
cations and sinus infections.
The ZAGA Concept includes prosthetic–bio- 8.
mechanical and surgical–anatomical criteria that
guide the decision-making in determining the
implant trajectory, the type of osteotomy and also
the choice of the most appropriate implant design.
The use of ZAGA achieves success by adapt-
ing technologies, criteria and tools to the patient’s 9.
anatomy, rather than adopting a rigid one-size-­
fits-all approach.
The results of using the combination of the 10.
ZAGA Concept, along with more individualised
instrumentation, including the new ZAGA
implant designs proposed by the authors, show a
consistently less traumatic osteotomy, increased
implant stability, improved bone-to-implant con-
tact, bone sealing and bed adaptation.
References
1. Brånemark P-I, Gröndahl K, Ohrnell L-O, Nilsson
P, Petruson B, Svensson B, et al. Zygoma fixture in
the management of advanced atrophy of the max-
illa: technique and long-term results. Scand J Plast
Reconstr Surg Hand Surg. 2004;38:70–85.
2. Jensen OT, Adams M, Cottam JR, Ringeman J. Occult
peri-implant oroantral fistulae: posterior maxil-
lary peri-implantitis/sinusitis of zygomatic or den-
C. Aparicio et al.
tal implant origin. Treatment and prevention with
bone morphogenetic protein-2/absorbable collagen
sponge sinus grafting. Int J Oral Maxillofac Implants.
2013;28:e512–20.
3. Davó R, Felice P, Pistilli R, Barausse C, Marti-Pages
C, Ferrer-Fuertes A, et al. Immediately loaded zygo-
matic implants vs conventional dental implants in
augmented atrophic maxillae: 1-year post-loading
results from a multicentre randomized controlled trial.
Eur J Oral Implantol. 2018;11:145–61.
Felice P, Barausse C, Davó R, Pistilli R, Marti-Pages
C, Ferrer-Fuertes A, et al. Immediately loaded zygo-
matic implants versus conventional dental implants in
augmented atrophic maxillae: three-year post-loading
results from a multicentre randomised controlled trial.
Clin Trials Dentistry. 2020;2:5–25.
Aparicio C, editor. Zygomatic implants: the anatomy-­
guided approach. 1st ed. Chicago: Quintessence;
2012.
Aparicio C. A proposed classification for zygomatic
implant patients based on the zygoma anatomy guided
approach (ZAGA): a cross-sectional survey. Eur J
Oral Implantol. 2011;4:269–75.
Aparicio C, López-Piriz R, Albrektsson T. ORIS
criteria of success for the zygoma-related rehabilita-
tion: the (revisited) zygoma success code. Int J Oral
Maxillofac Implants. 2020;35:366–78.
Aparicio C, Lopez-Piriz R, Peñarrocha
M. Preoperative evaluation and treatment planning.
Zygomatic implant critical zone (ZICZ) location. In:
Quimby A, Salam S, editors. Perspectives on zygo-
matic implants. Fernandes RP, Consul. Ed. Atlas
of the oral and maxillofacial surg clinics of North
America. Amsterdam: Elsevier; 2021. p. 185–202.
Aparicio C. Soft tissue management in zygo-
matic implant rehabilitation. In: Aparicio C, editor.
Advanced zygomatic implants: the ZAGA concept.
Chicago: Quintessence; 2023; in press.
Aparicio C, Polido WP, Chow J, David L, Davo R,
De Moraes EJ, Fibishenko A, Ando M, Mclellan G,
Nicolopoulos C, Pikos MA, Zarrinkelk H, Balshi
TJ, Peñarrocha M. Identification of the pathway and
appropriate use of four zygomatic implants in the
atrophic maxilla: a cross-sectional study. Int J Oral
Maxillofac Implants. 2021;36:807–17. https://doi.
org/10.11607/jomi.8603.
11. Aparicio C. The ZAGA concept as patient-specific
zygomatic therapy. Parameters for decision-making
on the implant trajectory. In: Aparicio C, editor.
Advanced zygomatic implants: the ZAGA concept.
Chicago: Quintessence; 2023; in press.
12. Nkenke E, Hahn M, Lell M, Wiltfang J, Schultze-­
Mosgau S, Stech B, et al. Anatomic site evaluation
of the zygomatic bone for dental implant placement.
Clin Oral Implants Res. 2003;14:72–9. https://doi.
org/10.1034/j.1600-­0501.2003.140110.x.
13. Mattsson T, Köndell PA, Gynther GW, Fredholm
U, Bolin A. Implant treatment without bone graft-
ing in severely resorbed edentulous maxillae. J Oral
Maxillofac Surg. 1999;57:281–7.
11 Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic…
14. Krekmanov L, Kahn M, Rangert B, Lindstrom
H. Tilting of posterior mandibular and maxillary
implants for im- proved prosthesis support. Int J Oral
Maxillofac Implants. 2000;15:405–14.
15. 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(1):39–49.
16. Brunski JB. In: Aparicio C, editor. Biomechanical
aspects of tilted regular and zygoma implants.
Zygomatic implants: the anatomy-guided approach.
London: Quintessence; 2012. p. 25–45.
17. Carter DR, Caler WE, Spengler DM, Frankel
DM. Fatigue behavior of adult cortical bone: the
influence of mean strain and strain range. Acta Orthop
Scand. 1981;52(5):481–90.
18. Brunski JB. In: Ratner ASHBD, Schoen FJ, Lemons
JE, editors. Metals: basic principles. Biomaterials sci-
ence: an introduction to materials in medicine. 3rd ed.
Waltham, MA: Elsevier; 2013. p. 111–9.
19. Harrison A. Methods of assessing visual acuity in
young children. Am Orthopt J. 1975;25:109–14.
20. Harrison A, Lewis TT. The development of an abra-
sion testing machine for dental materials. J Biomed
Mater Res. 1975;9(3):341–53.
21. Brunski JB, Aparicio C. Biomechanics in the context
of tilted implants. In: Aparicio C, editor. Advanced
zygomatic implants: the ZAGA concept. Chicago:
Quintessence; 2023; in press.
22. Corvello PC, Montagner A, Batista FC, Smidt R,
Shinkai RS. Length of the drilling holes of zygomatic
implants inserted with the standard technique or a
revised method: a comparative study in dry skulls. J
Craniomaxillofac Surg. 2011;39(2):119–23.
23. Ujigawa K, Kato Y, Kizu Y, Tonogi M, Yamane
GY. Three-dimensional finite elemental analysis of
zygomatic implants in craniofacial structures. Int J
Oral Maxillofac Surg. 2007;36:620–5.
311
24. Freedman M, Ring M, Stassen LFA. Effect of alve-
olar bone support on zygomatic implants: a finite
element analysis study. Int J Oral Maxillofac Surg.
2013;42:671–6.
25. Freedman M, Ring M, Stassen LFA. Effect of alveolar
bone support on zygomatic implants in an extra-sinus
position--a finite element analysis study. Int J Oral
Maxillofac Surg 2015;44:785–790.
26. Aparicio C, Manresa C, Francisco K, Claros P,
Alández J, González-Martín O, et al. Zygomatic
implants: indications, techniques and outcomes,
and the zygomatic success code. Periodontol 2000.
2014;66:41–58.
27. Aparicio A, Aparicio C. Prosthodontics aspects of
the zygoma rehabilitation. In: Aparicio C, editor.
Zygomatic implants: the anatomy-guided approach.
1st ed. Chicago: Quintessence; 2012.
28. Aparicio A, Aparicio C. Prosthetic rehabilitation. In:
Aparicio C, editor. Advanced zygomatic implants.
The ZAGA Concept. Chicago: Quintessence; 2023;
in press.
29. Becktor JP, Isaksson S, Abrahamsson P, Sennerby
L. Evaluation of 31 zygomatic implants and 74 regu-
lar dental implants used in 16 patients for prosthetic
reconstruction of the atrophic maxilla with cross-­
arch fixed bridges. Clin Implant Dent Relat Res.
2005;7:159–65.
30. Aparicio C, Manresa C, Francisco K, Aparicio A,
Nunes J, Claros P, et al. Zygomatic implants placed
using the zygomatic anatomy-guided approach versus
the classical technique: a proposed system to report
rhinosinusitis diagnosis. Clin Implant Dent Relat Res.
2014;16:627–42.
31. Lanza DC, Kennedy DW. Adult rhinosinusitis defined.
Otolaryngol Head Neck Surg. 1997;117:s1–7.
32. Lund VJ, Mackay IS. Staging in rhinosinusitis.
Rhinology. 1993;31:183–4.
 Clinical Techniques for Immediate
Loading
Stephanie Yeung and Saj Jivraj
Abstract
Patient factors and implant biomechanics
influence the rationale, requirements and tech-
niques for the immediate loading procedure.
Proper patient selection, treatment planning
and operation method will lead to a predict-
able, expeditious outcome for re-establishing
a patient’s comfort and function. There are
multiple subjective and objective patient and
surgical factors to consider. Additionally,
there are multiple approaches to completing
the immediate loading clinical procedure
itself, with the most common being direct,
direct–indirect or the indirect technique. Each
technique bears technical and patient-related
advantages and disadvantages. This section
will review the general requirements for
patient selection and describe the three meth-
ods of completing an immediate loading pro-
cedure for full-arch fixed implant-supported
restorations.
S. Yeung
Private Practice, Los Angeles, CA, USA
S. Jivraj (*)
Anacapa Dental Art Institute, Oxnard, CA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_12
12
12.1 Rationale for Immediate
Loading
Immediate loading is defined as the prosthetic
loading of dental implants within the first
week of loading [1]. From a biomechanical
standpoint, immediate loading can result in
success and survival rates comparable to con-
ventionally loaded dental implants [2].
Additionally, overall treatment time is
decreased and the patient’s functional abili-
ties are sooner established [3, 4]. Completing
this procedure yields the potential for
increased patient satisfaction predictably and
efficiently.
From a biomechanical standpoint, the suc-
cess underlying immediate loading is derived
from the allowance of 50–150 μm of micromo-
tion—and the ability of a well-designed
splinted restoration to limit it [3, 5]. Factors
that may influence micromotion and restorative
outcome include surgical planning, implant
positions, patient biology and prosthetic design
[6]. For the most predictable outcome, it is
imperative to select the best procedural course
with consideration to practicality and any clin-
ical restraints.
There are a variety of methods for fabricating
a splinted full-arch restoration within the first
week of implant placement. There are positive
313
314
and negative attributes to each method.
Restorations inserted within the day of implant
surgery will minimise the patient’s exposure to
anaesthesia and the restoration can precede post-
operative soft tissue swelling. Delaying insertion
by a few days may allow the patient time to rest.
However, the patient would also be subject to
repeated anaesthesia, in addition to considering
the risk of tissue expansion over healing
abutments.
The fabrication and insertion method selected
for immediate loading involves a series of objec-
tive and subjective variables. Objective determi-
nants include surgical planning, restorative
design and procedure timing. Subjective vari-
ables include personal preference, patient selec-
tion and patient preferences.
12.2 Requirements for Immediate
Loading
12.2.1 Patient Selection
There are multiple factors to consider in deter-
mining whether a patient is an ideal candidate for
immediate loading. Medical history, such as
bisphosphonates use, irradiation or immunosup-
pression, generally has a more difficult time with
wound healing and has higher implant failure
rates; thus, immediate loading may not be a good
option [7]. However, tobacco use and well-­
controlled diabetes may not necessarily pose a
risk [7, 8].
In addition to medical factors, there are
behavioural and dental factors to consider. A
history of periodontitis or parafunctional habits
may not be immediate contraindications [8, 9].
However, surgical factors related to implant
stability, such as position, bone quality and
force distribution, can contribute negative
impacts [10]. Therefore, prosthetic design must
also be factored in for optimal rigidity of the
prosthesis in conjunction to occlusal design for
function [11]. Postoperative patient compliance
to a soft diet and dental hygiene maintenance
S. Yeung and S. Jivraj
are also influential components for a successful
outcome [ 12–14].
12.2.2 Surgical Considerations
Placement of an adequate number of implants in
well-dispersed positions is necessary for suc-
cessful immediate loading. The goal in implant
numbering and positioning is to limit micromo-
tion and allow even distribution of occlusal
forces. The number and position of implants
may also be influenced by bone quality, insertion
torque at the time of surgery or even implant
length [8, 15, 16].
The accepted minimum number is four
implants in the mandible and four to six implants
in the maxilla; fewer implants may yield unpre-
dictable results [3, 16–18]. If the distance
between implants is too great, prosthetic failure
may occur as a result of a large cantilever; con-
versely, too little distance may decrease resin
bulk, thus leading to a weaker prosthesis [19].
12.2.3 Restorative Considerations
The ideal prosthesis used in full-arch immediate
loading is hygienic, rigid, aesthetic and allows
for an even distribution of forces. To avoid inter-
fering with healing processes, restorations should
be convex for ease of hygiene maintenance.
Additionally, screw retention is recommended to
avoid cement-related irritation as well as exces-
sive pull-out forces [20].
Aesthetics, rigidity and force distribution can
be managed through occlusal design and alloca-
tion of sufficient space for teeth and acrylic bulk
[8]. The importance of force distribution is para-
mount, considering that survival rates are gener-
ally improved when immediately loaded
prostheses opposing natural dentition have higher
success rates relative to opposing implants [21].
If occlusal forces are a potential concern, flatten-
ing cusps for balance and narrowing of occlusal
surfaces should decrease occlusal forces [3].
12 Clinical Techniques for Immediate Loading 315

12.3 Immediate Loading: Clinical

Methods

Regardless of loading method, there are pertinent

diagnostic details that need to be available prior
to proceeding with the procedure itself.
Preoperative information, such as radiographs,
diagnostic casts, clinical charting and photos,
should be made to aid surgical and restorative
planning. Radiographs should include a full-arch
cone beam computed tomography (CBCT) to
help determine implant positioning and any
adjunctive surgeries. Diagnostic casts can either
be made using conventional impression materials
or scanned intraorally. Preoperative photos
should include frontal, profile and smile views to
help determine tooth positioning and any dishar-
monies that can be surgically accounted for, such
as the transition zone from prosthesis to gingiva.
If necessary, a tooth setup should be made to
establish vertical dimension, phonetics, aesthet-
ics and occlusal plane.
Upon completion of implant placement, seat-
ing of multi-unit abutments is recommended to
elevate the fixture levels to or above gingival
height for clinical access, altering implant trajec-
tories if needed, passivity of the prosthesis and
hygienic access. There are scenarios in which
using multi-unit abutments is unfeasible, such as
situations involving limited restorative space.
Additionally, healing caps or healing abutments
should be used to maintain access to restorative
platforms while the fixed prosthesis is being con-
verted or fabricated.
Fig. 12.1 Intaglio of removable denture featuring well-­
extended flanges, full palatal coverage and ideal tooth
positioning over the crest of the alveolar ridge
positioning within the prosthesis, which could
result in a difference in chair time and compara-
bly improved strength of the resulting immediate
load prosthesis. Regardless of approach, both
require the fabrication of a denture or indexed
removable prosthesis prior to surgery. The remov-
able prosthesis is used to pick up temporary cyl-
inders fixed to the dental implants intraorally, and
then converted into a fixed prosthesis extraorally.
In the conventional method, it is important to
identify any anatomical landmarks available to
properly orient the prosthesis prior to any attempt
at conversion; landmarks may include the palate,
remaining teeth, pre-existing implants or even
unaltered ridge areas (Fig. 12.1). For the digital
method, the removable prosthesis must seat per-
fectly into the anchored guide.

12.3.1 Direct Technique: Direct 12.3.1.1 Conventional Approach

Denture Pick-Up Using the removable prosthesis, a rapid-set sili-
and Conversion cone impression is made to identify the implant
locations. The following images depict a com-
The direct technique differs from others in that it plete denture containing a polyvinyl siloxane bite
almost exclusively functions as a same-day post-­ registration material demarcating the implant
surgery solution. Ideally, there should be an sites. The removable prosthesis should be relieved
acceptable opposing arch with occlusion in this around these marked sites to allow a passive seat-
procedure. Currently, there are two main meth- ing of the prosthesis relative to the anatomical
ods of the direct technique: conventional and indices (Figs. 12.2, 12.3, and 12.4).
digital. The main difference between the two Temporary cylinders are to be seated at this
main methods is the predictability of implant point. Radiographs should be taken to verify
316
Fig. 12.2 Frontal view of denture used for conversion
Fig. 12.3 Rigid polyvinyl siloxane material indexing
location of healing abutments
Fig. 12.4 Relief of denture at sites marked by PVS
material
seating if at implant level. Parallelism between
the temporary cylinders should be visually
checked and any multi-unit abutments necessitat-
ing repositioning should be completed. Once par-
S. Yeung and S. Jivraj
Fig. 12.5 Seating of initial temporary abutment
Fig. 12.6 Seating with denture to check for passivity and
verify sufficient clearance for pick-up resin
allelism is deemed acceptable, the removable
prosthesis may be tried for passivity while
indexed to the selected anatomical reference(s).
The removable prosthesis should be tried over
one temporary cylinder at a time to ensure that
the trajectory of any single cylinder does not
interfere with seating of the prosthesis. Temporary
cylinders should not be in contact with any sur-
faces of the removable prosthesis; if contact is
visible, further relief of the prosthesis is neces-
sary. It is imperative that there is sufficient relief
around the temporary cylinders to ensure that
there is no interference in seating and that there
will be sufficient space for pick-up resin to flow
(Figs. 12.5, 12.6, 12.7, 12.8, 12.9, and 12.10).
Prior to using any pick-up resin, measures
must be taken to avoid allowing resin to flow into
undesired areas. A rubber dam or rubber dam
pieces should be adapted around all temporary
cylinders to prevent resin from flowing onto
12 Clinical Techniques for Immediate Loading
Fig. 12.7 Seating of denture over two temporary abut-
ments to verify passivity sufficient clearance for pick-up
resin
Fig. 12.8 Intraoral view of two temporary abutments.
Note: angulation is slightly off-angle, which may interfere
with passivity of denture upon insertion
Fig. 12.9 Seating of denture over four temporary abut-
ments to verify passivity sufficient clearance for pick-up
resin. Note: angulations are slightly off-angle, which may
interfere with passivity of denture upon insertion. All
implant accesses should be clearly visible from the occlu-
sal view. This denture required additional relief for the
implant in the upper-left region
317
Fig. 12.10 Intraoral view of four temporary abutments.
Note: angulation is slightly off-angle, which may interfere
with passivity of denture upon insertion
Fig. 12.11 Preparation for intraoral pick-up with rubber
dam isolation
sutures or into the surgical site. To prevent
potential screwdriver access issues, temporary
­
cylinder access holes should also be plugged with
removable block-out material, such as rapid-set
silicone or Teflon. The removable appliance
should be placed ensuring that it is seated in the
palate area (Figs. 12.11, 12.12, and 12.13).
Autopolymerising acrylic resin can be used to
carefully pick up the temporary cylinders. It is
recommended that temporary cylinders be
indexed into the prosthesis individually to main-
tain passivity and ensure sufficient resin is used
to secure the position. Once one cylinder has
been secured the patient must be viewed for
accurate tooth position and occlusal plane. Once
this is deemed satisfactory the remaining cylin-
ders can be attached. Once all temporary cylin-
ders have been indexed into the denture and the
resin has been allowed to sufficiently set, it may
318 S. Yeung and S. Jivraj

Fig. 12.12 Placement of protective material to prevent Fig. 12.15 Occlusal view of maxilla upon removal of
ingress of excess material into implant access holes in converted prosthesis
temporary abutment

Fig. 12.16 Intaglio view of converted prosthesis prior to

Fig. 12.13 Frontal view of removable denture in situ as finishing
pick-up resin is setting
finishing the implant fixture contact surfaces.
Flanges should be reduced to allow direct visibil-
ity of the analogue abutment collars from a lat-
eral view; this will aid in fabricating a hygienic,
convex gingival surface. Additional acrylic resin
can then be added to firmly fixate the temporary
cylinders, provide resin bulk and finalise the
shape of the fixed restoration. Temporary cylin-
ders should also be adjusted to remove occlusal
or contour interferences (Figs. 12.17, 12.18,
12.19, and 12.20).
Upon insertion of the finished converted pros-
Fig. 12.14 Occlusal view of removable as pick-up mate- thesis, passivity should be verified by tactile sen-
rial is setting sation when tightening screws and seating
verified with radiographs, followed by occlusal
be removed from the mouth for finishing proce- adjustment. Care should be taken to verify a fair
dures (Figs. 12.14, 12.15, and 12.16). distribution of occlusal forces, especially if there
Once the prosthesis is detached from the are any cantilevers. There should be no active
patient, polishing protectors should be connected gingival blanching or tissue pressure (Figs. 12.20
to the temporary cylinders to prevent over-­ and 12.21).
12 Clinical Techniques for Immediate Loading
Fig. 12.17 Intaglio view of converted prosthesis after
adding resin to create convex or more hygienic contours
Fig. 12.18 Removal of sharp edges and excess material
on cameo surface of converted prosthesis
Fig. 12.19 Frontal view of finished immediate load
prosthesis
The mandibular arch is much more chal-
lenging to load utilising the direct technique.
When a significant amount of bone reduction
has been done, the prosthesis is usually not
very stable and obtaining adequate centric
relation records can be difficult. This is com-
pounded by the numbness of the patient post
surgery.
319
Fig. 12.20 Posterior and intaglio view of immediate load
prosthesis
Fig. 12.21 Immediate load prosthesis in situ
The restorative dentist must work diligently
with the surgeon and laboratory technician to
determine approximately the amount of bone
reduction that is required, and this must be
approximately replicated on the casts.
12.3.1.2 Technique for the Mandible
The following are necessary for an optimal
outcome:
1. Approximation of bone reduction on casts.
2. Fabrication of a bone reduction guide with a
reference from which the surgeon can
measure.
3. Fully extended denture.
The following illustrates the clinical sequence:
(a) A silicone bite registration is placed in the
intaglio of the denture and the denture is
placed intraorally over the healing caps.
(b) The patient is guided into maximal intercus-
pal/CR position. This can be attained with
the use of a silicone index also.
320 S. Yeung and S. Jivraj

(c) This position is verified for repeatability.

(d) A section of the silicone material is removed
in the anterior area of the denture and a tem-
porary cylinder placed intraorally. A hole is
made in the intaglio of the denture corre-
sponding to the marking of healing cap. The
denture is seated over the temporary cylinder
intraorally.
(e) Self-cured acrylic resin is used to pick up the
temporary cylinder.
(f) The denture with attached temporary cylin-
der is removed. Fig. 12.22 Frontal view of mandibular removable den-
(g) The adjacent section of silicone is removed ture indexing implant healing abutments with aid of
opposing occlusion
from the intaglio of the denture and a tempo-
rary cylinder is placed intraorally. A second
hole is made in the intaglio of the denture
corresponding to the position of the second
temporary cylinder.
(h) The denture is placed back into the mouth
screw retained by the first picked up cylinder.
The rigid silicone material in the posterior
aspect provides anteroposterior stability. The
second temporary cylinder should not inter-
fere with the seating of the denture. The tem-
porary cylinder is picked up with self-cured
acrylic resin.
(i) A similar sequence is followed to attach the Fig. 12.23 Intaglio view of mandibular removable den-
third and then the fourth temporary ture with rigid polyvinyl siloxane index demarcating
implant healing abutment positions
cylinders.
(j) Once all temporary cylinders are picked up
the prosthesis is removed and taken to the
laboratory for finishing and processing
(Figs. 12.22, 12.23, 12.24, 12.25, 12.26,
12.27, 12.28, 12.29, 12.30, 12.31, 12.32,
12.33, 12.34, 12.35, 12.36, 12.37, 12.38, and
12.39).

12.3.1.3 Digital Method

The digital method of direct immediate loading
removes a significant amount of uncertainty from
the conventional workflow. The aid of bone-­
anchoring devices bypasses potential issues asso-
ciated with stability and orientation of the
removable prosthesis during the conversion pro-
cess. In the digital approach, many factors are
predetermined in the surgical planning process,
including implant position and multi-unit abut-
ment angulations. In some systems, when the
Fig. 12.24 Selective sectioning of PVS index and clear-
ance of area surrounding one implant position
fully guided surgical sequence is executed per-
fectly, many of the steps found in the conven-
tional approach can be bypassed. In the event that
a fully guided surgery cannot be executed to the
12 Clinical Techniques for Immediate Loading 321

Fig. 12.25 Intraoral frontal view of single temporary Fig. 12.28 Occlusal view of first temporary abutment
abutment to be picked up first pick-up with aid of opposing occlusion and remaining
PVS index to maintain position

Fig. 12.26 Intraoral occlusal view of denture seating to

check for passivity and verify sufficient clearance for Fig. 12.29 Intaglio view of first temporary abutment
pick-up resin after resin has set

Fig. 12.27 Frontal view of first temporary abutment Fig. 12.30 Intaglio view of conversion prosthesis as sec-
pick-up with aid of opposing occlusion and remaining ond section of index is removed for pick-up of second
PVS index to maintain position temporary abutment
322 S. Yeung and S. Jivraj

Fig. 12.31 Intraoral view of temporary abutment in situ Fig. 12.34 Drilling of initial holes through index to cre-
ate clearance for two more temporary abutments

Fig. 12.32 Intraoral occlusal view of pick-up of second

temporary abutment Fig. 12.35 Intaglio view of conversion prosthesis after
holes have been sufficiently widened to create clearance
for passivity of fit and space for material to flow around
remaining temporary abutments

Fig. 12.33 Intaglio view of two temporary abutments

after resin has set
Fig. 12.36 Intraoral frontal view of last two temporary
abutments
12 Clinical Techniques for Immediate Loading
Fig. 12.37 Intraoral occlusal view of one temporary
abutment being picked up
Fig. 12.38 Lateral view of finished immediate load
prosthesis
Fig. 12.39 Intraoral frontal view of finished immediate
load prosthesis in situ
original plan, the removable prosthesis may still
be usable for immediate loading using the con-
ventional approach. Additionally, some digital
workflows still rely entirely on the conventional
approach to immediate loading the removable
prosthesis.
323
12.3.1.4 This Is a Sample Workflow
Care must be taken to verify that the removable
prosthesis fully engages the anchored guide with-
out any interferences. This must be checked prior
to and after seating temporary cylinders. If any
interference is detected, the removable prosthesis
should be adjusted to allow passivity. It is imper-
ative that there is sufficient relief around the tem-
porary cylinders to ensure that there is no
interference in seating and that there will be suf-
ficient space for pick-up resin to flow.
Additionally, radiographs should be taken to ver-
ify seating of temporary cylinders (Figs. 12.40
and 12.41).
Prior to using any pick-up resin, measures
must be taken to avoid allowing resin to flow into
undesired areas. A rubber dam or rubber dam
pieces should be adapted around all temporary
cylinders to prevent resin from flowing onto
sutures or into the surgical site. To prevent poten-
tial screwdriver access issues, temporary cylinder
access holes should also be plugged with remov-
able block-out material, such as rapid-set silicone
or Teflon (Figs. 12.42 and 12.43).
Autopolymerising acrylic resin can be used to
carefully pick up the temporary cylinders. It is
recommended that temporary cylinders be
indexed into the prosthesis individually to main-
tain passivity and ensure sufficient resin is used
to secure the position. Once one cylinder has
been secured the patient must be viewed for
accurate tooth position and occlusal plane. Once
this is deemed satisfactory the remaining cylin-
ders can be attached. Once all temporary cylin-
ders have been indexed into the denture and the
resin has been allowed to sufficiently set, it may
be removed from the mouth for finishing proce-
dures (Fig. 12.44).
Once the prosthesis is detached from the
patient, polishing protectors should be connected
to the temporary cylinders to prevent over-­
finishing the implant fixture contact surfaces.
Additional extensions should be reduced to allow
direct visibility of the analogue abutment collars
from a lateral view; this will aid in fabricating a
hygienic, convex gingival surface. Additional
acrylic resin can then be added to firmly fixate
the temporary cylinders, provide resin bulk and
324 S. Yeung and S. Jivraj

Fig. 12.40 Intraoral view of multi-unit abutments after Fig. 12.43 Intraoral view of index for seating immediate
completion of fully guided surgery load prosthesis

Fig. 12.41 Intraoral view of temporary abutments seated Fig. 12.44 Intraoral view of immediate load prosthesis
on multi-unit abutments with pick-up resin

Fig. 12.42 Intraoral view of temporary block-out mate- Fig. 12.45 Intraoral view of immediate load prosthesis
rial placed in temporary abutments to prevent ingress of upon removal of excess material to verify seat within
excess resin during pick-up procedure index

Upon insertion of the finished converted pros-

finalise the shape of the fixed restoration. thesis, passivity should be verified by tactile sen-
Temporary cylinders should also be adjusted to sation when tightening screws and seating
remove occlusal or contour interferences verified with radiographs, followed by occlusal
(Fig. 12.45). adjustment. Care should be taken to verify a fair
12 Clinical Techniques for Immediate Loading 325

ing temporary abutments and holes in

prosthesis.
(e) Rubber dam (or similar material for block-­
out) is attached to the temporary cylinders to
prevent material ingress into surgical site.
(f) Autopolymerising resin is used to pick up the
temporary cylinders, one at a time.
(g) Once all temporary cylinders are picked up,
the prosthesis is removed and taken to the
laboratory for finishing and processing.

Fig. 12.46 Frontal view of finished immediate load pros-

thesis in situ 12.3.2 Direct–Indirect Technique:
Impression with Denture
distribution of occlusal forces, especially if there for Conversion
are any cantilevers. There should be no active
gingival blanching or tissue pressure (Fig. 12.46).In the direct–indirect technique, a conventional
denture or similarly indexed removable prosthe-
12.3.1.5 Technique sis is made prior to the surgery. This prosthesis
The restorative dentist must work diligently with is used to capture impression copings attached
the surgeon and laboratory technician to deter- to the dental implants/multi-unit abutments in a
mine approximately the amount of bone reduc- full-arch silicone impression intraorally, and
tion that is required, and this must be subsequently converted into a prosthesis extra-
approximately replicated on the casts. orally. This procedure works best with existing
The following are necessary for an optimal articulated study models since it allows for more
outcome: accurate jaw relation records and occlusal
adjustments during finishing procedures
1. Digital planning for fully guided surgery and (Fig. 12.47).
removable prosthesis. This procedure differs from the direct tech-
2. Fabrication of a bone-anchored guide, which nique in that a more accurate model depicting the
adapts perfectly to an alveolar reduction guide gingival architecture is made; additionally, it
and implant osteotomy/placement sleeves. maintains the benefits of using anatomical land-
3. Removable prosthesis that adapts to bone-­ marks for transferring implant positions. An
anchored guide or for conventional loading. additional advantage is if the immediate load pro-
visional were to break the clinician has a model
The following illustrates a sample clinical on which repairs can be performed.
sequence: Using the removable prosthesis, a rapid-set
silicone impression is made to generally identify
(a) Implant surgery is completed using bone-­ the implant locations (Fig. 12.48). (Figures 12.49
anchored guide. and 12.50 depict a complete denture containing a
(b) Removable prosthesis is tried to visually ver- polyvinyl siloxane bite registration material
ify that clearance is available around demarcating the implant sites. The removable
implants. prosthesis should be relieved around these
(c) Temporary abutments are placed. marked sites to allow a proper seating of the pros-
Radiographs are taken to verify seat as thesis based on identified anatomical indices.)
needed. Upon passive seating of the denture over the
(d) Removable prosthesis is again tried to verify healing caps or abutments and any minor adjust-
passivity and clearance between the protrud- ments necessary to account for occlusion or verti-
326
Fig. 12.47 Occlusal view of implants with multi-unit
abutments and healing abutments in situ
Fig. 12.48 Intaglio view of removable denture with rigid
polyvinyl siloxane material indexing positioning of heal-
ing abutments
Fig. 12.49 Cameo view of removable denture with relief
provided for passivity around pick-up impression
components
S. Yeung and S. Jivraj
cal dimension, a jaw relation can be obtained to
allow mounting of the poured model.
Pick-up impression copings may be seated at
this point. Radiographs should be taken to verify
seating. Subsequently, the removable prosthesis
should be tried for passivity while indexed to the
selected anatomical reference(s). Impression
copings should not be in contact with any sur-
faces of the removable prosthesis; if contact is
visible or detected otherwise, further relief of the
prosthesis is necessary. It is imperative that there
is sufficient relief around the temporary cylinders
to ensure that there is no interference in seating,
in addition to allowing sufficient space for
impression material to flow (Figs. 12.51, 12.52,
Fig. 12.50 Intraoral occlusal view of pick-up impression
copings on abutments
Fig. 12.51 Occlusal view of removable denture with
impression material surrounding critical components and
anatomical landmarks
12 Clinical Techniques for Immediate Loading 327

Fig. 12.52 Frontal view of removable denture with Fig. 12.54 Frontal view of removable denture with
impression material surrounding critical components and impression containing pick-up impression components
anatomical landmarks and corresponding lab analogues

Fig. 12.53 Intaglio view of removable denture with

impression containing pick-up impression components Fig. 12.55 Pouring of gypsum into removable denture
with impression material, pick-up impression components
and corresponding lab analogues
and 12.53). As an added method of security, self-­
curing resin may be used to splint impression
copings and minimise any distortion upon
removal of the impression.
Analogues should be attached to the impres-
sion copings prior to pouring the gypsum model.
The denture extensions should be lightly indexed
into the poured gypsum to allow ease of indexing
during subsequent finishing procedures; care
should be taken to avoid engaging any undercuts
in the flanges. Upon setting the gypsum, the
impression may be separated from the model. At
this point, the impression material and impres-
sion copings should be removed from the pros-
thesis. Without the impression copings, the Fig. 12.56 Lateral view of mounted removable denture
with impression material, pick-up impression components
removable prosthesis can be indexed to the model and corresponding lab analogues. Note: occlusal index for
and articulated (Figs. 12.54, 12.55, and 12.56). mounting
328 S. Yeung and S. Jivraj

After mounting the indexed removable pros-

thesis, it can once again be removed from the
impression to allow attachment of temporary cyl-
inders to the implant analogues. Once again,
there should be a passive, non-contacting rela-
tionship between the removable prosthesis and
the temporary prosthesis. At this stage, tempo-
rary cylinders should be adhered to the indexed
removable prosthesis with self-curing resin
(Figs. 12.57, 12.58, 12.59, and 12.60). After suc-
cessful attachment of all temporary cylinders,
flanges should be reduced to allow direct visibil- Fig. 12.59 Occlusal view of removable denture seated
ity of the analogue abutment collars from a lat- on mounted model, relieved to fit passively around tempo-
rary abutments. Note: impression material has been
eral view; this will aid in fabricating a hygienic,
removed, and temporary block-out material has been
convex gingival surface (Figs. 12.60, 12.61, placed in implant access holes to prevent ingress of excess
12.62, and 12.63). resin

Fig. 12.57 Occlusal view of gypsum model with impres-

sion copings Fig. 12.60 Placement of resin to adapt removable den-
ture to temporary abutments, while seated on gypsum
model

Fig. 12.58 Lateral view of mounted gypsum model with Fig. 12.61 Intaglio view of resin added to removable
temporary abutments seated on lab analogues denture, prior to finishing
12 Clinical Techniques for Immediate Loading
Fig. 12.62 Occlusal view of cameo surface of finished
immediate load prosthesis
Fig. 12.63 Intraoral lateral view of finished immediate
load prosthesis in situ
With the prosthesis fixed into the model, addi-
tional acrylic resin can be added to rigidly attach
the temporary cylinders, provide resin bulk for
strength and finalise the shape of the fixed resto-
ration. Temporary cylinders should be trimmed
to eliminate any interferences. Occlusion may be
adjusted on the articulator.
Upon insertion of the finished converted pros-
thesis, passivity should be verified by tactile sen-
sation when tightening screws and seating
verified with radiographs, followed by occlusal
adjustment. Care should be taken to verify a fair
distribution of occlusal forces, especially if there
are any cantilevers. There should be no visible
gingival blanching or tissue pressure (Figs. 12.64
and 12.65).
329
Fig. 12.64 Frontal view of finished immediate load pros-
thesis in situ
Fig. 12.65 Frontal view of maxillary and mandibular
wax try-in ready for conversion
12.3.3 Indirect Technique: Pick-Up
Impression with Extraoral
Conversion
Theoretically, an immediate-load fixed implant-­
supported restoration fabricated using the indi-
rect technique should be the strongest since it
avoids relieving larger holes into a removable
prosthesis for intraoral pick-ups. Additionally, it
is the least reliant on an existing denture for
establishing jaw relations. The procedure is time
consuming but does result in the most favourable
strength, aesthetics and fit.
There are two divergent methods for this
approach: conventional and digital. Both meth-
ods involve planning and processing of diagnos-
tic information, as well as impressions on the day
of surgery.
330 S. Yeung and S. Jivraj

In the conventional method, the equivalent of
impressions, jaw relation records and a wax try-
­in, is completed on the day of surgery. In the digi-
tal method, diagnostic information is used to
generate a digital denture tooth setup, which is
adapted to the digital impressions immediately
after surgery.
12.3.3.1 Conventional Method
On the day of surgery, there are multiple steps
taken. It involves PVS impressions of splinted
impression copings, jaw relation records and a
wax try-in for fit. The information is then all uti-
lised to process the immediate load prosthesis.
To obtain maximum strength the acrylic resin
can be reinforced with a silane-coated fibre,
which chemically bonds to the poly methyl
methacrylate resin (FIBERFORCE CST
Canada). A putty matrix is made of the tooth
setup and temporary cylinders are placed on the
master cast and opaqued. Fibre is wrapped
around the temporary cylinders in a specific
manner. The denture wax up is processed utilis-
ing injection processing for minimal shrinkage
and maximum strength (Figs. 12.66, 12.67,
12.68, 12.69, and 12.70).

Fig. 12.66 Gypsum

model made from
intraoral pick-up
impression. Putty matrix
of wax try-in verifies
sufficient clearance for
temporary abutments
and acrylic materials

Fig. 12.67 Temporary abutments are reinforced with fibre prior to addition of denture teeth and acrylic. After process-
ing and finishing, restoration is significantly more hygienic compared to direct immediate load prosthesis

Fig. 12.68 Frontal and

lateral view of maxillary
and mandibular wax
try-in
12 Clinical Techniques for Immediate Loading 331

12.3.3.2 Digital Method oral scanner used is executed. Flags are seated on
There are three key components for the digital the multi-unit abutments upon confirming angula-
approach to fabricating an indirect immediate load tion, and the scan is completed. An intraoral scan
restoration: patient selection, extraoral scanning or impression of the post-surgery soft tissue is
and computer-aided design and manufacturing. subsequently made. This information is then inte-
For this method, repeatable landmarks, such as grated with the digital tooth setup to manufacture
remaining teeth, must be identifiable in the a provisional using either additive or subtractive
patient’s mouth. Additionally, an extraoral scanner manufacturing processes (Figs. 12.65, 12.66,
for identifying implant positioning is strongly 12.67, 12.68, 12.69, 12.70, 12.71, 12.72, 12.73,
advised due to the intrinsic distortion associated 12.74, 12.75, 12.76, 12.77, and 12.78).
with intraoral scanning [22]. Lastly, none of this
can be completed without access to ­computer-­aided
design and manufacturing. The greatest shortcom-
ing of this method is the time required for manu-
facturing the prosthesis, which may require several
hours of laboratory fabrication time.
Prior to the day of surgery, intraoral and extra-
oral photos, and intraoral diagnostic scans with
jaw relationship information are obtained. This
information is used to design a digital mock-up of
tooth positioning, which will be confirmed upon
integrating post-surgery extraoral scan data. Upon
completion of surgery, the protocol for the extra-

Fig. 12.69 Finished prosthesis in situ Fig. 12.71 Lateral view of patient prior to surgery

Fig. 12.70 Finished

prosthesis in situ
332
Fig. 12.72 Frontal view of patient prior to surgery. Floss
marks midline, and selective teeth are used to aid digital
design of provisional implant prosthesis
Fig. 12.73 Intraoral frontal view of digital markers for
extraoral scanning in situ
Fig. 12.74 Intraoral frontal view of implant scan bodies
for intraoral tissue scan in situ
12.3.4 Direct Pick-Up Tooth-Only
Immediate Load Restoration
Bone preservation is considered a requirement
in more contemporary approaches to full-arch
implant rehabilitation. The above digital
S. Yeung and S. Jivraj
Fig. 12.75 Digital markers from extraoral scanning
combined with original diagnostic scan in design
software
Fig. 12.76 Digital markers from extraoral scanning,
intraoral tissue scan with scan bodies and original diag-
nostic scan in design software
Fig. 12.77 Digital design of provisional implant prosthe-
sis with precise implant positioning
method outlined an indirect digital method to
fabricate a full-arch immediate load provi-
sional replacing a tooth-only defect. Aesthetics
requires sculpting of the soft tissue to mimic
papilla. The following patient case presenta-
tion will outline a direct pick-up approach for
a tooth-only defect.
12 Clinical Techniques for Immediate Loading 333

The patient presented with a terminal dentition
and was treatment planned for a tooth-only maxil-
lary restoration and a mandibular restoration that
would require pink prosthetics (Fig. 12.79).
Impressions were made and a tooth-supported
surgical guide was fabricated for the maxilla.
Tooth-supported guides allow stability during
surgery and allow the surgeon to place dental
implants in an ideal three-dimensional position.
The surgeon uses the free gingival margin of the
guide for depth of implant placement and orien-
tation of the multi-unit abutment (Fig. 12.80).
Provisional restorations can be either milled
or conventionally processed (Fig. 12.81).
Once surgery is completed and tissues sutured,
a direct pick up of the provisional is done utilis-
ing the following process:

1. Protect the back of the throat.

2. Index the provisional on the caps of the mul-
tiunit abutments.
Fig. 12.78 Intraoral frontal view of provisional implant
prosthesis
3. Make holes with an acrylic bur.

Fig. 12.79 Preoperative

clinical situation who
has been treatment
planned for a maxillary
tooth-only zirconia-­
based restorations and
mandibular acrylic resin
prosthesis

Fig. 12.80 Analogue-­

fabricated tooth-­
supported guides for
surgical accuracy

Fig. 12.81 Milled

acrylic provisional for
chair-side pick-up
334 S. Yeung and S. Jivraj

4. Position the two anterior temporary cylin-
ders on the multi-unit abutments and try the
provisional. The palatal portion of the pros-
thesis should be flush with the palate. The
temporary cylinders should not interfere
with the seating of the provisional.
5. Place temporary cylinders on the posterior
multi-unit abutments one by one and ensure
the provisional seats without interference
from the temporary cylinders (Fig. 12.82).
6. The surgical site should be protected with a
rubber dam.
7. Teflon should be placed in the access holes
of the temporary cylinders.
8. Cold-cured acrylic resin should be used to
pick up the temporary cylinders within the
confines of the prosthesis.
9. The prosthesis should be removed, and heal-
ing caps replaced.
10. Ensure all temporary cylinders are stable
within the provisional.
11. Inject self-cured tooth-coloured acrylic
around the temporary cylinders to fill in the
defects.
12. The pontic areas should be built up to extend
into the extraction sockets by 2 mm.
13. Finish and polish and remove cantilevers. A
silane-coated fibre may be used to reinforce
the prosthesis (Fig. 12.83).
14. On delivery the provisional should com-
press the soft tissue and pontics should
extend within the extraction sockets
and support the tissue (Figs. 12.84 and
12.85).

Fig. 12.82 Pick-up of

temporary cylinders
chair side

Fig. 12.83 Acrylic

restorations after
conversion. Restoration
can also be fibre
re-enforced

Fig. 12.84 Day of

delivery of maxillary
and mandibular
acrylic-based
restorations. Day of
delivery and 1 week post
op. See tissue moulding
12 Clinical Techniques for Immediate Loading
Fig. 12.85 Definitive
zirconia restoration after
tissue sculpting
References
1. Esposito M, Grusovin M, Willings M, Coulthard P,
Worthington H. The effectiveness of immediate,
early, and conventional loading of dental implants:
a Cochrane systematic review of randomized con-
trolled clinical trials. Int J Oral Maxillofac Implants.
2007;22:893–904.
2. Papaspyridakos P, Chen C, Chuang S, Weber
H. Implant loading protocols for edentulous patients
with fixed prostheses: a systematic review and meta-­
analysis. Int J Oral Maxillofac Implants. 2014;29
Suppl:256–70.
3. Bruyn HD, Raes S, Ostman P, Cosyn J. Immediate
loading in partially and completely edentulous jaws:
a review of the literature with clinical guidelines.
Periodontol 2000. 2014;66(1):153–87.
4. Maló P, Nobre MA, Lopes A, Francischone C,
Rigolizzo M. “All-on-4” immediate-function con-
cept for completely edentulous maxillae: a clini-
cal report on the medium (3 years) and long-term
(5 years) ­outcomes. Clin Implant Dent Relat Res.
2012;14(Suppl 1):e139–50.
5. Szmukler-Moncler S, Salama H, Reingewirtz Y,
Dubruille J. Timing of loading and effect of micro-
motion on bone-dental implant interface: review
of experimental literature. J Biomed Mater Res.
1998;43(2):192–203.
6. Kern J, Kern T, Wolfart S, Heussen N. A systematic
review and meta-analysis of removable and fixed
implant-supported prostheses in edentulous jaws:
post-loading implant loss. Clin Oral Implants Res.
2016;27(2):174–95.
7. 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. 2016;19(1):4–19.
8. Peñarrocha-Oltra D, Covani U, Peñarrocha-Diago
M, Peñarrocha-Diago M. Immediate loading with
fixed full-arch prostheses in the maxilla: review
of the literature. Med Oral Patol Oral Cir Bucal.
2014;19(1):e512–7.
9. Li S, Di P, Zhang Y, Lin Y. Immediate implant and
rehabilitation based on All-on-4 concept in patients
with generalized aggressive periodontitis: a medium-­
335
term prospective study. Clin Implant Dent Relat Res.
2017;19(3):559–71.
10. Bahat O, Sullivan R. Parameters for successful
implant integration revisited part II: algorithm for
immediate loading diagnostic factors. Clin Implant
Dent Relat Res. 2010;12 Suppl 1:e13–22.
11. Yamaguchi K, Ishiura Y, Tanaka S, Baba K. Influence
of the rigidity of a provisional restoration sup-
ported 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(5):442–50.
12. Romanos G, Nentwig G. Immediate versus delayed
functional loading of implants in the posterior man-
dible: a 2-year prospective clinical study of 12 con-
secutive cases. Int J Periodontics Restorative Dent.
2006;26(5):459–69.
13. Romanos G, Nentwig G. Immediate loading of endos-
seous implants in the posterior area of the mandible.
Animal and clinical studies. Int J Oral Maxillofac
Implants. 2008;23(3):513–9.
14. Balshi T, Wolfinger G. Immediate loading of
Brånemark implants in edentulous mandibles: a pre-
liminary report. Implant Dent. 1997;6(2):83–8.
15. Lekholm U, Zarb G. Patient selection and preparation.
In: Tissue integrated prostheses: osseointegration
in clinical dentistry. Chicago: Quintessence; 1985.
p. 199–209.
16. Chiapasco M. Early and immediate restoration
and loading of implants in completely edentu-
lous patients. Int J Oral Maxillofac Implants.
1997;19(7):76–91.
17. Heydecke G, Zwahlen M, Nicol A, Nisand D, Payer
M, Renouard F, et al. What is the optimal number
of implants for fixed reconstructions: a system-
atic review. Clin Oral Implants Res. 2012;23(Suppl
6):217–28.
18. Mericske-Stern R, Worni A. Optimal num-
ber of oral implants for fixed reconstructions:
a review of the literature. Eur J Oral Implantol.
2014;7(2):S133–53.
19. Drago C. Cantilever lengths and anterior-
posterior spreads of interim, acrylic resin,
full-arch screw-­retained prostheses and their rela-
tionship to prosthetic complications. J Prosthodont.
2016;26:502–7.
336
20. Tarnow D, Emtiaz S, Classi A. Immediate load-
ing of threaded implants at stage 1 surgery in eden-
tulous arches: ten consecutive case reports with
1- to 5-year data. Int J Oral Maxillofac Implants.
1997;12(3):319–24.
21. Suarez-Feito J, Sicilia A, Angulo J, Banerji S, Cuesta
I, Millar B. Clinical performance of provisional
S. Yeung and S. Jivraj
screw-retained metal-free acrylic restorations in
an immediate loading implant protocol: a 242 con-
secutive patients’ report. Clin Oral Implants Res.
2010;21(12):1360–9.
22. Treesh JC, et al. Complete-arch accuracy of intraoral
scanners. J Prosthet Dent. 2018;120:382–8.
 Material Considerations
for Full-­Arch Implant-Supported
13
Restorations

Saj Jivraj and Sundeep Rawal

Abstract of prosthodontics has advanced to newer heights

and has enjoyed a great deal of innovation and
There are various materials to choose from
progressive development in recent years. This is a
when designing full-arch fixed implant-­
tremendous benefit to today’s patients who have
supported restorations. Material choices
high expectations, and providing functional and
include a traditional acryl resin titanium pros-
comfortable restorations alone may not be suffi-
thesis to monolithic milled zirconia. As tech-
cient to satisfy many of them. Patients have addi-
nological advancements occur, newer
tional desires in today’s therapy such as high
materials and manufacturing processes are
aesthetic demands, shorter treatment times, fewer
being introduced into these therapies; how-
visits and minimal maintenance issues. One treat-
ever, clear guidelines on design and material
ment option offered to these motivated patients is
selection are lacking. The purpose of this
the ability to rehabilitate the terminal or missing
chapter is to look at specific areas, including
dentition with a full-arch fixed implant-supported
screw access, restorative space, opposing den-
restoration.
tition, aesthetics, framework design and fabri-
Today there are various materials to choose
cation processes, to create guidelines to aid
from when designing full-arch fixed implant-­
clinicians in making relevant and predictable
supported restorations. Unfortunately, when
decisions with respect to therapy for patients
looking at the literature for guidance it is not sup-
with fixed implant-supported restorations.
portive of a true evidence base in terms of an
ideal material to utilise. There is no evidence to
The clinical replacement of teeth by osseointe- show one design is superior to another or one
grated implants has represented one of the most combination of materials is superior to another.
significant advances in restorative dentistry. Most articles are case reports, which follow a
Coupled with digital planning, digital impres- limited number of patients over a limited period
sions and CAD/CAM technology, the speciality of time [1]. Although these reports do provide us
with useful information, they cannot be classified
as true evidence. The reality is that CAD/CAM
S. Jivraj (*) technology is evolving, and by the time clinicians
Anacapa Dental Art Institute, Oxnard, CA, USA
have completed studies on a group of materials
S. Rawal and followed them for a period of time, those
Implant Support Services, Aspen Dental,
Chicago, IL, USA materials become obsolete and newer improved
materials or designs become available.
The Digital Dentistry Institute, Orlando, FL, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 337
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_13
338 S. Jivraj and S. Rawal

Despite technological advances, certain prin-
ciples remain the same. The purpose of this chap-
ter will be to give the reader clinical guidelines
on how to design a framework and the various
combination of materials that are available.
Design considerations in fabrication of the
prosthesis include but are not limited to.
1. Screw access trajectory.
2. Restorative space.
3. Nature of opposing dentition.
4. Aesthetic demands.
5. Framework cross-sectional area for cantile-
vers and around screw channels.
6. Ease of fabrication and passivity.
13.1 Screw Access Trajectory
When designing a splinted full-arch implant-­
supported restoration, screw retention has dis-
tinct advantages [2]. Among these advantages are
the following:
(e) Managing complications of the dental fix-
tures—access for dealing with implant
failure, peri-implant issues, infection,
etc., is more readily available.
It can be seen from the above that designing a
screw-retained restoration has a significant safety
factor with regard to long-term maintenance of
these prosthetics.
More and more often clinical situations pres-
ent where screw access trajectory is often in an
unfavourable position. In this scenario, the clini-
cian has two options:
1. Use of pre-angled abutments—pre-angled
abutments do come with specific collar
heights and this must be considered to maxi-
mise aesthetic outcomes.
2. Use of a two-part restoration with a primary
framework that corrects implant trajectory
and a secondary screw retained suprastructure
(Figs. 13.1, 13.2, 13.3, 13.4, and 13.5).

1. The precision of fit of screw-retained restora-

tions can be verified with radiographs using a
single screw test [3].
2. Delivering a screw-retained restoration also
involves less time with no cement clean-up
required [4].
3. Screw-retained restorations have total retriev-
ability, which is advantageous for the follow-
ing reasons:
(a) Periodic maintenance—it is a relatively
simple procedure to remove the prosthe-
sis if necessary for access to fixtures and
intermediary abutments.
(b) Dealing with loosened screws—access to
screws is typically direct.
(c) Fracture of the prosthesis—the prosthesis
can easily be removed for repair.
(d) Modification of the prosthesis—can Fig. 13.1 Emergence profile inadequate. Note ledge as
accommodate issues such as continued restoration emerges from implant
tissue remodelling.
13 Material Considerations for Full-Arch Implant-Supported Restorations 339

Fig. 13.2 Trajectory of implants have been accommo- Fig. 13.5 Definitive restorations with correct emergence
dated in fabricating prosthesis. Pre-angled abutments profile
should be selected to correct trajectory of dental implants

13.2 Restorative Space

Lack of restorative space is one of the most com-

mon occurrences that can compromise a restora-
tion [5]. Inadequate restorative space will result
in two scenarios:

(a) Restorative complications such as material

failure leading to repair or replacement of the
veneering materials or complete framework
fracture leading to failure of the entire pros-
thetic restoration.
(b) Changing the treatment plan from one resto-
Fig. 13.3 Diagnostic wax tooth try-in with corrected
ration type to another to accommodate the
emergence profile
space requirements.

Neither of the above scenarios is ideal and can

be avoided by good communication between the
surgical and restorative team prior to implemen-
tation of the therapy. The clinician must evaluate
whether the patient exhibits minimal, moderate
or advanced resorption to determine the available
restorative space and therefore the ideal type of
prosthesis to be fabricated.
General guidelines for space requirements are
the following:

Fig. 13.4 Provisional restoration fabricated to test aes- (a) Monolithic full-contour zirconia-fixed resto-
thetics and phonetics
rations require 10 mm or more of space from
340 S. Jivraj and S. Rawal

the head of the implant to the opposing

dentition.
(b) Porcelain fused to metal/zirconia-fixed resto-
rations require 12 mm or more of space from
the head of the implant to the opposing
dentition.
(c) Acrylic resin bonded to titanium-fixed resto-
rations will require 15 mm or more from the
head of the implant to the opposing
dentition.
(d) Implant-supported over-dentures will require
16 mm or more of space from the implant to Fig. 13.6 Milling titanium occlusals can maintain the
the opposing dentition [6]. vertical dimension

conducted to evaluate the clinical validity of

13.3 Nature of Opposing using a full-contour zirconia occlusal surface.
Dentition This study compared zirconia’s wear capacity to
that of feldspathic porcelain, and it was reported
Patients with implant-supported restorations that the antagonistic tooth wear was less in zirco-
have a reduced amount of proprioception, and as nia than feldspathic porcelain, suggesting that
a result these restorations have been subject to zirconia may be more beneficial for antagonistic
greater forces [7]. With this in mind, there have tooth wear [10]. The data on this subject is lim-
been studies looking at various restorative mate- ited and further studies are required.
rials and their effects not only on the implant-­ One clinical situation where the nature of the
supported prosthesis, but on the opposing opposing dentition is of note is when designing
dentition as well. One such clinical study investi- fully implant-supported prostheses for the maxil-
gated the maintenance requirements in patients lary and mandibular arches together. It has been
with implant-supported restorations vs. implant-­ advocated to restore the maxillary arch with a
supported restorations, implant-supported resto- zirconia-based ceramic prosthesis and an acrylic
rations vs. natural dentitions and resin bonded to titanium prosthesis for the man-
implant-supported restorations vs. complete den- dibular arch [11]. Advantages of using this
ture wearers [8]. This study reported that the opposing arch design include the following:
patients with implant vs. implant occlusions suf-
fered a higher degree of fracture and greater wear (a) Maximum aesthetics with minimal staining
of the occlusion (Fig. 13.6). over time with use of ceramics in the
Another study focused on occlusal surface maxilla.
design using noble metals, feldspathic porcelain (b) Absence of reported, ‘clicking’ by patients
and acrylic [9]. For stability of occlusal contact, with opposing ceramic surfaces.
clinicians have preferred a gold occlusal surface (c) Flexibility and resiliency in the system.
rather than porcelain and acrylic; however due to (d) Reduced costs (Fig. 13.7).
aesthetic concerns, patients often favour
­tooth-­coloured materials. Historically feldspathic One disadvantage would be increased wear of
porcelain has been the material of choice, but the mandibular acrylic-based restorations. This
more recently clinicians have utilised zirconia on can be considered a controlled failure, and the
the occluding surface of the restoration. One con- patient must be made aware that the acrylic resin
cern of clinicians has been the effect of zirconia teeth will most likely need to be replaced every
on the opposing dentition. An in vitro study was 5–7 years.
13 Material Considerations for Full-Arch Implant-Supported Restorations
Fig. 13.7 Use of zirconia in the maxilla and acrylic resin
titanium in the mandible has many advantages
13.4 Aesthetic Demands
Talented ceramists can produce high-level aes-
thetic results using both traditional noble metal
alloy and zirconia frameworks. In regards to light
transmission, both noble metal alloys and zirco-
nia have been shown to be opaque [12].
Anecdotally many laboratory technicians report
superior aesthetic results with zirconia frame-
works due to the ability to be able to colour the
zirconia and be able to have a tooth-coloured
framework rather than an opaque grey-coloured
framework which is usual with traditional high
noble metal alloy frameworks.
From an aesthetic perspective, ceramic-based
restorations with either high noble alloy or zirco-
nia frameworks are less likely to stain over time
and result in superior stable long-term aesthetic
results compared to acrylic resin bonded to tita-
nium restorations. As mentioned above, ceramics
should be considered for maxillary restorations
and acrylic resin titanium in the mandible when
full mouth implant rehabilitation is completed.
13.5 Cantilevers
13.5.1 Framework Cross-Sectional
Area for Cantilevers
and Around Screw Channels
Specific attention needs to be paid to dimensions
of the framework in the cantilever area and
around screw access channels (Figs. 13.8 and
341
Fig. 13.8 Inadequate thickness of zirconia around screw
access hole will result in fracture of the zirconia
framework
13.9). Specifically, the cross-sectional area of
the chosen material must be sufficient enough to
have strength and rigidity to perform in the intra-
oral environment. For screw channels, this is
typically most important when considering the
lingual or palatal cross-sectional area of the
material. When focusing on cantilevers, connec-
tor size is critical for traditional noble metal
alloys, titanium and zirconia frameworks. While
there is no specific data on the minimum dimen-
sions required for these frameworks, if space is
extremely limited the authors prefer traditional
noble metal frameworks. However, for the typi-
cal implant-supported restoration, patients who
have undergone moderate to advanced resorp-
tion will have plenty of room to provide robust
connectors with sufficient cross-sectional area.
Literature on tooth-supported zirconia-based
restorations recommended a minimal connector
size of 4 mm × 4 mm, and it is the authors’ pref-
erence to respect this 16 mm2 area for implant
frameworks as well as in the area of channels or
connectors [13].
There are few studies to guide clinicians on
the length of cantilever in the maxilla, especially
when utilising the more contemporary materials
such as zirconia. The length of the cantilever has
a significant effect on the failure of these types of
restorations, and in a meta-analysis it has been
shown that the length of cantilever is more sig-
nificant than the number of implants [14].
Deflection of the cantilever is related to its length;
so minute increases in length have a significant
342 S. Jivraj and S. Rawal

ous procedure, which is not only time consuming

but can add additional costs to treatment. With
the increasing costs of gold, clinicians have
moved away from traditional techniques and
have begun to employ more contemporary tech-
niques using CAD/CAM technology and materi-
als such as zirconia and titanium. These
techniques also require a high degree of skill but
are less time consuming in the manufacturing
process and due to the efficiencies gained from
Fig. 13.9 Cantilevers should also be minimised in zirco- these techniques tend to be less costly than con-
nia as this may result in fracture
ventional fabrication procedures.
Passivity in an implant framework has been
impact on the fracture complications of restora- notoriously difficult to achieve when utilising
tions. Lab-based studies on zirconia have shown screw-retained splinted restorations. Inaccuracies
that in implant frameworks are the result of multiple
variables, which include machining tolerances of
(a) The longer the cantilever the lower the load components, distortion in the impression mate-
to failure. rial, setting expansion of the die stone, expansion
(b) The smaller the connector size the less load and contraction of alloy and wax and distortion
to failure. of the framework during heat treatment and
(c) Failure usually occurred in the distal abut- application of porcelain [17].
ment wall [15]. Common solutions to provide a passive frame-
work have been sectioning and soldering or fabri-
Recommendations for the cantilever include cating cement-retained restorations. Although
cement-retained restorations have become
(a) Limit distal cantilever. increasingly accepted, they still have the disad-
(b) Limit buccal cantilever. vantage that they are not readily retrievable and
(c) Increase thickness of the framework in the studies have also shown that despite a clinician’s
cantilever section distal to the most distal best efforts, excess cement is often left behind
implant. which can result in biological complications [18].
(d) Limit occlusion on the cantilever. Another approach to achieve a passive screw-­
retained framework has been the use of the
adhesive-­ corrected implant frameworks where
13.5.2 Ease of Fabrication individual cylinders were cemented within the
and Passivity framework after it had been cast (KAL tech-
nique). This approach has merit in that it elimi-
Traditional techniques in fabricating full-arch nates many of the current prosthetic and
implant frameworks involve waxing casting and laboratory inaccuracies associated with tradi-
application of a veneering material such as tional techniques [19].
acrylic or porcelain. This approach has been With the utilisation of CAD/CAM technology,
adopted for many years and is considered the a lot of the variables have been eliminated and
gold standard for fabrication of implant-­ frameworks can be produced with high precision
supported restorations. The results achieved with [20] providing the operator has taken care in pro-
these techniques have been predictable and suc- ducing an accurate impression either from a
cessful [16]. Traditional techniques do require a material-based approach or optically, and the
high degree of skill and problems inherent with laboratory technician has exercised care in repli-
waxing and casting can lead to it being a labori- cating it into either an analogue cast or has cre-
13 Material Considerations for Full-Arch Implant-Supported Restorations 343

ated a digital file. Furthermore, due to the including the intaglio surface. One advantage is
elimination of potential errors the overall work- that it can be relined, but little is known about its
flow has been simplified by utilisation of CAD/ longevity in terms of biomechanics. Anecdotally,
CAM, which allows frameworks to be produced numerous colleagues have experienced fractures
in fewer clinical steps with less labour in the den-
of this type of framework. Failures may be due to
tal laboratory [21]. excessive cantilever or inadequate bar shape, and
There are several different materials that can further studies need to explore these issues. The
be used to fabricate these CAD/CAM frame- second type of framework may include I- or
works for implant-supported restorations, and L-shaped bar designs to maximise rigidity. One
these materials include but are not limited to advantage of this design is that due to the shape
of the titanium framework requiring less bulk of
1. Acrylic resin bonded or milled to titanium. material in any one dimension, adequate space
2. High-performance polymers: PEEK. and retention for acrylic resin can be achieved
3. Milled cobalt chromium. which maximises thickness in the cantilever area.
4. Zirconia – monolithic. The evidence base is also lacking in this design.
–– Minimally layered. Although these frameworks have served many
–– Hybrid design with zirconia frameworks patients well, particularly in the edentulous man-
and individually cemented crowns (lithium dible, success in the mandible does not automati-
disilicate or zirconia). cally translate to success in the maxilla
(Figs. 13.10, 13.11, and 13.12).
The authors have had clinical experience with
13.6 Acrylic Resin Bonded or repeated fracture of teeth, acrylic resin delamina-
Milled to Titanium tion and denture teeth wearing in the anterior
maxilla (Fig. 13.13). One possible factor for this
Framework designs for a full-arch, one-piece, clinical presentation could be the nature of force
implant-supported acrylic resin and titanium-­ application in the maxillary anterior region,
based restoration have changed significantly which is typically tensile in nature as opposed to
since the transition from gold frameworks to tita- the posterior maxillary region and the mandibular
nium [22]. Different manufacturers have differ- arch, which is mainly compressive in nature. This
ent designs available, and despite technological problem is exacerbated in patients who present
advances, frameworks still do not replicate the with signs of bruxism. These patients are prone to
characteristics familiar to gold frameworks. With accelerated wear of posterior teeth which will
titanium frameworks a few key parameters eventually lead to increased force and potential
become important: overload of the anterior teeth and result in frac-
tures. In order to avoid premature damage to
(a) Bulk for strength. maxillary anterior denture teeth, one possible
(b) Adequate access to oral hygiene. option is to extend the metal framework onto the
(c) Minimal display of metal.
(d) Retention for acrylic.
(e) Adequate space for acrylic resin.
(f) Adequate strength in the cantilever section.
(g) Attention to cross-sectional area.

When considering these parameters, there are

mainly two types of framework designs to sup-
port acrylic resin teeth. One of these designs is
the “minimalist” framework where acrylic is
wrapped around the bar and encompasses it 360°, Fig. 13.10 Original characteristics of gold frameworks
344
Fig. 13.11 Titanium frameworks with similar character-
istics to original gold frameworks
Fig. 13.12 Examples of wraparound and L-shaped
frameworks
Fig. 13.13 Fracture of acrylic resin tooth from titanium
framework
occlusal surfaces. The fabrication of prototypes
with selective and controlled cutback procedures
will allow accurate copy milling and incorporat-
ing metal posterior occlusal surfaces into the
framework. Another possible option is to utilise
new processes in the manufacturing of acrylic to
titanium restorations such as milling acrylic
around an embedded titanium framework utilis-
ing polychromatic monolithic acrylic [23]. This
S. Jivraj and S. Rawal
type of restoration may eliminate many of the
potential complications of traditional denture
teeth bonded to titanium with processed acrylic
such as delamination of teeth and fracture of
acrylic veneering materials. The evidence base is
lacking with these newer technologies, and
­further research needs to be conducted in these
areas.
These various designs and technologies can be
used in high- and low-force situations. As noted
previously, in high-force situations the teeth will
wear much more quickly and will potentially
need to be replaced as part of long-term mainte-
nance. Although it is possible to make attractive
restorations with denture teeth, the pink acrylic
does lose its sheen over time and can accumulate
greater amounts of stain compared to ceramic.
13.7 High-Performance
Polymers: PEEK
The reason for the recent enthusiasm surrounding
PEEK has been its potential for use as a metal
alternative. Perhaps the most interesting property
of PEEK for use as a framework material is its
Young’s elastic modulus (4 GPa), which allows
the PEEK substructure to more closely match the
biomechanical characteristics of the jaw’s natural
bone (2–12 GPa). Unusually, PEEK is well posi-
tioned in that it is strong and resistant to repeti-
tive cyclical loading cycles, yet is slightly elastic,
lightweight, and able to dissipate stress forces
placed on it. It is these ‘bone-like’ properties that
offer PEEK as a more biomechanically engi-
neered substructure material [24]. It is postulated
that the shock-absorbing properties of this mate-
rial may result in less stress being transferred to
the bone–implant interface. There is no evidence
to support such a claim although theoretically it
may seem reasonable. The Young’s elastic modu-
lus of PEEK (4 GPa) is similar to the acrylics
(2 GPa) and being a lot lower than titanium
(100 GPa), but still retaining sufficient stiffness
for rigidity of structure. However, unlike acrylic,
PEEK also has sufficient strength (120 MPa flex-
ural strength vs. 40 MPa for acrylic) and excel-
13 Material Considerations for Full-Arch Implant-Supported Restorations 345

lent flexural fatigue resistance to cyclical loads

that make it fit for the purpose of long-term resto-
rations. PEEK’s resistance to failure from flex-
ural fatigue may be of interest to potentially
address some of the technical complications
associated with cantilever design, and lab-based
tests have been published that show resistance to
failure with distal cantilevers of up to 19 mm Fig. 13.14 Milled cobalt chromium framework
length [25]. PEEK as a permanent framework
material has become an option in recent times
through the availability of CADCAM forms.
However, clinical data is typically limited at pres-
ent to case studies [26–28] although the first for-
mal clinical studies are starting to become
available [29].

13.8 Milled Cobalt Chromium

Cobalt chromium frameworks have had a major

resurgence in recent years. All of the traditional Fig. 13.15 Opaque must be applied appropriately to
problems with fit, bonding and corrosion related mask grey color of metal
to cast designs have been eliminated with the
inception of milled framework designs [29].
These frameworks are then veneered with porce-
lains to create traditional porcelain fused to metal
restorations. From an aesthetic point of view,
metal ceramic prostheses can be created in a way
that is more tooth-like than frameworks veneered
with acrylics, especially after some years of func-
tion in the oral cavity (Figs. 13.14, 13.15, 13.16,
and 13.17).
Fig. 13.16 Completed ceramics on cobalt chromium
CAD-CAM designs allow better control of framework
ceramic thickness, passive frameworks, predict-
able ceramic bonding and less bending than high
noble frameworks, especially in cantilevers.
Cobalt chrome frameworks are particularly
advantageous when less than 15 mm of restor-
ative space is available and a posterior cantilever
is present. The restoration can withstand occlusal
forces even at minimal thickness [29]. The main
attraction, however, seems to be the cost com-
pared to gold-based frameworks. The main disad-
vantages are laboratory based as an industrial
milling and sintering machine is required, with a
skilled dental technician to utilise these newer
Fig. 13.17 Intraoral view of mandibular restoration in
technologies. Fig. 13.16
346 S. Jivraj and S. Rawal

13.9 Zirconia

Zirconia frameworks have evolved significantly

over the last ten years and have become hugely
popular as a restorative material for fully implant-­
supported restorations. The primary advantage of
zirconia is that it is biocompatible, aesthetic and
has great material strength [30]. The tooth-like
colour of zirconia makes it beneficial in aesthetic
areas of the oral cavity, and the excellent wear Fig. 13.18 Monolithic zirconia framework with staining
characteristics make it advantageous in the poste-
rior areas as well. These properties have resulted
in the increased use of zirconia in the fabrication
of these restorations.
Clinical reports have evaluated restorations
with a zirconia structure supported by implants
and have provided some insight [31].
Zirconia has a high flexural strength, which
makes it suitable as a framework in veneered or
full-contour reconstructions. Some technical
complications are likely to occur; these include
but are not limited to
Fig. 13.19 Clinical picture of monolithic zirconia with
1. Chipping of the veneering ceramic. pink ceramic layering in situ
2. Debonding of the titanium inserts.
3. Catastrophic failure of the framework.
13.10 Monolithic
To reduce the risk of complication, there are a
myriad of details the clinician and laboratory From an evidence-based perspective, long-term
technician must respect. data (10 years plus) to support monolithic full-­
Zirconia frameworks can be designed accord- contour frameworks at this time is lacking. This
ing to the following parameters: statement should not be considered a deterrent,
but caution must be exercised during case selec-
1. Monolithic zirconia. tion (Figs. 13.18 and 13.19).
2. Minimally cutback zirconia with ceramic
layering.
3. Hybrid designs with individual lithium disili- 13.11 Minimally Layered
cate or zirconia crowns.
4. Hybrid designs with a primary titanium bar It is possible to achieve strength and maximum
with overlying zirconia framework which aesthetics by minimal layering zirconia frame-
may be layered or monolithic utilising intra- works with veneering porcelain [32]. However, a
oral scanning and CADCAM protocols. few clinical studies show that unsupported
13 Material Considerations for Full-Arch Implant-Supported Restorations 347

veneered ceramic has a higher risk of chipping

[33]. To take advantage of both the strength of
zirconia and ideal aesthetics, it is recommended
that frameworks be designed such that occlusal
contact areas are in monolithic zirconia with
minimal layering on the buccal surfaces in aes-
thetic areas. One caveat is that all veneered por-
celain must be appropriately supported, with
anatomically shaped design to the underlying zir-
conia framework [34]. When focusing on this
issue, questions often arise in regards to the flex-
ural strength of full-contour zirconia alone and Fig. 13.20 Acrylic prototype is tried intraorally to verify
the flexural strength of porcelain fused to zirco- occlusion and contours
nia systems. Clinicians have concerns about
potential chipping and fracture of the veneering
porcelain. Most studies will report that the
veneering porcelain is the weak point in any mul-
tilayer system, including traditional PFM tech-
niques [35]. Regardless of whether a noble metal
or zirconia framework is being used, the overly-
ing porcelain must be well supported [36]. Shear
bond strength of porcelain to zirconia has also
been investigated; studies show differences in
bond strength depending on the veneering porce- Fig. 13.21 Minimal cutback in acrylic
lain used and if the zirconia substructure is
coloured or uncoloured [36]. It is the authors’
recommendation that when using a zirconia
substructure compatible veneering porcelains
­
should be used and the heating and cooling cycles
must be carefully controlled. Limiting the veneer-
ing porcelain and having a full-contour zirconia
framework with zirconia occlusion is advanta-
geous in this regard (Figs. 13.20, 13.21, 13.22,
13.23, 13.24, 13.25, and 13.26).
One important design consideration with these
zirconia restorations is the incorporation of canti-
levers. Cantilevers in implant dentistry are valu- Fig. 13.22 Acrylic prototype scanned and milled in
zirconia
able for sites where anatomic structures such as
the maxillary sinuses exclude the ideal placement
of dental implants, and are being used more often tory studies are needed to establish the mechani-
for graft-less procedures. They may, however, cal properties of zirconia cantilever frameworks.
negatively affect the biomechanics of implant When designing zirconia-based implant
restorations and may result in mechanical and/or frameworks, the following should be considered:
biological problems. Presently, evidence is lim-
ited concerning the breakage of cantilevered zir- 1. Maximise connector dimensions, buccal-­
conia implant frameworks. This evidence is lingually and occlusal-gingivally.
mainly limited to anecdotal and expert clinical 2. Minimise distal cantilever length.
reports. Well-designed, clinically relevant labora- 3. Minimise buccal cantilever.
348 S. Jivraj and S. Rawal

4. Ensure very light occlusal contacts in the can-

tilever region.
5. Thicken the chimney around the most distal
implant and thicken the buccal and lingual
walls around the chimney of the implant.
6. Ensure monolithic zirconia is well polished.
Studies have shown it to be kind to the oppos-
ing occlusion.
7. Minimal post-sintering adjustment. This will
also help with preserving the strength of the
Fig. 13.23 Note occlusion entirely in zirconia material and avoiding accelerated ageing fail-
ures in the presence of saliva.
8. Design for retrievability. This allows simple
detachment of the appliance and the chance to
service the restoration or treat any implant-­
related problems. With proper implant place-
ment, this can be achieved in most situations
when treating the edentulous arch.
9. If restoring to the head of the fixture, the lit-
erature supports the use of a titanium insert.
This increases the maximum load-bearing
capacity of the restoration. It also compen-
Fig. 13.24 Minimally applied ceramics (lab work by sates for the three-dimensional distortion that
Kenji Mizuno CDT)
occurs post sintering. Zirconia abutments
have been designed with a titanium ­component
that has been fused or cemented to the zirco-
nia. The unique design feature is that it per-
mits titanium-to-titanium contact at the
abutment implant interface and results in the
same high degree of predictability associated
with conventional metal abutment–implant
connections [37].

Fig. 13.25 Maxillary minimally layered zirconia

restoration 13.12 Hybrid Designs
with Individual Ceramic
Crowns

These types of restorations provide many

advantages:

(a) Maximal aesthetics since there are individual

restorations especially with aesthetics in the
interproximal areas.

Fig. 13.26 Maxillary and mandibular zirconia-based res-

torations in situ
13 Material Considerations for Full-Arch Implant-Supported Restorations 349

(b) Stress distribution due to underlying splint-

ing and cross-arch stabilisation of the
implants.
(c) Ease of dealing with restorative complica-
tions—if a single crown were to fracture it
can be replaced individually (Figs. 13.27,
13.28, 13.29, 13.30, and 13.31).

Ideally they should be designed with the screw

access trajectories in a favourable position so that
the restoration can be readily serviced at hygiene
appointments. However, despite the clinician’s Fig. 13.29 Framework try-in intraorally
best intentions, anatomic limitations may not
allow screw-retained implant placement in the
anterior maxilla, even after correction with angled
abutments. In these situations a ‘hybrid’ between
a monolithic design and individual cemented res-
toration may solve a challenging problem created
by anterior implant trajectory [38].

Fig. 13.30 Maxillary hybrid zirconia restoration opposed

by acrylic titanium restoration

Fig. 13.27 Hybrid design; when screw access holes are

not ideally located, individual crowns can be made and
luted

Fig. 13.31 Smile view of restorations in Fig. 13.30

Fig. 13.28 Individual crowns in zirconia replacing max-

illary anterior teeth
350
13.13 Hybrid Designs
with a Primary Titanium Bar
and Overlying Zirconia
Framework Utilising
Intraoral Scanning
and CADCAM Protocols
The delivery of full-arch implant-supported res-
torations has been significantly advanced by the
rapid introduction of innovative digital technolo-
gies into clinical practice. These technologies
allow for greater ease, cost efficiencies, and
improved workflows. Intraoral scanning is one of
these technologies that has significantly improved
the acquisition of diagnostic data and clinical
information required for the definitive restora-
tion. It enables the clinician to execute a complex
implant rehabilitation in a fewer number of
visits.
Intraoral scanning for single-tooth implant
restorations has been shown to be just as accurate
as analogue techniques. Full-arch scans have not
been as reliable and consistent. It was shown that
the precision of full-arch scans decreases as the
distance between the scanning abutments
increases. This inaccuracy can be a result of scan-
ning protocols, scan abutment designs and the
different technologies associated with different
types of scanners. Recently scan gauges have
been introduced that standardise the scanning
procedure (Osteon Technologies). Scanning for
full-arch implant restorations on multi-unit abut-
ments has become a clinical reality.
The protocols to scan include but are not lim-
ited to.
1. A more controlled path for the scanner to fol-
low reduces the amount of scan head
movements.
2. Allowing more than one scannable feature on
the gauge to be deleted if tolerance of scan
captured is less than the known gauge
measurement.
3. Inclusion of an alignment procedure where
the scan information is analysed using an
increased point cloud data set for its reference
to the planes present in the gauge design.
S. Jivraj and S. Rawal
The manufacturing process has also benefited
from technology with laboratories now able to
complete the definitive restorations utilising a
full digital workflow.
Fabrication of full-arch zirconia restoration
supported by a titanium substructure can be com-
pleted by utilising a full digital workflow.
These types of full-arch restorations may pro-
vide the following benefits:
1. Ease of fabrication—CADCAM technology.
2. Passivity of the framework—Utilising scan
gauges and AI technology frameworks can be
fabricated with a true digital model-less work-
flow. This can result in a clinically acceptable
passive framework.
3. Implant/abutment interface—A titanium-to-­
titanium interface was used to minimise wear
on the head of the implant. There is no zirco-
nia touching the head of the fixture or even the
multi-unit abutment. The clinician is also able
to torque the prosthesis without creating
undue stress in the zirconia framework.
4. Occlusion/wear—The framework can be cre-
ated with full-contour zirconia with minimal
cutback or full-contour zirconia and stain.
The occlusion is designed in zirconia for sta-
bility of occlusal contacts.
5. Strength of framework/veneering porcelain—
The zirconia is supported by a titanium sub-
structure which biomechanically enhances the
restoration. Care must be taken to ensure the
thickness of zirconia is adequate.
6. Aesthetics—Is improved by minimal cutback
and layering.
7. Delivery/retrievability—The entire restora-
tion is screw retained and designed with
retrievability in mind.
The clinician must provide the following
information to the laboratory:
1. Intraoral scanning of gauges in specific
pathways.
2. Scanning of the tissues intraorally.
3. Scanning of the provisional restorations with
gauges extraorally and scanning maximum
intercuspation intraorally.
13 Material Considerations for Full-Arch Implant-Supported Restorations
4. Clinical photographs.
5. Prescription of the desired changes.
The clinical information is systematically
organised and manipulated in CAD software to
propose a design for the prosthesis. This design
can be previewed, and corrections made. The cli-
nician may choose to go directly to the definitive
restorations in one visit if the provisional restora-
tions satisfy the requirements of aesthetics, con-
tour and phonetics.
It is recommended however that a clinical try-
­in of a printed resin prosthesis be done prior to
definitive delivery to verify the clinician’s
requirements. The definitive restorations are fab-
ricated via a CADCAM process where the frame-
work is digitally designed and milled from a
blank of commercially pure titanium via a com-
puter numeric-controlled machine. Such a pro-
cess has shown to be efficient in producing
accurate, customisable and durable frameworks.
Today even the suprastructure is fabricated
through a CADCAM process to produce the
veneering acrylic or zirconia prosthesis.
The following patient presentation will illus-
trate the digital workflow.
The patient presented with a terminal denti-
tion and was treatment planned for a maxillary
and mandibular implant-supported restoration
(Fig. 13.32). Bilateral sinus lifts were performed
in the maxilla, and seven root-form implants
were placed in the maxilla and six in the mandi-
ble (Paltop Dynamic, Keystone Dental Group)
Fig. 13.32 Preoperative situation of a terminal dentition has been treatment planned for maxillary and mandibular
implant-supported restorations
351
(Fig. 13.33). Provisional restorations were fabri-
cated to optimise aesthetics, form and function
(Fig. 13.34). The advantages of a full digital
workflow include but are not limited to.
1. No impressions.
2. Clinician can complete the definitive restora-
tion in two visits post integration.
3. Aesthetics can be verified with a 3D-printed
try-in and modifications can be made.
4. No sophisticated equipment is required. The
practitioner can utilise their existing intraoral
scanner to capture all the data required
(Fig. 13.35).
The following data is required:
1. Proprietary scan gauges are placed and
scanned (Osteon Technologies) (Fig. 13.36).
2. The soft tissue is scanned (Fig. 13.37).
3. The undersurface of the provisional is scanned
(Fig. 13.38).
4. The patient is asked to occlude into maximum
intercuspation and a right and left bite scan is
performed (Fig. 13.39).
The following photos are also submitted with
the scans:
1. Provisionals in the mouth.
2. Smile.
3. Full face (Fig. 13.40).
352 S. Jivraj and S. Rawal

Fig. 13.33 After bilateral sinus lifts seven Paltop

Dynamic implants placed in the maxilla and six in the
mandible

Fig. 13.34 Provisional restorations fabricated

Fig. 13.35 Advantages of a digital workflow

Fig. 13.36 An example of scan gauges scanned in the

mouth (Osteon Technologies) Fig. 13.37 An example of soft tissue scan
13 Material Considerations for Full-Arch Implant-Supported Restorations 353

Fig. 13.38 An example of scanning of a provisional res-

toration undersurface

Fig. 13.39 An example of scanning the prosthesis in the

mouth and recording occlusal relationships

Fig. 13.40 Photos submitted to Osteon

354
All the data are uploaded to CAD software
and a proposed design is created for approval by
the clinician (Figs. 13.41 and 13.42).
Once approved, a primary titanium substruc-
ture is milled to support an overlying zirconia
framework. These two materials are bonded
together utilising a resin cement (Fig. 13.43).
The undersurface of the restoration and con-
tours is convex and cleansable (Fig. 13.44).
The definitive restorations are delivered and
screws torqued to the manufacturer’s recommen-
dations (Fig. 13.45).
Fig. 13.41 CAD design
Fig. 13.42 Restoration proposals of both sub structure and suprastructure
S. Jivraj and S. Rawal
Clinically these types of restorations have
been reported (personal communication) to have
less complications than monolithic and mini-
mally layered restorations. With that said they do
not have as long a clinical track record and a like-­
to-­like comparison cannot be made. They have
been advocated for use in situations when mini-
mal bone reduction is performed and the clini-
cian is planning for an FP1 type of restoration
(Figs. 13.46, 13.47, 13.48, 13.49, 13.50, 13.51,
13.52, 13.53, and 13.54).
13 Material Considerations for Full-Arch Implant-Supported Restorations 355

Fig. 13.43 Combination titanium/zirconia restoration

Fig. 13.44 Undersurface or restoration illustrating convex cleansable surface

Fig. 13.45 Definitive restorations delivered

356 S. Jivraj and S. Rawal

Fig. 13.49 FP1-type prosthesis designed to compress tis-

sue (ceramics by Artem Asemov)

Fig. 13.46 Zirconia overlay

Fig. 13.50 Occlusion in polished zirconia

Fig. 13.47 Milled titanium substructure

Fig. 13.48 Titanium is bonded to the zirconia overlay Fig. 13.51 Undersurface of restoration
with a resin cement
13 Material Considerations for Full-Arch Implant-Supported Restorations
Fig. 13.52 Lateral view showing compression against
tissue
Fig. 13.53 Intraoral view of FP1 restoration in the max-
illa and FP3 in mandible
Fig. 13.54 Smile view
13.14 Conclusion
It is readily evident that material selection for
full-arch implant-supported restorations is multi-­
factorial with a wide range of considerations for
clinical success. Design of frameworks, manu-
357
facturing processes utilised and clinical parame-
ters are just a few of these considerations, and
this chapter attempts to give guidelines to aid in
making relevant decisions for these prostheses.
While some basic parameters have been stated,
further studies need to be conducted to look into
specific areas in greater detail to be able to make
more predictable decisions with respect to these
therapies.
References
1. Rojas-Vizcaya F. Full zirconia fixed detachable
implant-retained restorations manufactured from
monolithic zirconia: clinical report after two years in
service. J Prosthodont. 2011;20:570–6.
2. Chee W, Felton D, Johnson P, Sullivan D. Cemented
versus screw-retained implant prostheses: which is bet-
ter? Int J Oral Maxillofac Implants. 1999;14(1):137.
3. Chee W, Jivraj S. Screw versus cemented implant sup-
ported restorations. In: Treatment planning in implant
dentistry. Lowestoft: British Dental Journal; 2007.
p. 81–7.
4. Sailer I, Muhlemann S, Zwahlen M, Hammerle CH,
Schneider D. Cemented and screw-retained implant
reconstructions: a systematic review of the survival
and complication rates. Clin Oral Implants Res.
2012;23(Suppl 6):163–201.
5. Jivraj S, Chee WWL, Corrado P. Treatment Planning of
the Edentulous Maxilla. Br Dent J. 2006;201(5):699.
6. Wicks RA. A systematic approach to definitive
planning for osseointegrated implant prostheses. J
Prosthodont. 1994;3:237–42.
7. Jacobs R, Van Steenberghe D. Comparative evalua-
tion of the oral tactile function by means of teeth or
implant supported prostheses. Clin Oral Implants Res.
1991;2:75–80.
8. Davis DM, Packer ME, Watson RM. Maintenance
requirements of implant supported fixed prosthesis
opposed by implant supported fixed prosthesis, natu-
ral teeth, or complete dentures. A five year retrospec-
tive study. Int J Prosthodont. 2003;16:521–3.
9. Yip KH, Smales RJ, Kaidonis JA. Differential wear of
teeth and restorative materials: clinical implications.
Int J Prosthodont. 2004;17(3):350–6.
10. Jung YS, Lee JW, Choi YJ, et al. A study on the in-­
vitro wear of the natural tooth structure by oppos-
ing zirconia or dental porcelain. J Adv Prosthodont.
2010;2:111–5.
11. Chang PC, Henegbarth EA, Lang LA. Maxillary
zirconia implant fixed partial dentures opposing an
acrylic resin implant fixed complete denture. A 2 year
clinical report. J Prosthet Dent. 2007;97(6):321–30.
12. Heffernan MJ, Aquilino SA, Diaz-Arnold AM,
Haselton DR, Stanford CM, Vargas MA. Relative
358
translucency of six all-ceramic systems. Part I: core
materials. J Prosthet Dent. 2002;88(1):4–9.
13. Larsson C, Wennerberg A. The clinical success of
zirconia-based crowns: a systematic review. Int J
Prosthodont. 2014;27(1):33–43.
14. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan
JY. Clinical complications in fixed Prosthodontics. J
Prosthet Dent. 2003;90:31–41.
15. Chong KK, Palamara J, Wong RH, Judge RB. Fracture
force of cantilevered zirconia frameworks an in vitro
study. J Prosthet Dent. 2014;1112:849–56.
16. Zarb GA, Jansson T. Laboratory procedures and pro-
tocol. In: Branemark PI, Zarb G, Albrektsson T, edi-
tors. Tissue integrated prostheses: osseointegration
in clinical dentistry. Chicago: Quintessence; 1985.
p. 303.
17. Jemt T. Three-dimensional distortion of gold
alloy castings and welded titanium frameworks.
Measurements of the precision of fit between com-
pleted implant prostheses and the master casts
in routine edentulous situations. J Oral Rehabil.
1995;22:557–64.
18. Korsch M, Walther W. Peri-implantitis associated
with type of cement: a retrospective analysis of dif-
ferent types of cement and their clinical correlation to
the peri-implant tissue. Clin Implant Dent Relat Res.
2014;17:e434. https://doi.org/10.1111/cid.12265.
19. Voitik AJ. The Kulzer abutment luting; Kal tech-
nique. A direct assembly framework method for
osseointegrated implant prostheses. Implant Soc.
1991;2(1):11–4.
20. Almasri R, Drago C, Siegel S, et al. Volumetric
misfit in CAD/CAM and Cast implant frame-
works: a university laboratory study. J Prosthodont.
2011;20:267–74.
21. Drago C, Howell K. Concepts for designing and fab-
ricating metal implant frameworks for hybrid implant
prostheses. J Prosthodont. 2012;21(5):413–24.
https://doi.org/10.1111/j.1532-­849X.2012.00835.x.
Epub 2012 Mar 13.
22. Drago C. Ratios of cantilever lengths and anterior-­
posterior spreads of definitive hybrid full-arch,
screw-retained prostheses: results of a clinical study.
J Prosthodont. 2018;27:402. https://doi.org/10.1111/
jopr.12519.
23. Kattadiyil MT, Goodacre CJ, Baba NZ. CAD/CAM
complete dentures: a review of two commercial fabri-
cation systems. Calif Dent Assoc. 2013;41(6):407–16.
24. Najeeb S, Zafar MS, Khurshid Z, Siddiqui
F. Applications of polyetheretherketone (PEEK) in
oral implantology and prosthodontics. J Prosthodont
Res. 2016;60(1):12–9. https://doi.org/10.1016/j.
jpor.2015.10.001.
25. Sereno N, Rosentritt M, Jarman-smith M, Lang
R, Kolbeck C. In-vitro performance evaluation of
polyetheretherketone (PEEK) implant prosthetics
S. Jivraj and S. Rawal
with a cantilever design. Clin Oral Implants Res.
2015;26(S12):296.
26. Tipton P, Siewert B. High performance polymers part
3. Private Dentistry UK; 2016.
27. Siewert B, Parra M. A new group of material in den-
tistry. PEEK as a framework material used in 12-piece
implant-supported bridges. Z Zahnärztl Implantol.
2013;29:148–59.
28. Moura GC. New possibilities for high performance
polymers in the MALO clinic protocol. In: British
Association of Restorative Dentistry conference, 4–6
June 2016.
29. Abduo J. Fit of CADCAM implant frameworks: a com-
prehensive review. J Oral Implantol. 2014;40:758–66.
30. Larsson C, Vult Von Steyern P. Implant supported full
arch zirconia based mandibular fixed dental prosthe-
ses. Eight year results from a clinical pilot study. Acy
Odontol Scand. 2013;71:1118–22.
31. Puri S, Parciak EC, Kattadiyil MT. Complete mouth
reconstruction with implant supported fixed partial
dental prosthesis fabricated with zirconia frame-
works: a 4 year clinical follow up. J Prosthet Dent.
2014;112:397–401.
32. Cheng CW, Chien CH, Chen CJ, Papaspyridakos
P. Complete mouth rehabilitation with modified
monolithic zirconia implant supported fixed dental
prosthesis and an immediate loading protocol: a clini-
cal report. J Prosthet Dent. 2013;109:347–52.
33. Guess PC, Bonfante EA, Silva NR, Coelho PG,
Thompson VP. Effect of core design and veneer-
ing technique on damage and reliability of Y-TZP-­
supported crowns. Dent Mater. 2013;29:307–16.
34. Miyazaki T, Nakamura T, Matsumura H, Ban S,
Kobayashi T. Current status of zirconia restorations.
J Prosthodont Res. 2013;57(4):236–61. https://doi.
org/10.1016/j.jpor.2013.09.001. Epub 2013 Oct 18.
35. Preis V, Letsch C, Handel G, Behr M, Schneider-­
Feyrer S, Rosentritt M. Influence of substructure
design, veneer application technique, and firing
regime on the in vitro performance of molar zirconia
crowns. Dent Mater. 2013;29:e113–21.
36. Mosharraf R, Rismanchian M, Savabi O, Ashtiani
AH. Influence of surface modification techniques
on shear bond strength between different zirconia
cores and veneering ceramics. J Adv Prosthodont.
2011;3(4):221–8. https://doi.org/10.4047/
jap.2011.3.4.221.
37. Kim JS, Raigrodski AJ, Flinn BD, Rubenstein JE,
Chung KH. Mancl LA in vitro assessment of three
types of zirconia implant abutments under static load.
J Prosthet Dent. 2013;109(4):255–63. https://doi.
org/10.1016/S0022-­3913(13)60054-­2.
38. Pozzi A, Tallarico M, Barlattani A. Monolithic lithium
disilicate full contour crowns bonded on CADCAM
zirconia complete arch implant bridges with 3-5 years
of follow up. J Oral Implantol. 2015;41(4):450–8.
 Clinical Steps for Fabrication
of a Full-Arch Implant-Supported
14
Restoration

Udatta Kher and Ali Tunkiwala

Abstract 14.1 Section I: Introduction

The ultimate goal in prosthetic rehabilitation
The final design planning and material choice for
of edentulous patients is the long-term fulfil-
the definitive fixed prosthesis should be accom-
ment of their functional and aesthetic require-
plished before the surgical placement of the
ments. The fabrication of such prostheses is an
implants following the principles of prostheti-
exacting process and needs meticulous atten-
cally driven implant dentistry. The actual clinical
tion towards several clinical and laboratory
steps will begin after the implants have osseointe-
steps. Each step is executed only after the pro-
grated. Whilst the rehabilitation of each arch can
ceeding step is verified so that the prostheses
be carried out one at a time, it is possible to
in the end will have a passive fit and superior
address both arches together with meticulous
accuracy. The need for effective communica-
attention to detail. A well-designed functional
tion with the dental laboratory is the bedrock
and aesthetic provisional prosthesis is imperative
of all prosthetic work. This chapter sum-
for the smooth transition to a definitive one as it
marises the conventional techniques and pros-
aids tremendously in lab communication at all
thetic workflow for fabrication of full-arch
stages.
fixed implant prostheses. In Sect. 14.2, a novel
For the full-arch fixed implant prostheses, the
fast-tracking protocol has been devised,
number of clinical prosthetic steps needed in fab-
wherein from impression to delivery, the
ricating the definitive restorations has been
entire workflow can be carried out in one or
depicted in Flowchart 14.1.
two appointments.

14.1.1 Step 1: Impressions

Impressions for definitive prostheses can be done

at the implant level or abutment level, based on
the initial prosthetic plan (Flowchart 14.2). The
implant-level approach entails using components
that directly connect to the implant platform. The
abutment-level approach utilises a multi-unit
abutment that is torqued on the implant, and all
U. Kher · A. Tunkiwala (*) the following prosthetic steps are performed over
Private practice, Mumbai, India

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 359
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_14
360
Flowchart 14.1 Conventional sequence and appointments for full arch implant rehabilitation
the abutments. Working at abutment level allows
the restorative margin to be taken further away
from the crestal bone, and thus, it is biologically
a better option, provided there is sufficient restor-
ative space to accommodate the extra height of
the multi-unit abutments. Moreover, working at
abutment level will make all the subsequent pros-
thetic steps, like verification of fit, easier and
thereby helps minimising errors. Lastly, as the
abutment can allow implant trajectories to be
straightened out and get screw accesses to the
desirable positions, it reduces overall distortions
in the impressions. The basic technique and prin-
ciples of impression-making at implant or abut-
U. Kher and A. Tunkiwala
ment level will remain the same, although the
componentry for each will be different.
The impression must accurately represent the
exact three-dimensional, implant/abutment posi-
tions and the surrounding soft tissue contours.
Having a well-healed soft tissue around the
implants is desirable as inflamed, unhealed tis-
sues may bleed during impression procedures
and affect the setting time and dimensional accu-
racy of the materials [1]. If a provisional restora-
tion has been designed to shape the gingival
tissue architecture to achieve a positive emer-
gence profile, it must be copied in the impression
procedure [2–5].
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
Flowchart 14.2 Analogue and Digital Workflow for Implant impressions/scans
14.1.1.1 Impression Techniques
Closed Tray Technique
The closed tray or indirect transfer technique is
suited only when the implants are placed parallel
to each other. The closed tray copings are attached
to the implant or the multi-unit abutment and an
impression taken with elastomeric materials.
After the retrieval and disinfection of the impres-
sion, the implant or abutment replica as applica-
ble is attached to the impression coping and
reinserted within the impression (Fig. 14.1). The
key to a successful closed tray impression lies in
this step of relocating the coping-replica assem-
bly within the impression. For maximum accu-
racy the height of the coping that is captured
above the tissues must be sufficient and the sys-
tem should have designed the impression coping
that facilitates accurate indexation within the
impression. Some systems have a plastic cap over
the copings that gets picked up with the impres-
361
sion material and allows for a definitive seat of
the coping-replica assembly within the impres-
sion (Fig. 14.2). The closed tray technique, how-
ever simple, is contraindicated for non-parallel
implant trajectories as there will be distortion in
the set material during retrieval from the mouth
due to the mismatch in their paths of withdrawal
(Figs. 14.3, 14.4, 14.5, 14.6, and 14.7).
Open Tray Technique
The open tray impressions are preferred in cases
where implants are placed deeper or have a thick
band of soft tissue over them (Fig. 14.8).
Moreover, this is the technique of choice when
implants are not parallel to each other [6]. Full-­
arch impressions for implant-supported restora-
tions require a high degree of accuracy for which
the open tray or direct pick-up technique in a
rigid custom tray is preferred [2–5].
The open tray copings may be engaging
(hexed) or non-engaging (non-hexed) (Figs. 14.8
362 U. Kher and A. Tunkiwala

Fig. 14.1 Closed tray impression coping Fig. 14.2 Closed tray impression coping with plastic
transfer cap

Fig. 14.3 Upper full-arch implants. Closed tray tech-

nique is used here as the parallelism between the implants Fig. 14.4 Upper full-arch implants impression using the
is within the acceptable range closed tray technique
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
Fig. 14.5 Snap impression copings
Fig. 14.6 Lower implants with multi-unit abutments
Fig. 14.7 Closed tray copings for multi-unit abutments
and 14.9). The former is used only for single
implants and the latter for multiple implants as
would be the case for full-arch cases.
These copings are designed with undercuts on
them and a long screw that will protrude beyond
the selected tray. After the impression material
has set, the long screw is disengaged completely
363
Fig. 14.8 Hexed open tray coping for single-implant
restorations
and the tray retrieved with the impression coping
embedded within the material securely. The
implant or abutment replica, as applicable, is
fixed to the impression coping. At this point, the
clinician must not use uncontrolled force to fixate
the replica as that can lead to rotation of the cop-
ing within the elastomeric impression and thereby
lead to a flaw. To overcome this potential error, it
is advisable to splint the open tray copings to
each other with a rigid material, intraorally
[7–9].
Literature supports the use of splinted impres-
sion copings with a rigid material with low-­
dimensional change [6–10]. Several techniques
have been used for splinting of the impression
copings such as autopolymerising resin, dual-­
cured resins, plaster and prefabricated resin bars
364 U. Kher and A. Tunkiwala

Fig. 14.10 Open tray copings that have not been splinted

Fig. 14.11 Upper-arch implants ready for impressions

Fig. 14.9 Non-hexed copings for multiple-implant

restoration

(Figs. 14.10 and 14.11). The splinting of copings

with autopolymerising resin which is sectioned
and reconnected after setting are considered to
provide maximum accuracy and are thus preferred Fig. 14.12 Floss tied to the open tray copings to act as
[7, 11, 12]. The necessity to section the splints scaffold for resin splinting
connecting the copings and reconnecting them
intraorally arises due to the polymerisation shrink-
age of the material that can lead to a certain amount
of pressure between all copings, thereby leading to
an invisible flaw in the impression.
The splinting of the copings could be per-
formed intraorally in one step or could be done
on a primary model and splinted extraorally. Both
these techniques will need the copings to be sec-
tioned and reconnected with fast-setting resin
intraorally (Figs. 14.12, 14.13, 14.14, 14.15, and
14.16). Fig. 14.13 Open tray copings splinted with pattern resin
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
Fig. 14.14 Splinted open tray impression done with
polyether on custom tray
Fig. 14.15 Lower multi-unit abutments
Fig. 14.16 Open tray copings for multi-unit abutments
14.1.1.2 Impression Materials
Polyvinyl siloxane or polyether impression mate-
rials are the preferred options for making impres-
sions due to their higher level of accuracy and
dimensional stability [8, 13, 14]. A custom tray
coated with an appropriate tray adhesive is pre-
ferred for making the impressions [15, 16].
365
Fig. 14.17 Stock tray with plastic inserts for open tray
technique
However, stock trays designed especially for the
open tray technique could also be used
(Fig. 14.17).
14.1.2 Step 2: Verification Jig
The verification jig is fabricated on the master
model. These jigs are generally made using tem-
porary titanium cylinders that have been splinted
with each other on the master cast. The clinician
will try these in the next appointment with the
one screw (Sheffield) test. The jig is screwed onto
the distal-most implant and must not lift up from
the contralateral implant. A distortion-free radio-
graph may be done to verify the same. In case the
verification jig fits perfectly, the impression is
deemed to be correct and the next step of jaw
relation may be undertaken at the same appoint-
ment. However, if the verification jig is not seat-
ing accurately or passively, it must be sectioned
between the offending implants and rejoined
intraorally with fast-setting resin. The lab must
be informed of this act so that they can relocate
the implant or abutment replica in its correct
position within the stone model and make an
altered master cast with accurate positions of all
implants/abutment replicas.
The verification jig may be made in acrylic resin
(Figs. 14.18 and 14.19). These need to be thick so
that the flexion of the resin during seating of the jig
does not give a false negative result, thereby mis-
leading the clinician to think that the jig is accurate
or passive. To avoid such errors, an alternative rec-
366
Fig. 14.18 Plaster verification jig
Fig. 14.19 When resin verification jig lacks passivity or
accuracy, it must be sectioned and individual cylinders left
on each implant
Fig. 14.20 New resin can be used to join the cylinders
intraorally and lab informed
ommendation is to make the verification jigs with
impression plaster (Fig. 14.20). The brittle plaster
will break if the screw is forced in due to lack of
passivity, thereby preventing a potential impression
error to go through to the next step.
U. Kher and A. Tunkiwala
14.1.3 Step 3: Interocclusal Records
[16, 17]
Accurate interocclusal records are required to
enable the lab to mount the upper and lower
­master casts in accurate relation with each other.
In cases where both arches are being restored
together, the upper arch is mounted with an aes-
thetically accurate face bow record, such as a
dentofacial analyser. The lower cast will be
mounted in centric relation with regard to the
upper cast, and this should be accomplished at
the desired vertical dimension of occlusion
(Fig. 14.21).
The steps would be as follows:
(a) Upper rim adjustment keeping parallelism
with the inter-pupillary line and the Camper’s
plane.
(b) Vertical dimension of occlusion determina-
tion using the freeway space as a guideline.
(c) Centric relation record.
In full-arch cases, these interocclusal records
can be done in four ways:
1. Conventional complete denture bases on
residual ridge.
2. Screw-retained complete denture bases
(Figs. 14.22, 14.23, 14.24, and 14.25).
3. Two-piece screw-retained bases (Figs. 14.26
and 14.27).
4. Using Aluwax on healing abutments/final
abutments (Fig. 14.28).
Fig. 14.21 Conventional record bases for jaw relation
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration 367

Fig. 14.25 Several other lines marked to help select the

right size of teeth in the lab
Fig. 14.22 Screw-retained record base for jaw relation

Fig. 14.26 The fixed screw-retained part of the two-­

Fig. 14.23 CR recorded on fixed screw-retained bases
piece record base

Fig. 14.24 Midline transfer along with cuspid line

Fig. 14.27 The second part of the record base with wax
marked on rim
rim
368
Fig. 14.28 Aluwax records the JR on stock abutments
In most cases of full-arch prosthodontics,
at least two interocclusal records are recom-
mended at two different stages during the
treatment.
14.1.3.1 Conventional Complete
Denture Bases on Residual
Ridge
This is done on movable record base just like in
complete denture prosthodontics.
Pros
It is an easy technique and can be done without
any additional lab steps or componentry.
Cons
(a) Record bases may be unstable, leading to an
error in CR records.
(b) The entire movable base feels bulky to most
patients.
(c) Presence of flanges may create confusion
with lip support.
14.1.3.2 Screw-Retained Complete
Denture Bases
Pros
The record bases are fixed to the implants and
thus the accuracy of the record is much higher.
Cons
(a) Record bases need to be lab fabricated.
(b) The long temporary cylinders used in the
record bases can be a nuisance during adjust-
ment of the height of the wax rim as they will
interfere and will need to be shortened
repeatedly.
U. Kher and A. Tunkiwala
14.1.3.3 Two-Piece Screw-Retained
Bases
Record bases are made in two parts per arch that fit
into each other. The first part is screwed onto the
implants, thereby providing stability, and the sec-
ond part is snapped onto the first one. The second
part has the wax rim and can be easily removed
from the mouth to adjust the same and snapped
back to check the height and the arch form.
Pros
Prevents repeated unscrewing as with the case of
single screw-retained base.
Cons
(a) Needs lab fabrication and additional
componentry.
(b) Needs sufficient restorative space.
14.1.3.4 Using Aluwax on Healing
Abutments/Final Abutments
This is with stable components like tall healing
abutments or stock abutments on implants, but
needs a lot of calculations. The nose-chin points
should be marked with approved provisional in
place, and then the vertical dimension is repro-
duced for the CR record using wax to record the
abutments.
Pros
(a) Records done on stable components.
(b) No bulky record bases in the mouth.
Cons
(a) You will need extra set of all same
abutments.
(b) Chances of error in VDO high as there is no
anterior stop.
14.1.4 Step 4: Teeth Set for Try-In
The goal of this step is to verify the teeth arrange-
ment from an aesthetic and functional
standpoint.
Two types of trials can be done after the jaw
relation is taken.
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration 369

(a) Complete denture try-in on record bases. patient a trial that will feel and look exactly
In cases where there is no fixed provi- like the final prostheses as far as the overall
sional restoration made and the incisal posi- design is concerned (Figs. 14.31, 14.32,
tion of upper incisors is not approved from 14.33, 14.34, and 14.35).
the facial aspect, it is prudent to carry out a This trial is a prototype of the final prosthe-
denture trial (Figs. 14.29 and 14.30). This ses and can be made in resin. The most com-
trial must be preferably screw-retained on mon method of fabrication for such trials is to
some temporary cylinders or can be a con-
ventional complete denture trial on record
bases. An important aspect here is that the
denture should not have a labial flange so
that the lip support or the lack of it can be
judged by the patient and the clinician during
the trial. All aspects of aesthetics, phonetics,
vertical dimension and occlusion in harmony
with CR must be judged and, if needed, cor-
rected at this stage.
(b) Resin prototype screwed-in trial.
This trial is the key step, an important
milestone in the full-arch implant recon-
Fig. 14.31 Complete denture try-in on screw-retained
struction workflow. The goal is to give the
base

Fig. 14.29 Complete denture try-in on movable base Fig. 14.32 Resin prototype

Fig. 14.30 Complete denture try-in on movable base Fig. 14.33 Resin prototype
370
Fig. 14.34 Resin prototype being tested intraorally
Fig. 14.35 New bite records on resin prototype
mill them with polymethyl methacrylate
(PMMA), and these can be shaped, stained
and coloured as needed to meet the patients’
aesthetic requirements (Figs. 14.36 and 14.37).
In cases where a complete denture (CD) trial
was carried out and approved, it can serve as a
template for designing these PMMA prototypes.
The technician will scan these approved CD trials
and design the PMMA prototype in a software
(Exocad) and will share the view of the final
aspects. Once approved by the clinician, the mill-
ing can be carried out in resin with temporary
cylinders fixed to the prototype. The staining and
polishing are then carried out, and the resin pro-
totype delivered to the clinician.
At the time of PMMA prototype clinical trials,
it is crucial to check all aspects of the final
prostheses.
A checklist as follows may be used:
(a) Passivity (one-screw test).
(b) Incisal edge position.
(c) Pink–white junction (within the prototype).
(d) Pink–pink junction (between the prototype
and the tissues).
(e) Occlusion.
(f) Phonetics and vertical dimension of
occlusion.
U. Kher and A. Tunkiwala
Fig. 14.36 Bisque trial
Fig. 14.37 New CR record on Bisque trial to fine-tune
the occlusion in the lab
(g) Shape of intaglio.
(h) Overall look and feel of the prostheses must
be acceptable.
The aesthetic aspects such as midline, axial
inclinations, presence of adequate labial corridor,
and proportions of the teeth must be evaluated
and corrected if needed. The upper plane must be
critically evaluated and corrected to meet aes-
thetic requirements by staying parallel to the
inter-pupillary line.
In full smile position (Duchene smile), the pro-
portion of pink to white on the prototype must be
assessed with photographs or videography. The
teeth must appear in correct proportion to the face
and sufficient zone of pink must remain. In cases
where the pink aspect of the prostheses is too nar-
row (<1.5 mm), it is better to omit it and make the
teeth appear longer and shape and stain the cervical
aspect like a root. This can be done if the patient
does not have a high lip line. Phonetic sounds like
F, V and S sounds must be checked and adjustment
made to incisal edge position and profile if needed.
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
Fig. 14.38 Space present between the intaglio and the
tissues
Fig. 14.39 Bite registration paste added between the
intaglio and the tissues for lab communication
Fig. 14.40 The lab will now make an index of this record
and add ceramic to close the gap
Another aspect to verify is the shape of the
intaglio, which must be convex and put mild
pressure on the tissues so that no space remains
between the prototype and the tissues for air to
escape during speaking (Figs. 14.38, 14.39, and
14.40). This design will also facilitate good over-
all hygiene. Occlusal adjustments must be carried
out to achieve uniform contacts of equal intensity
371
on all teeth. These contacts must be ideally veri-
fied with shimstock so that each tooth is able to
hold the same in maximum intercuspation. Any
cantilevers in the prostheses must be relieved by
100 μm so as not to overload them. In cases
where major occlusal changes are needed it is
advisable to take another bite record with bite
registration paste so that the lab can remount the
lower master cast and address the need for occlu-
sal adjustments in the lab setting.
14.1.5 Step 5: Framework Trial
Once the necessary adjustments are done on the
PMMA prototype, the lab will then go ahead and
start the manufacturing process of the final
prostheses.
There are several designing and material
options, based on which the next step will be
chosen.
Flowcharts 14.3 and 14.4 depict the various
material options and their combinations.
In case a hybrid design is chosen, a framework
trial will be needed to verify passivity and accu-
racy of fit. Passive fit is a prerequisite for the
long-term survival with minimal technical or
mechanical complications and for maintaining
successful long-term osseointegration [18].
Milled frameworks produce the best accuracy
of fit and must be chosen when possible. Cast
frameworks inherently have a poorer fit due to
casting shrinkage and also may be prone to inter-
nal defects and porosity. A milled framework will
be free from both these issues. The designing of
these frameworks may be done to layer ceramic
directly to it or it can be done in the form of a
screw-retained framework with individual struts
on it to receive cement-retained crowns or bridges
(Fig. 14.41). In either case, the framework must
be designed with a controlled cutback leaving
adequate room for the ceramic work.
14.1.6 Step 6: Bisque Trial
The last trial, and the one that must never be
underestimated in its value, is the Bisque trial,
372 U. Kher and A. Tunkiwala

Flowchart
14.3 Options for
Zirconia based full arch
restorations

Flowchart 14.4 Material choices for full arch fixed implant supported restorations

especially if a fixed prosthesis is being fabricated

for both arches at the same time. If the steps so
far have been diligently followed, there will be
hardly any changes required at the Bisque trial
stage.
A detailed checklist, as follows, must be fol-
lowed to methodically check and, if necessary,
make the final corrections:

• Passivity of prostheses.
• Length of teeth/incisal edge position.
Fig. 14.41 Screw-retained restoration • Pink and white junction.
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
• Shape/bulk of teeth and prostheses.
• Arch form/lip support.
• Occlusion.
• Pink/pink junction (intaglio).
• Intaglio: spaces/shape.
All the things that are checked in the frame-
work trial pertaining to fit and accuracy of the
prostheses have to be rechecked at the bisque
stage. Additionally, the aesthetic parameters have
to be verified in a detailed manner to confirm the
teeth position with the lip dynamics and the smile
line of the patient. Since these parameters for
such prosthesis are evaluated with the trial den-
tures and then a fixed PMMA trial, at this stage,
very little aesthetic change should be necessary.
The occlusion has to be checked to provide
maximum intercuspation at the desired centric
relation condylar position. Uniform contacts of
equal intensity must be achieved on both sides
and the anterior guidance should be effective in
providing the desired posterior leeway and dis-
clusion [19–21]. The anterior guidance must be
within the envelope of function to respect the
chewing pathway, thus avoiding any
interference.
The tissue surface of the prostheses must be
then assessed to verify a positive tissue contact
on the edentulous areas between the implants. In
the maxillary anterior region, lack of such con-
tact can lead to air escaping during speech, lead-
ing to a flutter of the lips that can be very annoying
for the patient. A modified ridge lap or an ovate
pontic is recommended in this region of the pros-
theses. Similar design must be produced in the
posterior regions to avoid food entrapment below
the prostheses.
On screwing down the prosthesis over the
implants, there is usually some degree of soft tis-
sue blanching. Within limits this blanching is
desirable and will disappear in a few minutes.
Excessive blanching for a prolonged period may
lead to tissue necrosis. In such a situation, it may
be necessary to reduce the emergence contour of
the restoration around the implant.
The undersurface of the prostheses must be
highly polished and made of materials that do not
degrade with time. Ceramic or titanium itself is
373
the recommended material to contact the tissue
surface. Acrylics can lead to tissue irritation due
to their inherent water sorption. The clinician
must account for a need to rebase this part of the
prostheses a few years down the line. Dense com-
posite resins (Bio-HPP) may be an option to con-
sider here due to their bio-inertness.
An interocclusal record at this stage is neces-
sary with bite registration paste for the lab to
remount the casts and fine-tune the occlusion to
allow for good contacts.
14.1.7 Step 7: Prosthesis Delivery
The soft tissues around the implants should look
in good health on the day of the prosthesis deliv-
ery. Chlorohexidine gel may be placed on the soft
tissues around the implants [22]. If the bisque
trial has been performed correctly, there should
be no need for any further occlusal adjustments.
It is desirable to use lab screws during the manu-
facture of the prostheses and the subsequent tri-
als. During prostheses delivery, new abutment or
prosthetic screws must be used to provide opti-
mal screw mechanics.
14.1.7.1 Delivery of Screw-Retained
Restorations
The glazed prosthesis is carefully placed over the
implants, and all prosthetic screws are tightened
one by one manually. The gingival tissues in the
edentulous areas between the implants may pre-
vent seating of the prostheses. A fit checker can
be used to identify pressure points on the tissues
from the prostheses and relived slightly if needed.
Once the first screw seats and is hand-tightened
completely, the diagonally opposite screw must
be hand-tightened. Once all screws are seated
and hand-tightened, they must be torqued as per
the manufacturer’s instructions.
The screw access channels must then be filled
with PTFE tape and sealed using composite resin
restoration [23]. Occlusion must be rechecked in
its static and dynamic contacts to relieve any high
points in the prostheses.
The following occlusal criteria must be met
with all full-arch prostheses:
374 U. Kher and A. Tunkiwala

(a) All teeth must have at least one good contact
and must be able to hold shimstock.
(b) The contacts must be of equal intensity.
(c) Any cantilever on the prostheses must be
relieved by 100 μm to prevent overload.
(d) Chewing pathway adjustment must be car-
ried out to enable a friction-free and smooth
chewing experience.
All areas that are adjusted after delivery must
be smoothened and polished with a dedicated
intraoral ceramic polishing kit.
14.1.8 Step 8: Postoperative
Instructions and Follow-Up
Patients are advised about the maintenance of
hygiene for fixed restorations on implants. Use of
superfloss, interdental brushes and irrigation
devices is necessary. The patients are recalled at
1-week, 3-month, 6-month and 1-year intervals
for a follow-up and assessment of prosthesis.
Oral prophylaxis using plastic-ended curettes is
done to avoid scratching the implant surfaces

14.1.7.2 Delivery of Cement-Retained

Restorations
In case of cement-retained restorations, the indi-
vidual abutments are seated in correct orientation
in the mouth with an orientation jig (Fig. 14.42).
Each abutment is hand-tightened over the implants
and the fit of the final prostheses is verified. All aes-
thetic and occlusal adjustments are carried out as
discussed above. Each abutment is torqued as per
the manufacturer’s instructions, and their screw
access channel is covered with PTFE tape [23]. Fig. 14.43 Pick-up jigs for accurate orientation of abut-
The prosthesis is then luted. Definitive cemen- ment from model to mouth
tation is never an option for full-arch cement-­
retained prostheses. An implant-specific temporary
resin cement is preferred as it will allow the pos-
sibility of retrievability at a later stage.
Any cement excess in the sulcus has the
potential of causing peri-implantitis [24, 25].
Hence cement excess is very meticulously
cleaned using explorers and dental floss. Intraoral
radiographs are taken to ensure that all cement
excess is thoroughly cleaned (Figs. 14.43, 14.44,
and 14.45).

Fig. 14.44 Orientation jig for abutments

Fig. 14.42 Abutments on model for cement-retained Fig. 14.45 Final cement-retained restorations
restorations
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration 375

[25]. The prosthesis maybe removed once a year
for maintenance and cleaning of the
undersurface.
14.1.9 Conclusion
An accurate impression depicting the three-­
dimensional implant positions and a perfectly
recorded jaw relation record are critical steps for
the fabrication of a full-arch implant-supported
restoration. A series of verifications and trials are
required in order to avoid major adjustments in
the final prosthesis. Technological advances have
simplified fabrication of these prostheses, but it
has inadvertently stepped up the expenses
involved in the laboratory fabrication of these
prostheses. It is imperative for the clinician to
master the clinical steps and work in tandem with
the laboratory technician in order to avoid repeats
and remakes in prosthetic work and provide well-­
designed prostheses to patients.
tional and aesthetic requirements. An immediately
loaded restoration following a chairside denture
conversion technique, or a lab-fabricated provi-
sional, fitted within the next couple of days is ide-
ally suited for this protocol.
The following steps are undertaken in the fast-­
tracking protocol:
1. A thorough evaluation of implant prosthesis
and the health of the peri-implant tissues is
made during the follow-up visit, prior to the
initiation of the prosthodontic phase. The
provisional restoration should display satis-
factory aesthetics and should have uniform
occlusal contacts of equal intensity across
the arch. If found to be deficient, a detailed
occlusal adjustment is made prior to pro-
ceeding to the next step (Fig. 14.46).
2. An interocclusal record is made using bite
registration paste or Aluwax (Fig. 14.47).

14.2 Section 2: Fast-Tracking

Implant Prosthodontic
Protocol for Fully Edentulous
Patients

The conventional approach for fabrication of a

definitive prosthesis for full-arch implant cases
requires multiple visits [27]. A novel, time-saving
technique for full-arch implant prosthodontics is Fig. 14.46 Immediate loading with screw-retained
presented in this section. The technique is indi- acrylic provisional restoration using denture conversion
cated for cases in which an immediate fixed pro- technique for an edentulous patient
visional restoration has been delivered on the day
of implant placement or within 72 h of implant
placement or for cases where the clinician has
made an aesthetically and functionally acceptable
provisional restoration before starting the pros-
thetic phase for the definitive restoration.

14.2.1 Technique

The prerequisite for this technique is to have a

well-fitted and well-adjusted screw-retained pro-
visional restoration that meets the patient’s func- Fig. 14.47 After 3 months: bite registration
376
3. The prosthesis is unscrewed to expose the
underlying multi-unit abutments.
4. The provisional restoration is thoroughly
cleaned extraorally and fitted over the multi-­
unit abutments with the help of the long
screws of the open tray impression copings
(Figs. 14.48 and 14.49).
5. A customised or a stock tray modified for
an open tray impression is used for record-
ing the impression. Tray adhesive is applied
and an open tray impression is made of the
prosthesis using polyether impression
material. Care is taken to inject the poly-
ether material on the underside of the pros-
thesis in order to record the soft tissue
profile (Fig. 14.49).
6. After setting of the material, the long screws
are loosened to release the prosthesis from
the MUAs and the prosthesis is picked up in
the impression.
Fig. 14.48 Open tray impression coping screws engag-
ing the provisional restoration
Fig. 14.49 Open tray impression of the prosthesis
U. Kher and A. Tunkiwala
7. After thoroughly disinfecting the impres-
sion, laboratory analogues are attached to the
prosthesis with the help of the long screws.
8. Gingival mask is prepared around the neck of
the analogues and allowed to set. A die stone
model is poured (Figs. 14.50 and 14.51).
9. After setting of the model, the prosthesis is
removed from it and refixed on the model
using the internal screws.
10. This assembly is now articulated using the
bite registration and mounted on a semi-­
adjustable articulator against the opposing
cast (Fig. 14.52).
11. After mounting, a labial index is made
around the two articulated models for pro-
viding the lab with the incisal edge position
of the provisional restoration.
12. The prosthesis can now be released from the
model and delivered back to the patient.
13. The articulated model, along with the incisal
edge position, is sent to the laboratory
(Fig. 14.53).
Fig. 14.50 Provisional denture picked up in the impres-
sion. Analogues attached and model pouring initiated
Fig. 14.51 Master cast
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration 377

The laboratory now has the three essential ele-

ments for proceeding with the final restoration
(Figs. 14.54, 14.55, 14.56, and 14.57):

1. An accurate impression.
2. An accurate jaw relation recorded.
3. An ideal incisal edge position and occlusal
plane reference.

The distinct advantages of this time-saving

technique are as follows:
Fig. 14.52 Mounted using bite registration
1. The possibility of recording an accurate
impression and a jaw relation record on the
same day, thus saving the patient and clinician
multiple appointments.
2. The impression is a pick-up impression of the
well-fitted provisional restoration. Hence, it is
very accurately recorded with no errors that
may get incorporated into the traditional
workflow.
3. The recorded jaw relation record is made
using the patient’s adjusted prosthesis. Hence,
there are very few chances of errors occurring
in the process.
Fig. 14.53 Provisional restoration released and delivered
4. The labial silicone index provides an exact
to patient. Articulator sent to laboratory for fabrication of
the final restoration representation of the teeth positions.

Fig. 14.54 CAD-CAM design for final zirconia-based prosthesis

378
Fig. 14.55 Definitive restoration—monolithic zirconia
with staining and pink ceramic [28]
Fig. 14.56 Upper and lower definitive restorations in
occlusion
Fig. 14.57 Postoperative radiograph
5. The additional appointments of impression
verification trials and metal trials are avoided.
The clinician can proceed directly to a bisque
trail.
The following are the limiting factors for this
technique:
1. In cases wherein the implants have not
received any provisional restorations.
U. Kher and A. Tunkiwala
2. The multi-unit abutments need to be changed
after healing and soft tissue remodelling. In
certain situations, the MUAs may need to be
replaced with different collar heights ones to
match the soft tissue contours after complete
healing. In such a situation, the provisional
restoration will need to be replaced with a
new one or the existing restoration may need
to be modified prior to fast-tracking protocol.
14.2.2 Conclusion
The fast-track technique for the fabrication of a
full-arch definitive implant-supported prosthesis
significantly reduces overall treatment time and
the number of appointments without the loss of
accuracy and precision.
14.3 Partial Extraction Therapy
(PET) for Multiple Teeth
and Full-Arch Implant-­
Supported Reconstructions
Full-arch reconstruction with implant-supported
restorations is a complex treatment procedure
wherein the clinician is faced with numerous
challenges. One of the biggest limitations with
long-standing edentulous ridges is finding ade-
quate bone for implant placements. Ridge altera-
tion after extractions of all teeth is commonly
observed. Pneumatisation of the sinus is one of
the most common post-extraction complications
in posterior maxilla that limits the available bone
for the implant placement. Another common
occurrence is the limited amount of attached kera-
tinised issues around implants placed in fully
edentulous jaws. It is well established that
implants are at a higher risk of bone loss and peri-­
implantitis when there are deficient attached tis-
sues around implants. Extensive amount of hard
and soft tissue augmentation procedures is
required in cases where teeth have been com-
pletely extracted. The other challenge during the
restorative phase is to create good emergence pro-
files around implant abutments and pontic sites.
Improper emergence profiles lead to a poor aes-
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
thetic end result and difficulty in long-term main-
tenance of the implant-supported restoration.
Socket shields procedures, performed by pre-
serving the labial part of the roots, have been suc-
cessfully done for single-teeth implant-supported
restorations. Extending the scope of partial
extraction therapies to multiple sites needing
post-extraction immediate implant placements
will have a significant benefit in maintaining the
alveolar ridge architecture around the implants.
In the past, clinicians have found it extremely
challenging to reconstruct loss of alveolus and
surrounding teeth structures after extractions of
multiple teeth in the aesthetic zone. Hard and soft
tissue augmentation for multiple implant sites is
a complex treatment procedure. Vertical augmen-
tation has limited long-term success rate as
reported in the literature. Hence, an alternative
protocol which is aimed at.
preserving bone and soft tissue instead of
reconstructing tissues could be the solution to
these problems.
Performing multiple PETs on adjacent sites
needing post-extraction implant placements
should be undertaken by clinicians after getting
comfortable with PET procedures on single teeth.
The rationale for doing socket shield procedures
for adjacent implant sites was highlighted in
Chap. 5. By extending this scope further to
involve a greater number of teeth along with the
applications of pontic shields and root submer-
gence technique, the clinician can handle more
challenging situations in treating multiple
implant sites and full-arch implant-supported
reconstructions. A high level of clinical expertise
and experience in single-teeth PET procedures is
required for clinicians to undertake such complex
cases.
14.3.1 Challenges in Multiple Sites
Treated with PET
1. Time-consuming process for partial extrac-
tions of roots: Partial extractions of multiple
roots can take much longer than extracting the
whole tooth. This may increase the overall
surgical time for the procedure.
379
2. Prosthetically driven implant placements:
Placing multiple implants in ideal locations is
simpler when one does post-extraction imme-
diate placements since the sockets provide the
exact locations for insertion of implants.
However, managing implant trajectories and
depth of placements can be quite challenging.
Guided implant placements using CT-guided
stents will be helpful to overcome this
difficulty.
3. Fabrication of a fixed temporary restoration:
Fabricating a fixed provisional restoration on
the day of the surgery is also a time-­consuming
process and needs the services of the restor-
ative dentist and the laboratory.
4. Management of minor healing complications
like internal and external shield exposures:
With more shields to prepare in full-arch
cases, the incidence of minor complications
like internal and external exposures is likely
to be more and management of these compli-
cations during the healing phase is an addi-
tional burden on the clinician.
The following case utilises all the PET proce-
dures for a maxillary full-arch implant-supported
reconstruction.
A 65-year-old healthy non-smoker male
reported repeated debonding of his crowns which
were done 15 years ago (Figs. 14.58 and 14.59).
The underlying teeth were badly destroyed due to
secondary caries under the crowns and were non-­
restorable. A decision was made to extract the
Fig. 14.58 Preoperative situation. Failing upper
dentition
380 U. Kher and A. Tunkiwala

was taken to completely remove the apex of the

root and the periapical area was thoroughly
debrided using small-tipped bone curettes
(Figs. 14.61, 14.62, and 14.63). A small piece of
collagen plug was placed in the socket to help in
retaining the blood clot.

Fig. 14.59 Radiograph showing endodontically treated

teeth with post and cores and periapical lesions

teeth and provide him with an implant-supported

fixed denture. The periodontal status was satis-
factory. He desired a fixed provisional restoration
during the healing phase of his treatment. His
treatment was divided into three phases.

Fig. 14.60 Fixed provisional restorations on natural

14.3.2 Phase 1: Socket Shields teeth
and Tooth-Supported
Provisional Restorations

In the first phase of treatment, a well-adjusted

fixed provisional restoration was fabricated on
the existing teeth after removal of the old restora-
tions (Fig. 14.60). The provisional restoration
was designed to adapt to desirable function, pho-
netics and aesthetics. Thereafter socket shield
procedures were performed on teeth 12, 13, 21
and 23 utilising the technique described in Chap.
2. The implants placed after the socket shield
procedures were kept submerged. Few strategic
Fig. 14.61 Condition of underlying natural teeth
teeth were chosen to support the fixed provisional
restoration.

14.3.3 Phase 2: Pontic Shield, Root

Submergence Technique
and Implant-Supported
Provisional Restorations

After 3 months of healing time, the provisional

restoration was removed. The submerged
implants were surgically exposed and temporary
titanium abutments were attached onto these
Fig. 14.62 Partial extraction therapies on four anterior
implants. Tooth 11 was prepared for a pontic teeth. Socket shields with implant placement in teeth 12,
shield since it had a minor periapical lesion. Care 13, 21 and 23
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
Fig. 14.63 Fixed provisional restoration on the remain-
ing natural teeth
Fig. 14.64 Surgical exposure of osseointegrated implants
Fig. 14.65 Pontic shield preparation for tooth 11
Teeth 14, 15 and 24 were prepared for root
submergence. The roots were kept at the level of
the crestal bone and the tissue around them was
allowed to close by secondary healing
(Figs. 14.64, 14.65, and 14.66).
A putty index was prepared before the
removal of the existing teeth supported provi-
381
Fig. 14.66 Root submergence technique for teeth 14, 15
and 24. Temporary titanium abutments for supporting a
screw-retained fixed provisional restoration
Fig. 14.67 Silicone index of the provisional restoration
sional restoration, which provided the form for
fabrication of the implant-supported fixed resto-
ration (Fig. 14.67). The openings of the tempo-
rary titanium abutments were filled with cotton.
An autopolymerising composite material was
used to fabricate the implant-supported provi-
sional restoration with the help of the putty
index (Figs. 14.68 and 14.69). After setting of
the material, the cotton pieces were removed
from the abutments and the internal screws were
loosened. The provisional restoration attached
to the titanium abutments were removed from
the mouth and voids were filled using light-
cured flowable resin material. Finishing and
polishing was done and the provisional screw-
retained restoration was fixed over the implants.
Occlusal adjustments were done so as to achieve
382 U. Kher and A. Tunkiwala

Fig. 14.68 Fabrication of a screw-retained fixed provi- Fig. 14.70 Fast-tracking protocol. Long screw attached
sional restoration on osseointegrated implants

Fig. 14.69 Maxillary screw-retained restoration on all

the osseointegrated implants
Fig. 14.71 Pick-up impression and model making

uniform contacts of equal intensity across all the

teeth in the arch.

14.3.4 Phase 3: Fast-Tracking to Final

Restoration

After 4 weeks of healing time, the provisional

restoration was removed and the fabrication of
the definitive restoration was initiated
(Figs. 14.70, 14.71, 14.72, 14.73, and 14.74). The
soft tissue contours developed with the provi- Fig. 14.72 Master cast
sional restoration were found to be satisfactory.
The final restoration was a screw-retained porce-
lain fused to metal prosthesis (Figs. 14.75, 14.76, 14.81). Occlusal adjustments were done and the
14.77, 14.78 and 14.79). The internal screws of screw accesses were sealed using composite resin
the prosthesis were torqued at 30 Ncm as recom- (Fig. 14.82).
mended by the manufacturer (Fig. 14.80 and
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration 383

Fig. 14.75 Soft tissue architecture seen after removal of

the provisional restoration

Fig. 14.76 Screw-retained porcelain fused to metal fixed

restoration

Fig. 14.73 Mounting with provisional restoration to rep-

licate accurate vertical dimension of occlusion

Fig. 14.77 Right lateral view of the definitive screw-­

retained fixed restoration

Fig. 14.74 Provisional restoration delivered to patient

and articulated models sent to laboratory for fabrication of Fig. 14.78 Left lateral view of the definitive screw-­
final restoration retained fixed restoration
384 U. Kher and A. Tunkiwala

14.3.5 Conclusion

The most desired outcome for long-span and

Fig. 14.79 Close-up view displaying healthy peri-­
implant soft tissue contours
Fig. 14.80 Partial extraction therapy procedures
full-­arch implant-supported cases is to achieve a
definitive prosthesis without any pink ceramics
to replace the missing alveolar ridge. This is
very rarely possible with conventional implant
therapy without extensive hard and soft tissue
grafting procedures. Preservation of healthy
parts of the roots by performing partial extrac-
tion therapies has made it possible for clinicians
to accomplish such results without subjecting
patients to complex augmentation procedures.
One of the greatest benefits of PET procedures
for full-arch implant-supported reconstructions
is the preservation of the attached keratinised
tissue around the implants and pontic sites. The
presence of attached tissue around the implants
significantly reduces the possibilities of devel-
oping biological complications around the
implants in future.

References
1. Misch CE. Contemporary implant dentistry. 3rd ed.
St. Louis: Mosby – Elsevier; 2007. p. 731.
2. McCartney JW, Pearson R. Segmental framework
matrix: master cast verification, corrected cast guide,
and analogue transfer template for implant-supported
prostheses. J Prosthet Dent. 1994;71:197–200.
3. Herbst D, Nel JC, Driessen CH, Becker PJ. Evaluation
of impression accuracy for osseointegrated
implant supported superstructures. J Prosthet Dent.
Fig. 14.81 Postoperative radiograph of the upper full-­ 2000;83:555–61.
arch implant-supported restoration with multiple PET 4. Hsu CC, Millstein PL, Stein RS. A comparative anal-
sites ysis of the accuracy of implant transfer techniques. J
Prosthet Dent. 1993;69:588–93.
5. Inturregui JA, Aquilino SA, Ryther JS, Lund
PS. Evaluation of three impression techniques for
osseointegrated oral implants. J Prosthet Dent.
1993;69:503–9.
6. Moreira AH, Rodrigues NF, Pinho AC, Fonseca
JC, Vilaça JL. Accuracy comparison of implant
impression techniques: a systematic review. Clin
­
Implant Dent Relat Res. 2015;17(Suppl 2):e751–64.
7. Filho HG, Mazaro JV, Vedovatto E, Assunção WG,
dos Santos PH. Accuracy of impression techniques
Fig. 14.82 Six-year follow-up of the definitive for implants. Part 2 - comparison of splinting tech-
restoration niques. J Prosthodont. 2009;18(2):172–6.
14 Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration
8. Lee H, So JS, Hochstedler JL, Ercoli C. The accu-
racy of implant impressions: a systematic review. J
Prosthet Dent. 2008;100(4):285–91.
9. Vigolo P, Fonzi F, Majzoub Z, Cordioli G. An evalu-
ation of impression techniques for multiple inter-
nal connection implant prostheses. J Prosthet Dent.
2004;92(5):470–6.
10. 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(4):836–45.
11. Cabral LM, Guedes CG. Comparative analysis of 4
impression techniques for implants. Implant Dent.
2007;16(2):187–94.
12. Assif D, Nissan J, Varsano I, Singer A. Accuracy
of implant impression splinted techniques: effect of
splinting material. Int J Oral Maxillofac Implants.
1999;14:885–8.
13. Baig MR. Accuracy of impressions of multiple
implants in the edentulous arch: a systematic review.
Int J Oral Maxillofac Implants. 2014;29(4):869–80.
14. Wee AG. Comparison of impression materials for
direct multi-implant impressions. J Prosthet Dent.
2000;83:323–31.
15. Donovan TE, Chee WW. A review of contemporary
impression materials and techniques. Dent Clin North
Am. 2004;48:445–70.
16. Hobo S, Ichida E, Garcia LT. Osseointegration and
occlusal rehabilitation. Chicago: Quintessence; 1989.
p. 159–62, 171–3.
17. Rungcharassaeng K. Fabricating a stable record
base for completely edentulous patients treated with
osseointegrated implants using healing abutments. J
Prosthet Dent. 1999;81:224–7.
18. Kan JY, Rungcharassaeng K, Bohsali K, Goodacre
CJ, Lang BR. Clinical methods for evaluating implant
framework fit. J Prosthet Dent. 1999;81:7–13.
19. Sadowsky SJ. The role of complete denture prin-
ciples in implant prosthodontics. J Calif Dent Assoc.
2003;31(12):905–9.
20. Quirynen M, Naert I, van Steenberghe D. Fixture
design and overload influence marginal bone loss and
385
fixture success in the Branemark system. Clin Oral
Implants Res. 1992;3:104–11.
21. Lundgren D, Laurell L. Biomechanical aspects of fixed
bridgework supported by natural teeth and endosse-
ous implants. Periodontol. 2000;1994(4):23–40.
22. Paolantonio M, Perinetti G, D’Ercole S, Graziani F,
Catamo G, Sammartino G, Piccolomini R. Internal
decontamination of dental implants: an in vivo
randomized microbiologic 6-month trial on the
effects of a chlorhexidine gel. J Periodontol.
2008;79(8):1419–25.
23. Schoenbaum TR, Wadhwani C, Stevenson
RG. Covering the implant prosthesis screw access
hole: a biological approach to material selection and
technique. J Oral Implantol. 2017;43(1):39–44.
24. Gapski R, Neugeboren N, Pomeranz AZ, et al.
Endosseous implant failure influenced by crown
cementation: a clinical case report. Int J Oral
Maxillofac Implants. 2008;23:943–6.
25. Wilson TG. The positive relationship between
excess cement and peri-implant disease: prospec-
tive clinical endoscopic study. J Periodontol.
2009;80:1388–92.
26. Burns J, Palmer R, Howe L, Wilson R. Accuracy of
open tray implant impressions: an in vitro compari-
son of stock versus custom trays. J Prosthet Dent.
2003;89:250–5.
References for Fast Tracking
27. Kher U, Tunkiwala A, Jivraj S, Reshamvala A. Clinical
steps for fabrication of a full-arch implant-supported
restoration: metal ceramics, zirconia, acrylic titanium.
In: Jivral S, editor. Graftless solutions for the eden-
tulous patient. New York: Springer; 2018. p. 213–41.
28. Tunkiwala A, Kher U, Bijlani P. Numerical guide-
lines for selection of implant supported prostheses for
completely edentulous patients. Quintessence India.
2017;1(1):47–54.
 Speech and Facial Aesthetic
Considerations for the Contour
15
of Fixed Prostheses

Glen Liddelow and Graham Carmichael

Abstract The clinician has many challenges to address

when treatment planning for edentulous patients
The treatment of edentulous or soon-to-be
or those with a terminal dentition that will soon
edentulous jaws requires surgical and pros-
be rendered edentulous in one or both jaws. It is
thetic skill to achieve a functional outcome.
easy to concentrate on the fundamental aspects of
These interventions have a profound impact
placing sufficient implants into available bone
on facial aesthetics with respect to support for
and subsequently providing a prosthesis that
the perioral tissues and lower face. Patients
allows for mastication. However, the patient has
may present with significant loss of support-
very real concerns about how they will look and
ing tissue necessitating prosthetic replace-
whether they will be socially acceptable. Patients
ment. Ideally, this intervention should be
with terminal dentitions may well have had many
determined in the diagnostic phases to more
years of dental embarrassment and difficulties
predictably achieve the desired result and
with speaking and eating. Almost all will be
patient approval. Change in position of teeth
unhappy with their appearance both smiling and
and prosthetic contour can detrimentally affect
with lips closed. Many men grow facial hair to
speech. This chapter aims to provide a back-
cover their unsightly teeth, and most patients
ground to the effects of prosthesis contour and
limit their smile to decrease tooth display.
techniques to enhance aesthetics and maxi-
It is important therefore to record the
mise phonetic adaptation.
presenting situation in detail to discuss which
aspects are acceptable to the patient and those
which need to be changed. The patient’s aesthetic
G. Liddelow (*) expectation should be clearly determined. The
School of Dentistry, University of Western Australia, use of photographs, either historical of the patient
Crawley, WA, Australia themselves or of the patient’s idealised preference,
Craniofacial Unit, Princess Margaret Hospital, will help the clinician to tailor the treatment
Subiaco, WA, Australia towards the patient’s expectation of outcome or
G. Carmichael alternatively decide that this expectation is
School of Dentistry, University of Western Australia, outside the scope of the clinician’s ability. Frank
Crawley, WA, Australia
discussion can then determine a realistic outcome
Craniofacial Unit, Princess Margaret Hospital, or referral to a colleague. Pretreatment
Subiaco, WA, Australia
photographic series and video recordings are
Maxillofacial Department, Royal Perth Hospital,
Perth, WA, Australia

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 387
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_15
388
important not only in the diagnostic phases but
also in post-treatment evaluation.
Whilst many prescriptive dental examination
protocols exist, assessment of the entire dentofa-
cial region may be perceived to be more familiar
to oral and maxillofacial surgeons or facial plas-
tic surgeons than for routine dental management.
The field of plastic surgery has reported the use
of three-dimensional imaging to document facial
contours since 1979 [1]. Dentists are uniquely
placed to significantly modify dentofacial aes-
thetics and orofacial contours with fixed or
removable intraoral dental prostheses.
Assessment of the orofacial contours must form
part of the examination process for appropriate
maintenance or modification with any treatment
provided. Symmetry in prosthesis, smile and oro-
facial contour is important; however, perfect
facial symmetry is unusual in nature and may be
an idealistic goal which is unachievable in recon-
struction. Therefore the patient should be guided
to what is clinically achievable.
Anthropometry is defined as ‘the scientific
study of the measurements and proportions of the
human body’ [2], and dental applications histori-
cally have been focused on orthodontic investiga-
tions in monitoring facial growth, and
reconstructive planning following congenital
issues such as cleft lip and palate, trauma or neo-
plasm. Traditional anthropometry lacks the abil-
ity to measure shape as the focus is direct
measurement of distance and angulation between
reference points. The anatomical curvature has
important roles in natural facial form, and Katina
et al. [3] defined the anatomical curves of the face
which follow ridges, troughs and ruts of the facial
surface rather than single points. This allows for
more accurate recording and complete assess-
ment of overall facial characteristics, including
angles, surface arcs, the volume of the face and
surface area of the face which provides signifi-
cantly more diagnostic information of facial form
than simply linear points.
The investigation of the facial curvature once
utilised direct alginate impressions of the face;
however, three-dimensional photography has
been shown to have a higher precision than direct
measurement with callipers between recognisa-
G. Liddelow and G. Carmichael
ble soft tissue landmarks of the face [4]. By quan-
tifying facial dimensions, treatment planning for
the replacement of deficient or missing facial tis-
sue can be simplified following measurements
from existing facial tissues or anatomical norms.
Once the fundamental plan is established, the
provision of clinical treatment and liaising with
the technical auxiliaries has a more appropriate
focus.
Evolving technologies with computer-aided
design (CAD) reconstruction from cone beam
computer topography (CBCT) or computer
topography (CT) and have enabled the assess-
ment and quantification of change in facial curva-
ture and space over time [5]. Whilst Nanda et al.
[6] described the use of three-dimensional images
as a quantitative measure to establish soft tissue
averages for anthropological and genetic sci-
ences, Marques et al. [7] have subsequently
reported a high degree of reproducibility of true-
ness and precision with 3D facial scanning imag-
ing technologies. Patients can then be compared
to anatomical norms to idealise diagnosis and
treatment planning, or to measure volumetric tis-
sue change during treatment. The current focus
of three-dimensional photography and facial
scanning is to avoid repeated radiation exposure
combined with CBCT or CT data.
Avoiding repeated radiation exposure in the
assessment of facial profiles and contours has
particular appeal with juvenile and adolescent
demographics. Orthodontically, the use of three-­
dimensional stereophotogrammetry has identi-
fied statistically different change in lower lip
protrusion after bracket removal in patients of
various gender and lip thickness [8]. The degree
of change however may be below that of clinical
relevance as changes were also observed with
variable facial muscle tension and changes in lip
position. With potential errors being incorporated
from these variables, the ability to retake the ste-
reophotogrammetric image numerous times is
significantly safer than repeated radiation
exposure.
Three-dimensional radiographic imaging to
assess alveolar bone volume for implant surgery
is recognised as the gold standard of diagnostic
assessment [9, 10]. The accurate identification of
15 Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses 389

vital structures such as the inferior alveolar

nerve canal, maxillary sinus, floor of nose, men-
tal foramen and submandibular fossa is critical
to optimise safe implant placement, and two-
dimensional imaging is inadequate for appropri-
ate diagnosis [11]. Assessment of alveolar bone
topography and the available bone height and
width will enable the appropriate selection of
dental implant/s, and their position to optimise
­prosthetic outcomes [9]. The diagnostic assess-
ment of key characteristics such as maxillary
incisal edge position, occlusal vertical dimen-
sion with appropriate freeway space and planned
development of transition line to optimise aes- Fig. 15.1 DTX plan of atrophic quad zygoma showing
thetics all improve predictability of treatment implanmt positions and prosthetic tooth position
and patient satisfaction.
The use of three-dimensional virtual treatment
planning software such as DTX® idealises the
prosthetically planned implant placement as
visualisation of the tooth position and bone is
possible [12]. Predetermination of prosthetic
form and position enables surgical planning to
control implant position and angulation as well
as identify a need for alveolectomy providing
vertical height for prosthesis to maximise the
materials’ strength and aesthetic properties. The
transition line between natural tissue and pros-
thesis can be aesthetically challenging to mask,
and if the prosthesis requires replacement of teeth
and gingival tissues, it may be best to position Fig. 15.2 DTX plan of maxillary All on 4 showing implant
this junction under the lip line to disguise the position and prosthetic tooth replacement position
prosthesis. A tooth-only prosthesis will use the
gingival margin as its transition line, and care in a predictable manner. The retrusion and
must be taken to recreate anatomical gingival inversion of the upper lip follows the loss of
form to frame the prosthetic teeth. As implant support from the upper teeth and alveolus, and
position cannot be modified post surgery, place- resulting mesialisation of the modiolus exacer-
ment needs to be prosthetically planned three-­ bates the visual deficiency in tissue volume. A
dimensionally with consideration of bone fixed or removable dental prosthesis can be
modification if necessary, and not simply rely on used to support the curtain of tissues and pro-
placement at existing crestal bone height vide support to the lip and facial tissues altering
(Figs. 15.1 and 15.2). the facial form. A removable denture can utilise
Cawood and Howell [13] described the the denture flange for this support, whereas a
changes in anatomical form of the edentulous fixed prosthesis relies on implant position and
maxilla and mandible and consequences to the bridge design to maximise the tissue support.
facial form that result from the potential atro- Provision must be made for cleansibility to
phy. The collapse of the circumoral muscles ensure stability of peri-implant tissues with
around the mouth as well as those of the eleva- both fixed implant bridges and implant over-
tor and depressor muscles alters the facial form denture prostheses.
390
15.1 Incisor Position
The position and form of the maxillary incisors is
an area more dependent on artistic and aesthetic
skill than scientific rigour [14, 15]. Traditionally
the incisors in complete denture patients were
placed closer to the residual ridge to reduce lever-
age forces and hence improve stability of the
tissue-­supported prosthesis. As alveolar resorp-
tion is directed palatally, the position of the inci-
sors will also move palatally as the patient ages.
Lip support is reduced, and, coupled with an age-­
related loss in soft tissue collagen, the facial pro-
file becomes more sunken in appearance.
Plumping of flanges to remove vertical lines usu-
ally has the effect of reducing vermillion display
so that the clinician should aim to achieve soft
tissue effects primarily from incisor position and
secondarily with more subtle support from the
prosthetic soft tissue.
Lip prominence, especially projection and
display of the vermillion is most dependent on
incisor position. An implant-retained prosthesis
does not depend on traditional concepts of
denture retention so the anterior teeth can be
placed in any position desired. Indeed, for a long-
standing denture wearer, placing the incisors in a
position similar to an age-matched patient with a
natural dentition can be a dramatic change.
Coachman et al. [16] developed a process for
designing the changes to a patient’s existing ante-
rior dentition digitally, and this has also evolved
with consideration of dynamic movement along
with the static form [17]. The ‘digital smile
design’ protocol can be automated; however,
individual clinician control is recommended to
optimise the patient-specific outcome. The treat-
ment visualisation aids communication directly
with the patient and also technicians for a more
accurate transfer of information to achieve more
predictable treatment outcomes. The planning
time should increase treatment efficiency and
predictability of treatment delivery (Fig. 15.3).
Anterior tooth position, especially when teeth
have been lost for many years, can be difficult to
quantify, and any form of smile assessment will
improve diagnostic patient communication. The
classic complete denture literature is invaluable
G. Liddelow and G. Carmichael
Fig. 15.3 Digital smile design simulation of prosthetic
tooth replacement in the terminal dentition
[18], and the competent provision of complete den-
tures should be a basic requirement for the clinician
embarking on extensive implant rehabilitation. The
use of time-honoured phonetic tests and other diag-
nostic techniques can ease the transition for many
patients. Even though implants can enable the
placement of teeth in almost any position, if teeth
are placed outside the envelope of adaptability for
that particular patient, speech and comfort will
always be impaired. A common example is creating
a class I incisor relationship in a significant class II
skeletal base. These patients may be used to a sig-
nificant protrusion with incision and ‘s’ sounds. The
‘correction’ therefore may be too sizeable for com-
fortable adaptation with the patient complaining of
being ‘locked in’ or restricted. A similar statement
can be made for class III relationships.
15.2 Determination of Facial
Support
15.2.1 Consequence of Jaw Atrophy
One of the natural consequences of tooth loss is
the remodelling of the alveolar ridge. Whilst
there is biological variation, a reduction in alveo-
lar ridge width over the first 12 months has been
reported, with approximately two-thirds of this
reduction occurring within the first 3 months
after tooth extraction [19]. As more horizontal
bone loss occurs especially in the anterior max-
illa, and with an increasing number of teeth lost,
the consequence for facial tissue change
increases, and there is a greater need for pros-
thetic support for the lips and surrounding peri-
oral musculature (Figs. 15.4 and 15.5).
15 Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses 391

planning. The use of stereophotogrammetry

provides additional control in this prosthodontic
diagnosis and treatment with a high degree of
accuracy [7]. Using appropriate three-
dimensional radiographic imaging of the patient
Fig. 15.4 Minimal loss of alveolar height hence support and diagnostic template, CAD superimposition
for the facial tissue is largely only from the prosthetic teeth of the scans enables accurate planning of implant
placement with software such as DTX to avoid
critical anatomical structures [20]. This can then
translate to a high degree of precision of
placement using computer-guided surgical
templates [21, 22] such as NobelGuide [23] or
dynamic navigated surgery protocols using the
X-guide (Figs. 15.6 and 15.7) [24].
Whilst challenges exist in the establishment of a
single protocol using the different imaging device
data formats for facial skeleton, extraoral soft tissue
and dentition including the surrounding intraoral
soft tissue [25], the incorporation of a non-invasive
Fig. 15.5 Significant prosthetic replacement of lost tissue technology such as stereophotogrammetry will ben-
efit patient outcomes. The technology can be
prosthodontically utilised for fixed and removable
The loss of occlusal vertical dimension can be prostheses, and as Fig. 15.8 indicates, analysing
exacerbated by teeth or prosthesis wear, or dental volumetric change between the patient’s original
treatment that does not compensate for this loss. and provisional prosthesis aids in establishing the
With alveolar bone volume atrophy, the three-­ optimal lip support and facial tissue form.
dimensional maxillomandibular relationship has Quantifying the amount of change with
a tendency for the mandible to become more thermal imaging of superimposition of the three-­
prognathic and requires consideration for pros- dimensional images helps the patient to understand
thetically directed implant placement. the process without an intimate knowledge of
anatomy or technical dental mechanics. It is
advisable to use and modify as necessary a provi-
15.2.2 Lip Support sional PMMA (Fig. 15.9) or wax try in prosthesis
to idealise and finalise the design prior to progres-
When the optimal tooth position for aesthetics, sion to the definitive prosthesis (Fig. 15.10).
phonetics and prosthetic lip and tissue support is Once the design has been formally accepted
established following diagnostic assessment and by clinician and patient, this is then replicated in
provisional mock-up, it is important that the posi- the final prosthesis, and Fig. 15.11 highlights the
tion is replicated with the final prosthesis whether minimal difference observed with superimposi-
it be tissue or implant borne. Digital diagnostic tion of three-dimensional photographic images
and design tools may aid in this process in both between diagnostic and final prostheses.
static and dynamic forms [17]. Finalising of the Patients’ individual aesthetic requirements
prosthetic plan should always be performed prior play a critical role in prosthodontic treatment
to surgery for appropriate implant positioning to planning [26]; however, anatomical variability
meet prosthetic requirements. prevents a predetermined prescription for achiev-
A diagnostic workup is required with ing a satisfactory outcome. Stereophotogramme-
simulation of final tooth position and tissue try aids assessment of lip position and tissue
support for patient approval and surgical support, and communication of this with the
392
Fig. 15.6 CBC T Scan of patient with diagnostic template in situ
Fig. 15.7 CBCT scan of diagnostic template in same
orientation
patient. Figures 15.10 and 15.11 graphically
show the significant volumetric change a remov-
able maxillary prosthesis has not only to the
G. Liddelow and G. Carmichael
maxillary lip, but to the entire lower half of the
face. Figure 15.12 shows a thermal image of
volumetric change between presenting and trial
prostheses designed to increase maxillary lip
­
support and compensate for vertical face height
loss following continued alveolar ridge atrophy.
Figure 15.13 indicates some residual volumetric
change between diagnostic wax-up and final
prosthesis which may be acceptable to the patient
or highlight the limits of prosthodontic treatment
and the need for additional facial contouring
with injectable fillers. Advances in image com-
parison software (Geomagic Control X, 3D Sys-
tems Korea) also allow for more precise analysis
as Figs. 15.14 and 15.15 indicate with analysis
15 Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses 393

Fig. 15.8 (a, b) Volumetric tissue change between a

original and provisional prosthesis recorded with three-
dimensional photographs and superimposition of images

b
394 G. Liddelow and G. Carmichael

Fig. 15.9 Provisional PMMA maxillary implant

Fig. 15.10 Definitive zirconia maxillary implant
prosthesis replacing teeth and alveolar tissues
prosthesis replacing teeth and alveolar tissues following
provisional prosthesis design

Fig. 15.11 (a, b) Volumetric tissue change between a

provisional and definitive maxillary implant prosthesis
replacing teeth and alveolar tissues shown in Fig. 15.8
15 Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses 395

Fig. 15.13 Thermal image of volumetric change between

trial and definitive prosthesis

Fig. 15.11 (continued)

Fig. 15.14 Thermal image with measurement analysis

(Geomagic Control X) between presenting and trial
prosthesis

Fig. 15.12 Thermal image of volumetric change between

presenting and trial prosthesis
396
Fig. 15.15 Thermal image with measurement analysis
(Geomagic Control X) between provisional and final
prosthesis
of maxillary treatment in different patients,
resulting in improvements in patient outcomes.
15.3 Summary of Clinical Advice
for Orofacial Aesthetics
1. Comprehensive dental, skeletal and orofacial
assessment
2. Digital or intraoral simulation of prosthesis
for patient/clinician acceptance
3. Aesthetic and phonetic assessment with ideal
maxillary incisor edge position
4. Prosthetic planning prior to any surgery
5. Prosthesis transition line not in visible smile
display
6. Prosthesis contour idealises lip support and
contour
7. Prosthesis enables normal lip movement
8. Delay any injectables until treatment with
provisional prosthesis
15.4 Speech
The production of intelligible speech is a complex
performance involving most of the orofacial
musculature and structural components. These
G. Liddelow and G. Carmichael
work in concert, coordinated by the face senso-
rimotor cortex, to produce an array of sounds per-
ceived as language [27]. The pronunciation of
consonants depends on the position of the lips,
teeth, tongue and palate. From anterior to poste-
rior, sounds may be produced via a bilabial
(P,B,M,W), labio-dental (F,V), apico-alveolar
(T,D,N,L,R,S,Z), palatal (J,SJ,ZJ), velar
(K,G,NG,NJ) and glottal (R,H) approach
(Fig. 15.16) [28].
The fricative /S/ sound is the most complex to
produce and requires anterior placement of the
tongue as close to the incisors as possible without
touching, the jaw opening is slight and the dor-
sum is flattened and pressed against the palatal
aspects of the premolars and molars [29]. This
sound can therefore be influenced by slight
changes in oral anatomy from incisors to molars,
as well as changes in vertical dimension and pal-
atal contour. The remaining most commonly dis-
torted sounds are /z/, /sh/, /t/ and /zj/ (Fig. 15.17).
The system is highly sensitive to changes in
structure which may be as small as replacement
of a single tooth [30]. The larger the intervention,
the greater the impact. Van Lierde et al. [31]
reported self-satisfaction with speech to be worse
with conventional removable prostheses com-
pared to fixed implant prostheses. Rehabilitation
of the edentulous maxilla therefore has the poten-
tial to impact speech in a significant way. Despite
this potential, little attention has been paid to
speech impact with prosthetic interventions.
The method of rehabilitation for the edentulous
maxilla has been investigated by Jacobs et al.
[32] comparing 138 patients with complete
dentures and fixed implant prostheses in the max-
illa against natural dentition, two implant retained
overdentures and fixed prostheses in the mandi-
ble. The authors found no statistical difference
between different prosthesis design over a long
time frame. Heydecke et al. [33] performed a
within-subject study comparing long-bar over-
dentures with fixed prostheses and overdentures
with and without palatal coverage. The results of
the study after a 2-month period indicated more
intelligible speech with an overdenture compared
15 Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses
Fig. 15.16 Production
of consonants in various
regions of the orofacial
space
K,G,NG,N,J
R F,V
Fig. 15.17 Volumetric tissue change between original
and provisional prosthesis recorded with three dimen-
sional photographs and superimposition of images
to a fixed prosthesis. The presence of a palate
comparing overdenture designs made no statisti-
cal difference. These patients all transitioned
from an existing complete maxillary denture, and
397
J,SJ,ZJ
T,D,N,L,R,S,Z
P,B,M,W
the follow-up analysis time is brief. Therefore the
amount of adaptation required is commensu-
rately less for an overdenture than a fixed
prosthesis.
A Dutch-controlled study [30] showed 87%
of test subjects rehabilitated with a fixed maxil-
lary prosthesis on four implants to have conso-
nant distortion after an average of 7.3 months
compared with 0% of controls. Similarly, Jacobs
et al. [32] showed 84% of test subjects with a
variety of prostheses to have speech distur-
bances on average 9 years after treatment com-
pared to the control group (natural dentition) of
52%. A Swedish study [34] compared speech
problems prior to treatment (37%) with fixed
maxillary dental prostheses and showed an
increase to 60%, 3–6 months after treatment. A
study by Bothur and Garsten [35] reported
speech deterioration in 5 of 6 patients rehabili-
398
tated with zygomatic implants 4 months after
treatment.
The presence of interdental spaces, that is,
taller abutments, to provide a space between the
tissue surface of the prosthesis and the residual
ridge has not been shown to be a factor in speech
intelligibility in two studies [33, 36] despite the
belief by clinicians and patients that ‘airflow’
through the spaces hampers phonetics. The abil-
ity to perform adequate plaque control should
therefore be paramount in the design of all
prostheses.
Lundqvist et al. [36] observed a greater
correlation with speech disturbance post
treatment in patients with hearing loss. A gender
­discrepancy with speech change has not generally
been reported; however, Van Liede et al. [30]
reported greater overall patient satisfaction from
females.
Design of prosthesis and interventions to
improve speech after treatment have a paucity of
evidence. Collaert et al. [29], in a pertinent study
on 10 patients receiving maxillary fixed prosthe-
ses, showed 7/10 patients with speech problems 3
weeks after treatment. The method of manufacture
of the provisional bridge was the patient’s own
converted denture. After reducing the palatal vol-
ume of the premolars to a more canine form, 5/7
patients returned to baseline ability and the remain-
ing two patients improved. No adjustment was
made to incisor form and interdental spaces were
provided to facilitate cleaning. The authors empha-
sise the need for a provisional prosthesis that is
easily amended to expedite speech adaptation.
The contour of the palatal aspects is dependent
on the position of the implants and the material of
the prosthesis. Implants should therefore be
precisely prosthetically directed so that access
for screw holes and space for abutments is within
the confines of the prosthetic dentition. This
enables the prosthesis to be as thin as possible so
as not to encroach on the tongue space. Zygomatic
implants should be placed more buccally so that
the head of the implant exits the occlusal surface
of the prosthetic tooth instead of the historically
palatal position. Prosthetically directed implants
require a meticulous digital prosthetic/surgical
radiographic workup followed by surgical guid-
G. Liddelow and G. Carmichael
ance. Particular attention should be paid to the
effects of angulated abutments on the contour of
the prosthesis (Fig. 15.18).
Any change in the orofacial milieu will elicit a
neuroplastic change for the patient to adapt to a
new prosthesis. Adaptation to dental-specific
changes is dependent on neuroplasticity within
the M1 and S1 face sensorimotor cortex [27, 37].
A functional MRI study by Yan et al. [38] showed
that these neuroplastic changes in the sensorimo-
tor cortex after provision of fixed implant pros-
theses are markedly different to removable
complete dentures and approach the activity of
the natural dentition. The authors conclude that
the closer the final prosthesis restores the original
function, the closer the sensory motor system
will come to re-establishing its original charac-
teristics [38].
The time for neuroplastic change and hence
adaptation to the prosthesis will vary depending on
the magnitude of the intervention and the individ-
ual’s inherent adaptability. The adaptation required
when a patient transitions from a complete denture
to a fixed prosthesis will be greater than from a
largely intact, terminal dentition to a fixed prosthe-
sis. This adaptation is further influenced by envi-
ronmental aspects such as disease and psychosocial
profile, genetic factors, intrinsic processes and the
masticatory components [39]. Estimates range
from at least 3 months up to 3 years [25, 28, 36]. A
realistic time frame for the majority of patients
would be 3–6 months. Patients should be coun-
selled prior to treatment commencing that time for
adaptation is required and will vary between indi-
Fig. 15.18 Definitive zirconia maxilalry implant
prosthesis, replacing teeth and alveolar tissues following
provisional prosthesis design
15 Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses
viduals. Practice helps. Speaking various difficult
sentences and ‘tongue twisters’ will accelerate
adjustment to the new prosthesis. Recording or
speaking to another person providing feedback
can fine-tune the process. Speech intelligibility
can be extremely important for some patients and
should not be underestimated by the treating clini-
cians. Patients should be aware that consulting a
speech therapist may be required if there is still
room for improvement after prosthetic adjustment
and fine-tuning [28, 40].
15.5 Summary of Clinical Advice
for Speech Adaptation
• Prosthetically directed implants for a slim
prosthesis bucco-palatally
• Provisional bridge to enable adjustments
• Adequate tongue space in the premolar region
and correct vertical dimension
• Practice
• Time: 3–6 months for most patients
• Consultation with a speech therapist if there is
prolonged speech disturbance
15.6 Conclusions
Maxillary implant rehabilitation is potentially one
of the most complex treatment endeavours.
Patients are more educated and discerning. Implant
treatment has progressed far beyond the wonder of
osseointegration and pure function. The treating
clinician should be aware of the effects of loss of
supporting orofacial structures and possible tech-
niques of replacement. The design of prostheses
and the subsequent delivery should factor in facial
contour for improved aesthetics and simultane-
ously facilitate speech adaptation.
References
1. Karlan M. Contour analysis in plastic and
reconstructive surgery. Arch Otolaryngol.
1979;105:670–9.
399
2. Oxford online dictionary. https://
en.oxforddictionaries.com/definition/anthropometry.
Accessed April 2017.
3. Katina S, Mcneil K, Ayoub A, Guilfoyle B, Khambay
B, Siebert P, Sukno F, Rogas M, Vittert L, Waddington
J, Whelan P, Bowman A. The definitions of three-­
dimensional landmarks on the human face: an
interdisciplinary view. J Anat. 2016;228:355–65.
4. Weinberg S, Scott N, Neiswanger K, Brandon
C, Marazita M. Digital three-dimensional
photogrammetry: evaluation of anthropometric
precision and accuracy using a Genex 3D camera
system. Cleft Palate Craniofac J. 2004;41:507–18.
5. Fourie Z, Damstra J, Gerrits P, Ren Y. Accuracy and
repeatability of anthropometric facial measurements
using cone beam computed tomography. Cleft Palate
Craniofac J. 2011;48:623–30.
6. Nanda V, Gutman B, Bar E, Alghamdi S, Tetrads S,
Lusis A, Eskin E, Moon W. Quantitative analysis of
3-dimensional facial soft tissue photographic images:
technical methods and clinical application. Prog
Orthod. 2015;16:21–30.
7. Marques D, Alves R, Pinto R, Caramês JRB, Francisco
H, Caramês JMM. Int J Prosthodont. 2021;34:578–84.
8. Kim Y, Lee N, Moon S, Jang M, Kim H, Yun
P. Evaluation of soft tissue changes around
the lips after bracket debonding using three-
dimensional stereophotogrammetry. Angle Orthod.
2015;85:833–40.
9. Monsour P, Dudhia R. Implant radiography and
radiology. Aust Dent J. 2008;53(1 Suppl):S11–25.
10. Tyndall D, Price J, Tetradis S, Ganz S, Hildebolt
C, Scarfe W. Position statement of the American
Academy of Oral and Maxillofacial Radiology on
selection criteria for the use of radiology in dental
implantology with emphasis on cone beam computed
tomography. Oral Surg Oral Med Oral Pathol Oral
Radiol. 2012;113:817–26.
11. Dreiseidler T, Mischkowski R, Neugebauer J, Ritter
L, Zoller J. Comparison of cone- beam imaging with
orthopantomography and computerized tomography
for assessment in presurgical implant dentistry. Int J
Oral Maxillofac Implants. 2009;24:216–25.
12. Katsoulis J, Pazera P, Mericske-Stern R. Prosthetically
driven, computer-guided implant planning for the
edentulous maxilla: a model study. Clin Implant Dent
Relat Res. 2009;11:238–45.
13. Cawood J, Howell R. Reconstructive preprosthetic
surgery. I. Anatomical considerations. Int J Oral
Maxillofac Surg. 1991;20:75–82.
14. Spear F, Kokich V, Mathews D. Interdisciplinary
management of anterior dental esthetics. J Am Dent
Assoc. 2006;137:160–9.
15. Fradeani M. Evaluation of dentolabial parameters as
part of a comprehensive esthetic analysis. Eur J Esthet
Dent. 2006;1:62–9.
16. Coachman C, Calamita M. Digital smile design:
a tool for treatment planning and communication
400
in aesthetic dentistry. Quintessence Dent Technol.
2012;35:103–11.
17. Coachman C, Calamita MA, Sesma N. Dynamic
documentation of the smile and the 2D/3D digital
smile design process. Int J Periodontics Restorative
Dent. 2017;37(2):183–93.
18. Pound E. Utilizing speech to simplify a personalized
denture service. J Prosthet Dent. 2006;95:1–9. Reprint
of J Prosthet Dent 1970;24:586–600.
19. Schropp L, Wendel A, Kostopoulos L, Karina T. Bone
healing and soft tissue contour change following
single-tooth extraction. Int J Periodontics Restorative
Dent. 2003;23:313–23.
20. Tahmaseb A, Wismeijer D, Coucke W, Derksen
W. Computer technology applications in surgical
implant dentistry: a systematic review. Int J Oral
Maxillofac Implants. 2014;29(Suppl):25–42.
21. Abboud M, Wahl G, Guirado JL, Orentlicher
G. Application and success of two stereolithographic
surgical guide systems for implant placement with
immediate loading. Int J Oral Maxillofac Implants.
2012;27:634–43.
22. Vasak C, Watzak G, Gahleitner A, Strbac G,
Schemper M, Zechner W. Computed tomography-
based evaluation of template (NobelGuideTM)-guided
implant positions: a prospective radiological study.
Clin Oral Implants Res. 2011;22:1157–63.
23. Jung R, Schneider D, Ganeles J, Wismeijer D,
Zwahlen M, Hammerle C, Tahmaseb A. Computer
technology applications in surgical implant dentistry:
a systematic review. Int J Oral Maxillofac Implants.
2009;24(Suppl):92–109.
24. Joda T, Bragger U, Gallucci G. Systematic literature
review of digital three dimensional superimposition
techniques to create virtual dental patients. Int J Oral
Maxillofac Implants. 2015;30:330–7.
25. Kaewsiri D, Panmekiate S, Subbalekha K, Mattheos
N, Pimkhaokham A. The accuracy of static vs
dynamic computer assisted implant surgery in single
tooth space: a randomised controlled trial. Clin Oral
Implants Res. 2019;30:505–14.
26. Carlsson G. Fact and fallacies. An evidence base for
complete dentures. Dent Update. 2006;33:134–42.
27. Sessle B, Adachi K, Avivi-Arber L, Lee J, Nishiura
H, Yao D, Yoshiko K. Neuroplasticity of face primary
motor cortex control of orofacial movements. Arch
Oral Biol. 2007;52:334–7.
28. Molly L, Nackaerts O, Vandewiele K, Manders E,
van Steenberghe D, Jacobs R. Speech adaptation
after treatment of full edentulism through immediate-­
loaded implant protocols. Clin Oral Implants Res.
2008;19:86–90.
G. Liddelow and G. Carmichael
29. Collaert B, Van Dessel J, Konings M, Nackaerts O,
Zink I, Slagmolen P, Jacobs R. On speech problems
with fixed restorations on implants in the edentulous
maxilla: introduction of a novel management
concept. Clin Implant Dent Relat Res. 2015;17(Suppl
2):745–50.
30. Van Lierde K, Browaeys H, Corthals P, Matthys C,
Mussche P, Van Kerckhove E, De Bruyn H. Impact
of fixed implant prosthetics using the ‘all-on-
four’ treatment concept on speech intelligibility,
articulation and oromyofunctional behaviour. Int J
Oral Maxillofac Surg. 2012;41:1550–7.
31. Van Lierde K, Browaeys H, Corthals P, Mussche
P, Kerkhoven VAN, E, DE Bruyn H. Comparison
of speech intelligibility, articulation and
oromyofunctional behaviour in subjects with
single-tooth implants, fixed implant prosthetics or
conventional removable prostheses. J Oral Rehabil.
2012;39:285–93.
32. Jacobs R, Manders E, Van Looy C, Lembrechts D,
Naert I, van Steenberghe D. Evaluation of speech
in patients rehabilitated with various oral implant-­
supported prostheses. Clin Oral Implants Res.
2001;12:167–73.
33. Heydecke G, McFarland D, Feine J, Lund J. Speech
with maxillary implant prostheses: ratings of
articulation. J Dent Res. 2004;83:236–40.
34. Lundqvist S, Haraldson T, Lindblad P. Speech
in connection with maxillary fixed prostheses on
osseointegrated implants: a three-year follow-up
study. Clin Oral Implants Res. 1992;3:176–80.
35. Bothur S, Garsten M. Initial speech problems in
patients treated with multiple zygomatic implants. Int
J Oral Maxillofac Implants. 2010;25:379–84.
36. Lundqvist S, Lohmander-Agerskov A, Haraldson
T. Speech before and after treatment with bridges on
osseointegrated implants in the edentulous upper jaw.
Clin Oral Implants Res. 1992;3:57–62.
37. Calford M. Degree of adaptability of the
somatosensory cortex to change: prospects for
integration of bone-mounted dental prostheses. Clin
Exp Pharmacol Physiol. 2005;32:115–8.
38. Yan C, Ye L, Zhen J, Ke L, Gang L. Neuroplasticity
of edentulous patients with implant-supported full
dentures. Eur J Oral Sci. 2008;116:387–93.
39. Sessle B. Mechanisms of oral somatosensory and
motor functions and their clinical correlates. J Oral
Rehabil. 2006;33:243–61.
40. Fonteyne E, Van Doorne L, Becue L, Matthys C,
Bronckhorst E, De Bruyn H. Speech evaluation during
maxillary mini-dental implant overdenture treatment:
a prospective study. J Oral Rehabil. 2019;46:1151–60.
 Laboratory Fabrication
of Full-­Arch Implant-Supported
16
Restorations

Kenji Mizuno, Aram Torosian, Saj Jivraj,

and Michael Tuckman

Abstract allow completion of treatment predictably and

efficiently.
Success in full-mouth implant rehabilitation
This chapter will discuss three materials
requires clear and concise communication
that are commonly used for full-arch implant
between the dentist and the dental technician.
rehabilitation from a laboratory perspective.
It is the dentist’s responsibility to provide a
complete prescription of what is required and
the dental technician’s responsibility to ensure
that the restoration is completed according to
Accurate impressions, cast verification and jaw
that prescription.
relation records are imperative for an optimal
The clinician should provide accompany-
outcome and are common to fabrication tech-
ing information such as accurate impressions,
niques for any material. For repeatable jaw rela-
jaw relation records and a facebow transfer.
tion records, rigid bases need to be fabricated.
The technician should provide accurate
The authors prefer a two-piece occlusal rim. The
diagnostic and master casts together with
primary part is screw-retained to the implants/
attention to detail at each subsequent step so
abutments, and the secondary part is removable
that chair time is reduced for the treating
and can be modified (Figs. 16.1, 16.2, 16.3, 16.4,
clinician.
16.5, 16.6, 16.7, and 16.8).
Developing a strong working relationship
and harbouring a philosophy of teamwork will

K. Mizuno · S. Jivraj (*)

Anacapa Dental Art Institute, Oxnard, CA, USA
A. Torosian
Ronald Goldstein Center for Esthetic and Implant
Dentistry, Dental College of Georgia at Augusta
University, Augusta, GA, USA
e-mail: atorosian@augusta.edu
M. Tuckman
Osteon Medical, Mulgrave, VIC, Australia
e-mail: michael@osteonmedical.com

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 401
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_16
402 K. Mizuno et al.

Fig. 16.1 Primary base of occlusal rim in triad material Fig. 16.4 Wax rims created to average dimensions
for the mandible

Fig. 16.2 Secondary wax rim which fits over the primary
part
Fig. 16.5 Primary parts of rims screw retained
intraorally

Fig. 16.3 Primary base of occlusal rim in triad material

for maxilla
Fig. 16.6 Midline marked on maxillary rim
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 403

able in that it is strong and resistant to repetitive

cyclical loading cycles, yet is slightly elastic,
lightweight and able to dissipate stress forces
placed on it. It is these ‘bone-like’ properties that
offer PEEK as a more biomechanically engi-
neered substructure material.
The Young’s elastic modulus of PEEK (4 GPa)
is similar to the acrylics (2 GPa) and being a lot
lower than titanium (100 GPa), but still retaining
sufficient stiffness for rigidity of structure.
However, unlike acrylic, PEEK also has suffi-
Fig. 16.7 Level of mandibular occlusal rim set cient strength (120 MPa flexural strength versus
40 MPa for acrylic) and excellent flexural fatigue
resistance to cyclical loads that make it fit for the
purpose of long-term restorations. PEEK’s resis-
tance to failure from flexural fatigue may be of
interest to potentially address some of the techni-
cal complications associated with cantilever
design, and lab-based tests have been published
that show resistance to failure with distal cantile-
vers of up to 19 mm length [1].
Shock absorption tests have demonstrated a
strong correlation between the damping behav-
iour of implant-supported crowns and their mate-
rial composition [2]. Studies have shown that the
Fig. 16.8 Vertical dimension and centric relation
registered shock-absorbing capacity of polymer materials
was higher than that of ceramics and metals. In
recent studies that compared titanium, cobalt
chrome, zirconia, lithium disilicate, PMMA
16.1 High-Performance (acrylic) and PEEK, it was the latter material that
Polymer: PEEK demonstrated the biggest differential between
forces applied at an occlusal crown surface and
The high-performance polymer, poly etherether- forces transferred through to the implant fixture
ketone (PEEK), was first introduced as a load-­ side [3]. This property of a framework material
bearing biomaterial for spinal fusion surgery may be of interest for aspects of patient comfort
over 15 years ago (Invibio Biomaterials or for particular cases with parafunctional con-
Solutions). Since then, medical grade PEEK siderations. The weight of a PEEK framework
polymers have matured into an established bio- (e.g. 5 g) is also significantly less than one repli-
material. Until recently its use in dentistry was cated in titanium (17 g).
limited to healing caps and temporary abut- PEEK as a permanent framework material has
ments. Perhaps the most interesting property of become an option in recent times through the
PEEK for use as a framework material is its availability of CADCAM forms. However, clini-
Young’s elastic modulus (4 GPa), which allows cal data is typically limited at present to case
the PEEK substructure to more closely match studies [4–6]. Prospective studies are becoming
the biomechanical characteristics of the jaw’s available, but there is currently no long-term fol-
natural bone (2–12 GPa). PEEK is quite favour- low-­up [7].
404 K. Mizuno et al.

16.2 Laboratory Fabrication 2. The correct surface preparation of the frame-

Process work prior to bonding is important to roughen
the surface and create additional surface area
PEEK frameworks can be designed according to to provide a mechanical key. This can be
the following guidelines for full-arch implant-­ achieved using grit blasting, for example.
supported prosthetics [8]. In general, when
designing any structural polymer part, there A variety of traditional approaches can be
should be the avoidance of any notches or sharp used to create the aesthetics on a PEEK frame-
angles into the framework. These notches, scoops work. For example, veneering with composite
and grooves can create potential areas of weak- materials, use of injection-moulded acrylic and
ness for polymers and propagate cracks. If acrylic teeth to create a hybrid wraparound, or
unavoidable, then the framework thickness hybrid designs with the use of individual crowns
behind the area should be at least 2 mm thick and (ceramic, zirconia or lithium disilicate).
the angle must be greater than 45°. Whatever the preference for finishing the
prosthetic framework, it is important to follow
Anatomical Implant Substructures If the the supplier’s guidance as although techniques
prosthetic is screw–retained, then a bonded metal are straightforward there are specific nuances
connector can be used, or in instances where the (Figs. 16.9, 16.10, 16.11, 16.12, 16.13, 16.14,
PEEK material is direct to implant, then consid- 16.15, 16.16, 16.17, and 16.18).
erations should be made for the interface of
PEEK with the particular implant system and
screw design. For example, screw head designs
that are conical and of smaller diameter will more
readily cut into the polymer if in direct contact,
whilst wider flat-headed screws are more com-
patible. Abutment wall minimum thickness
should be 1 mm. Current guidance for minimum
widths of the framework anterior and posterior
base are 8 mm and 9 mm, respectively. Minimum
framework height of 5 mm and at sites of the
implants the material should be at least 1.5 mm
on the buccal side and 2 mm on the lingual side.

Implant Bars The bar height should have a Fig. 16.9 Failing dentition
minimum of 4 mm. Posterior wall thickness
should be a minimum of 6 mm and anterior wall
thicknesses a minimum of 5 mm. Abutment wall
thickness minimum should be 1 mm.

Other key considerations for PEEK frame-

works are [9–11]

1. The correct selection of compatible bonding

agents, adhesives and cements. The user
should refer to the material supplier’s guide-
lines since PEEK is not compatible with all
cements and veneering systems that are typi- Fig. 16.10 Custom tray impressions following
cally used for traditional materials. osseointegration
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 405

Fig. 16.11 Digitised master model with laboratory

analogues
Fig. 16.14 CADCAM milling path calculation of the
nested framework

Fig. 16.12 Digitised model with proposed framework

design

Fig. 16.15 Lateral view of the final veneered PEEK

framework

Fig. 16.13 Digitised model with proposed framework

design and veneers

Fig. 16.16 Occlusal view of PEEK prosthetics after

placement
406
Fig. 16.17 Final PEEK restorations showing aesthetics
that can be developed
Fig. 16.18 Intraoral view of restoration in Fig. 16.17
16.3 Acrylic Resin Titanium
Hybrid
The original frameworks made by the Branemark
group had been fabricated from type III gold.
Because of the high cost of this material, alloys
of silver palladium and gold palladium had been
used in recent years. Passivity in these types of
frameworks had been notoriously difficult to
achieve. Inaccuracies were the result of multiple
variables, which included machining tolerances
of components, distortion in the impression
material, setting expansion of the die stone,
expansion and contraction of alloy and wax and
distortion of the framework during heat treatment
[12, 13].
Common solutions to provide a passive frame-
work had been sectioning and soldering or fabri-
cating the framework in multiple pieces which
were then soldered on a master cast. Another
K. Mizuno et al.
approach to achieve a passive screw-retained
framework had been use of the adhesive-­corrected
implant frameworks where individual cylinders
were cemented within the framework after it had
been cast (KAL technique). This approach had
merit in that it eliminated many of the current
prosthetic and laboratory inaccuracies associated
with traditional techniques [14–17].
With CADCAM technology a lot of the vari-
ables have been eliminated and frameworks can
be produced with high precision providing the
operator has taken care in producing an accurate
impression and the laboratory technician has
exercised care in pouring it.
Prior to the CADCAM process, accurate
impressions, jaw relation records and a wax trial
set are completed. The framework is designed
with the final tooth position in mind.
Since the transition from gold to titanium
frameworks, the designs have changed quite con-
siderably (Figs. 16.19 and 16.20). Different man-
ufacturers have different designs available but
none rival the designs that were possible with
traditional casting techniques. This may be due to
limitations in scanning and milling but consider-
able progress is being made in this area.
There are certain principles that design of the
framework must adhere to. These include but are
not limited to [18]
1. Bulk for strength
2. Adequate access for oral hygiene
3. Minimal display of metal
4. Retention for acrylic resin
5. Adequate space for acrylic resin
6. Adequate thickness of framework in the canti-
lever area
7. Attention to cross-section
8. Minimise the cantilever
There are essentially two types of titanium
framework that exist.
Wraparound This is a minimalist framework
where acrylic resin is wrapped around the tita-
nium framework. The tissue surface is acrylic
resin and can be readily relined. Little is known
of its biomechanical longevity. In the author’s
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 407

Fig. 16.19 Comparison of traditional gold and titanium frameworks

Fig. 16.20 Wraparound framework

Fig. 16.21 L-shaped

framework

experience, common problems include fracture
of the bar. Whether this is due to inadequate
dimensions or excessive cantilever is unknown
(Fig. 16.20).
I- or L-Shaped Design This design maximises
the rigidity, has adequate space and retention for
acrylic and has adequate dimensions in the canti-
lever area (Fig. 16.21).
When considering longevity, these types of
restorations fail by
1. Fracture of the bar
2. Fracture of the restorative material
3. Wear of the teeth
Length of the cantilever is the most common
cause of restoration failure. If looking at deflec-
408
Fig. 16.22 Milled metal occlusal surfaces to maintain
vertical dimension
tion of the restoration, it is proportional to the
length of the cantilever and thickness of the
cross-section. Small increases in length have a
dramatic effect of deflection. Most articles rec-
ommend a cantilever length which is two times
the anteroposterior spread. It is the author’s opin-
ion that the cantilever should be minimised as
much as possible and should only be extended as
minimally as possible [19].
With CADCAM technology the problem of
wear can also be addressed by milling metal
occlusal surfaces to maintain the patients’ exist-
ing vertical dimension of occlusion (Fig. 16.22).
16.4 Laboratory Fabrication
Process
Attention to detail starts with pouring the impres-
sion using a low-expansion die stone. Appropriate
powder liquid ratios and vacuum mixing for the
time indicated by the manufacturer must be
adhered to. A verification index must be provided
to the clinician to verify accuracy of the master
cast. This index is made from impression plaster.
A brittle material that is not forgiving is used.
The verification index is tried in with one screw.
If the plaster index breaks, the master cast is
deemed to inaccurate and a new impression must
be made. The use of an acrylic resin material for
verification of the master cast may give the clini-
cian a false positive result and is not recom-
mended. Jaw relation records utilising a two-part
rigid occlusal rim must be accomplished after
which a wax trial set-up must be evaluated
intraorally.
K. Mizuno et al.
The wax trial prosthesis must be verified for
correct aesthetics, phonetics, occlusal plane, ver-
tical dimension of occlusion and centric relation.
The framework is designed with the tooth set-
up in mind and must satisfy the following
­
requirements:
1. Bulk for strength – I- or L-shaped bars are
preferred for maximum rigidity. If a conven-
tional wraparound bar is being used, a mini-
mum cross-section of 4 × 4 mm must be used.
The cylinders around the screw access holes
should measure at least 0.65 mm in wall
thickness.
2. Adequate access for oral hygiene: The under-
surface should be designed with a convex sur-
face which compresses the tissue. Immediately
adjacent to the implants/abutments, there
should be sufficient space to allow the patient
to utilise and interproximal brush.
3. Minimal display of metal: This should be
designed into the framework and finish lines
placed appropriately.
4. Retention for acrylic resin: There should be
sufficient characteristics on the framework to
prevent separation of the resin from the metal
framework.
5. Adequate space for acrylic resin: There should
be a sufficient thickness of acrylic resin for
strength. 2–3 mm thickness is considered
optimal.
6. Cantilever: This is based on the anteroposte-
rior spread of the implants and should be
designed so that the cantilever is biomechani-
cally favourable.
7. Attention to cross-section: The area distal to
the most terminal implant is the area that is
under the most load. Specific attention to
cross-section in this region must be given to
limit the flexibility.
A specific framework design will be presented
incorporating all the principles discussed above.
Many technicians prefer to design the framework
using the CAD software. The current software
does not allow incorporation of all the features in
design, and often the framework has to be modi-
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 409

fied on return from the milling centre. This spe- 6. The space that was previously occupied by
cific design allows adequate support for acrylic the wax will be utilised for the titanium sub-
resin and teeth but involves a few more analogue structure. This space is evaluated to ensure
steps for completion. there is sufficient space for the bar, acrylic

1. A putty matrix (A) is made of the wax tooth

try-in is made on the articulator (Figs. 16.23,
16.24, 16.25, and 16.26).
2. A putty matrix (B) is made of the wax tooth
try-in to index the buccal and incisal surfaces
(Fig. 16.27).
3. A lingual index is made of matrix (B) with a
soft putty material (Figs. 16.28, 16.29, and
16.30).
4. The teeth are removed, leaving the wax sub-
structure intact (Fig. 16.31).
5. The teeth are placed in matrix (B) and set
back onto the model (Fig. 16.32). Fig. 16.25 Putty index to maxillary base (A)

Fig. 16.23 Mandibular wax-up being prepared for index-

ing on articulator
Fig. 16.26 Intaglio of putty index

Fig. 16.24 Plaster base mounted on articulator with

notches to receive putty index Fig. 16.27 Buccal and incisal putty index (B)
410 K. Mizuno et al.

Fig. 16.31 Teeth removed from wax-up

Fig. 16.28 Lingual putty index

Fig. 16.32 Teeth put in matrix (B)

resin and tooth. If space is insufficient, the

teeth are adjusted to create space
Fig. 16.29 Lateral view of lingual putty index
(Fig. 16.33a, b). 3 mm of acrylic thickness is
required. The bar dimensions must be suffi-
cient for rigidity.
7. Wax is applied to the teeth in matrix B to
secure them into place (Fig. 16.33c).
8. Two holes are made in the lingual index.
Matrix (B) and the lingual index are
replaced back onto the cast and secured via
the use of elastic bands (Figs. 16.34 and
16.35).
9. A light body impression material is injected
into the holes to occupy the space held previ-
ously by the wax. This forms an intaglio
Fig. 16.30 Intaglio of lingual index index (Fig. 16.36).
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 411

a b c

Fig. 16.33 (a) Matrix with teeth on cast to evaluate space on the right side. (b) Matrix with teeth on cast to evaluate
space on the left side. (c) Teeth waxed into matrix (B) to secure them into place

Fig. 16.34 Holes made in lingual index Fig. 16.37 Lingual index removed to show intaglio
index

Fig. 16.35 Lingual index with holes seated on cast

Fig. 16.38 Intaglio index cleaned up and adjusted to
ensure sufficient space between teeth and index

10. The intaglio index is trimmed and cleaned.

This index will be used for scanning to create
the titanium substructure (Fig. 16.37, 16.38,
16.39, and 16.40).
11. The master cast is also scanned so that the
CAD software can recognise the implant
platform.
12. The titanium framework is designed using
Fig. 16.36 Soft light body impression material injected CAD software (Figs. 16.41, 16.42, 16.43,
into holes to capture intaglio of index and teeth 16.44, 16.45, and 16.46).
412 K. Mizuno et al.

Fig. 16.42 Intaglio index scanned

Fig. 16.39 Intaglio index which will be used for

scanning

Fig. 16.43 Framework designed in reference to the inta-

glio index to ensure framework is designed with tooth
position in mind

Fig. 16.40 Lateral view of intaglio index

Fig. 16.44 Buccal view of framework design

13. The framework is milled (Figs. 16.47, 16.48,

and 16.49a, b).
14. The framework is verified on the cast in refer-
ence to the putty matrix. The putty matrix (A)
with and the titanium substructure on the mas-
ter cast are replaced on the articulator for a final
Fig. 16.41 Master cast scanned verification of the required space for acrylic
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 413

Fig. 16.45 Occlusal view of framework design Fig. 16.46 Definitive framework design

Fig. 16.47 Buccal view of milled framework in lab

Fig. 16.48 Lateral view of framework

a b

Fig. 16.49 (a) Occlusal view of framework. (b) Alternative framework design showing additional retention, designed
in the same way

resin. If space is required, teeth may need to be
adjusted as necessary (Fig. 16.50a, b).
15. The framework is degreased and cleaned
with acetone.
16. The framework is sandblasted with
50-micron aluminium oxide (Fig. 16.51).
17. A metal primer is applied (Fig. 16.52).
18. The first opaque layer is applied which has a
higher degree of opacity to block the greyness
of the titanium framework. Polymer powder is
sprinkled onto the opaque layer to enhance the
bonding surface (Figs. 16.53, 16.54, and 16.55).
414 K. Mizuno et al.

a b

Fig. 16.50 (a) Framework with putty matrix (B) in place to check space for acrylic resin. (b) Framework with putty
matric (A) to check space for acrylic resin

Fig. 16.53 First layer of opaque applied

Fig. 16.51 Framework sandblasted with 50 microns alu-
minium oxide

Fig. 16.54 Second layer of opaque applied

Fig. 16.52 Metal primer applied
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 415

19. The second layer of opaque is applied; this optimum aesthetics. Although zirconia is an
has a more pink gingival colour. Polymer excellent material, it has often been misunder-
powder is sprinkled onto the opaque layer to stood. There have been many reports of chipping
enhance the bonding surface (Fig. 16.56a, b). and fracture that have been attributed to the mate-
20. The titanium bar and teeth are waxed, and
the definitive contours of the restoration fully
waxed up.
21. The gingival base is then invested and pro-
cessed in heat-cured resin (Figs. 16.57,
16.58, 16.59, 16.60, and 16.61).
22. The prosthesis is deflasked finished and pol-
ished. Occlusion is evaluated on the
articulator.

16.4.1 Zirconia

Zirconia has been used quite extensively because Fig. 16.57 Wax-up completed
of its biocompatibility, strength and potential for

Fig. 16.55 Polymer powder sprinkled on to opaque to

enhance bonding surface Fig. 16.58 Undersurface of wax-up indexed in silicone

a b

Fig. 16.56 (a) Fully opaque framework. (b) Full opaque alternative framework
416
Fig. 16.59 Wax-up invested and sprued
Fig. 16.60 Occlusal surface of wax-up covered with a
rigid putty
Fig. 16.61 Flasks filled with stone ready for processing
K. Mizuno et al.
rial itself, when improper handling is usually the
culprit.
Success and long-term stability of implant-­
supported zirconia full-mouth restorations can be
achieved when important parameters are fol-
lowed in detail.
Design considerations in fabrication of the
prosthesis include [20]
1. Ease of fabrication
2. Passivity of the framework
3. Implant/abutment interface
4. Occlusion/wear
5. Design of framework
6. Veneering porcelain
7. Aesthetics
8. Delivery/retrievability
16.5 Ease of Fabrication
Traditional techniques in fabricating full-arch
implant frameworks involve waxing casting and
application of porcelain. This approach has been
adopted for many years and is considered the
gold standard for fabrication of implant-­
supported restorations. The results achieved with
these techniques have been predictable and suc-
cessful. Traditional techniques do require a high
degree of skill and problems inherent with wax-
ing and casting can lead to it being a laborious
procedure which is time consuming. With the
increasing costs of gold, clinicians have moved
away from traditional techniques and have begun
to employ more contemporary techniques using
CADCAM technology and material such as zir-
conia and titanium. These techniques also require
a high degree of skill but are less time consuming
in the manufacture process.
16.6 Restorative Space
Sufficient space must exist to fabricate a biome-
chanically sound restoration. The type of zirconia
restoration will depend upon the type of defect
present (just tooth or tooth and tissue). The need
to hide the transition zone often necessitates alve-
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 417

olectomy and the use of pink ceramics. If utilis- exercised care in pouring it. Specifically zirconia-­
ing pink ceramics, 14–16 mm of space is required based restorations employ the use of titanium
from the head of the fixture to the incisal edge. bases which allow for compensation of the three-­
This space requirement is component based. dimensional distortion that occurs post sintering
2 mm is required for the titanium interface, [23, 24].
2–3 mm for pink ceramics and 10–11 mm of
tooth length to achieve aesthetic proportions. If
less than 12 mm is present, zirconia-based resto- 16.7 Implant/Abutment Interface
rations may still be utilised but without the pink.
Attention in this instance must be given to con- Traditional techniques involve casting gold onto
nector dimensions [21]. an abutment cylinder, with the abutment implant
interface being titanium to titanium. With the
advent of zirconia and CADCAM technology,
16.6.1 Passivity of the Framework many abutments are fabricated of full zirconia
where the abutment implant interface is tita-
Passivity in an implant framework has been noto- nium to zirconia. With titanium and zirconia
riously difficult to achieve when utilising screw-­ being different in chemical composition, fret-
retained splinted restorations. Inaccuracies in ting wear can occur over time. Vibration and
implant frameworks are the result of multiple micromovements are a common cause of fret-
variables, which include machining tolerances of ting wear. The hardness of the material is
components, distortion in the impression mate- strongly correlated with its wear behaviour. A
rial, setting expansion of the die stone, expansion study to evaluate the effect of zirconia on the
and contraction of alloy and wax and distortion abutment interface has been reported specifi-
of the framework during heat treatment and cally on the external hex. A simulation of 500
application of porcelain [22]. chewing cycles was performed on an implant-
Common solutions to provide a passive frame- supported restoration on which the abutment
work have been sectioning and soldering or fabri- screw was minimally loosened. This was said to
cating cement-retained restoration. Although represent clinical reality when a patient is not
cement-retained restorations have become aware of micromovement between the abutment
increasingly accepted, they still have the disad- and the implant restorative platform. A titanium-
vantage that they are not readily retrievable and to-titanium and a zirconia-to-­titanium interface
studies have also shown that despite a clinician’s were compared. The damage to the external hex
best efforts excess cement is often left behind was most significant on the implant that was
which can result in biological complications. loaded with the ceramic abutment. The corners
Another approach to achieve a passive screw-­ of the hex were rounded. Titanium debris that
retained framework has been use of the adhesive-­ was abraded from the external hex by the all
corrected implant frameworks where individual ceramic abutment was also visible. Clinically
cylinders were cemented within the framework the anti-rotational property associated with the
after it had been cast (KAL technique). This external hex can be considered compromised
approach has merit in that it eliminates many of and is a point of concern. Zirconia abutments
the current prosthetic and laboratory inaccuracies have been designed with a titanium component
associated with traditional techniques. that has been fused or cemented to the zirconia.
With CADCAM technology a lot of the vari- The unique design feature is that it permits
ables have been eliminated and frameworks can metal-to-metal contact at the abutment implant
be produced with high precision providing the interface and results in the same high degree of
operator has taken care in producing an accurate predictability associated with metal abutment–
impression and the laboratory technician has implant connections.
418
16.8 Occlusion/Wear
Patients with implant-supported restorations
have a reduced amount of proprioception. As a
result the restorations have been subject to greater
forces.
Occlusal surfaces have been designed using
noble metals, feldspathic porcelain and acrylic. A
clinical study investigated the maintenance
requirements in patients with implant vs. implant,
implant vs. natural dentition and implant vs. den-
ture occlusion. The study reported that patients
with implant-to-implant occlusions suffered a
higher degree of fracture and greater wear of the
occlusion. For stability of occlusal contact, clini-
cians have preferred a gold occlusal surface over
ceramic and acrylic. Due to aesthetic concerns,
patients often favour tooth-coloured materials.
Feldspathic porcelain has been the material of
choice. More recently clinicians have utilised zir-
conia on the occluding surface of the restoration.
Concerns by clinicians have been the effect of
zirconia on the opposing occlusion. An in vitro
study was conducted to evaluate the clinical
validity of using a full-contour zirconia crown.
This study compared zirconia’s wear capacity to
that of feldspathic porcelain. The study reported
that the antagonistic tooth wear was less in pol-
ished zirconia than feldspathic porcelain, sug-
gesting that zirconia may be more beneficial for
antagonistic tooth wear. The data on this subject
is limited and further studies are required.
16.9 Design of Framework
Specific attention needs to be paid to dimensions
of the framework in the cantilever area. Connector
size is critical for both traditional noble metal and
zirconia frameworks. There is no specific data on
the minimum dimensions required for an all-­
zirconia framework [25, 26].
16.10 Veneering Porcelain
Questions often arise in regard to the flexural
strength of zirconia alone and the flexural strength
of the zirconia porcelain system. Clinicians have
concerns about potential chipping and fracture of
K. Mizuno et al.
the veneering porcelain. Most studies will report
that the veneering porcelain is the weak point in
any multilayer system including traditional PFM
techniques. Regardless of whether a noble metal or
zirconia framework is being used, the overlying
porcelain must be well supported. Shear bond
strength of porcelain to zirconia has also been
investigated, and studies show differences in bond
strength depending on the veneering porcelain
used and if the zirconia substructure is coloured or
uncoloured. It is the author’s recommendation that
when using a zirconia substructure a compatible
veneering porcelain should be used and the heating
and cooling cycles must be carefully controlled.
Limiting the veneering porcelain and having a full
contour zirconia framework with zirconia occlu-
sion is advantageous in this regard [27, 28].
16.11 Aesthetics
Talented ceramists can produce high-level aes-
thetic results using both traditional noble metal
and zirconia frameworks. In regards to light
transmission both noble metal and zirconia have
been shown to be opaque. Anecdotally many lab-
oratory technicians report superior aesthetic
results with zirconia frameworks due to the abil-
ity to be able to colour the zirconia and be able to
have a tooth-coloured framework rather than an
opaque grey-coloured framework which is usual
with traditional metal ceramic frameworks.
16.12 Delivery/Retrievability
When designing a splinted full-arch implant-­
supported restoration, screw retention has a dis-
tinct advantage. The precision of fit of
screw-retained restorations can be verified with
radiographs using a single-screw test. Delivering
a screw-retained restoration also involves less
time with no cement clean-up required.
Retrievability is advantageous for (1) periodic
maintenance, (2) dealing with loosened screws,
(3) fracture of the prosthesis and (4) modification
of the prosthesis due to continuing tissue
resorption.
It can be seen that designing a screw-retained
restoration has a significant safety factor.
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 419

16.13 Laboratory Process guide pins the screw access holes are pro-
tected. The matrix of the interim is perfo-
16.13.1 Full-Arch Zr-Implant rated using a drill bit—on the most distal
Prosthesis areas of the arch one per side (Figs. 16.63
and 16.64).
1. Immediately after the conversion of the den- 3. Using a lingual matrix previously taken of
ture to an interim fixed prosthesis, patient is the interim on the master cast, Ti cylinders
requested to attend for intraoral and extraoral are modified to proper height. Using the
pictures and an aesthetic analysis was per- guide pins to fix the modified temp Ti cylin-
formed so that this current information can ders, the silicone matrix is placed back on the
be used to transfer to a well-made prototype master cast over the guide pins and injected
provisional restoration. A seven-step aes- with PMMA using a mono-jet syringe
thetic analysis is a good guideline to follow (Fig. 16.65).
for evaluating a patient’s aesthetic require- 4. Upon curing of the PMMA and removal of
ments and designing the prototype. It con- the silicone, a carbide bur was used to per-
sists of evaluating the (a) smile line, (b) form a uniform reduction about 1.5 mm on
incisal profile, (c) length, (d) proportion, (e) all surfaces of the converted prosthesis. This
tooth-to-tooth proportion, (f) gingival outline created space allows to wax in a new design.
and (g) desired fullness. Seldom the interim
prosthesis includes sufficient information to
allow visualisation of the final aesthetic out-
come; often it provides a starting point
because it is a conversion of the initial
removable denture. This approach is by far
the most accurate and predictable way to pre-
cisely evaluate the various parameters essen-
tial to the success of the definitive restoration
(Fig. 16.62).
2. This technique includes duplication of the
interim, fabrication of a splinted acrylic sup-
port jig/framework and wax design. The con-
version procedure begins with the duplication
of the interim prosthesis using a silicone
material (anaxdent) on the master cast. Using
Fig. 16.63 Hole being made in putty index to duplicate
converted prosthesis

Fig. 16.62 Intraoral view of converted prosthesis Fig. 16.64 Putty matrix seated on cast with guide pins
420
Fig. 16.68 Cutback acrylic substructure
Fig. 16.65 PMMA injected into putty matrix to dupli-
cate converted prosthesis
Fig. 16.66 Acrylic duplicate of converted prosthesis
Fig. 16.69 Initial wax-up
Fig. 16.67 Acrylic cutback in preparation for wax-up
Using information gathered from the patient
and images, desired modifications and
improvements during analysis, a new wax-up
is undertaken (Figs. 16.66 and 16.67).
K. Mizuno et al.
5. The wax-up is completed in two stages. The
first stage is to wax-design the teeth. The sec-
ond stage is to wax-design the gingiva. The
first step is to wax a central to proper propor-
tion about 11.5 mm length, then apply the
buccal body layer and bulk of the wax, creat-
ing three facial planes. This should now
establish desired length, bulk and basic mor-
phological shape of the tooth and its long
axis. Repeat the same steps for the contralat-
eral side and then using the same waxing
principle to wax the lateral and canine teeth
stopping at the first bicuspids. Once the gen-
eral shapes and proportions are met for all
the teeth, the spaces for the papillae and
gingiva will start to appear naturally
­
(Figs. 16.68, 16.69, and 16.70).
6. The key then is to start balancing the gingival
and tooth proportions and apply the funda-
mental knowledge of gingival aesthetics. The
best way to assess the overall balance of the
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 421

Fig. 16.72 Frontal view on articulator

Fig. 16.70 Lateral view of wax-up on acrylic
substructure

Fig. 16.73 Intraoral try-in for wax-up to determine if

additional modifications are required
Fig. 16.71 Frontal view of wax-up to evaluate
aesthetics

wax design is to take a frontal image using a

magnetic table, open in keynote and using
the magnetic table as a true horizontal refer-
ence, place one vertical line through the mid-
line one horizontal line at the incisal edge.
Additional horizontal reference lines can be
placed on the laterals and canines to check
the balance symmetry and lengths of the
incisal edges of the anterior and posterior
Fig. 16.74 Retracted view to evaluated occlusal plane
teeth. Additionally the horizontal reference
lines are placed on the gingival levels of cen-
tral/lateral/canines. Now you can carefully 7. Wax design try-in. Images should be taken to
and objectively analyse the balance of the reassess aesthetics and final adjustments can
gingival levels, tooth lengths, symmetry and be made during this stage (Figs. 16.73 and
asymmetry. Necessary wax adjustments are 16.74). The wax design now serves as the
performed at this stage with high precision. blueprint to scan and copy mill a multi-layer
A wax design can be efficiently and precisely prototype prosthesis.
completed using the described steps 8. This workflow involves scanning in Ti temp
(Figs. 16.71 and 16.72). abutments as ‘preps’ in 3 shape, then scan-
422 K. Mizuno et al.

Fig. 16.75 Guide pins used to fix modified temporary

cylinders

Fig. 16.77 Completed resin jigs

Fig. 16.76 Since temporary cylinders are non-engaging,

a positioning jig is required
Fig. 16.78 Titanium temporary cylinders scanned as
preparations
ning the wax-up to copy mill the design.
Using a lingual matrix previously taken of
the interim on the master cast, Ti cylinders
are modified to proper height. Using the
guide pins to fix the modified temp Ti
­cylinders, undercuts/grooves on Ti temp cyl-
inders are blocked using wax. Since the temp
cylinders are non-engaging, a positioning jig
is required to repeat the positions of Ti inter-
faces after scanning. Using a light cure resin Fig. 16.79 Wax-up is scanned
(primopattern), the Ti cylinders are con-
nected (Figs. 16.75, 16.76, and 16.77).
9. An order in 3 shape is created by selecting individually for the high-resolution image
the tooth numbers for the implants, and in the (Figs. 16.78 and 16.79).
‘frame’ category the “wax-up” icon is Design steps in 3 shape
selected and then in the ‘bridge’ category the 10. Select margin points; care must be taken to
‘wax-up bridge’ icon is selected. The system set individual insertion direction to avoid
now is setup to scan the Ti temps as ‘preps’, crossing the margin line (set individual mar-
and the wax design scanning spray is used to gin direction). Proceed to set individual
scan the Ti temp followed by the scan of the insertion directions for the remaining units
wax design. Care must be taken to sandblast (Figs. 16.80, 16.81, and 16.82).
the interface and keep the neck area smooth 11. Mark margin line and set individual insertion
using wax when scanning the Ti interfaces directions for each unit. Please note in step 2
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations
Fig. 16.80 Margin points selected in three shape
Fig. 16.81 Individual
margin directions
selected
that the individual insertion direction may
end up different than the margin direction—
the key is to have a green line all the way
around with no red margins (Figs. 16.83,
16.84, and 16.85).
12. Die interface allows for adjustment of the
desired die spacer. Cement gap and extra
cement gap can be adjusted to fit specific
needs for each case. A good rule of thumb for
423
Ti abutments are 0.20 cement gap, 0.40 extra
cement gap, 1 mm distance to margin line
and 0.20 distance to margin line. Drill radius
and drill may vary on milling machine or
milling centre (Figs. 16.86, 16.87, and
16.88).
13. At this stage in frame design (wax-up
bridge)—dental designer combines and
merges the wax-up, scan of temp cylinder
424 K. Mizuno et al.

Fig. 16.82 Individual

insertion directions set
for individual units

Fig. 16.83 Margin line

and individual insertion
lines set for each unit

Fig. 16.84 Individual

insertion directions may
end up different than the
margin direction
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 425

Fig. 16.85 There

should be a green line
all the way around with
no red margins

Fig. 16.86 Die

interface allows
adjustment of die spacer

Fig. 16.87 Cement gap

should be adjusted to fit
specific needs of each
case
426 K. Mizuno et al.

Fig. 16.88 Cement gap

may need to be adjusted
for each cylinder

Fig. 16.89 Wax-up and

scan of temporary
cylinder is merged

scan and interfaces – and an active cut spline

for each prep unit needs to be selected. This
spline line (green line) simply connects the
‘wax scan’ to the ‘prep scan’. Care must be
taken to have a smooth circular outline with
uniform space all the way around
(Figs. 16.89, 16.90, and 16.91).
14. Frame design (sculpt) after completion of the
spline on remaining units, the bridge now is
‘connected’ to the prep scan and becomes
sculptable. During this stage in the ‘wax
Fig. 16.90 The wax scan is connected to the prep scan
knife’ settings in the sculpt toolkit menu, the
teardrop shape is selected and the scan data
that is sharp can be smoothed down without 15. The screw access holes must be cleared dur-
altering the general shape (Figs. 16.92, ing this stage to be able to have a screw-­
16.93, and 16.94). retained bridge. This must be done manually.
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations
Fig. 16.91 There should be a smooth circular outline all
the way around
Fig. 16.93 Scan data before smoothing
Fig. 16.95 Screw
access holes need to be
cleared
During frame design stage—in sculpt—
sculpt toolkit—attachment settings—there
are three options: group/attachment/default
orientation. Select—holes—hole 3.0 × 5.0
mm—view direction. This allows us to man-
ually set/sculpt precise access holes in the
bridge; this will be milled now with screw
427
Fig. 16.92 Bridge is connected to the prep scan and is
now sculptable
Fig. 16.94 Scan data after smoothing
access holes. Using a transparent view of
bridge and from an occlusal view direction,
the holes can be placed in the same axis as
the interfaces. These attachments are fully
customisable using handles to adjust height
position in the Y axis and X axis (Figs. 16.95,
16.96, and 16.97).
428
Fig. 16.96 Screw
access holes can be
sculpted manually
Fig. 16.97 Transparent
view of bridge can be
used to visualise access
holes
16. After placing the attachments in the desired
position, the play button is selected and the
reduction will take place and screw access
holes are placed (Figs. 16.98, 16.99, and
16.100).
17. Bridge and interfaces scanned, sculpting
completed and screw access holes placed—
STL file—ready for a mill of a PMMA multi-­
layer screw-retained prototype restoration
with Ti interfaces (Fig. 16.101).
18. Milled PMMA multi-layer (harvest dental).
The gingival area of the milled prototype was
prepared with 0.5-mm depth-cutting burs to
control the cutback and achieve a uniform 20. This mixture is used to apply in the inter-
design. The marked lines provide a guide;
after the initial depth cuts, more depth cuts
K. Mizuno et al.
are performed in between and finally refined
using carbide burs. Gingival area is ready to
receive internal stain and composite
(Figs. 16.102 and 16.103).
19. Opti-bond FL(Kerr) is applied to the gingival
interface to increase the bond of PMMA to
composite. A combination of red/white/blue
stains is used to create internal vascularity,
colour and depth prior to applying the com-
posite. A total of three composite shades are
used: dark pink, light pink and orange pink.
A hybrid layer of stain/composite is created
by using red composite stain and dark pink.
proximal and interdental areas, the dark pink
composite added near the transition to the
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 429

Fig. 16.98 Screw

access holes are placed
using software

Fig. 16.99 Evaluation

of undersurface

Fig. 16.100 Evaluation

of trajectory of screw
access holes
430 K. Mizuno et al.

Fig. 16.101 Bridge and

interfaces have been
scanned, sculpting
complete and screw
access holes completed

Fig. 16.104 Stain applied to prototype

Fig. 16.102 Milled PMMA restoration to be used as a

definitive prototype

Fig. 16.105 Gingival areas corrected

Fig. 16.103 Prototype cutback in gingival area for pink
acrylic
natural tissues, the light pink composite is
used to cover and create the final morphol-
ogy, and the orange pink is used in small
amounts near the mucco-gingival junction.
An assortment of diamond burs is used to
make morphological corrections to the gingi-
val area as well as the tooth areas.
Interproximal and incisal embrasures are
redefined with diamond disks and an acrylic
polishing compound with a felt wheel is used
to manually polish the gingival and tooth sur-
faces (Figs. 16.104 and 16.105).
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations
Fig. 16.106 Intraoral try-in of acrylic prototype to deter-
mine if any adjustments are required
Fig. 16.107 Final prototype
21. Full face and lower 1/3 smile views of the
full-arch implant-supported screw-retained
PMMA multi-layer prototype – this now
allows us to have a removable blueprint of
the definitive prosthesis and serves to test
drive aesthetics and function. Any refine-
ments needed now can be transferred to the
final zirconia prosthesis (Figs. 16.106 and
16.107).
22. The duplication and injection method for the
framework is identical as previously
described for an interim to wax design
conversion.
23. The tooth shade is determined using the
Noritake A-D shade guide system
(Fig. 16.108). The gingival shade was deter-
mined using the Noritake shade and colour
guide (Fig. 16.109). Photographs are taken
with multiple pink colour tabs to determine
pink, dark pink, orange and bright areas for
natural gingival colour reproduction during
the ceramic stages.
431
Fig. 16.108 Shade matching completed
Fig. 16.109 Gingival shades taken
24. The frame design parameters are extremely
critical in full-arch cases. A few basic prin-
ciples can be followed to ensure ­predictability.
A conservative approach requires precise
and controlled preparation of the framework.
A minimal facial-only cutback technique is
utilised, with a facial-only cutback of
between 0.7 and 0.1 mm with a full-lingual
supported in zirconia. To allow for maximum
strength and support the cutback, the facial
surface should terminate at the incisal edge,
with no reduction of incisal edge, keeping at
least 0.5 mm bucco-lingual thickness of the
incisal edges. An identical reduction also
applies to the gingival areas. Utilising a
0.5 mm depth cutter to control the depth of
the facial reduction, a precise reduction can
be achieved in two stages. In the first stage
the depth cut into the gingival area at the ver-
432 K. Mizuno et al.

Fig. 16.110 Prototype prepared for minimal cutback for

layered ceramics Fig. 16.112 Undersurface of cutback prototype scanned

Fig. 16.113 Master cast scanned

Fig. 16.111 Cutback prototype

tical bisected midline of each tooth and then

one depth cut in between two teeth. Depth
cuts are made vertically and horizontally on
the teeth in a ‘tic-tac-toe’ pattern, then all the
remaining areas are reduced and refined. To
ensure uniform reduction the bur is used par-
allel to the three planes of the teeth
(Figs. 16.110 and 16.111).
25. Following the finalisation of the resin frame-
work pattern the case is taken through a scan- Fig. 16.114 Occlusal and incisal surfaces of cutback
prototype scanned
ning and designing sequence to fabricate a
CAM (Nobel 2G scanner, Nobel Biocare)
machined yttrium-tetragonal zirconia poly- 26. Due to milling constraints and diameters of
crystal (Y-TZP) framework (Procera implant milling burs, some areas of the mill need
bridge, Nobel Biocare). Step 1: scan the inta- modifications. The most critical areas are
glio. Step 2: scan implant positions using the inter-incisal embrasures; the embrasures
model implant locators. Step 3: scan the top- of the milled zirconia framework should
side. The software merges all scans, and the reflect the design of the resin framework
case is ready to design and mill (Figs. 16.112, pattern. The final details of the bridge are
16.113, 16.114, and 16.115). redefined with rotary instruments, using a
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 433

Fig. 16.115 CAD software used to finalise design

Fig. 16.117 Embrasures of zirconia framework refined

manually

Fig. 16.116 Milled zirconia framework

slow speed and a thin honeycomb disc

(Brasseler USA) (Figs. 16.116, 16.117, and
16.118).
27. The framework is tried in. Verification of fit
is checked during this stage.
28. The challenge of using pure white zirconia
for a framework is that it will have a signifi- Fig. 16.118 Completed manual modification of
cant effect on the target shade, even if the framework
ceramic of the target shade was used in the
build-up. The solution to this is to use inter- while giving the ceramist the ability to repro-
nal stains for (Noritake CZR) to achieve a duce chroma, control value, create depth and
similar chroma and value, that of the target internal characterisation, so using internal
shade. An additional advantage of using stain to create colour and characteristics are
internal stains is that it adds minimal bulk an indication for cases that have minimal
434
Fig. 16.119 Very bright colour of framework needs to be
addressed
Fig. 16.120 Wash bake interdental areas separated with
very thin blade to give the illusion of individual units
layering space. Internal stains can be mixed
with bright/dilution internal powder to soften
and lower the intensity of the chroma. The
wash bake is carried out using opacious den-
tin. At the first build–up, the main goal is to
fill the facial with ceramic mass using the
dentin mixture and create the tooth shapes.
After building the final tooth shapes with the
dentin ceramic, translucent powders are
added to the corners and incisal 1/3 area.
Mamelon powders are used near the incisal
1/3 for internal effects to create characteris-
tics. Prior to baking, the first build-up always
makes sure to condense the ceramic and
finally use a Kolinsky hair brush (Smile Line
USA) to feather and condense the ceramic
grains together. Separate the units in the
interdental areas with a very thin blade
(Smile Line USA) before baking to prevent
tearing and uniform/controlled shrinkage of
the ceramic (Figs. 16.119, 16.120, and
16.121).
29. The internal stain bake is an integral part of
creating a natural structure and colour of the
Zr framework: this technique was developed
K. Mizuno et al.
Fig. 16.121 Result after initial bake
by Mr Hitoshi Aoshima in which the Noritake
(Noritake Japan) internal stains are ‘painted’
on during this procedure to achieve the life-
like characteristics of natural teeth. The
internal live stain has three stages. In the first
stage you paint the chroma and value, in the
second stage you paint the white band and
any horizontal characteristics, and in the
third and final stage you can apply vertical
characterisations. The internal stain recipe is
determined by the standard colour recom-
mendation from the manufacturer, then you
can make adjustments based on your prefer-
ence. For this case simple but effective com-
bination of colours was used to stain the
characteristics. Incisal blue 1 and incisal blue
2 are used at the incisal 1/3 to accentuate the
translucency and create more depth, cervical
2 is used with dilution powder to integrate
more chroma at the gingival 1/3. White inter-
nal stain mixed with mamelon 1 and dilution
is used for the mamelon effect and crack
lines.
30. Bright areas are replicated using white
together with dilution powder. The intensity
of any internal stain can be altered by vary-
ing the ratio between the stain and dilution.
The key is to have colour contrasts by mixing
the internal stains with dilution powder to
soften the internal stains. All the stains must
be feathery and must integrate into each
other in a very delicate manner (Figs 16.122
and 16.123).
31. During this bake, the lustre layers LTO, LT1
and Agua blue 2 were used as a skin layer to
complete the contours of the teeth only and
filter the internal effects. Using a Sharpie
marker the desired gingival levels are marked
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations
Fig. 16.122 Internal stain bake
Fig. 16.123 Close-up view to illustrate internal stains
Fig. 16.124 Internal stains used
and marked with a diamond bur at slow
speed. These markings are used as reference
points to guide the gingival ceramic b­ uild-­up.
After morphological adjustments are com-
pleted on the teeth, the gingival area is lay-
ered using gingival powders from the same
ceramic kit (Figs. 16.124 and 16.125).
32. An understanding of natural gingival anat-
omy is key to achieving natural and harmoni-
ous gingival aesthetics. To that effect, the
gingival levels of the lateral incisors should
be 1–1.5 mm lower than those of the central
incisors, which can be the same as the canine
gingival levels. The papilla should fill 40%
435
Fig. 16.125 Marks used to guide build-up of gingival
ceramic
of the space from the cervical to the incisal
edge. The gingival zeniths of central incisors
should be placed 1 mm distal from the mid-­
axis of the tooth; those of the lateral incisors
should be placed 0.3–0.5 mm distal from the
mid-axis. The zeniths of the canines can be
placed right along the mid-axis of the tooth.
A reddish and opaque ceramic is used in the
transitional/junctional area in order to mimic
attached mucosa. Apply a darker tissue layer
mixed with red stain in all the areas’ inter-
dental papilla. A brighter and lighter pink
ceramic is used on top of the root areas and
more chromatic reddish pink shade in the
interproximal. The gingiva may be slightly
over-contoured to compensate for the firing
shrinkage – tissue 5 was used for the inter-
proximal areas extending all the way to the
gingival margins. A combination of tissue 3,
tissue 2 and tissue 1 was used to complete the
gingival shapes. Tissue 3 and tissue 2 powder
was used for the free gingival margin area.
For the bright areas a mixture of A1 dentin
powder and tissue 3 was used (Figs. 16.126
and 16.127).
33. This is the bake right before glaze which is
the contour bake for both tooth and gingiva
areas. This bake is one of the most important
because at this stage the gingival levels,
papilla proportions and gingival zeniths can
be refined and perfected by adding small
amounts of gingival ceramic powders. It is
also during this bake that the ceramist can
add small amounts of gingival ceramics to
mimic small nuances found in natural gin-
giva. Free gingival margin areas require
some translucent powders to be mixed with
436
Fig. 16.126 Gingival ceramic build-up
Fig. 16.127 Natural characteristic of gingiva incorpo-
rated in build-up
the gingival powders in 1:1, 1:2, 2:1 mixing
ratios, depending on the desired level of free
gingival translucency. Dentin powders are
also mixed with gingiva in a 1:1 ratio to cre-
ate some bright areas in the attached gingiva
and attached mucosal areas. Chromatic den-
tins can also be used to create some orange
areas most often seen in natural gingiva. The
key is to work in an asymmetrical random
manner; however, it still maintains balance
of the effects. A harmonious gingival mor-
phology proportionally balanced with tooth
structure is a prerequisite for achieving natu-
ral gingival aesthetics. A key ingredient to
creating a natural gingiva is to contour the
gingiva using a natural stone cast for
­morphological reference and inspiration dur-
ing the fabrication process. Burs are used to
create texture that mimics nature. After tex-
turing, the ridges are softened with grey sili-
cone wheels and then a pink silicone wheel.
A diamond dresser is used to alter the shape
K. Mizuno et al.
Fig. 16.128 Gingival areas refined
Fig. 16.129 Lateral picture to show texture and contour
of gingiva
of the silicone wheels. The next step of the
surface treatment involves the use of a pearl
surface bur and a felt wheel to provide a
matte finish on the surface. In the last step, a
grey silicone is used on the line angles and
high spots of the morphology to create highly
reflective surfaces. The advantage of using
these polishers in different grits and shapes is
to create a surface with differential lustres,
high-shine areas, matte finish areas and dif-
ferent groove depths. The reflection of these
different surface treatments will mimic a
natural tooth surface (Figs. 16.128, 16.129,
and 16.130).
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations
Fig. 16.130 Gold powder used to show texture and
shape
Fig. 16.131 Hand polished ceramic 16.14 Conventional Analogue
34. During the stain/glaze stage the morphology
and texture can be controlled via low-fusing
additions. In order to retain the surface tex-
ture during glaze, the glaze/stain firing cycle
has to be 30–50° lower than the high temp of
the ceramic and the temperature of the lower
fusing ceramic must be within the range of
that final temp. And during this stage, a com-
bination of a stippling brush and a higher
fusing sprinkle technique will further accen-
tuate the surface finish. After glaze, a combi-
nation of rubber wheels (Shofu, Edenta) is
used to create a matt finish and high lustre
areas in the gingiva to create a lifelike gingi-
val effect. The free gingiva and root promi-
nences are highly polished using a silicone
high shine wheel (Shofu) (Fig. 16.131).
35. Final intraoral and extraoral views
(Figs. 16.132 and 16.133).
437
Fig. 16.132 Intraoral view of definitive restoration
Fig. 16.133 Completed maxillary restoration
Concepts Challenged: Digital
and Non-digital Workflows
The advancement of computer-aided design
(CAD) and computer-aided manufacturing
(CAM) has allowed new opportunities in the field
of implant prosthodontics. Conventionally, the
standard approach for full implant arch restora-
tions consisted of applying impression tech-
niques to create stone casts that were then used
by the dental laboratory to manufacture acrylic
and porcelain fused to metal restorations using
the casting technique, which can be laborious and
technique sensitive. In contrast, CAD/CAM tech-
nology brought precision and reproducibility into
the process, reducing the necessary manpower
and creating a seamless workflow for dentists and
patients alike.
However, CAD/CAM technology still has
some drawbacks. CAD packages can be expen-
438
sive to acquire and require training to implement.
CAM requires large upfront investment to pur-
chase/commission the machinery and also in
order to prepare the premises to receive them. For
that reason, some dental laboratories are opting
for a hybrid approach, especially for full-arch
implant restorations, that include having the Ti
substructure designed and milled in a specialised
centre and then processing the acrylic teeth at the
final stage.
16.15 Digital Fabrication
Techniques: Advantages
and Disadvantages
The introduction of CAD/CAM technology has
significantly changed the way that full-arch
implant-supported restorations are fabricated.
Digitally designed prostheses allow practitio-
ners to have more control over the outcome and
give patients a chance to have a glimpse over the
final results through tools such as virtual smile
design. In addition, industrial CAD packages
allow for a high degree of predictability over the
final product, allowing manufacturers to apply
engineering concepts that would otherwise be
impossible to achieve. Some of those features
include, but are not limited to, precise dimen-
sion control and radiuses that match the tools
available, ­traceability of all the components in
the restoration process and a faster turnaround
time.
16.16 Full Digital Workflow
in Producing Definitive
Restorations
Digital technologies (Nexus iOS digital work-
flow) have been developed to ensure precision.
All data required for a digital design is recorded
without the need for analogue impressions, ver-
ification jigs or additional photogrammetry
K. Mizuno et al.
components. The process relies solely on a vali-
dated intraoral scanner and a proprietary scan
gauge kit.
The following steps are required for a single
full-arch implant-supported restoration. (See
Chap. 13 for clinical workflow.)
1. Proprietary scan gauges are placed and
scanned right to left and then left to right
(Osteon Technologies)
2. Prosthesis/provisional in situ
3. Opposing arch scanned
4. Soft tissue is scanned
5. Existing prosthesis is scanned extraorally
6. Patient is asked to occlude into maximum
intercuspation and a right and left bite scans
are performed
The following photos are also submitted with
the scans:
1. Provisionals in the mouth
2. Smile
3. Full face
From a laboratory perspective, the following
steps are completed sequentially:
1. Receipt of scan data and verification of accu-
racy of scans (see Chap. 13)
2. Design assembly
3. Bar milling
4. Finishing
5. Final case delivery
16.17 Design Assembly
The definitive restoration is fabricated by refer-
encing various images of the overlay teeth and
the bar design (Fig. 16.134a–f). The design is
sent to the clinician for final approval.
Adjustments can be made at this stage
(Fig. 16.135a, b).
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 439

d e

f g

Fig. 16.134 (a) Design overlay demonstrating cross-­ titanium bar in relation to overlay. (e) Bar and overlay
section of bar in anterior area. (b) Design overlay demon- independent of tissue scans. (f) Access holes demon-
strating cross-section of bar in posterior area. (c) Design strated. (g) Occlusal view of access holes
overlay demonstrating material thickness. (d) Position of
440 K. Mizuno et al.

Fig. 16.135 (a) Completed design for approval by clinician. (b) Completed design lateral view

16.18 Milling

CAM is utilised to plan and mill the titanium bar

utilising an industrial process on a 5-axis CNC
milling machine (Fig. 16.136a–c). The zirconia
overlay is also milled (Fig. 16.137).
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 441

Fig. 16.136 (a) CAD for milling. (b) CAD for milling. (c) Demonstrating access hole
442 K. Mizuno et al.

16.19 Finishing

The zirconia is sintered and tried over the tita-

Fig. 16.137 Zirconia overlay sintered
nium bar for passivity of fit (Fig. 16.138a, b). The
overlay is polished and final adjustments can be
made on the benchtop. The framework is stained
and glazed (Fig. 16.139), and a final fit check
over the titanium bar is made.
The titanium bar is polished and final adjust-
ments to the zirconia overlay made.
The overlay is cemented onto the zirconia
framework using a resin cement (Fig. 16.140a–d).
Proprietary techniques are used to ensure suffi-
cient film thickness of resin cement, fit of the tita-
nium bar within the overlay structure and adequate
bond strength between the two interfaces.

a b

Fig. 16.138 (a) Zirconia overlay and titanium bar. (b) Zirconia overlay and titanium bar

Fig. 16.139 Final adjustment of

zirconia overlay
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations 443

a b

c d

Fig. 16.140 (a) Zirconia nexus overlay. (b) Zirconia/titanium nexus restoration. (c) Titanium bar being polished. (d)
Zirconia overlay being polished

16.20 Delivery

The definitive restoration is delivered to the clini-

cian together with all prosthetic screws and com-
ponents required for delivery (Fig. 16.141a, b).
444
a b
Fig. 16.141 (a) Definitive acrylic overlay on titanium bar. (b) Definitive zirconia restoration on titanium bar
16.21 Conclusion
There are various materials to choose from when
designing full-arch fixed implant-supported res-
torations. Material choices range from a
­traditional acryl resin titanium, zirconia (mono-
lithic/layered) to a titanium-supported zirconia
restoration. As technological advancements
occur, newer materials and manufacturing pro-
cess are being introduced into these therapies;
however, clear guidelines on design and material
selection are lacking.
CADCAM technology allows the clinician to
adopt a much more efficient workflow, producing
a more accurate restoration in a shorter amount of
time. Additional advantages include stored digi-
tal data allowing a quicker turnaround time
should failure occur.
Acknowledgements The authors thank Dr Bernd
Siewert, Clinica Somosaguas, E-28223 Madrid, Spain, for
Figs. 16.9, 16.10, 16.11, 16.12, 16.13, 16.14, 16.15, and
16.16. The authors would like to thank Juvora U.K. for
technical information related to PEEK. The authors would
like to thank Drs Udatta Kher and Ali Tunkiwala for
Figs. 16.17 and 16.18. Surgery was performed by Dr
Udatta Kher Prosthodontics by Dr Ali Tunkiwala. The
authors would like to thank Amy M Camba for clinical
Figs. 16.74, 16.75, 16.76, 16.77, 16.78, 16.79, 16.80,
16.81, 16.82, 16.83, 16.84, 16.85, 16.86, 16.87, 16.88,
16.89, 16.90, 16.91, 16.92, 16.93, 16.94, 16.95, 16.96,
16.97, 16.98, 16.99, 16.100, 16.101, 16.102, 16.103,
16.104, 16.105, 16.106, 16.107, 16.108, 16.109, 16.110,
16.111, 16.112, 16.113, 16.114, 16.115, 16.116, 16.117,
16.118, 16.119, 16.120, 16.121, 16.122, 16.123, 16.124,
16.125, 16.126, 16.127, 16.128, 16.129, 16.130, and
16.131. The authors would like to thank Dr. Gerarad
Chiche and the Department of Prosthodontics and
Aesthetic Dentistry at Georgia Regents University.
K. Mizuno et al.
References
1. Sereno N, Rosentritt M, Jarman-smith M, Lang
R, Kolbeck C. In-vitro performance evaluation of
polyetheretherketone (PEEK) implant prosthetics
with a cantilever design. Clin Oral Implants Res.
2015;26(12):296.
2. Conserva E, et al. The use of a masticatory robot to
analyze the shock absorption capacity of different
restorative materials for prosthetic implants: a pre-
liminary report. Int J Prosthodont. 2009;22(1):53–5.
3. Study conducted at Regensberg University, Germany
on file at Invibio Dental, UK.
4. Siewert B. Production of implant supported bridges
from PEEK Blanks. DZW Die ZahnarztWoche
Digital Dental News, 2013, p. 22–31.
5. Tipton P and Siewert B. High performance polymers
part 3. Private Dentistry UK. 2016.
6. Siewert B, Parra M. A new group of material in den-
tistry. PEEK as a framework material used in 12-piece
implant-supported bridges. Z Zahnärztl Implantol.
2013;29:148–59.
7. Moura Guedes C. New possibilities for high perfor-
mance polymers in the MALO clinic protocol. British
Association of Restorative Dentistry Conference.
2016.
8. JUVORA processing guidance, technical certification
instructions, Invibio Dental, UK.
9. Kern M, Lehmann F. Influence of surface condition-
ing on bonding to polyetheretherketone (PEEK). Dent
Mater. 2012;28:1280–128.
10. Schmidlin PR, Stawarczyk B, Wieland M, Attin T,
Hämmerle CH, Fischer J. Effect of different surface
pre-treatments and luting materials on shear bond
strength to PEEK. Dent Mater. 2010;26:553–9.
11. Keul C, Liebermann A, Schmidlin PR, Roos M, Sener
B, Bogna S. Influence of PEEK surface modification
on surface properties and bond strength to veneering
resin composites. J Adhes Dent. 2014;16:383–92.
12. Branemark PI, Hansson BO, Adell R, et al.
Osseointegrated implants in the treatment of the eden-
tulous jaw. Experience from a 10-year period. Scand J
Plast Reconstr Surg Suppl. 1977;16:1–132.
16 Laboratory Fabrication of Full-Arch Implant-Supported Restorations
13. Wohrle PS, Cornell D. QDT. 2008;31:1–17.
14. Stumpel L. JCDA. 1994;22(47):1–6.
15. Brozini T, Petridis H, Tzanas K, et al. A meta-
analysis of prosthodontic complication rates of
implant supported fixed dental prosthesis in eden-
tulous patients after an observation period of at
least 5 years. Int J Oral Maxillofac Implants.
2011;26:304–31.
16. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP,
Galluci GO. A systematic review of biologic and
technical complications with fixed implant rehabili-
tations for edentulous patients. Int J Oral Maxillofac
Implants. 2012;27:102–10.
17. Branemark PI, Svensson B, Van Steenberghe D. Ten-­
year survival rates of fixed prosthesis on four or six
implants ad modum Branemark in full edentulism.
Clin Oral Implants Res. 1995;6:227–31.
18. Drago C, Howell K. Concepts for designing and fab-
ricating metal implant frameworks for hybrid implant
prostheses. J Prosthodont. 2012;21:413–24.
19. Drago C. Cantilever lengths and anterior-
posterior spreads of interim, acrylic resin,
full-arch s­crew-­
retained prostheses and their rela-
tionship to prosthetic complications. J Prosthodont.
2016;26(6):502–7.
20. Moscovitch M. Consecutive case series of monolithic
and minimally veneered zirconia restorations on teeth
and implants. Upto 68 months 5-year results. Int J
Periodontics Restorative Dent. 2015;35:315–23.
21. Venezia P, Torsello F, Cavalacanti R, D’Amato
S. Retrospective analysis of 26 complete arch mono-
lithic zirconia prosthesis with feldspathic porcelain
445
veneering limited to the facial surface. J Prosthet
Dent. 2015;114:506–12.
22. Al-Meraikhi H, Chee W, Takanashi T. An alterna-
tive to traditional implant supported porcelain fused
to metal restorations. Quintessenec Dent Technol.
2014;37:113–24.
23. Goldberg J, Torbati A, Aalam AA, Chee W. Implant
supported full arch zirconia fixed dental prostheses for
the rehabilitation of a patient with a failing dentistion.
Qunintessenece Dent Technol. 2016;39:179–96.
24. Menini M, Pera F, Migliorati M, Pesce P, Pera
P. Adhesive strength of the luting technique for
passively fitting screw retained implant supported
prosthesis: an in vitro evaluation. Int J Prosthodont.
2015;281:37–9.
25. Cheng CW, Chen CH, Chen CJ, Papaspyridakos
P. Complete mouth implant rehabilitation with modi-
fied monolithic zirconia implant supported fixed den-
tal prostheses and an immediate loading protocol. J
Prosthet Dent. 2013;109:347–52.
26. Rojas-Vizcaya F. Retrospective 2 to 7 year follow up
study of 20 full arch implant supported monolithic
zirconia fixed prosthesis. Measurements and recom-
mendations for an optimal design. J Prosthodont.
2016;27(6):501–8.
27. Chang JS, Ji W, Choi CH, Kim S. Catastrophic failure
of a monolithic zirconia prostheses. J Prosthet Dent.
2015;113:86–90.
28. Carames J, Tovar Suinaga L, Yu YC, Perez A, Kang
M. Clinical advantages and limitations of monolithic
zirconia restorations full arch implant supported recon-
structions case series. Int J Dent. 2015;2015:392496.
 Prosthetic Complications
with Immediately Loaded,
17
Full-­Arch, Fixed
Implant-Supported Prostheses

Frank J. Tuminelli, Saj Jivraj, Steven Bongard,

and David Powell

Abstract and arise during the different phases of the

Immediate placement and immediate loading
of dental implants with full-arch fixed implant-­
supported prostheses has repeatedly been
shown to be a successful treatment modality.
Today, it is becoming a standard treatment
approach that provides an incredible service to
patients by streamlining the transition from a
terminal dentition to a fixed prosthesis, elimi-
nating the need for an interim removable den-
ture and reducing overall treatment time.
However, obtaining and maintaining a suc-
cessful treatment outcome with this therapy
can be challenging. From a prosthodontic
standpoint, complications can be numerous
F. J. Tuminelli (*)
American Board of Prosthodontics,
Saint Paul, MN, USA
VA NY Harbor Healthcare System,
New York, NY, USA
Hofstra Northwell School of Medicine,
Hempstead, NY, USA
Private Practice, Manhasset, NY, USA
e-mail: frank.tuminelli@va.gov
S. Jivraj
Anacapa Dental Art Institute, Oxnard, CA, USA
S. Bongard · D. Powell
Private Practice, Toronto, ON, Canada
treatment process. The aim of this chapter is to
review the most common prosthetic complica-
tions that occur with full-­arch fixed implant-
supported prostheses, discuss methods to
prevent these issues and present management
strategies.
17.1 The Nature of Complications
Complications are inherent in all aspects of med-
icine and dentistry and must be differentiated
from failure. When treating patients with implant
therapy, one can expect complications as a nor-
mal part of practice. In fact, complications should
be expected and discussed with patients prior to
commencing treatment. The ability to deal with
the challenges in the broad variety of surgical and
restorative options with implant treatment results
in successful practice; more importantly it returns
patients to the state of function and fulfilment
[1–4]. It is important that we understand the
nature of biological change, adaption, evolution
to a steady state and the inevitable progression
that material wear has on biology [5].
This chapter will attempt to explore the routes
to complications, some that occur early on, dur-
ing the surgical phase or early in implant
loading.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 447
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_17
448
Complications will be discussed under the fol-
lowing subheadings:
1. Diagnosis and treatment planning
2. Treatment execution
3. Biological failures
4. Mechanical failures
5. Failure of material
6. A combination of the above
This chapter will attempt to explore this broad
and ever-involving modality, and though it is not
our intention to provide all the answers, it is our
goal to highlight what is normal in the realm of
practice, how to evaluate the presentation and
perhaps provide insight into solutions for our
patients, with the goal of maintaining their oral
health quality of life.
17.2 Diagnosis and Treatment
Planning Failures
The importance of this phase cannot be overem-
phasised. It entails carefully examining the
patient and gathering a series of detailed records,
including photos and mounted casts, to facilitate
the key decisions that will impact the final prosth-
odontic result.
Complications arising from this phase are iat-
rogenic in nature. They will lead to a suboptimal
prosthesis from either a mechanical or aesthetic
perspective.
Complications do arise when time is not spent
on diagnosis. Careful evaluation of the patient is
key, and presentation of a treatment plan that is
based on a sound scientific foundation is
imperative.
From a diagnostic perspective, several param-
eters need to be evaluated before deciding upon
the type of prosthesis that is most appropriate for
the patient. The following considerations pertain
to restorative treatment planning.
1. Positioning of the maxillary and mandibular
incisal edge
F. J. Tuminelli et al.
2. Restorative space, choice of material and
number of implants
3. Lip support, smile line and lip length
4. Contours and emergence
5. Tissue contact
6. Occlusion
17.3 Position of the Maxillary
and Mandibular Incisal Edge
The maxillary incisal edge position is determined
utilising the principles of aesthetics and phonet-
ics. Traditional guidelines tell us when the patient
makes the ‘F’ sound, the incisal edge should
touch the vermillion border of the lower lip. Once
the incisal edge position has been established, the
length for the central incisors is determined.
Often this is not realised in restorative treat-
ment planning. Implant dentistry is a restorative-­
driven discipline, and if the maxillary central
incisor is incorrectly positioned in the patient’s
face the implants also will not be placed to cor-
rect depth. This has repercussions on aesthetics
and function. This will be illustrated in the fol-
lowing patient presentation. The patient pre-
sented with existing integrated implants and an
implant- and mucosa-supported full-mouth resto-
rations. Her existing complaints included
1. Unhappy with aesthetics
2. The patient felt maxillary incisal edge was
touching the lower lip with too much
intensity
3. Too much support for the lip
4. The patient reported excessive contact of her
teeth at rest
5. She had requested a fixed restoration from her
previous dentist and was provided with a
removable
On clinical evaluation, implants were found to
be integrated. Maxillary incisal edge was deemed
to be in the incorrect position. The patient’s lip
was over supported, and the patient had been
restored at an excessive occlusal vertical dimen-
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses
sion. The implants had been placed at an inade-
quate depth and were encroaching upon
restorative space (Figs. 17.1 and 17.2).
The following factors needed to be addressed
in the treatment plan:
1. Positioning the maxillary incisal edge
appropriately
2. Correction of the excessive lip support
3. Closure of the excessive vertical dimension
4. Creation of restorative space for a fixed
restoration
5. Improvement of aesthetics
Impressions were made and a wax tooth try-in
was performed to evaluate the incisal edge posi-
tion and overall aesthetics (Fig. 17.3). On
approval of the try-in, a flangeless tooth try-in
was performed to ensure the patient was a candi-
date for fixed implant-supported restorations
(Fig. 17.4). It was deemed that the existing
Fig. 17.1 Patient presentation with excessive display of
pink acrylic and maxillary incisal edges in incorrect
position
Fig. 17.2 Incorrect implant position. Implants placed too shallow compromising restorative space
449
implants were in the incorrect position and
required removal. Although not optimal choice,
the patient must understand why implant removal
is required and the risks involved.
The treatment plan and sequence involved the
following:
1. Data collection including required imaging
2. Removal of the existing implants required
alveolectomy to create restorative space and
placement of implants at correct depths and
angulations (Fig. 17.5)
3. Immediate loading of the implants and fabrica-
tion of a transitional restoration at the required
occlusal vertical dimension (Fig. 17.6)
4. Evaluation of aesthetics, phonetics and occlu-
sal vertical dimension during the healing
phase and appropriate adjustments made
(Figs. 17.7 and 17.8)
5. Fabrication of the definitive restoration
(Figs. 17.9, 17.10, and 17.11)
Fig. 17.3 Wax try-in to evaluate occlusal plane and
aesthetics
450 F. J. Tuminelli et al.

Fig. 17.4 Flangeless try-in

Fig. 17.5 Implant removal, alveolectomy and implant

placement (Paltop Dynamic Implants Keystone Dental
Group)

Fig. 17.6 Maxillary and mandibular immediate load provisional restorations

17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 451

Fig. 17.7 Immediate load provisionals in situ

Fig. 17.8 Frontal and profile view of provisional restorations

The clinician’s objective when treating fail-

ures is to objectively assess all the diagnostic cri-
teria and evaluate how each one can be addressed.
With a systematic approach, optimal outcomes
can be achieved.

Fig. 17.9 Frontal view of definitive restoration in situ

452
Fig. 17.10 Profile view of definitive restoration in place
17.4 Failures Pertaining
to Restorative Space, Choice
of Restorative Material
and Number of Implants
1. Lack of restorative space is one of the most
common occurrences that can compromise a
restoration.
Inadequate restorative space will result in
two scenarios:
a. Restorative complications such as material
failure leading to repair or replacement of
the veneering materials or complete frame-
work fracture leading to failure of the
entire prosthetic restoration
b. Changing the treatment plan from one res-
toration type to another to accommodate
the space requirements
2. Incorrect choice of material may also be detri-
mental. Selecting a material that requires
additional bone reduction for restorative space
F. J. Tuminelli et al.
Fig. 17.11 Facial view of definitive restoration in place
is questionable. It is the author’s opinion that
materials should be chosen that requires mini-
mal bone reduction. The restoration should be
biomechanically sound and maximise
aesthetics.
3. Number of implants.
Unfortunately, the All-on-4™ concept has
been used as a panacea for full-arch implant
reconstruction and often patients are treated dog-
matically with this treatment protocol. [6, 7]
Often bone is removed needlessly to satisfy a cer-
tain treatment philosophy [8]. The All-on-4™
concept has been proposed for specific clinical
situations. It has a specific surgical, prosthetic
and maintenance protocol. It should not be a
treatment solution for all edentulous or soon to be
edentulous patients.
Minimally invasive full-arch implant dentistry
adheres to the concept of preserving and keeping
bone. Bone reduction is virtually eliminated, and
the patient maintains their own gingiva. Although
four implants are considered standard, the place-
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses
ment of additional implants is considered advan-
tageous. As a practising clinician, implant failure
should always be a consideration. If additional
implants have been placed, the clinician can still
transition the patient in a fixed restoration. These
additional implants also help in distributing stress
over a wider area. Treatment planning based on
the diagnostic factors will dictate how much bone
will need to be removed. The goal should always
be bone preservation and over-engineering to
ensure a long-term successful outcome.
In many clinical situations, there is an abun-
dance of bone where more than four implants can
be placed, and bone reduction may not be
required.
In the author’s opinion, more than four
implants are required when
1. There is an abundance of bone and biome-
chanically cantilevers can be avoided
2. The patient presents with a dentition that
exhibits signs and symptoms of excessive
force
3. The patient has uncontrolled metabolic dis-
ease which compromises healing
4. The poor quality bone
The advantages and considerations of placing
more implants and preserving bone include the
following:
1. There is the ability to segment the prosthesis
and complication management becomes eas-
ier for the clinician.
2. If in the future an implant were to fail, there
are enough implants, where the patient may
not have to undergo surgery again.
3. The thought process that making an impres-
sion on four implants is easier than making an
impression on five or six does not hold merit.
Today with advancements in digital technolo-
gies analogue impression making may soon
become obsolete at multi-unit abutment level.
When placing implants, the clinician must
begin with the end in mind visualising the
definitive restoration. Zirconia requires spe-
cific connector dimensions and requires the
implants not be placed too close together.
453
Zirconia also requires specific thickness so
that the implants together with the multi-unit
abutments must be positioned to allow for
this.
4. Maintenance of bone in between the implants
can be obtained by banking roots.
5. If a catastrophic failure were to occur and all
the implants were lost, then we still have the
opportunity to retreat the patient.
The following patient presentation will illus-
trate a restorative failure encompassing all the
points discussed above.
The patient presented with severe tooth wear
seeking a solution to his terminal dentition. His
desire was to have fixed restorations throughout
the whole treatment process.
On clinical evaluation, the following were
found:
1. Inadequate restorative space
2. Lack of tooth structure for predictable tooth
replacement (Fig. 17.12)
3. Patient exhibited signs of bruxism
4. Over-eruption of teeth as a compensatory
mechanism to the wear which resulted in
excess bone (Fig. 17.13)
Often clinicians are faced with decision per-
taining to occlusal vertical dimension. Should the
vertical be restored or not in a full-mouth implant
rehabilitation? Will opening the vertical cause
additional issues from a biomechanical perspec-
tive. Rather than focus on occlusal vertical dimen-
sion, the clinician should be more concerned
about restorative space and how to obtain it.
Space for full-mouth rehabilitation on
implants can be obtained through
1. Restoring occlusal vertical dimension if
required
2. Reduction in bone strategically
3. Combination of the above
The patient was diagnosed as having a termi-
nal dentition. Evaluation of the vertical dimen-
sion of occlusion revealed the patient having
6 mm of interocclusal distance. This does not
454
Fig. 17.12 Occlusal and buccal views demonstrating severe tooth surface loss
Fig. 17.13 Presenting panoramic radiograph
necessarily mean the patient has lost vertical
dimension of occlusion, but it does provide the
clinician with some space to open the vertical
should they decide. The patient was also sent for
a sleep study to eliminate sleep-disordered
breathing as a contributory cause of the
breakdown.
The following was treatment planned:
1. Extraction of all remaining teeth
2. Execution of the All-on-4™ treatment
concept
3. Alveolectomy with four implants placed in
the maxilla and four implants in the mandible
(Figs. 17.14, 17.15, and 17.16)
4. Immediate loading (Fig. 17.17)
5. Definitive restoration would be an acrylic
resin/metal-based restoration with metal
occlusal surfaces to minimise wear on the
posterior teeth (Figs. 17.18 and 17.19)
Treatment execution went to plan, and the
patient was extremely satisfied with the outcome
in both the provisional and definitive phase.
F. J. Tuminelli et al.
On reflecting on the treatment plan, several
critical errors were made:
1. The patient presents with an abundance of
bone and severe tooth surface loss. This tooth
surface loss could be attributed to attrition,
abrasion or erosion. Most likely it would be a
combination of them. In patients with an
abundance of bone and signs of excessive
force, it is the author’s opinion that the All-­
on-­4™ treatment concept is not the treatment
of choice. In this clinical scenario, additional
implants would be indicated to distribute the
forces over a wider area. The patient had an
abundance of bone and 6–8 or even 10
implants could have been placed based on the
clinician’s treatment proposal. With the abun-
dance of bone, there is no need to tilt the distal
implants and have a cantilever. This can be
eliminated with additional implants
(Fig. 17.20).
2. The restorative material of choice is incorrect.
Despite providing metal occlusal surfaces,
acrylic resin/metal-based restorations require
a significant amount of space. This space is
created by unnecessary alveolectomy.
Alveolectomy could be avoided by choosing a
more conservative restorative option
(Figs. 17.21 and 17.22).
3. Failure of the acrylic resin restoration by
over-engineering the metal framework. The
clinician must be cognisant of the space
requirement for materials. Acrylic resin
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 455

Fig. 17.14 Surgical measurement for alveolectomy

Fig. 17.15 Mandibular alveolectomy

Fig. 17.16 Dental Implants placed following the All-on-4™ protocol

requires 3 mm of thickness over the frame- Despite the above errors, the restoration has
work to be biomechanically sound been in situ for 13 years (Fig. 17.24). Repairs are
(Fig. 17.23). readily done due to the restoration being screw
retained and retrievable.
456 F. J. Tuminelli et al.

Fig. 17.17 Panoramic view of implant placement

Fig. 17.18 Framework design with metal occlusal surface

Fig. 17.20 Panoramic illustrating abundance of bone

and the possibility of placing additional implants

Fig. 17.19 Acrylic resin metal-based restoration

17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 457

Fig. 17.21 Bone reduction done to accommodate restorative materials

Fig. 17.22 Restorative space required for ceramic and acrylic-based restorations

Fig. 17.23 Biomechanical failure. Acrylic resin delaminated from metal

458
Fig. 17.24 Restoration has been in situ for 13 years
17.5 Failures Related to Lip
Support and Smile Line
The movement of the upper lip during speech and
smiling should be evaluated. Assessment of the
patient’s facial and lip support in frontal view and
in profile needs to be made so the clinician can
determine which type of prostheses would be
more suitable. Often patients present with a
removable denture seeking a fixed solution [9–
11]. Patients who have had removable prostheses
for an extended period often required a buccal
flange to provide lip support for aesthetics. Fixed
prostheses cannot have a buccal flange because a
concave intaglio surface would collect plaque
and food debris, thereby preventing access for
proper hygiene.
The clinician must evaluate all the diagnostic
factors (Chap. 1) to determine whether this is
feasible.
Patients often present having undergone treat-
ment and being unhappy with the result [12]. Its
important to question the patient to determine
what they are unhappy with and which aspect of
their smile they would like addressed [13]. Prior
to embarking upon retreatment, the clinician
must explain to the patient that a provisional
prosthesis will be required to evaluate aesthetics
and function. The provisional must be presented
as the most important phase of treatment and a
F. J. Tuminelli et al.
definitive restoration should not be fabricated
unless the patient is satisfied with the transitional
restoration [6, 11, 14]. This will be illustrated in
the following patient presentation.
The patient presented with the following con-
cerns that she would like addressed. She had pre-
viously had implant-supported restorations in
another office and was not satisfied with them.
Her concerns included the following:
1. Excessive gingival display
2. Inadequate lip support
3. Discrepancy in the proportions of then teeth
On clinical examination, the following were
found:
1. Closed vertical dimension
2. Excessive display of pink on smiling
(Figs. 17.25 and 17.26)
3. Poor tooth proportions
4. Failing implants in the maxilla
5. Space beneath restorations causing a food trap
The following treatment plan was
implemented.
The maxillary implants were to be removed,
bone recontouring done in the maxilla to lift the
occlusal plane apically. Four implants were
placed in each arch, and a provisional prosthesis
was fabricated for both maxilla and mandible.
The objectives of the provisional were to
1. Decrease gingival display (Fig. 17.27)
2. Improve tooth proportions (Fig. 17.28)
3. Restore the height of the lower third of the
face
4. Eliminate food entrapment
All of the above objectives must be achieved
in the provisional restoration prior to embarking
upon fabrication of the definitive prosthesis.
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 459

Fig. 17.25 Patient presented with existing restorations. Patient unhappy with contours and aesthetics

Fig. 17.26 Smile view demonstrating excessive display

of pink acrylic
460
Fig. 17.27 Frontal and smile view of new transitional restorations demonstrating correct position of teeth and
gingiva
Fig. 17.28 Pre- and postop views
17.6 Failures Related
to Emergence and Contours
The contours of the restorations must be planned
from the outset. The emergence profile of the res-
torations should be straight as it exits the gingival
margin [14, 15]. Often this requires alveolectomy
to create sufficient space.
One misconception about graft less protocols
is that they always require a significant amount of
bone reduction. Bone reduction must have a
rationale, and the minimum bone reduction must
be done to satisfy the requirements of implant
placement and fabrication of a biomechanically
sound restoration.
F. J. Tuminelli et al.
Contours and emergence are related to implant
placement in relation to the maxillary incisal
edge position. Often errors result from inade-
quate implant placement and dental technicians
compensate for that by ridge lapping the tissue. A
concave undersurface is not cleansable
(Figs. 17.29 and 17.30). Patients often want a
fixed restoration over a removable. In patients
with severe resorption and severe lack of lip sup-
port, this is not always possible, and the advan-
tages of a removable implant-supported
restoration with a buccal flange should be consid-
ered. If fixed restorations are provided, these
often result in speech impediments and contours
that cannot be cleaned (Fig. 17.31).
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 461

Fig. 17.29 Concave undersurface of restoration. Patient

is unable to keep it clean

Fig. 17.30 Plaque

accumulation within the
intaglio of the
restoration

Fig. 17.31 Concave undersurface and bulky contours of restoration

462
17.7 Failures Related to Tissue
Surface
The provisional and definitive restoration should
satisfy the following criteria:
a. Reduce food entrapment: Following 3 months
of healing, the acrylic provisional should be
relined so that its compresses the tissue sur-
face and creates a concave tissue surface
allowing a convex restoration surface.
b. Provide cleansable contours by developing
the tissue as outlined above.
c. Eliminate speech impairment. The t and d
sounds relate to the palatal aspects of the max-
illary prosthesis, and this area can be adjusted
to accommodate for that. The ‘S’ sound is
developed utilising the closest speaking space,
and this should also be corrected in the provi-
sional prior to proceeding to the definitive
restoration.
Fig. 17.32 Tissue inflammation as a result of poor con-
tours and polish
Fig. 17.34 Pre- and postop view of tissue after undersurface is corrected
F. J. Tuminelli et al.
d. The tissue contact should be intimate, but
accessible to oral hygiene procedures.
e. The tissue surface should be highly
polished.
Patients often present with the complaint of
bleeding from the undersurface of the prosthesis.
Bleeding is usually related to inflammation of the
tissue surface. Inflammation can be caused by
poor hygiene or an undersurface that is concave
and not highly polished (Figs. 17.32 and 17.33).
Correction of this issue may require replace-
ment of the restoration if it is zirconia based or
relining and repolishing of the restoration if it is
acrylic based (Fig. 17.33). The undersurface of
the restoration should be convex and highly pol-
ished. The area adjacent to the implants should
allow passage of an interproximal oral hygiene
cleaning aid (Figs. 17.34 and 17.35).
Fig. 17.33 Undersurface of restoration demonstrating
excessive plaque build-up
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses
Fig. 17.35 Undersurface restoration should be well pol-
ished and convex
17.8 Failures Related to Occlusion
Most of the patients seeking treatment with full-­
arch fixed prostheses have a terminal dentition
that forces them to develop a modified jaw posi-
tion in order to masticate their food. Therefore,
capturing the patient’s jaw relationship in this
habitual position is likely to be inaccurate and
result in transitional fixed prostheses that do not
occlude with an even force distribution. As a
result, the interim prostheses are much more
prone to fracture (Fig. 17.36). Thankfully, this is
an aspect that can be corrected from the transi-
tional phase to the definitive phase. In order to
avoid this scenario, clinicians should capture
interocclusal record in centric relation, which is
the most predictable position available.
The design of the occlusal relationship and
occlusal scheme really is dependent upon the res-
torations that are being fabricated. If both the
maxilla and mandible are being restored simulta-
neously, it would be recommended that the
restorative materials be compatible. It is also rec-
ommended that any full-mouth rehabilitation
supported by implants patients be given an occlu-
sal device to wear especially at night to minimise
the potential for fracture of the restorative materi-
als. When both arches have fixed implant restora-
tions, the basic occlusal principles are to be
followed such as mutually protected occlusions
that allow for anterior guidance. The goal of the
restorative dentist should be two: place the final
463
Fig. 17.36 Fracture of restoration
Fig. 17.37 Severe wear of acrylic-based restorations
restoration or restorations into a position that is
coincident with condylar position and repeatable.
In excursive movements the posterior teeth
should disclude. This is based on mechanics
rather than science. Implant-supported restora-
tions lack proprioception [16]. Patients many
times will present with fracture or severe wear of
the restorative material (Fig. 17.37). It is advis-
able that flatter cusps and wider fossas be used to
allow for some freedom of movement.
17.9 Failure Resulting
from Inadequate Treatment
Execution
Fabrication of full-arch implant-supported resto-
rations is a task with added complexity. There are
a number of variables that need to be understood
and controlled.
Errors may occur in each step of the treatment
process from impressions to delivery of the defin-
itive restorations.
464
Many companies promote digital technology
as a solution to treatment protocols and simplify
the treatment process. Digital technology must be
seen as an adjunct to sound analogue principles.
Digital technology will not compensate for inad-
equate understanding of the steps required. The
clinician has a responsibility to understand the
workflow and be cognisant of what can go wrong
in each step.
The immediate load process at the time of sur-
gery presents significant difficulty for the novice
practitioner. Often this is delegated to the labora-
tory technician. It is the clinician’s responsibility
to understand what is required, the sequence of
steps involved and what the final outcome of the
provisional restoration should be. Other chapters
discuss immediate loading in detail.
The objectives of the immediate load should
be
Fig. 17.38 Lack of fit may require detaching offending temporary cylinder and chairside pickup
Fig. 17.39 Chairside pickup
F. J. Tuminelli et al.
1. Aesthetics
2. Adequate vertical dimension
3. Adequate occlusal management
4. A passive a restoration as possible
5. Appropriate contours for cleansability
The most significant complication is for the
immediate provisional not to fit. If this is the case
offending temporary cylinder must be removed
from the provisional and repicked up at chairside
(Fig. 17.38). It is not uncommon for the provi-
sional prosthesis to apply pressure through the soft
tissue over the residual ridge. In many instances,
this is a result of post-surgical swelling and will
resolve itself once the healing phase is firmly
underway. If the patient demonstrates subprosthe-
sis ulcerations after a 2-week period of healing, the
prosthesis should be carefully removed, and the
intaglio surface adjusted (Fig. 17.39).
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses
17.10 Impression Making and Cast
Verification
The impression dictates fit of the definitive resto-
ration. Significant experience and time are
required at this step. Controversy exists over
splinting or non-splinting of the impression cop-
ings. Outcome of each technique appears to be
operator dependent [17]. Once the impression is
made, it must be poured very carefully in low-­
expansion die stone and the master cast verified
for accuracy. Most laboratories provide a verifi-
cation jig. These verification jigs can be made of
different materials that range from acrylic resin
to impression plaster. Each material has its
advantages and disadvantages. (This will be dis-
cussed in a separate chapter.) The ultimate out-
come is a restoration that fits passively utilising
the single-screw test (Sheffield test). If the frame-
work does not fit, this will necessitate additional
impressions and verifications (Fig. 17.40).
With the advent of scan gauges, clinicians can
predictably scan a full arch and expect to receive
a restoration that will have a passive fit intra-
orally. The scanning process does require a learn-
ing curve but ultimately decreases the time to the
definitive restoration (Fig. 17.41).
Fig. 17.40 Framework misfit
465
Fig. 17.41 Scan gauges in situ designed to allow accu-
racy in full arch scanning (Osteon Medical Technologies)
17.11 ­Complications/
Considerations
with the Definitive
Restorations
17.11.1 Insertion
Prior to the fabrication and insertion of the final
prosthesis, all-inclusive relationships phonetic
and aesthetic concerns for the patient should be
carried out in the provisional restoration. If these
are well done, the insertion should be seamless.
Most insertion issues are usually the result of
either not accurately recording soft tissue rela-
tionships and therefore having the patient experi-
enced discomfort upon insertion of the final
restoration or not seating the final restoration due
to an inaccurate recording of the implant posi-
tions [17]. If these have been done correctly and
laboratory fabrication has followed the suggested
recommendations of the manufacturer of the
materials, one should experience a predictable
appointment [6, 11, 18, 19].
466
The initial placement of the prosthesis can
result in blanching because of the pressure from
the intaglio surface of the prosthesis. If the con-
tour and position of the prostheses is correct, this
is transitory and readily dissipates in 5–10 min
[18, 19]. The clinician needs to be aware that soft
tissue can act as an impediment to the prostheses
not seating. If this is the case, the intaglio surface
will need to be adjusted. The patient should not
be feeling acute pain or distress during the inser-
tion appointment, some minor discomfort, pres-
sure or ‘pinching’ is normal. The clinician should
use a sequential protocol for tightening abutment
and/or prosthetic screws and monitor the soft tis-
sue colour in addition to the patient feedback.
Radiographic confirmation is a valuable tool to
ensure that the soft tissue is not preventing the
full-arch prosthesis from engaging either the
implant if abutment.
A frequent question in a full-arch restoration
retained by multiple prosthetic screws or abut-
ment screws is what is the sequence by which the
screws are tightened. There is no hard and fast
rule, but it is probably advised to tighten screws
by hand that are directly across from each other
and work your way around the prosthesis. Every
effort should be made to engage all the screws by
gently hand-tightening them. At that point the
patient should be left for a few minutes to allow
for relaxation of the engaged screws some possi-
ble compression of soft tissue end seating of the
full prosthesis. The practitioner can then go back
and secure the screws one more time. It is not
recommended that the screws be torqued to the
manufacturer’s recommendation on the initial
insertion. For numerous reasons, the prosthesis
may need to be removed for soft tissue adjust-
ments or be returned to the laboratory if the
patient is not satisfied with the aesthetic results.
If the screws are torqued, they may become unus-
able and need to be replaced. It would be advis-
able to torque the screws once the patient is
completely satisfied, the occlusion has been sta-
bilised, there are no soft tissue issues and the
period that the patient is wearing the permanent
restoration has been uneventful. This varies by
patient.
F. J. Tuminelli et al.
17.12 Biological Failures
Biological complications can occur from a myr-
iad of events and can be divided into early inter-
mediate and late. In the early or immediate stage,
they are a result of the surgical event and/or the
immediate load prosthesis if that was placed.
Strictly speaking complications of the surgical
event will either be one or a combination of
bleeding, pain, swelling, altered sensation or
paresthesia.
In the case of bleeding, these are medical
emergencies that require immediate intervention
and are managed effectively by the surgeon.
These can be controlled by a gamut of approaches
from pressure to additional suturing, ligation of
vessels (in the most serious of clinical events). It
is the opinion of the authors that these levels of
complications are beyond the scope of this
chapter.
Pain and infection are complications or expec-
tations of the surgical event and depending upon
the extent of surgery premedication can be pre-
scribed and the protocols are well documented.
These are done in a preventive light by some
practitioners as routine even in healthy individu-
als [20, 21].
17.13 Mechanical Failures
Mechanical failures are related to the implant,
abutment screw and prosthetic screw. When there
is screw loosening of the prosthetic screw or
abutment screw, this is a complication that needs
to be dealt with immediately [22–26]. Any mobil-
ity of the prosthesis that is transferred to an inte-
grating endosseous implant may result in failure
of the implant. Other mechanical failures such as
prosthetic screw and abutment screw fracture are
very rare but can occur. Screws fracture due to
misfit of the restoration or excessive force
(Figs. 17.42 and 17.43). Screw removal can be a
laborious process. If the screw is not distorted
within the abutment or implants, they are rela-
tively easy to remove. Screw removal can be
facilitated with an explorer moved in a counter-
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses
Fig. 17.42 Screw fracture and interim restoration fracture
Fig. 17.43 Clinical screw fracture
clockwise direction or an ultrasonic unit with fine
tip. If any vestige of the screw is visible, one can
use a high-speed handpiece with a small, inverted
cone or number 2 round bar, and holding it at the
three o'clock position engage the screw thread;
this will very rapidly remove the screw. This
works well both for the prosthetic screw and
abutment screw if they can be rotated coronally
to where they are above the area that they engage
the screw channel. However, if the screw is not
retrievable, especially the abutment screw one
option is to turn the screw as far apical as it can
go either with an explorer or other instrument and
make enough threads accessible for another abut-
ment screw. When the prosthetic screw is not
retrievable, this sometimes requires cutting
through the abutment and removing the abutment
itself so that you can replace it.
There are few studies to guide clinicians on
the length of the cantilever in the maxilla espe-
467
Fig. 17.44 Restoration demonstrating excessive
cantilever
cially when utilising the more contemporary
materials such as zirconia [27]. The length of the
cantilever has a significant effect on the failure of
these types of restorations, and length of the can-
tilever can be more significant than the number of
implants [27, 28] (Fig. 17.44). Deflection of the
cantilever is related to its length; so minute
increases in length have a significant impact on
the fracture complications of restorations. Lab-­
based studies on zirconia have shown that
a. The longer the cantilever the lower the load to
failure (Fig. 17.45)
b. The smaller the connector size the less load to
failure
c. Failure usually occurred in the distal abutment
wall
468
Fig. 17.45 Cantilever fracture in zirconia restoration
Recommendations for cantilever include
a. Limit distal cantilever
b. Limit buccal cantilever
c. Increase thickness of the framework in the
cantilever section distal to the most distal
implant
d. Limit occlusion on the cantilever
17.14 Material Failures
Today there are various materials to choose from
when designing full-arch fixed implant-supported
restorations. Unfortunately, when looking at the
literature for guidance it is not supportive of a
true evidence base in terms of an ideal material to
utilise. There is no evidence to show one design
is superior to another or one combination of
materials is superior to another. Most articles are
case reports, which follow a limited number of
patients over a limited period of time.
As in all dental restorations, the choice of
material comes with potential complications;
these are similar to those seen in tooth-borne res-
toration [23, 26].
Material failure can be grouped into the fail-
ure of the tooth component and/or the substruc-
ture. Acrylic/metal restorations are much more
accommodating in managing failures. One must
realise that acrylic resin was not designed for
F. J. Tuminelli et al.
Fig. 17.46 Acrylic tooth fracture
Fig. 17.47 Fracture of acrylic from framework. Could be
a result of inadequate framework design
implants but used as an afterthought. Wear or
breakage of acrylic resin-based restorations
should not be seen as a complication but rather a
consequence of the restorative material. This
must be explained to the patient prior to embark-
ing upon extensive treatment so that disappoint-
ments can be avoided at a later date.
The loss of a denture tooth can be dealt with
simply by replacing it and reattaching it to the
prosthesis (Fig. 17.46).
Large-scale fracture of the alveolar compo-
nent, such as acrylic, can also be repaired intra-
orally under certain circumstances. If that is not
possible, the prosthesis should be removed very
carefully, and the separated components reat-
tached with acrylic resin. Often this requires
the restoration to be sent to the laboratory for
definitive repair (Figs. 17.47 and 17.48). Large-
scale delamination of acrylic is a result of inad-
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 469

4. Ensure very light occlusal contacts in the can-

tilever region.
5. Thicken the chimney around the most distal
implant and thicken the buccal and lingual
walls around the chimney of the implant.
6. Ensure monolithic zirconia is well polished.
Studies have shown it to be kind to the oppos-
ing occlusion.
7. Minimal post-sintering adjustment. This will
also help with preserving the strength of the
material and avoiding accelerated ageing fail-
ures in the presence of saliva.
8. Design for retrievability. This allows simple
Fig. 17.48 Delamination of section of acrylic resin from detachment of the appliance and the chance to
substructure service the restoration or treat any implant-­
related problems. With proper implant place-
ment, this can be achieved in most situations
when treating the edentulous arch.

17.15 Restoration Failures Require

Removal of the Restoration
and Laboratory Repair

It is recommended that patients be given their

provisional restorations to keep upon insertion of
Fig. 17.49 Fracture of ceramic from zirconia
framework the definitive restoration so that if repair is
required the patient can leave the office with a
fixed provisional restoration in situ (Fig. 17.50).
equate framework design or inadequate
processing.
Failures in zirconia-based restorations are
much more difficult to manage. If it is a simple
ceramic fracture, the restoration can be removed
from the mouth and sent to the laboratory for
definitive repair (Fig. 17.49).
When designing zirconia-based implant
frameworks, the following should be considered:

1. Maximise connector dimensions, buccal-­

lingually and occlusal-gingivally.
2. Minimise distal cantilever length. Fig. 17.50 Failure of distal implant necessitating sec-
3. Minimise buccal cantilever. tioning of restoration to reduce length of cantilever
470
17.16 Implant Failure
One of the more ominous complications with
implant restorations is the failure of one or more
implants [18, 19, 29, 30]. Depending on the loca-
tion, the arch and the number of implants in the
restoration, this can be catastrophic. If there are
sufficient implants to support the prosthesis, it
can be modified depending upon the location of
the implant that failed. The most desirable failure
would be an implant in the middle of the prosthe-
sis that still enables the prosthesis to have implant
support anterior and posterior to the implant that
needs to be removed. Depending on the restored
arch, the prosthesis can be removed, the implant
removed and the prosthesis modified by convert-
ing that area to a pontic. Potentially some graft-
ing can be performed if there is significant loss of
hard and/or soft tissue. This may be a significant
complication for maxillary prosthetics. If there is
a lack of soft tissue adaption to the anterior part
of the prosthesis, the patient may complain of
speech issues and hissing sounds because of air-
flow under the prosthesis. In both the maxilla and
the mandible, these could be potential food traps
and require the patient to have a more diligent
home care regimen to prevent soft tissue irrita-
tion hyperplasia or other reactionary biological
responses (Fig. 17.51).
When a terminal implant fails, this may neces-
sitate reducing the length of the cantilever on the
prosthesis. Depending upon the material the
prosthesis is fabricated from, this presents a chal-
lenge. A full-arch zirconia restoration is difficult
to section and polished to an acceptable finish. In
Fig. 17.51 Occlusal view of sectioned restoration
F. J. Tuminelli et al.
that instance, the restoration can be sent to the
dental laboratory for proper adjustments. If the
patient does not have their provisional restora-
tion, a restoration must be fabricated in a timely
manner. This is where digital technology can
facilitate fabrication. If the laboratory does have
a digital file, a provisional restoration can be
milled relatively quickly.
Acrylic-/metal-based are much more accom-
modating and sectioning of the prosthesis can be
done within the dental office.
In either one of those scenarios, it may neces-
sitate advising the patient that this prosthesis
does not have long-term stability and will not sat-
isfy the functional requirements of mastication
for a patient and therefore additional implants
may be needed and a new prosthesis fabricated.
17.17 The Maintenance Phase
Finally, the maintenance phase begins as soon as
the definitive prosthesis is inserted and extends
indefinitely. At this point, prosthetic complica-
tions are simply an eventuality [23, 26]. Unlike
some of the other phases of treatment, they are
not iatrogenic in nature. They will take place
because of the limitations of the material.
A major advantage of the immediate loading
protocol is that once the treatment is completed,
the patient will have a provisional prosthesis to
rely on if their definitive prosthesis breaks [31].
Even if the repair cannot be performed on the
same day, he or she can have the provisional
prosthesis placed while the repairs are being
performed.
Furthermore, it is helpful to have frequent
recall to monitor the integrity of posterior occlu-
sion and determine the need for a refurbishing of
the prosthetic teeth [31]. Furthermore, these fre-
quent recalls can allow the clinician to test the
implants, remove plaque and calculus, observe
the soft tissues and modify prosthesis contours if
necessary.
Lastly, frequent removal and replacement of
these prostheses entail the manipulation of small
parts, including prosthetic screws and even the
screwdrivers themselves. These components can
17 Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses
be swallowed or, worse, aspirated and lead to
serious complication. Steps aimed at avoiding
this occurrence are very important. One such
trick is the use of torque drivers with long shafts
and magnetic tips.
17.18 Conclusion
Successful treatment with immediately loaded
full-arch fixed implant-supported prostheses
requires substantial amounts of planning and
skilled execution. Many prosthetic complications
can occur when rendering this treatment, but
many of these are avoidable and highly manage-
able. Efforts should be made to prevent these
complications and plan for the challenges that
will inevitably occur over the years after
treatment.
References
1. Afrashtehfar KI. The all-on-four concept may be a
viable treatment option for edentulous rehabilita-
tion. Evid Based Dent. 2016;17(2):56–7. Felton
D. Complete edentulism and co-morbid diseases: an
update. Journal of Prosthodontics 2016.
2. Douglass CW, Shih A, Ostry L. Will there be a need
for complete dentures in the United States in 2020?
Boston: Harvard School of Dental Medicine; 2020.
3. Kuboki T, Okamoto, et al. Quality of life assessment
of bone anchored fixed partial denture patients with
unilateral mandibular distal-extension edentulism.
JPD. 1999;82(2):182–7.
4. Diaz J, et al. Changes in general and oral health -
related quality of life in immediate or conventionally
loaded dental implants: a nonrandomized clinical
trial. IJOMI. 2014;29(2):391–401.
5. Schmalz G, Arentholt-Bindslev D. Biocompatibility
of dental materials. Heidelberg: Springer; 2009.
6. Ramezanzadwe S, Yates J, Tuminelli F, Keyhan SO,
Yousefi P, Jose L-L. Zygomatic implants placed in
atrophic maxilla: and overview of current systematic
reviews and meta-analysis. Maxillofac Plast Reconstr
Surg. 2021;43(1):1.
7. Ramezanzadel S, Keyhan SO, Tuminelli FJ, Fallah
HR, Yousefil P, Lopez-Lopez J. Dynamic-assisted
navigational system in zygomatic implant surgery: a
qualitative and quantitative systematic review of cur-
rent clinical and cadaver studies. J Oral Maxillofac
Surg. 2020;79(4):799–812.
471
8. Clinicaltrials.gov. The TREFOIL concept 5-year
clinical investigation (NCT02940353). https://clini-
caltrials.giv/ct2/show/NCT02940353. Accessed June
22, 2017.
9. Goodacre C, et al. Fixed vs removable complete arch
implant prosthesis: a literature review of prosthodon-
tic outcomes. EJOMI. 2017;10:13–34.
10. 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 consecu-
tive patients presenting for routine maintenance. Clin
Implant Dent Relat Res. 2017;19(1):56–68.
11. Tuminelli FJ, Neugarten J, Ayvazian EG. Clinical
report on restoration of patient with immediate
loaded maxillary restoration supported by zygo-
matic/endosseous implants and mandibular prothesis
utilizing three-implant solution. N Y State Dent J.
2022;88(4):38–41.
12. Pera WD, et al. Number of implants placed for
complete-arch fixed prostheses: a systematic review
and meta-analysis. Immediate versus delayed load-
ing of dental implants supporting fixed full-arch
maxillary prostheses: 10-year follow-up report. Int J
Prosthodont. 2018;32:27–31.
13. Furhauser R, et al. Evaluation of soft tissue around
single-tooth implant crowns: the pink esthetic score.
Clin Oral Implants Res. 2005;16(6):639–44.
14. Tuminelli FJ. Contributor to edentulous treatment
guidelines. Lucerne, foundation for oral rehabilita-
tion. Author of 20+ modules on single tooth implant
restorations. 2016. Available from FOR.org. https://
www.for.org/en/treatment-­guidelines.
15. Goodacre, Goldstein and Tuminelli. Implant Dentistry
DVD, Loma Linda University. School of Dentistry,
Chapter - Implant Fixed Complete Dentures, 2007.
16. Sheets CG, Earthman JC. Tooth intrusion in implant
assisted prostheses. J Prosthet Dent. 1997;77:39–45.
17. Baig MR, et al. The accuracy of impression of mul-
tiple implants in the edentulous arch: a systematic
review. IJOMI. 2014;29(4):869–80.
18. Tuminelli FJ, Walter LR, Neugarten J, Bedrossian
E. Immediate loading of zygomatic implants: a
systematic review of implant survival, prosthe-
sis survival and potential complications. EJOMI.
2017;10(1):79–87.
19. Neugarten J, Tuminelli FJ, Walter L. Two bilateral
zygomatic implants placed and immediately loaded: a
retrospective chart review with up to 54 month follow
up. IJOMI. 2017;32(6):1399–403.
20. Hazem A, et al. Comparison of pre-prosthetic implant
complications and failures between obese and non-­
obese patients. IJOMI. 2016;31(5):1093–9.
21. Kellersarian SV, et al. Efficacy of local systemic statin
delivery on the osseointegration of implants: systemic
review. IJOMI. 2017;32(3):497–506.
22. Wittenben J-G, et al. The clinical performance of
screw versus cement retained fixed implant sup-
472
ported reconstructions: a systematic review. IJOMI.
2014;29(suppl):84–98.
23. Pjetursson BE, et al. A systematic review of the sur-
vival and complication rates of implant-supported
FDPs after a mean observation period of at least 5
years. Clin Oral Implants Res. 2012;23(6):22–38.
24. Wadhwani C, Hess T, Faber T, Piñeyro A, Chen
CSK. A descriptive study of the radiographic den-
sity of implant restorative cements. J Prosthet Dent.
2010;103(5):295–302.
25. Zeno HA, Butrago RL, Sternberger SS, Tover N,
Coehlo P, Kurtz KS, Tuminelli FJ. The effect of gin-
gival entrapment on screw loosening at the implant
abutment interface part 1- an in vitro study. J
­ prospective multivariate regression analysis of overall
Prosthodont. 2016;25(3):216–23.
26. Goodacre CJ, et al. Clinical complications
with implants and implant prostheses. JPD.
2003;90(2):121–32.
27. Walter L, Greenstein G. Utility of measuring anterior-­
posterior spread to determine distal cantilever
F. J. Tuminelli et al.
length off a fixed implant-supported full-arch pros-
thesis: a review of the literature. J Am Dent Assoc.
2020;151(10):790–5.
28. Brunski JB, et al. In vivo bone response to biome-
chanical loading at the bone/dental-implant interface.
Adv Dent Res. 1999;13(1):99–119.
29. Jemt T. Implant survival in the partially edentu-
lous jaw – 30 years of experience. Part 1: a retro-­
prospective multivariate regression analysis of overall
implant failures in 4,585 consecutively treated arches.
Int J Prosthodont. 2018;31:425–35.
30. Jemt T. Implant survival in the partially edentu-
lous jaw – 30 years of experience. Part III: a retro-­
implant failures in 2915 consecutively treated arches.
Int J Prosthodont. 2019;32:36–43.
31. Schnitman PA, et al. Ten-year results for Brånemark
implants immediately loaded with fixed prostheses at
implant placement. IJOMI. 1997;12(4):495–503.
 Management of Failure
and Implant-Related
18
Complications in Graft-Less
Implant Reconstructions
(for Atrophic Jaws)

Andrew Dawood and Susan Tanner

Abstract patient, who must be carefully counselled and

consented. Treatment should be undertaken by
This chapter examines the management of
well-trained and skilled operators with the
some of the complications associated with
support of an experienced team.
graft-less implant solutions which may lead to
and include implant failure for patients with
atrophic jaws. In an anatomically constrained
18.1 Introduction
environment, the use of a limited number of
angled or short implants, and in extremely
For patients suffering from advanced atrophy, a
atrophic maxillae, the use of zygomatic
graftless implant solution may offer several
implants is becoming widespread. Though
advantages. However, as this may make use of
such treatment has been shown to be predict-
short or angled implants, there may be limited
able and generally trouble-free, failure can not
anchorage and reduced mechanical advantage. In
only lead to loss of function, but in the graft-
an already anatomically constrained environ-
less treatment there is the potential to create a
ment, these conditions impart a degree of com-
range of complications, such as sinus infec-
plexity which may make complications or failure
tion and extraoral infection which may be
all the more difficult to manage.
more serious than those encountered in con-
When planning such treatment, access to
ventional dental implant treatments. Managing
high-quality 3D imaging with cone beam com-
failure can be complex, so careful forethought
puted tomography (CBCT) [1] is mandatory and
is required to avoid complication and leave
the use of planning software as well as guided
scope to salvage a compromised reconstruc-
surgery where appropriate will help to ensure that
tion. Failure and complication will cause dis-
the experienced surgeon reliably places implants
ruption and upset for the dentist and the
which will go on to provide predictable problem-­
free support for implant prostheses. Access to
A. Dawood (*) high-quality artefact-free [2] 3D imaging
Department of Head and Neck Surgery, University becomes even more important in the event of fail-
College London Hospital, London, UK ure, enhancing the surgeon’s capability to diag-
The Dawood and Tanner Specialist Dental Practice, nose and resolve problems (Fig. 18.1).
London, UK Given the anatomical constraints and surgical
S. Tanner challenges, attention to detail in prosthetic plan-
The Dawood and Tanner Specialist Dental Practice, ning and in the provisional and definitive phases
London, UK

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 473
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_18
474 A. Dawood and S. Tanner

a b

c d

Fig. 18.1 Standard panoramic radiograph (a) shows little years later the immediately placed implants are entirely
evidence of a problem with anterior maxillary implants outside of the bony envelope of the maxilla. (d) This view
(arrowed). However, reformatted axial (b) and cross-­ shows failure of the implant
sectional (c) views from CBCT examination show that 7

of prosthetic reconstruction is also of paramount 18.2 Failure to Plan

importance. Poor prosthetic planning may not
only lead to aesthetic and prosthetic complica-
tions (see previous chapters in this series), but
might also lead to inadequate surgical planning,
inadequate surgical preparation of the jaw, inap-
propriate implant positioning, inappropriate
loading and ultimately to implant failure.
In this chapter, we will describe some of the
compromises and complications which may lead
to failure in graftless treatments and describe the
strategies that the authors have used to manage
complications and salvage situations where there
has been failure.
Many aspects of planning have been covered in
other sections of this book.
18.3 Implant Failure
Like any other implant treatment, there is always
a risk of implant failure. Clearly most patients
who need graftless treatments have not been very
successful at maintaining their teeth, and many of
these individuals may not be adept at looking
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions…
a b
c d
Fig. 18.2 These patients believed that they were to have
‘All-on-4’ treatment. In this case (a), the maxillary
implants are all positioned anteriorly for this inadequate
reconstruction which failed with fracture of three abut-
ment screws and failure of the remaining functional
implant. The panoramic radiograph suggests that no
attempt has been made to fully utilise the available jaw to
after their implants either. All the recognised
risks of implant failure will apply; smokers [3],
those who suffer from periodontal disease [4],
diabetics [5], patients prescribed bisphospho-
nates [6] and individuals in poor health [7] will
all be at risk of implant failure. As patients age,
medical problems may arise which may compli-
cate remedial treatment; for example, a patient
may become diabetic or may begin antiresorptive
therapy, and dexterity may decline.
Even in highly atrophic jaws, graftless treat-
ments may use a combination of short and angled
implants to immediately support fixed provi-
sional prostheses. In the All-on-4® protocol, the
distal implants are angled to broaden their span,
improving support. Lack of respect for the bio-
475
broaden the span of implant support (b). Note the pres-
ence of an intact opposing dentition. In this case (c), the
implants are also poorly positioned anteriorly—note the
fractured abutment screw in the right rear implant. The
patient was provided with a much repaired and poorly
constructed and totally inadequate provisional prosthesis
(d), which was still in use 2 years after surgery
mechanics of this form of reconstruction can lead
to failure (Fig. 18.2).
Numerous studies have shown excellent out-
comes for such treatments [8], though for an indi-
vidual who experiences a failure, a proven high
success rate in the literature will be of little sol-
ace. Any reduction of support for a provisional or
fixed prosthesis can lead to overload and escalat-
ing failure of prosthetic components, or implants.
Thus every part of the assembled reconstruction
needs to be correctly implemented. If abutment
or prosthetic screws are incorrectly torqued, or
abutments or bridgework poorly seated, other
components or the more securely connected
implants may fail. In the event of early implant
failure soon after surgery, loss of support as an
476
implant loosens may impose additional stress
upon the provisional prosthesis which may frac-
ture. The use of a provisional prosthesis is impor-
tant as it serves to splint and stabilise the implants
during the healing period and reduces the risk of
inappropriate loading of individual implants by a
removable denture. It is also key in that if an
implant fails early on, it does so before an invest-
ment in the definitive fixed prosthesis has been
made.
Where atrophy is minimal and when planning
for porcelain-bonded or zirconia bridgework
without a gingival component, the provisional
bridge may be insubstantial and prone to fracture.
On the other hand, excessive jaw reduction for a
patient with minimal atrophy may remove bone
that might have proved valuable later in the event
of a failure—patients must be specifically con-
sented to jaw reduction.
With an increase in the use of in-lab milling
for the production of provisional bridgework or
zirconia frameworks, there is an associated use of
‘Ti-base’-type inserts, which are cemented into
the milled prosthesis. Cementation failure is not
unusual and can lead to unfavourable loading
patterns, and early or late implant failure of
implants or implant components.
Where there is an early failure, patient man-
agement will be more straightforward if another
suitable implant site is immediately available to
augment support for the bridgework or if there is
at least a removable prosthesis to hand. This may
be facilitated if a digital workflow was followed
as milling or printing of a new modified prosthe-
sis may be straightforward. Certainly, easy
access to laboratory services and the possession
of technical skills will make all the difference to
prompt management. If anchorage for the
remaining implants is less than ideal, or if two or
A. Dawood and S. Tanner
more implants fail, or healing of newly placed
implants is not advanced at the time of failure,
there may well be a need for the patient to wear
a removable prosthesis as an interim measure.
Patients may become upset if asked to wear a
removable prosthesis, particularly where multi-
ple teeth have been removed and the jaw reduced,
reducing stability and retention for a patient who
may have no previous experience of using a
removable prosthesis. It is therefore sensible to
discuss failure and to make contemporaneous
notes of this discussion long before treatment, in
addition to providing clear written information
preoperatively.
In the case of later implant failure, there is the
advantage that remaining implants may be stable
and dental extraction sites in a more advanced
healed state.
Patients may be unaware of implant problems
until they are severe. Late loss of an implant as a
result of, for example, peri-implantitis may be
accompanied by a great deal of bone loss, quite
likely affecting more than a single implant, as in
Fig. 18.3, with devastating consequences.
If a single implant is lost, a provisional bridge
might continue to function on three implants
whilst the site heals, particularly if the implants
are well distributed (Fig. 18.4). Failure of a single
terminal support may again be the catalyst to
prosthetic failure or the loss of further implants;
in this event, a fixed prosthesis may need to be
shortened to avoid an extended cantilever. Where
practical, provision of more than four implants
may be beneficial for patients who are perceived
to be at higher risk of implant failure. If a defini-
tive prosthesis has already been provided for the
patient, the provisional prosthesis may be modi-
fied with a view to later adapting the definitive
prosthesis.
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions… 477

a b

c d

Fig. 18.3 This 60-year-old smoker was referred with
multiple implants affected by peri-implantitis (a, b). The
implants had been placed at the same time as teeth were
removed, in narrow, tall ridges. Subsequent remodelling
likely left the implants outside the bony envelope coro-
nally, exposed threads leaving the tissues more vulnerable
to peri-implantitis. A decision was made to maintain the
implants with surgical debridement and enhanced hygiene
care (c), until smoking cessation about 5 years later
improved prospects for a new reconstruction (d). The
replacement implants were simultaneously placed more
deeply into the wider bony base, in the position of the
explanted original implants
478
a b
Fig. 18.4 Panoramic radiograph (a), showing implant
treatment in both jaws for a patient who had advanced
periodontal disease. The asymptomatic implant in the
upper-left lateral incisor position was found to have failed
3 months after surgery when the patient presented with a
fracture of her temporary prosthesis. Implants have been
placed in the tuberosity/pterygoid area, but these have not
18.4 Removing Failing Implants
Long implants are often used to provide robust
immediate stability for a temporary prosthesis.
Because of this, even when a failing implant has
lost as much as 50% of its supporting bone,
removing the partially osseointegrated implant
A. Dawood and S. Tanner
been immediately loaded. Reformatted panoramic (b) and
cross-section (c) reconstructed from CBCT, 12 weeks
after removal of failed implant. Note extensive bone loss
only conspicuously visible in the cross-section; replace-
ment of the implant consequently delayed, with the recon-
struction completed 6 months later (d)
can be challenging and has the potential to cause
extensive bony destruction. Whilst it may feel
reassuring to use long implants, consider what
this may mean if they ever need to be removed.
Strategies for less invasive implant removal
include the use of close-fitting trephines
(Fig. 18.5a), ultrasonic instrumentation
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions… 479

a b

c d

Fig. 18.5 Various approaches to implant removal. (a) With a trephine. (b) With an ultrasonic device. (c) High-speed
surgical turbine with rear-venting exhaust. (d) Reverse torque implant retrieval tool

(Fig. 18.5b) and bone removal with a fine fissure
bur in a rear exhausting air turbine handpiece
(Fig. 18.5c); all techniques require patience,
­precision and copious irrigation. Bone removal
should of course be kept to a minimum—implant
retrieval tools (Fig. 18.5d) provide a useful
adjunct to this armamentarium, enabling the less
invasive removal of implants, though these must
be used with caution as there is a tendency for
thinner walled implants to split if they are still
osseointegrated for more than 4–5 mm of their
length. In practice all these approaches may be
best combined for the most bone-conserving out-
come, focusing upon a gentle technique with
minimal heat production. As removal of a par-
tially osseointegrated implant can be so destruc-
tive, when making the decision to remove an
implant affected by peri-implantitis, careful con-
480
sideration must be given to the patients’ age and
the rate of disease progression before moving
towards explantation.
18.5 ‘Rescue’ Implants
In the atrophic jaw, the position of the most pos-
terior implant which may be angled distally to
broaden support and spread load is usually con-
strained by the critical anatomical structures
which demarcate the easily exploitable bone. If
attempting to immediately replace a failed
implant with a ‘rescue’ implant, there may be the
option to use a longer or wider implant, but using
the same site may be a risky strategy unless the
cause of the failure is well understood and there
is a reasonable expectation that the outcome will
be better; it is not uncommon to find that there is
extensive bone loss in the failure site, particularly
if the failure is not immediately identified, which
may well be the case as the ailing implant will be
splinted by the bridgework. However, if there are
sufficient implants to keep the prosthesis in func-
tion, the area may be allowed to heal before
replacing the implant in the same position.
Guided surgery may be used to accurately reposi-
tion the implant such that the original prosthesis
may be simply connected to the new implant or
A. Dawood and S. Tanner
adapted in the laboratory to fit the new situation
(Fig. 18.6). CBCT imaging makes it possible to
carefully scrutinise the jaw for alternative implant
sites; if an implant is loose, consider imaging
after explantation of the implant and with the
prosthesis removed in order to reduce the amount
of local radiographic artefact related to the
implant and prosthesis. With more and more
CBCT scanners available, this is a situation
where the type of CBCT apparatus and the set-
tings used should be carefully considered for an
optimised high-resolution result.
Salvaging the situation will be easier when
there is more bone available and the implants
have been widely spread, leaving more space for
a ‘rescue’ implant to be positioned in a new site.
If it is an angled distal implant, the sinus in the
upper jaw or mental nerve in the lower jaw may
limit the span of the implants driving the posi-
tioning of the new implant more anteriorly
(Fig. 18.7), such that the span may be narrower
than that of the original situation.
In the maxilla, a zygomatic implant may be
used to replace a failed implant in order to rescue
a situation or provide a new reconstruction in the
event of failure, as in Fig. 18.8. The ­tuberosity/
pterygoid area may also provide a useful
contingency.
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions… 481

a b

c
d

Fig. 18.6 A 65-year-old patient developed rapidly pro-
gressive bone loss associated with front left mandibular
implant ((a) 4 years post-surgery; (b) just 3 years later).
Poor cleaning (c), depression and loss of diabetic control
may all have been factors. With removal of the implant,
the return of diabetic control and a return to satisfactory
maintenance behaviour the situation seemed stable a year
later, with the patient functioning on three of the four orig-
inal implants. 2 years later another implant is failing and
the entire reconstruction potentially lost (d, e). Remedial
treatment involved reverse engineering the original
implant positions in a stone model, with the addition of
a new longer multi-unit abutment in place on an implant
replica (f). This allowed a sleeve to be positioned within
a surgical guide designed to rigidly connect to the other
implants using a guided cylinder (g). A scan was taken
with the guide in place to verify the practicality of replac-
ing the implant. Fully guided surgery was used to place
the implant (h); the multi-unit abutment was fitted and
the original prosthesis replaced. Remarkably, the same
process was later used to replace the front right implant.
A panoramic radiograph (i) shows both front implants
replaced with the original prosthesis fitted, and progres-
sive failure of the left rear implant; this was eventually
also replaced, although for this implant because of the dif-
ficulty of precisely replicating the angular geometry, the
prosthesis framework was adapted to pick up a titanium
cylinder (j). The 9-year timeline for this treatment is por-
trayed in panel (k)
482 A. Dawood and S. Tanner

i j

Fig. 18.6 (continued)

18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions… 483

a b

Fig. 18.7 Describes the management of a situation
encountered when providing full-arch implant treatment
for a patient with a class III skeletal relationship (a, b),
where the patient wished to have prostheses set up in a
class I dental relationship. This arrangement is mechani-
cally complex in that an angled distal implant emerging
close to the mental foramina will tend to emerge more
towards the front of the reconstruction. In this case, failure
of the distal implant on the left side (c), perhaps through
mechanical overloading, meant that the provisional pros-
thesis was only supported by the remaining three implants
in an early healing state. The patient having never worn a
removable prosthesis was extremely keen to continue to
function with a fixed prosthesis. A short implant was
inserted at the same time as removing the failed implant
and the provisional prosthesis modified accordingly.
Following a 10-week healing period the site of the failed
implant remained unsuitable (d), so instead, an alternative
site was found further forwards (e), making the presence
of the short implant all the more important. A similar short
implant was also placed on the right side, at the same
time, and treatment proceeded uneventfully (f, g)
484 A. Dawood and S. Tanner

e f

Fig. 18.7 (continued)

18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions…
a b
Fig. 18.8 The management of a patient who developed
refractory peri-implant problems around three of four
dental implants is described (a). A decision was made to
remove and replace the implants as only a provisional
fixed prosthesis was in place, and it was considered that
the implants could not be relied upon to support a defini-
tive prosthesis. Removal of the implants was accom-
plished with a combination of bone removal with
ultrasonic instrumentation and implant retrieval tools.
This proved extremely challenging; use of the retrieval
18.6 Failure and Zygomatic
Implants
Zygomatic implants were first used in 1998 [9]
and have a high success rate [10]. They may be
used alone in the ‘quad zygoma’ [11] configura-
tion or together with dental implants to support
an implant-supported prosthesis. Whilst a great
deal has been published on the outcome of treat-
ment with zygomatic implants in conjunction
with conventional dental implants [12], less has
been written about the use of zygomatic implants
485
tool on one of the implants resulted in fracture (b). It may
well have been possible to replace the implants at the time
of the removal; however, poor healing in the explantation
sites was anticipated. Six months later there had been a
considerable amount of remodelling (c, d), and direct
replacement of the implants was impossible. The patient
in the meantime was most unhappy about having to wear
a removable prosthesis. Zygomatic implants were used in
conjunction with the single retained and a single new den-
tal implant to finally support a prosthesis (e)
in a quad configuration [13]; however, it is clear
that this is also a successful treatment for most
patients [14]. Studies have shown that for recon-
structions supported by both zygomatic and den-
tal implants, it is the (usually short) dental
implants that have the higher failure rate [15].
For this reason, when planning the zygomatic
implants, it is prudent to carefully consider the
positioning of a rear zygomatic implant to allow
for placement of a further anterior zygomatic
implant in the event of failure of one of the dental
implants. Consider the positioning of the left
486
Fig. 18.9 The placement of the left zygomatic implant
would preclude or complicate placement of an anterior
zygomatic implant if the short dental implant was to fail
later on—whereas on the right side there is more space
between the orbital rim and the distal implant
zygomatic implant in Fig. 18.9; the tip of the
implant is too close to the orbital rim to permit
the subsequent placement of an additional ante-
rior zygomatic implant, making it difficult to
simply retrieve the situation with the addition of
a new zygomatic implant should the anterior
implant fail, whereas on the right side there is
sufficient clearance for an additional zygomatic
implant to be placed if necessary. Because zygo-
matic implants are longer and run in close prox-
imity to critical anatomical structures, the use of
CBCT and planning software is mandatory.
Whilst a combination of four dental or zygo-
matic implants may be sufficient to support a
fixed prosthesis, in the event of an implant failure
the situation may be mitigated if a fifth (or sixth)
implant is also provided. Where adequate bone is
present, a dental implant positioned in the maxil-
lary tuberosity region will broaden support for a
prosthesis and may serve as a valuable contin-
gency [16].
18.7 Maxillary Sinus and Shaft-­
Related Complications
Maxillary sinus-related complications have been
described in 0–37% [17] of patients treated with
zygomatic implants; some of these patients also
have oro-antral communication around the
implant.
A. Dawood and S. Tanner
Fig. 18.10 This patient developed severe pain which was
diagnosed as acute sinusitis soon after zygomatic implant
surgery. The sinus was drained with a hypodermic needle
and syringe, and antibiotics prescribed with relief of
symptoms
Sinus complications may appear early on in
treatment (Fig. 18.10), later on or very much later
on. No study has re-examined those patients
treated with zygomatic implants many years later
or has examined the status of the sinus in asymp-
tomatic patients long after surgery. Little infor-
mation exists on the later appearance of
complications in the much longer term as the tis-
sues around the implants remodel, the patient
ages and as changes in health and well-being take
place. As the use of the zygomatic implant
becomes more commonplace, it could be that
younger patients are being treated; yet with only
a 20-year experience of the use of this implant
type it may be difficult to predict the behaviour of
the implant over a very long period of time,
whilst the consequences of longer-term failure
could be severe.
Recession or peri-implant inflammation
around the neck of the zygomatic implant may
lead to microbial colonisation of the threaded
shaft (Fig. 18.11). As the implant may penetrate
the maxilla to enter the maxillary sinus (the origi-
nal intra-maxillary approach, ad modem
Brånemark), this may lead to chronic inflamma-
tion or infection in the sinus.
The authors have seen chronic sinusitis in
patients treated at or referred to their practice,
which has necessitated further surgical measures.
Functional endoscopic sinus surgery (FESS)
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions…
a b
Fig. 18.11 Over an 8-year period the condition of the
soft tissues around this zygomatic implant deteriorated (a)
as the patient’s medical history grew more complicated—
persistent inflammation of the tissues around the threaded
shaft of a zygomatic implant has led to extensive bone loss
improves ventilation and drainage of the sinus,
and for some patients this has brought symptom-
atic relief. Sinus problems may be more likely if
the sinus membrane is perforated or the zygo-
matic implant lies wholly within the sinus, losing
contact with the sinus wall.
If sinus symptoms or peri-implant recession
and inflammation are severe, removal of the
implant may be possible (Fig. 18.11), but if the
implant is well anchored in the zygoma it may be
more practical to section the implant close to the
junction with the zygoma and abandon the osseo-
integrated apical portion as it may be excessively
traumatic to remove the entire implant
(Fig. 18.12).
Whether a result of gingival or sinus inflam-
mation, bone loss around the shaft of the implant
may mean that tissues around the resulting defect
are unsupported and poorly vascularised and may
487
and remodelling and oro-antral communication. The
zygomatic implant was removed by re-attaching the fix-
ture mount and applying a reverse torque, leaving a large
oro-antral fistula (b). A flap was mobilised and the defect
closed in two layers (c)
heal poorly after surgery, even when the implant
has been removed, leaving a persistent fistula.
By using a so-called extramaxillary approach
[18] to zygomatic implant placement, the implant
platform may be more favourably positioned and
the implant shaft less likely to invade the sinus—
although if the implant is excessively buccally
positioned, recession of the buccal tissues may be
precipitated, particularly in the absence of an
adequate cuff of keratinised tissue. Recession
around a threaded shaft may result in cleaning
difficulties, plaque accumulation and inflamma-
tion. Newer generations of zygomatic implants
with a threaded apical portion and an unthreaded
shaft, placed using an extramaxillary approach,
have been introduced in the hope that the absence
of threads along the threaded shaft will minimise
recession and the problems associated with
exposed threads, whilst the extramaxillary
488 A. Dawood and S. Tanner

a b

Fig. 18.12 Ten years after the original surgery, this
patient was taking steroids and alendronic acid. Tissue
inflammation progressed to oroantral fistula and break-
down of the surrounding bone (a). With the implant
robustly anchored in bone, the shaft was sectioned as it
entered the zygoma (b) and the apex abandoned in situ—
note the useful presence of an implant positioned distally
in the tuberosity region which meant that the reconstruc-
tion could be maintained. (c) Implant was sectioned
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions…
Fig. 18.13 Infection associated with the apex of a zygo-
matic implant manifesting extraorally; this implant was
removed with a great deal of difficulty
approach would minimise sinus problems. Some
of these newer implant designs use a machined
reduced diameter or flattened shaft to avoid
prominence. Surgical strategies to thicken over-
lying tissues, for example, with the buccal fat
pad, may also help to reduce recession. However,
long-term comparative results are not available to
validate these different approaches to treatment,
and the authors continue to see recession around
shafts of different configurations, from various
manufacturers, placed by different surgeons
(Fig. 18.13).
18.8 Apical Infection
Earlier forms of zygomatic implants have a hol-
low ‘bone chamber’ at the apex. Infection associ-
ated with the apex of a zygomatic implant has
been rarely reported though it is a known and dis-
tressing complication. In the authors’ experience,
on one occasion an infection which was refrac-
tory to antibiotics and was draining extraorally
(Fig. 18.14) was treated by removal of the
implant—this was exceptionally difficult and
also traumatic and destructive; the patient was
left with an indurated and unsightly scar.
On another occasion reported by the authors
[19], a patient was referred with a recurrent infec-
tion associated with the apex of a zygomatic
implant (Fig. 18.15). An apical radiolucency sur-
489
Fig. 18.14 Extraoral representation of infection with
zygomatic implant
rounding the hollow bone chamber at the apex of
the anterior zygomatic implant was identified,
and removal of the implant was discussed with
the patient who resisted the idea as the implant
appeared robustly anchored. Instead, after careful
radiographic and surgical planning the apex of
the implant was directly accessed through an
extraoral incision in a procedure which took
place under a short general anaesthetic, resecting
the apical 6 mm of the implant, including the
bone chamber, completely resolving the prob-
lem. The same patient also needed to have the
apex of an uncomfortably protruding zygomatic
implant trimmed, and with failure of a short ante-
rior dental implant, provision of a fourth zygo-
matic implant—this needed to be fitted into the
limited bulk of bone between the right orbit and
the rear zygomatic implant. Eliminating the bone
chamber would seem to be a positive step towards
eliminating such issues, and contemporary
implants do not incorporate this feature. However,
the authors have recently encountered a similar
refractory infection associated with the apex of a
zygomatic implant without a bone chamber.
Somewhat surprisingly, this resolved when the
area was surgically accessed and debrided using
an intraoral approach, without ever having a clear
understanding of the aetiology of the problem.
490
a b
Fig. 18.15 Infection associated with the apex of a zygo-
matic implant, with bone loss in orbital rim around the
apex of the left anterior zygomatic implant seen on CBCT
scout view (a). The apex of the implant accessed via extra-
oral incision (b). The resected apex of the implant (c).
Healing was uneventful (d), although the short anterior
dental implant subsequently failed as seen in panoramic
radiograph (e) taken after resection of front left zygomatic
A. Dawood and S. Tanner
implant apex; note loose framework with fractured abut-
ment screw. The failed dental implant was replaced with a
further zygomatic implant (f); note absence of threads
along shaft of implant, with extramaxillary placement. At
the same time the extensive protrusion as seen in the refor-
matted cross-section (g) was reduced by resecting the
implant apex. The prosthesis was then adapted to the new
situation (h)
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions…
f g
Fig. 18.15 (continued)
18.9 Discussion
In recent years it seems that the offer and uptake
of full-arch treatments including the All-on-4®
treatment protocol, or versions of this protocol (a
minimum of four dental implants, two ‘straight’
and two tilted to immediately support a fixed
prosthesis), have markedly increased. The use of
this protocol has been shown to be predictable,
with Malo et al. [20] reporting cumulative
patient-related and implant-related success rates
of 94.8% and 98.1%, respectively, at 5 years, and
93.8% and 94.8%, respectively, with up to 10
years of follow-up on 245 patients restored with
980 implants, and this is the authors’ strategy of
choice for atrophic jaws. Although there is a rea-
sonable body of literature available to support the
use of this concept, studies generally refer to
patients treated with dental implants, zygomatic
implants and restorative components made by a
particular manufacturer; it may not be appropri-
491
ate to extrapolate results to other implant and
restorative systems.
The elegance of graftless full-arch treatment
lies in its apparent simplicity. Securing implants
in the bulk of bone of the anterior maxilla or
mandible may eliminate the need for grafting and
allow straightforward treatment even where there
is moderate atrophy—indeed treatment is more
straightforward where there is moderate atrophy
as there is then adequate restorative space for
prostheses without the need to reduce the jaw.
This approach appears so straightforward that to
gain access to that bulk of bone the decision to
remove teeth may seem compelling, and where
there is no atrophy, the need to remove bone in
order to secure sufficient space for the recon-
struction may seem a reasonable price to pay for
the ease of treatment. However, any expediency
gained by removing teeth or bone must be care-
fully balanced against alternative forms of treat-
ment, the anticipated longevity of the
492
reconstruction and the risk and consequences of
failure—all points to be discussed with the
patient before treatment.
Reported failure rates in implant dentistry are
low; however, most studies are based in institu-
tions, with treatments performed by experienced
teams which include experts in the field using
mainstream implant systems. As more and more
implants are placed, and more and more
patients—perhaps younger patients—are treated,
it could be that real failure rates are in fact higher
than reported, and that failure in the short term,
and certainly in the longer term, will be seen
more often in implant and general dental prac-
tice, whilst failure over much longer periods
becomes conspicuously more significant. Whilst
the rate of failure is indeed an important statistic,
the damage resulting from the failure of that par-
ticular approach to treatment, and the impact
upon the ability to provide remedial treatment
deserves better attention in the literature.
Careful planning and patient selection is prob-
ably the best way to avoid failure, but despite
every care, anyone actively involved in extensive
implant treatments will face failure. It is impor-
tant that when failure is encountered the surgeon
and prosthodontist take the opportunity to reflect
upon the causes and learn from every experience.
Competently managing failure is an important
challenge, perhaps the greatest challenge in
implant dentistry; the wisdom gained through
successfully managing complications is
invaluable.
The use of zygomatic implants has enabled
graftless, simplified treatments for patients who
have a highly atrophic maxilla and has improved
the quality of life for thousands of patients.
Nonetheless, with their use an entirely new spec-
trum of complications has appeared. The authors
find the zygomatic implant to be tremendously
useful for many of their patients, particularly
elderly patients with massive atrophy; however,
an 18-year-long experience of working with
zygomatic implants, and the recognition of the
potential for longer-term complications means
that the implant is used with circumspection. The
need for the extra biomechanical support contrib-
uted by the implant should be carefully evalu-
A. Dawood and S. Tanner
ated; the easiest way to avoid the particular
complications associated with the zygomatic
implant is not to use it.
An experienced and easily accessible team
including individuals expert in surgical and
prosthodontic aspects of treatment, skilled tech-
nicians and local dental laboratory facilities, and
access to state-of-the-art imaging facilities is
important to success and essential when manag-
ing failure. A sympathetic and empathetic team,
who provide support for the patient before, dur-
ing and after treatment, with carefully thought-­
out planning and treatment protocols is just as
important as is the need to provide detailed pre-
operative information to the patient and obtain
rigorous informed consent.
References
1. Dawood A, Patel S, Brown J. Cone beam CT in dental
practice. Br Dent J. 2009;207(1):23–8.
2. Schulze R, et al. Artefacts in CBCT: a review.
Dentomaxillofac Radiol. 2011;40(5):265–73.
3. Chrcanovic BR, Kisch JT, Albrektsson T, Wennerberg
A. Factors influencing early dental implant failures. J
Dent Res. 2016;95(9):995–1002.
4. Gurgel BC, Montenegro SC, Dantas PM, Pascoal AL,
Lima KC, Calderon PD. Frequency of peri-implant
diseases and associated factors. Clin Oral Implants
Res. 2016;10:1–7.
5. de Araújo NM, Maló P, Gonçalves Y, Sabas A,
Salvado F. Dental implants in diabetic patients: ret-
rospective cohort study reporting on implant survival
and risk indicators for excessive marginal bone loss at
5 years. J Oral Rehabil. 2016;43(11):863–70.
6. Guazzo R, Sbricoli L, Ricci S, Bressan E, Piattelli A,
Iaculli F. Medication-related osteonecrosis of the jaw
and dental implants failures: a systematic review. J
Oral Implantol. 2017;43(1):51–7.
7. Heitz Mayfield LJ, Needleman I, Salvi GE, Pjetursson
BE. Consensus statements and clinical recommenda-
tions for prevention and management of biologic and
technical implant complications. Int J Oral Maxillofac
Implants. 2014;29:346–50.
8. Yates JM, Brook IM, Patel RR, Wragg PF, Atkins SA,
El-Awa A, et al. Treatment of the edentulous atrophic
maxilla using zygomatic implants: evaluation of sur-
vival rates over 5-10 years. Int J Oral Maxillofac Surg.
2014;43(2):237–42.
9. Bränemark PI. Surgery and fixture installation.
Zygomaticus fixture clinical procedures. 1st ed.
Goteborg: Nobel. Biocare AB; 1998. p. 1.
10. Dos Santos PL, Silva GH, Da Silva Pereira FR,
da Silva RD, Campos ML, Mattos TB, Gulinelli
18 Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions…
JL. Zygomatic implant subjected to immediate load-
ing for atrophic maxilla rehabilitation. J Craniofac
Surg. 2016;27(8):e734–7.
11. Stiévenart M, Malevez C. Rehabilitation of totally
atrophied maxilla by means of four zygomatic
implants and fixed prosthesis: a 6-40-month follow-
­up. Int J Oral Maxillofac Surg. 2010;39(4):358–63.
12. Bedrossian E, Rangbert B, Stumpel L, Indresano
T. Immediate function with the zygomatic implant: a
graftless solution for the patient with mild to advanced
atrophy of the maxilla. Int J Oral Maxillofac Implants.
2006;21:937–42.
13. Wang F, Monje A, Lin GH, Wu Y, Monje F, Wang
HL, Davó R. Reliability of four zygomatic implant-­
supported prostheses for the rehabilitation of the
atrophic maxilla: a systematic review. Int J Oral
Maxillofac Implants. 2015;30(2):293–8.
14. Aparicio C, Manresa C, Francisco K, Ouazzani
W, Claros P, Potau JM, Aparicio A. The long-term
use of zygomatic implants: a 10-year clinical and
radiographic report. Clin Implant Dent Relat Res.
2014;16(3):447–59.
15. Davó R, Malevez C, Rojas J, Rodríguez J, Regolf
J. Clinical outcome of 42 patients treated with 81
immediately loaded zygomatic implants: a 12- to
493
42-month retrospective study. Eur J Oral Implantol.
2008;1(2):141–50.
16. Curi MM, Cardoso CL, de Ribeiro KC. Retrospective
study of pterygoid implants in the atrophic pos-
terior maxilla: implant and prosthesis survival
rates up to 3 years. Int J Oral Maxillofac Implants.
2015;30(2):378–83.
17. Chrcanovic BR, Abreu MH. Survival and complica-
tions of zygomatic implants: a systematic review. Oral
Maxillofac Surg. 2013;17(2):81–93.
18. Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela
R, Pascual A, Codesal M, Barluenga N, Manresa
C, Franch M. Extrasinus zygomatic implants: three
year experience from a new surgical approach for
patients with pronounced buccal concavities in the
edentulous maxilla. Clin Implant Dent Relat Res.
2010;12(1):55–61.
19. Dawood A, Kalavrezos N. Management of extra-­
oral complications for a patient treated with four
zygomatic implants. Int J Oral Maxillofac Implants.
2017;32(4):893–6.
20. Malo P, de Araújo NM, 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 fol-
low-­up. J Am Dent Assoc. 2011;142(3):310–20.
 Maintenance of Full-Arch
Implant-­Supported Restorations:
19
Peri-­Implant and Prosthetic
Considerations

Satish Kumar, Kian Kar, and Saj Jivraj

Abstract Long-term success of full-arch implant-­supported

restorations is dependent on several factors,
Peri-implant disease develops silently, and
including maintenance of healthy peri-implant
often it is diagnosed when bone loss has
tissue, prevention of peri-implant diseases and
already occurred. The prevalence of peri-­
properly functioning prosthetic components.
implantitis in the literature is overestimated
This chapter will describe patient selection and
but it does occur. It is an unpredictable disease
risk assessment, peri-implant and prosthetic con-
to treat, and practitioners should make every
siderations to maintain full-arch implant-­
effort to prevent its occurrence if possible.
supported restorations. Peri-implant diseases are
This is best achieved through a personalised
defined based on assessment of probing depths,
approach to both home care and office hygiene
presence or absence of clinical inflammation and/
visits, whose duration and frequency should
or bleeding on probing and radiographic bone
be determined according to the individual
level/loss around implants (Table 19.1). Absence
patient’s need. The objective of an effective
of clinical inflammation with maintenance of
dental implant maintenance programme is to
alveolar bone level consistent with initial bone
recognise early signs of inflammation, peri-­
remodelling is considered as healthy peri-implant
implant mucositis and be able to reverse it
tissue. Presence of clinical inflammation such as
back to health.
bleeding on probing and/or suppuration with
maintenance of alveolar bone level consistent
with initial bone remodelling is considered as
peri-implant mucositis. Clinical inflammation
with probing depths of 6 mm or more than 6 mm
of radiographic bone loss beyond initial bone
remodelling may constitute a diagnosis of peri-­
S. Kumar (*)
Arizona School of Dentistry and Oral Health, implantitis (Fig. 19.1).
A. T. Still University, Mesa, AZ, USA
e-mail: satishkumar@atsu.edu
K. Kar
Herman Ostrow School of Dentistry of USC,
University of Southern California,
Los Angeles, CA, USA
S. Jivraj
Anacapa Dental Art Institute, Oxnard, CA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 495
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_19
496
Table 19.1 Definitions [1–3]
Terminology
Peri-implant health
Peri-implant mucositis
Peri-­implantitis
a b
c
S. Kumar et al.
Definition
A diagnosis of peri-implant health is made when there is
 • Absence of clinical signs of inflammation
 • Absence of bleeding and/or suppuration on gentle probing
 • No increase in probing depth compared to previous examinations
 • Absence of bone loss beyond crestal bone-level changes resulting from initial
bone remodelling
A diagnosis of peri-implant mucositis is made when there is
 • Presence of bleeding and/or suppuration on gentle probing with or without
increased probing depth compared to previous examinations
 • Absence of bone loss beyond crestal bone-level changes resulting from initial
bone remodelling
A diagnosis of peri-implantitis is made when there is
 • Presence of bleeding and/or suppuration on gentle probing
 • Increased probing depth compared to previous examinations
 • Presence of bone loss beyond crestal bone-level changes resulting from initial
bone remodelling
However, clinicians at times do not have the previous clinical and radiographic
examination to make a diagnosis according to the above criteria when other
clinicians placed the implants. In these situations, the diagnosis of peri-implantitis
can be made based on these findings:
 • Presence of bleeding and/or suppuration on gentle probing
 • Probing depths of ≥6 mm
 • Bone levels ≥3 mm apical of the most coronal portion of the intraosseous part of
the implant
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations 497

19.1 Patient Selection and Risk regular maintenance in rough-surfaced implants

Assessment [8]. Clinicians should explain the reasons clearly
to the patient why a predisposition to periodontal
When a patient is deemed to benefit from a full-­ disease and/or poor oral hygiene will affect the
arch implant-supported prosthesis, clinicians longevity of implants and set clear expectations
must carefully weigh these benefits against risks on maintaining excellent oral hygiene. Heavy
including patients’ medical conditions such as smoking is another major risk factor for long-­
uncontrolled diabetes and medications such as term success of implants. Patients who smoked
cancer therapy including immunosuppressants >10 cigarettes/day have been shown to have a
and antiresorptive therapy. Diabetes mellitus, higher incidence of marginal bone loss around
smoking, lack of oral hygiene and history or the implants than those patients who smoked <10
presence of periodontitis were reported to be risk cigarettes/day [9]. Clinicians must clearly dis-
factors of peri-implantitis [4]. Bleeding on prob- cuss effect of smoking on wound healing and
ing and bone loss around implants have been implant success with the patient and engage the
shown to be increased in diabetic patients [5]. patient in smoking cessation programme
Patients with type 2 diabetes mellitus, even when (Fig. 19.3). Age-related cognitive decline and
well controlled, have been shown to be at a higher loss of dexterity should also be considered as
risk of peri-implant disease [6]. Previous history patients need to be able to follow home care
of periodontitis and poor oral hygiene (Fig. 19.2) instructions to maintain good peri-implant health
is detrimental to peri-implant health. Periodontal and the restorations. Patient compliance with the
pathogenic bacterial counts within the implant supportive periodontal/peri-implant maintenance
abutment interface of implants in patients with therapy has been reported to be unsatisfactory.
peri-implantitis were significantly higher com- Hence, educating and motivating patients to keep
pared to those implants surrounded by healthy up with the important maintenance appointments
peri-implant tissues [7]. History of periodontitis is key [10].
affects implant survival negatively even under

Fig. 19.1 (a–c) These figures show peri-implant disease.
Clinical and radiographic view of maxillary left implant-
supported prosthesis demonstrating various peri-implant
conditions. Mesial implant (tooth site # 12) presents with
probing depth ranging 2–4 mm, clinically healthy mucosa
(no BOP and suppuration) and radiographic bone level to
first thread consistent with the normal threshold of post-
restorative bone remodelling) representing a diagnosis of
peri-implant health. Distal implant (tooth site # 14) pres-
ents with probing depth ranging 3–5 mm, inflamed
mucosa with BOP and radiographic bone level to first
thread consistent with the normal threshold of post-restor-
ative bone remodelling representing a diagnosis of peri-
implant mucositis. Middle implant (tooth site # 13)
presents with probing depth ranging 6–9 mm, inflamed
mucosa with BOP and suppuration and radiographic bone
level to 8th thread and more than 3 mm bone loss from the
threshold of post-restorative bone remodelling represent-
ing a diagnosis of peri-implantitis. (Courtesy of Dr Maria
Galvan and Dr Kian Kar)
498
a b
Fig. 19.2 Clinical images of full-arch implant-supported
prostheses showing poor maintenance. The patient com-
plained of general discomfort and was unable to point to
the exact area and described the lower right side as more
uncomfortable. She said that they were painful all over but
had difficulty describing it. These photographs were taken
when the patient presented after having worn them for
about a year without maintenance. (a) Prostheses in the
patient’s mouth showing areas of concave ridge laps that
S. Kumar et al.
make self-cleansing and patient at-home cleaning diffi-
cult. (b) Intaglio surface of maxillary prosthesis showing
significant plaque and debris accumulation. (c) Maxillary
occlusal photograph showing significant peri-implant and
soft tissue inflammation. (d) Intaglio surface of mandibu-
lar prosthesis showing significant plaque and debris accu-
mulation. (e) Mandibular occlusal photograph showing
significant peri-implant and soft tissue inflammation.
(Courtesy of Dr Russell Crockett, DMD)
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations 499

Fig. 19.3 Radiographic presentation of a patient with a
history of periodontitis and cigarette smoking. (a) Initial
presentation of the patient prior to treatment. (b) Full
mouth radiographic series after completion of rehabilita-
tion. (c) Radiographic presentation of peri-implant bone
loss 7 years after rehabilitation associated with presence
of biofilm-induced inflammation leading to peri-­
implantitis. (d) Full-mouth radiographic series 11 years
after rehabilitation. Note progressive periodontal bone
loss, prominently on mandibular anterior and loss of max-
illary molar implants. The patient reported continuous
smoking of 10+ cigarettes per day with infrequent mainte-
nance visits. (Courtesy of Dr Sara El Husseini and Dr
Kian Kar)
500 S. Kumar et al.

Fig. 19.3 (continued)

19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations
19.2 Peri-Implant Considerations
19.2.1 Supportive Periodontal
and Peri-Implant Therapy
A crucial part of implant therapy is the mainte-
nance of implants and prosthesis after the final
restoration has been seated. This is to prevent
complications and ensure long-term success. In
the era of personalised medicine, implant mainte-
nance protocols as part of supportive periodontal
or peri-implant therapy must also be customised
to individual patients based on their risk factors
as well as clinical and implant-related factors.
Patients must be educated well on potential com-
plications and early signs and preventive efforts,
before, during and after implants have been
restored. It is difficult to predict which patient
with history of periodontitis will continue
experiencing biological complications after
­ factors are ideal for long-term success [12–14].
implant therapy. What is clear is that people with
a history of advanced periodontitis with risk fac-
tors such as smoking and diabetes are at a much
higher risk of peri-implantitis. Therefore, for
patients with such risks, stringent implant main-
tenance protocols are warranted. These include
increased frequency of maintenance (supportive
therapy) appointments )3-month intervals),
mechanical plaque control (scaling), as well as
anti-infective therapy such as sub-mucosal irriga-
tion (chlorhexidine, iodine, diluted sodium hypo-
chlorite) and local delivery of antimicrobials
(doxycycline spheres or metronidazole gel) when
early signs of mucositis are detected to reduce the
risk of peri-implantitis.
19.2.1.1 Professional In-Office
Maintenance Protocol
Bone remodelling after implant placement is to
be anticipated as the peri-implant tissue heals
around the implant to form the supracrestal
attached tissues (biological width). This remod-
elling is not only influenced by the position of the
implant in the bone but also by a number of other
local and systemic factors. The final crestal level
of bone will be established after the remodelling
process. To monitor any bone loss beyond the ini-
tial remodelling process, clinicians are advised to
501
obtain baseline radiographs as well as clinical
evaluation including probing measurements after
the seating of the implant-supported prosthesis.
Another radiograph should be taken to establish
the new bone level after a loading period when
the physiological remodelling has been com-
pleted. If another clinician has placed and
restored the implants, efforts should be made to
obtain the clinical examination record and radio-
graphs. This is essential because bone loss that
occurs more than the reasonable loss occurring
during remodelling phase could indicate peri-­
implantitis [11].
There is lack of evidence on the efficacy of
recall intervals, [12] and expert consensus and
reviews have mostly recommended recall
­intervals between 3 and 6 months as a lifelong
regimen. Recall intervals should also be custom-
ised based on individual patient’s needs, and risk
Supportive peri-implant therapy has been shown
to improve peri-implant health and thus improved
survival rate and reduced incidence of peri-­
implantitis and peri-implant mucositis [15]. Peri-­
implant marginal bone loss has been reported to
be significantly reduced in patients with support-
ive peri-implant therapy compared to those who
did not receive the same [16].
Mechanical debridement using scalers (man-
ual, sonic, ultrasonic), polishers and airflow
devices are the mainstay of non-surgical treat-
ment. Scalers made with plastic or nylon tips are
used to prevent abutment surface damage but are
usually not effective. Hand instruments such as
titanium tip curettes (Fig. 19.4) or ultrasonic
instrumentation can be used to debride exposed
rough surface implant threads [14]. Airflow
devices have shown some promise with improved
short-term clinical outcomes with reduced bleed-
ing on probing [17].
A scientific panel comprising experts
appointed by the American College of
Prosthodontists, American Dental Association,
Academy of General Dentistry and American
Dental Hygienists Association published clinical
practice guidelines in 2016 [18] for removable
and fixed, tooth-borne, as well as implant-borne
restorations focusing on patient recall, profes-
502
Fig. 19.4 Titanium curettes used for mechanical debride-
ment around exposed implant threads. (Courtesy of Ms
Jean Brady)
Table 19.2 Professional biological maintenance proto-
col [18]
Recall intervals between 3 and 6 months as a lifelong
regimen are recommended. The appointment interval
should be customised based on individual patient’s
needs and risk factors
Extraoral and intraoral health and dental examination
Oral hygiene instructions
Oral hygiene intervention (cleaning of any natural
teeth, tooth-borne restorations, implant-borne
restorations or implant abutments)
Short-term use of chlorhexidine gluconate as the oral
topical agent of choice when needed
Mechanical debridement using scalers (manual, sonic,
ultrasonic), polishers and airflow devices. Cleaning
instruments should be chosen based on their
compatibility with the type and material of the
implants, abutments and restorations
sional maintenance (biological and mechanical)
and at-home maintenance. The biological profes-
sional maintenance guidelines for implant-borne
fixed restorations including implant-supported
complete arch-fixed prostheses are given in
Table 19.2 [18].
S. Kumar et al.
19.2.1.2 Patient At-Home
Maintenance Protocol
Patients must be trained in office to use different
home care devices such as brushes, electric rotary
brushes and floss threads. Oral irrigators may be
useful in certain difficult-to-access sites
(Fig. 19.5). Over-the-counter mouth rinses with-
out alcohol should be encouraged especially to
those with dry mouth. Adjunctive use of chlorhex-
idine has short-term benefits in reducing the
inflammation when used with mechanical
debridement but should not be recommended for
long term due to limited benefits and also side
effects such as discoloration and taste distur-
bances [19].
The at-home maintenance guidelines for
implant-borne fixed restorations including
implant-supported complete arch-fixed prosthe-
ses are shown in Table 19.3 [18].
19.2.2 Peri-Implant Biological
Complications
Peri-implant tissue is referred to the tissue sur-
rounding dental implants and is comprised of soft
tissue (peri-implant mucosa) and hard tissue
(bone) components. Following the placement of
implant, osseointegration is defined as ‘a direct
functional and structural connection between liv-
ing bone and the surface of a load-carrying
implant’ occurs [20]. After the placement of
implant abutment, wound healing of the soft tis-
sue occurs, creating the peri-implant mucosa
which protects the underlying bone osseointe-
grated with the implant. There are a few critical
differences in the peri-implant tissues compared
to the periodontium. Peri-implant tissues lack
cementum and periodontal ligament. In addition,
there are no inserting fibres from the connective
tissue into the implant surface, and there is less
vascularisation in the zone between the bone crest
and the junctional epithelium. Peri-implant
mucosa is reported to be about 3–4 mm high with
2 mm of epithelium [1, 21]. Keratinised mucosa
has been reported to help with patient comfort and
ease of plaque removal. Reduced keratinised tis-
sue width has been shown to be associated with
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations
a plaque accumulation, soft tissue inflammation,
b thickness around implants, malposition or off-
Fig. 19.5 Examples of patient at-home maintenance
aids: (a) manual toothbrush, inter-proximal brushes, floss
and floss threaders; (b) electric toothbrush and oral irriga-
tor. (Courtesy of Ms Jean Brady)
Table 19.3 Patient at-home maintenance protocol [18]
Brush twice daily with oral hygiene aids such as dental
floss, water flossers, air flossers, interdental cleaners
and electric toothbrushes
Use oral topical agents such as toothpaste containing
0.3% triclosan
Over-the-counter mouth rinses without alcohol for
patients with dry mouth
Short-term use of chlorhexidine gluconate when
indicated
When prescribed, wear occlusal device during sleep
Clean occlusal device before and after use, with a soft
brush and the prescribed cleaning agent
When not in use, store the occlusal device in the
provided container
503
mucosal recession, marginal bone loss leading to
an increased prevalence of peri-implantitis and
patient discomfort (Fig. 19.6) [22, 23]. Addition
of keratinised tissue width and thickness can
improve plaque control and reduction of inflam-
mation and symptoms (Fig. 19.7). However, the
actual width of keratinised mucosa that is required
for peri-implant health is not clear [24]. It is
important to underscore the influence of surgical
factors that influence occurrence of peri-implant
tissue complication. These include limited bone
angle implant position, lack of keratinised and
mucosal tissue thickness and excessive trauma to
bone during osteotomy procedures. These all can
lead to undesirable healing and tissue remodelling
after implant placement that can predispose the
site to biological complications such as inflamma-
tion and mucosal recession.
Dental implants are frequently affected by
peri-implant diseases, namely, peri-implant
mucositis and peri-implantitis [25, 26]. In 2017,
the American Academy of Periodontology and
the European Federation of Periodontology
jointly conducted a world workshop bringing
together international experts who published a
series of reviews and consensus manuscripts
Fig. 19.6 Mandibular right implant with mucosal reces-
sion, lack of attached and keratinised mucosa, with high
frenum attachment and shallow vestibular depth limiting
oral hygiene access and plaque control. (Courtesy of Dr
Kian Kar)
504
Fig. 19.7 (a) Patient 6 years after full mandibular arch
rehabilitation with implant-supported implant-retained
fixed detachable prosthesis. The patient reported tender-
ness to brushing and had limited oral hygiene access due
to shallow vestibular depth and tenderness to palpation.
Mucosal recession and inflammation are present. (b)
Radiographic appearance of bone level to second thread.
(c) Epithelialised graft harvested from maxillary edentu-
lous ridge for soft tissue augmentation of mandibular
anterior implants with the aim to increase zone of kera-
S. Kumar et al.
tinised and attached tissue, deepen the vestibule and pro-
vide oral hygiene access and patient comfort. (d) Soft
tissue graft placed over recipient site and secured with
periosteal tacking sutures. (e) Clinical appearance of man-
dibular anterior implants after soft tissue healing provid-
ing wider zone of keratinised and attached mucosa,
increased vestibular depth, oral hygiene access and cover-
age over exposed implant components. (Courtesy of Dr
Christopher Pham and Dr Kian Kar)
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations 505

b c

d e

Fig. 19.7 (continued)

including defining peri-implant health and peri-­ meaningful outcomes such as patient-reported
implant diseases (Table 19.1) [1–3, 11, 27, 28]. outcomes and adverse events have not been fre-
Regular maintenance of implants will enable quently reported [29].
early detection of peri-implant complications and
hence early intervention. Clinicians have 19.2.2.1 Management of Peri-Implant
attempted several treatment modalities to salvage Mucositis
implants from peri-implantitis. While peri-­ The prevalence of peri-implant mucositis in fully
implant mucositis is usually reversible when edentulous patients has been reported to be as
detected early for the first time but if the cause or high as 57% at the patient level and 47% at the
source of inflammation persists, peri-implant implant level [25]. Non-surgical mechanical
mucositis will progress to irreversible peri-­ debridement using hand and powered instru-
implantitis, and treatment becomes unpredictable ments and use of airflow devices to remove bio-
and challenging. Evidence is not robust in thera- film and local factors will aid in reduction of
peutic modalities, and clinical outcome measures inflammation [17]. Combined use of diode laser
are usually restricted to common clinical param- and mechanical debridement has been shown to
eters such as probing pocket depth and bleeding have no additional clinical benefits when com-
on probing which may not be accurate. Clinically pared to mechanical debridement alone [30].
506
19.2.2.2 Management
of Peri-Implantitis
A recent study determined the prevalence of peri-­
implantitis to be 19.53% and 12.53% at the
patient level and at implant level, respectively
[26]. Another study looked at the prevalence of
peri-implant mucositis and peri-implantitis spe-
cifically in patients rehabilitated with full-arch,
implant-supported restorations [25]. The preva-
lence of peri-implantitis in fully edentulous
patients was reported to be between 1.5% and
29.7% at the patient level and between 2.1% and
20.3% at the implant level. The prevalence rates
based on definitions attributing to a microbial
disease aetiology have been challenged by an
alternate view. This view emphasises the role of
immune system in bone remodelling and also
progressive bone loss due to immune rejection
with minimal role of bacterial biofilms [31, 32].
The 5th ITI Consensus Statement provided a pro-
tocol (Table 19.4) for the management of peri-­
implantitis [33, 34].
Peri-implantitis treatment followed by regular
supportive care has been shown to have high
patient- and implant-level survival with stable
peri-implant bone levels and other clinical param-
eters [35]. A systematic review that compiled 16
randomised controlled trials examining various
mechanical, chemical and physical decontamina-
tion protocols did not find a single decontamina-
tion method that is superior to others. Use of
titanium brushes for decontamination and
implantoplasty showed better clinical outcomes
[36]. Systemic administration of antibiotics is not
recommended for the treatment of peri-­implantitis
[37]. The AAP best evidence consensus con-
cluded that laser therapy, namely, Er:YAG, CO2
or diode lasers, in combination with surgical or
non-surgical therapy, did not provide meaningful
clinical benefits such as probing depth reduction,
clinical attachment level gain, among others, in
the treatment of peri-implant diseases [38].
Photodynamic therapy provided similar clinical
benefits to conventional non-surgical therapy
[39]. Both resective and regenerative surgical
procedures have shown improved clinical out-
comes. However, resective surgery leads to sig-
nificant post-surgical recession compared to
S. Kumar et al.
Table 19.4 Management of peri-implantitis [33, 34]
Thorough assessment and diagnosis
Control of both local and systemic risk factors for
peri-implantitis
Non-surgical debridement
Early reassessment of peri-implant health within 1–2
months
Surgical access if resolution has not been achieved by
non-surgical methods:
 • Open-flap debridement
 • Thorough surface decontamination of the implant
and associated prosthetic components
 • Option of regenerative/reconstructive or resective
approaches
 • Appropriate postoperative anti-infective therapy
Supportive care tailored to the patient risk profile
usually between 3 and 6 months
regenerative surgical therapy [40]. Use of bone
grafts in regenerative therapy may help improve
clinical outcomes such as recession [41].
Implantoplasty may be necessary in certain clini-
cal situations to avoid further biofilm formation
and is another viable treatment for periimplantitis
[42], and it can be done in conjunction with
regenerative as well as resective approaches
(Fig. 19.8) [43].
19.2.2.3 Management of Peri-Implant
Recession
When there is a lack of thick, soft tissue pheno-
type around the future implant sites, clinicians
could consider augmenting these sites with soft
tissue grafts to maintain optimal peri-implant
health as well as prevent peri-implant mucosal
recession. Keratinised mucosa <2 mm around
dental implants in patients who do not comply
with routine maintenance therapy are prone to
develop peri-implant diseases [22]. Soft tissue
augmentation procedures such as free gingival
graft, connective tissue graft, allografts or xeno-
grafts can be used to improve the soft tissue phe-
notype before placing multiple implants for a
full-arch prosthesis (Figs. 19.7 and 19.9)
[44–46].
Malpositioning of implants and lack of buc-
cal bone are some factors leading to recession of
the peri-implant mucosa that develops after
implant placement. This in turn can be a nidus
for plaque accumulation and onset of peri-
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations 507

a b

d e

Fig. 19.8 (a) Occlusal view of and implant affected by
peri-implantitis, mucosal inflammation and bone loss
associated with implant sites # 26 and 27. (b) Radiographic
bone loss of 3 mm on most mesial implants. This bone
loss could be related to proximity of implants, differences
in implant platforms, angulation and position contributing
to inflammatory problems and biological complications
leading to peri-implant mucositis and peri-implantitis. (c)
Mucoperiosteal full-thickness flap elevation to access for
implant debridement and decontamination. Note facial
bone loss and dehiscence on both mesial implants. (d)
Implantoplasty and surface decontamination with
chlorhexidine and saline. (e) 8 months postoperative buc-
cal view. Note resolution of clinical inflammation,
2–3 mm probing depths and no BOP. (f) 8 months postop-
erative occlusal view. Note resolution of clinical inflam-
mation, 2–3 mm probing depths and no BOP. (Courtesy of
Dr Jane Law and Dr Kian Kar)
508
Fig. 19.9 (a) Appearance of mucosal tissue 1 year after
full-arch implant-supported implant-retained fixed
detachable prosthesis. Note mucosal recession, lack of
keratinised attached tissue, shallow vestibular depth, high
frenum attachment, mucosal tenderness and limited oral
hygiene access. (b) Appearance of peri-implant mucosa
implant diseases. When implants are otherwise
functional and can be maintained for long term,
mucosal recession can be improved by soft tis-
sue augmentation procedures [44]. Free gingival
grafts have been shown to be more effective in
the augmentation of keratinised mucosa around
dental implants compared to soft tissue substi-
tutes, but in some scenarios such as avoidance
of second surgical site or patient preference,
soft tissue substitutes could be an alternative to
enhance peri-implant soft tissue coverage [45].
Similarly, connective tissue graft provides bet-
ter soft tissue thickness compared to soft tissue
substitutes [46].
S. Kumar et al.
after placement of epithelialised graft to increase mucosal
thickness, keratinised and attached tissue, increased ves-
tibular depth and oral hygiene access. Note good oral
hygiene and healthy tissue appearance. (Courtesy of Dr
Shira Scholten and Dr Kian Kar)
19.3 Prosthetic Considerations
Certain prosthetic factors could contribute to the
complications and failure of implant-supported
full-arch prostheses such as poor implant pros-
theses design (concave intaglio surfaces) leading
to poor accessibility for removal of plaque and
poor function. For example, convex emergence
profile of the abutment or prosthesis and >30
angle of emergence has been shown to cause
peri-implantitis stemming from lack of accessi-
bility for oral hygiene [47].
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations
Table 19.5 Mechanical professional maintenance guide-
lines [18]
Perform detailed examination of the prosthesis,
prosthetic components and patient education about
complications
Recommend and perform adjustment, repair,
replacement or remake of any or all parts of the
prosthesis and prosthetic components that could impair
patients’ optimal function
Consider using new prosthetic screws when an
implant-borne restoration is removed and replaced for
professional mechanical maintenance
Fabricate an occlusal device whenever indicated such
as in patients with clenching and bruxism
Educate the patient to wear the occlusal device during
sleep
Hygiene instructions, detailed examination of the
occlusal device and patient education about problems
with the occlusal device
The occlusal device should be professionally cleaned
extraorally using professionally accepted mechanical
and chemical methods
19.3.1 Professional Maintenance
Guidelines
The mechanical professional maintenance guide-
lines for implant-borne fixed restorations includ-
ing implant-supported complete arch-fixed
prostheses are shown in Table 19.5 [18].
19.4 Prosthetic Maintenance
Delivery of the definitive restorations is the
beginning of the journey from a patient perspec-
tive. The clinician should educate the patient at
every opportunity with regard to hygiene mainte-
nance and dietary restrictions. Unless a compre-
hensive maintenance protocol is established, the
long-term outcome may be compromised.
A position paper released by the American
College of Prosthodontists emphasises the fol-
lowing key parameters with regard to mainte-
nance [48].
1. Maintenance is a dual responsibility between
the treating clinician and the patient. The
patient must understand their role in the over-
all process.
509
2. The prosthesis has to be designed so that it is
cleansable. This requires a flat or convex
undersurface.
3. The emergence profile and pontic design must
be optimal and no ledges designed in the pros-
thesis that will cause difficulty in oral hygiene
maintenance.
4. A rigorous homecare program must be
instituted.
From a prosthetic perspective, common con-
cerns include
• How often do you remove the prosthesis?
• What procedures are performed at recall in
terms of hygiene?
• What are the most common complications?
• Do you replace the screws if you remove the
restoration?
• What are the post-delivery instructions?
A majority of the following guidelines pre-
sented are in conjunction with the position paper
published by the American College of
Prosthodontists.
1. How often do you remove the prosthesis?
Restoration design is critical. The under-
surface of the restoration should be designed
with a convex or a flat surface so that it is
readily cleansable (Fig. 19.10). This will
result in the tissue contours being concave.
This outline must be developed with the pro-
visional restoration so that when the definitive
impressions are made this information is
accurately transferred to the laboratory tech-
nician. On many occasions when there has
been inadequate restorative space the techni-
cian is forced to create concave restoration
designs, which will be a detriment to the peri-­
implant tissues. The emergence profile must
be optimal and allow proper cleansing of the
restoration.
Removal of the prosthesis is based on risk
assessment. During the first year following deliv-
ery of the definitive restoration, the patient is kept
510
Fig. 19.10 Undersurface of prosthesis should be convex
and highly polished
on a 3-month recall. At this recall appointment,
the following are evaluated:
• Per-implant tissue health and a comprehensive
soft tissue examination
• A review of the patients’ medical history
• Mobility of the restoration – integrity of
screws
• Wear on the teeth
• Occlusion on the prosthesis
• Speech impediments
The restoration is removed if any of the above
factors are deemed to be causing harm to the res-
toration or peri-implant tissues. There is no evi-
dence base to support a specific recall regimen.
Each regimen is individually developed based on
risk assessment. If the hygiene around the resto-
ration is optimal, the restoration passive and free
of problems, there is no indication to remove the
restoration. It is recommended that radiographs
be taken every 2 years.
2. What procedures are performed at the recall
appointment in terms of hygiene?
There is a lack of evidence in regard to pro-
cedures performed at hygiene appointments.
Currently no guidelines exist in regard to
1. Hygiene intervals
2. What procedures are performed at hygiene
3. What types of instruments are used
S. Kumar et al.
4. What recommendations are provided in terms
of hygiene
With lack of evidence, it is the authors’ opin-
ion that as many hygiene aids be provided to the
patient as possible. The clinician must under-
stand that these patients did not present with the
most optimal hygiene practice. There is a reason
they lost all of their teeth and are currently in
implant-supported restorations.
With lack of evidence, the following guide-
lines can be provided:
1. Hygiene recall should be based on risk assess-
ment. In patients with poor oral hygiene,
recall intervals should be closer.
2. At the hygiene appointment, the hygienist
should use curettes which do not scratch the
titanium surface. Calculus removal must be
undertaken and thorough debridement of the
undersurface of the prosthesis with a waterjet
device.
3. Curettes, waterjet devices, rubber cups and
interproximal brushes should be used at the
hygiene appointment.
4. The patient should be instructed in the use of
water jet devices, superfloss, use of a powered
toothbrush, use of mouthwashes and inter-
proximal brushes to be able to clean adjacent
to the implants.
3. What are the most common complications?
Common complications include but are not
limited to
• Abrasion of acrylic resin teeth (Fig. 19.11)
• Fracture of layered ceramic (Fig. 19.12)
• Resorption of tissue beneath the prosthesis
(Fig. 19.13)
• Framework fracture
• Inflamed peri-implant tissues due to poor
hygiene or rough undersurface of the prosthe-
sis (Fig. 19.14)
Fracture and abrasion of the acrylic resin are
commonly related to occlusal overload.
Traditionally 8–10 micron articulating paper and
shimstock has been used to evaluate the occlu-
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations 511

Fig. 19.13 Space developing underneath the prosthesis

Fig. 19.11 Abrasion or fracture of an acrylic resin tita-
due to resorption
nium prosthesis

sion. In patients with implant-supported restora-

tions, they have reduced osseo-perception and as
a result can exert higher forces on the prosthetic
teeth than they had with their natural dentition.
Over the last decade, digital occlusal analysis has
been used as an adjunct to finesse the occlusion.
The advantage of this approach is that the clini-
cian is not only able to see the position of the
contacts but also the timing of closure and the
intensity of occlusal contacts. This is visualised
Fig. 19.12 Fracture of layered ceramic on zirconia on a bar graph and the appropriate occlusal
framework

Fig. 19.14 Undersurface of restoration poorly contoured and rough resulting in inflammation of the tissue
512
adjustments are made. All patients must finish
treatment with fabrication of a night-time appli-
ance and must adhere to the wear of this appli-
ance to prevent mechanical complications.
4. Do you replace the screws if you remove the
restoration?
There is no evidence to guide the clinician
in regard to when the prosthetic screws should
be replaced. When the restoration is delivered,
the screws are torqued to the manufacturer’s
recommendations, and this provides a clamp-
ing force that holds the abutment to the
implant and creates a pre-load within the
screw. The joint separating forces should be
less than the clamping forces. There are many
manufacturers who claim that their screws
can be torqued three times (personal commu-
nication). This needs to be verified by an inde-
pendent study. Based on this information,
screws should be replaced the fourth time the
restoration is removed.
5. What are the post-delivery instructions?
Patients are given dietary advice and are
encouraged to avoid very hard foods that may
break their prosthesis. Chewing ice and biting
down on bones should be discouraged.
Patients should be reminded that the prosthe-
sis is not lifelong, and at some stage the pros-
thesis may need to be replaced. The patient
should be given their provisional restoration
to store in a safe place. Should fracture of the
definitive restoration occur, the patient will
have a backup prosthesis to transition in
whilst the repair is completed. The clinician
should have the discussion that maintenance
will be required and fractures and wear are
likely to occur over time. It would be prudent
for the clinician to remind the patient visually
how they presented at the practice and how
much progress has been made.
The use of a night-time appliance should be
advised, and a comprehensive maintenance pro-
gramme established to maintain peri-implant
health and re-educate the patient on oral hygiene
measures.
S. Kumar et al.
19.5 Conclusion
The dental team needs to help patients under-
stand the importance of recognising the initial
stages of inflammation around dental implants
and peri-implant mucositis because it is more
predictable to correct them in the beginning.
Treating peri-implantitis is not predictable today,
and a consensus has not been reached on best
practices. However, with the 2015 published
guidelines on peri-implant mucositis prevention,
it makes it easier to predictably maintain dental
implants. Patients must be motivated to follow a
regular dental implant maintenance interval, as
this has been shown to decrease implant failures.
In a 17-year retrospective study, subjects with no
maintenance had the lowest cumulative survival
rate, while regular maintenance patients had the
dental implant failure rate reduced by 90%. If
patients had less than one maintenance visit per
year, the failure rate was reduced by 60% [49].
Implant patients should be educated on a per-
sonalised home care programme, based on their
needs and abilities. Furthermore, the dental team
should ensure that hygiene interval schedules and
appointment lengths are customised to meet the
individual patient’s needs.
References
1. Araujo MG, Lindhe J. Peri-implant health. J
Periodontol. 2018;89(Suppl 1):S249–56. https://doi.
org/10.1002/JPER.16-­0424.
2. Heitz-Mayfield LJA, Salvi GE. Peri-implant mucosi-
tis. J Periodontol. 2018;89(Suppl 1):S257–66. https://
doi.org/10.1002/JPER.16-­0488.
3. Schwarz F, Derks J, Monje A, Wang HL. Peri-­
implantitis. J Periodontol. 2018;89(Suppl 1):S267–
90. https://doi.org/10.1002/JPER.16-­0350.
4. Dreyer H, Grischke J, Tiede C, Eberhard J,
Schweitzer A, Toikkanen SE, Glöckner S, Krause
G, Stiesch M. Epidemiology and risk factors of
peri-implantitis: a systematic review. J Periodontal
Res. 2018;53(5):657–81. https://doi.org/10.1111/
jre.12562.
5. Dioguardi M, Cantore S, Quarta C, Sovereto D,
Zerman N, Pettini F, Muzio LL, Cosola MD,
Santacroce L, Ballini A. Correlation between diabe-
tes mellitus and peri-implantitis: a systematic review.
Endocr Metab Immune Disord Drug Targets. 2022.
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations
https://doi.org/10.2174/18715303236662210211004
27.
6. Lagunov VL, Sun J, George R. Evaluation of biologic
implant success parameters in type 2 diabetic glyce-
mic control patients versus health patients: a meta-­
analysis. J Investig Clin Dent. 2019;10(4):e12478.
https://doi.org/10.1111/jicd.12478.
7. Tallarico M, Canullo L, Caneva M, Özcan
M. Microbial colonization at the implant-abutment
interface and its possible influence on periimplantitis:
a systematic review and meta-analysis. J Prosthodont
Res. 2017;61(3):233–41. https://doi.org/10.1016/j.
jpor.2017.03.001.
8. Lin CY, Chen Z, Pan WL, Wang HL. Is history
of periodontal disease still a negative risk indica-
tor for peri-implant health under supportive post-­
implant treatment coverage? A systematic review
and meta-analysis. Int J Oral Maxillofac Implants.
2020;35(1):52–62. https://doi.org/10.11607/
jomi.7714.
9. Afshari Z, Yaghini J, Naseri R. Levels of smok-
ing and peri-implant marginal bone loss: a system-
atic review and meta-analysis. J Evid Based Dent
Pract. 2022;22(3):101721. https://doi.org/10.1016/j.
jebdp.2022.101721.
10. Amerio E, Mainas G, Petrova D, Giner Tarrida L,
Nart J, Monje A. Compliance with supportive peri-
odontal/peri-implant therapy: a systematic review.
J Clin Periodontol. 2020;47(1):81–100. https://doi.
org/10.1111/jcpe.13204.
11. Berglundh T, Armitage G, Araujo MG, Avila-Ortiz
G, Blanco J, Camargo PM, Chen S, Cochran D,
Derks J, Figuero E, Hämmerle CHF, Heitz-Mayfield
LJA, Huynh-Ba G, Iacono V, Koo KT, Lambert
F, McCauley L, Quirynen M, Renvert S, Salvi
GE, Schwarz F, Tarnow D, Tomasi C, Wang HL,
Zitzmann N. Peri-implant diseases and conditions:
consensus report of workgroup 4 of the 2017 world
workshop on the classification of periodontal and
peri-implant diseases and conditions. J Periodontol.
2018;89(Suppl 1):S313–8. https://doi.org/10.1002/
JPER.17-­0739.
12. Bidra AS, Daubert DM, Garcia LT, Gauthier MF,
Kosinski TF, Nenn CA, Olsen JA, Platt JA, Wingrove
SS, Chandler ND, Curtis DA. A systematic review of
recall regimen and maintenance regimen of patients
with dental restorations. part 2: implant-borne res-
torations. J Prosthodont. 2016;25(Suppl 1):S16–31.
https://doi.org/10.1111/jopr.12415.
13. Monje A, Aranda L, Diaz KT, Alarcón MA,
Bagramian RA, Wang HL, Catena A. Impact of
maintenance therapy for the prevention of peri-­
implant diseases: a systematic review and meta-­
analysis. J Dent Res. 2016;95(4):372–9. https://doi.
org/10.1177/0022034515622432.
14. Greenstein G, Eskow R. High prevalence rates of
peri-implant mucositis and peri-implantitis post den-
tal implantations dictate need for continuous peri-­
implant maintenance. Compend Contin Educ Dent.
2022;43(4):206–13; quiz 214.
513
15. Lin CY, Chen Z, Pan WL, Wang HL. The effect of
supportive care in preventing peri-implant diseases
and implant loss: a systematic review and meta-­
analysis. Clin Oral Implants Res. 2019;30(8):714–24.
https://doi.org/10.1111/clr.13496.
16. Atieh MA, AlAli F, Alsabeeha NHM. Outcome
of supportive peri-implant therapy on the rates of
peri-implant diseases and marginal bone loss: a sys-
tematic review and meta-analysis. Quintessence
Int. 2021;52(2):122–31. https://doi.org/10.3290/j.
qi.a45428.
17. Atieh MA, Almatrooshi A, Shah M, Hannawi H,
Tawse-Smith A, Alsabeeha NHM. Airflow for initial
nonsurgical treatment of peri-implantitis: a systematic
review and meta-analysis. Clin Implant Dent Relat
Res. 2022;24(2):196–210. https://doi.org/10.1111/
cid.13072.
18. Bidra AS, Daubert DM, Garcia LT, Kosinski TF, Nenn
CA, Olsen JA, Platt JA, Wingrove SS, Chandler ND,
Curtis DA. Clinical practice guidelines for recall
and maintenance of patients with tooth-borne and
implant-borne dental restorations. J Prosthodont.
2016;25(Suppl 1):S32–40. https://doi.org/10.1111/
jopr.12416.
19. Zhao R, Liu S, Liu Y, Cui S. Adjunctive use of active
compounds such as chlorhexidine in the nonsurgical
treatment of peri-implant mucositis for oral health:
a systematic review and meta-analysis. Oxidative
Med Cell Longev. 2022;2022:2312784. https://doi.
org/10.1155/2022/2312784.
20. Albrektsson T, Sennerby L. State of the art in oral
implants. J Clin Periodontol. 1991;18:474–81.
21. Zheng Z, Ao X, Xie P, Jiang F, Chen W. The bio-
logical width around implant. J Prosthodont Res.
2021;65(1):11–8. https://doi.org/10.2186/jpr.
JPOR_2019_356.
22. Monje A, Blasi G. Significance of keratinized
mucosa/gingiva on peri-implant and adjacent peri-
odontal conditions in erratic maintenance compli-
ers. J Periodontol. 2019;90(5):445–53. https://doi.
org/10.1002/JPER.18-­0471.
23. Ramanauskaite A, Schwarz F, Sader R. Influence
of width of keratinized tissue on the prevalence of
peri-­implant diseases: a systematic review and meta-­
analysis. Clin Oral Implants Res. 2022;33(Suppl
23):8–31. https://doi.org/10.1111/clr.13766.
24. Ravidà A, Arena C, Tattan M, Caponio VCA, Saleh
MHA, Wang HL, Troiano G. The role of keratin-
ized mucosa width as a risk factor for peri-implant
disease: a systematic review, meta-analysis, and
trial sequential analysis. Clin Implant Dent Relat
Res. 2022;24(3):287–300. https://doi.org/10.1111/
cid.13080. Epub 2022 Mar 17.
25. Ramanauskaite A, Galarraga-Vinueza ME, Obreja
K, Sader R, Schwarz F. Prevalence of peri-implant
diseases in patients with full-arch implant-supported
restorations: a systematic review. Int J Prosthodont.
2021;34:s27–45. https://doi.org/10.11607/ijp.6488.
26. Diaz P, Gonzalo E, Villagra LJG, Miegimolle B,
Suarez MJ. What is the prevalence of peri-­implantitis?
514
A systematic review and meta-analysis. BMC Oral
Health. 2022;22(1):449. https://doi.org/10.1186/
s12903-­022-­02493-­8.
27. Hämmerle CHF, Tarnow D. The etiology of hard- and
soft-tissue deficiencies at dental implants: a narrative
review. J Periodontol. 2018;89(Suppl 1):S291–303.
https://doi.org/10.1002/JPER.16-­0810.
28. Renvert S, Persson GR, Pirih FQ, Camargo
PM. Peri-implant health, peri-implant mucositis, and
peri-implantitis: case definitions and diagnostic con-
siderations. J Periodontol. 2018;89(Suppl 1):S304–
12. https://doi.org/10.1002/JPER.17-­0588.
29. Derks J, Ichioka Y, Dionigi C, Trullenque-Eriksson
A, Berglundh J, Tomasi C, Graziani F. Prevention
and management of peri-implant mucositis and peri-­
implantitis: a systematic review of outcome mea-
sures used in clinical studies in the last 10 years. Clin
Oral Implants Res. 2022. https://doi.org/10.1111/
clr.13925.
30. Atieh MA, Fadhul I, Shah M, Hannawi H, Alsabeeha
NHM. Diode laser as an adjunctive treatment for
peri-implant mucositis: a systematic review and meta-­
analysis. Int Dent J. 2022;72(6):735–45. https://doi.
org/10.1016/j.identj.2022.06.026.
31. Albrektsson T, Becker W, Coli P, Jemt T, Mölne J,
Sennerby L. Bone loss around oral and orthopedic
implants: an immunologically based condition. Clin
Implant Dent Relat Res. 2019;21(4):786–95. https://
doi.org/10.1111/cid.12793.
32. Albrektsson T, Tengvall P, Amengual-Peñafiel L, Coli
P, Kotsakis G, Cochran DL. Implications of consid-
ering peri-implant bone loss a disease, a narrative
review. Clin Implant Dent Relat Res. 2022;24(4):532–
43. https://doi.org/10.1111/cid.13102.
33. Heitz-Mayfield LJ, Needleman I, Salvi GE, Pjetursson
BE. Consensus statements and clinical recommenda-
tions for prevention and management of biologic and
technical implant complications. Int J Oral Maxillofac
Implants. 2014;29(Suppl):346–50. https://doi.
org/10.11607/jomi.2013.g5.
34. Heitz-Mayfield LJ, Aaboe M, Araujo M, Carrión
JB, Cavalcanti R, Cionca N, Cochran D, Darby
I, Funakoshi E, Gierthmuehlen PC, Hashim D,
Jahangiri L, Kwon Y, Lambert F, Layton DM,
Lorenzana ER, McKenna G, Mombelli A, Müller F,
Roccuzzo M, Salvi GE, Schimmel M, Srinivasan M,
Tomasi C, Yeo A. Group 4 ITI consensus report: risks
and biologic complications associated with implant
dentistry. Clin Oral Implants Res. 2018;29(Suppl
16):351–8. https://doi.org/10.1111/clr.13307.
PMID: 30328181.
35. Roccuzzo M, Layton DM, Roccuzzo A, Heitz-­
Mayfield LJ. Clinical outcomes of peri-implantitis
treatment and supportive care: a systematic review.
Clin Oral Implants Res. 2018;29(Suppl 16):331–50.
https://doi.org/10.1111/clr.13287.
36. Baima G, Citterio F, Romandini M, Romano F,
Mariani GM, Buduneli N, Aimetti M. Surface decon-
tamination protocols for surgical treatment of peri-
implantitis: a systematic review with meta-­analysis.
S. Kumar et al.
Clin Oral Implants Res. 2022;33(11):1069–86.
https://doi.org/10.1111/clr.13992.
37. Toledano-Osorio M, Vallecillo C, Toledano R,
Aguilera FS, Osorio MT, Muñoz-Soto E, García-­
Godoy F, Vallecillo-Rivas M. A systematic review and
meta-analysis of systemic antibiotic therapy in the
treatment of peri-implantitis. Int J Environ Res Public
Health. 2022;19(11):6502. https://doi.org/10.3390/
ijerph19116502.
38. Lin GH, Suárez López Del Amo F, Wang HL. Laser
therapy for treatment of peri-implant mucosi-
tis and peri-implantitis: an American Academy of
Periodontology best evidence review. J Periodontol.
2018;89(7):766–82. https://doi.org/10.1902/
jop.2017.160483.
39. Chambrone L, Wang HL, Romanos GE. Antimicrobial
photodynamic therapy for the treatment of periodon-
titis and peri-implantitis: an American Academy of
Periodontology best evidence review. J Periodontol.
2018;89(7):783–803. https://doi.org/10.1902/
jop.2017.170172.
40. Sanz-Martín I, Cha JK, Sanz-Sánchez I, Figuero E,
Herrera D, Sanz M. Changes in peri-implant soft
tissue levels following surgical treatment of peri-­
implantitis: a systematic review and meta-analysis.
Clin Oral Implants Res. 2021;32(Suppl 21):230–44.
https://doi.org/10.1111/clr.13840.
41. Derks J, Ortiz-Vigón A, Guerrero A, Donati M,
Bressan E, Ghensi P, Schaller D, Tomasi C, Karlsson
K, Abrahamsson I, Ichioka Y, Dionigi C, Regidor E,
Berglundh T. Reconstructive surgical therapy of peri-­
implantitis: a multicenter randomized controlled clin-
ical trial. Clin Oral Implants Res. 2022;33(9):921–44.
https://doi.org/10.1111/clr.13972.
42. Esteves Lima RP, Abreu LG, Belém FV, Pereira
GHM, Brant RA, Costa FO. Is implantoplasty effi-
cacious at treating peri-implantitis? A systematic
review and meta-analysis. J Oral Maxillofac Surg.
2021;79(11):2270–9. https://doi.org/10.1016/j.
joms.2021.06.015.
43. Lin CY, Chen Z, Chiang HL, Pan WL, Wang HL. The
impact of implantoplasty in regenerated and nonre-
generated treatment modalities in peri-implantitis:
a systematic review and meta-analysis. Int J Oral
Maxillofac Implants. 2022;37(5):859–68. https://doi.
org/10.11607/jomi.9436.
44. Giannobile WV, Jung RE, Schwarz F, Groups of
the 2nd Osteology Foundation Consensus Meeting.
Evidence-based knowledge on the aesthetics and
maintenance of peri-implant soft tissues: osteol-
ogy foundation consensus report part 1-effects of
soft tissue augmentation procedures on the main-
tenance of peri-implant soft tissue health. Clin Oral
Implants Res. 2018;29(Suppl 15):7–10. https://doi.
org/10.1111/clr.13110.
45. Montero E, Molina A, Matesanz P, Monje A, Sanz-­
Sánchez I, Herrera D. Efficacy of soft tissue sub-
stitutes, in comparison with autogenous grafts, in
surgical procedures aiming to increase the peri-­
implant keratinized mucosa: a systematic review. Clin
19 Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations
Oral Implants Res. 2022;33(Suppl 23):32–46. https://
doi.org/10.1111/clr.13751.
46. Cairo F, Barbato L, Selvaggi F, Baielli MG, Piattelli
A, Chambrone L. Surgical procedures for soft tissue
augmentation at implant sites. A systematic review
and meta-analysis of randomized controlled trials.
Clin Implant Dent Relat Res. 2019;21(6):1262–70.
https://doi.org/10.1111/cid.12861.
47. Schwarz F, Alcoforado G, Guerrero A, Jönsson D,
Klinge B, Lang N, Mattheos N, Mertens B, Pitta J,
Ramanauskaite A, Sayardoust S, Sanz-Martin I,
515
Stavropoulos A, Heitz-Mayfield L. Peri-implantitis:
summary and consensus statements of group 3. The
6th EAO Consensus Conference 2021. Clin Oral
Implants Res. 2021;32(Suppl 21):245–53. https://doi.
org/10.1111/clr.13827.
48. American College of Prosthodontists. Maintenance of
full arch implant restorations. a position paper.
49. Gay IC, et al. Role of supportive maintenance
therapy on implant survival: a university-based
17 years retrospective analysis. Int J Dent Hyg.
2015;14(4):267–71.
 Clinical Patient Presentations
20
Saj Jivraj

Abstract treatment. The clinician must also be astute

enough to recognise the risk factors and under-
Many fully edentulous patients tolerate com-
stand when this treatment protocol is not indi-
plete dentures because they have been told
cated. All patients are not candidates for
they are not candidates for implant therapy.
graftless solutions. Often more than four
Atrophy of the jaws is cited as the main rea-
implants are indicated and required. Often
son. Patients with a terminal dentition are also
bone reduction is unnecessary. This treatment
treatment planned this way, with clinicians
concept must not be a panacea for treatment of
choosing the conventional protocol of extrac-
all edentulous patients. A thorough medical
tion, healing and delayed implant placement.
and clinical evaluation must be undertaken
The reason for these assertions could be ana-
prior to treatment planning a patient for a
tomic because of pneumatised sinuses or
graftless solution that involves immediate
severe bone resorption. Most of these patients
loading of dental implants. This chapter will
are reluctant to go through extensive grafting
illustrate the diagnosis and treatment planning
procedures. Most patients if given the option
of five patients with differing clinical presen-
would also prefer to avoid a removable pros-
tations. Workflow, treatments sequence and
thesis in the interim period.
treatment execution will be presented.
As the treating clinician, our task becomes
to reassure the patient that the above are mis-
conceptions. Graftless solutions are a reality,
and patients can be rehabilitated without hav-
On a global scale, the number of edentulous indi-
ing to go through extensive grafting and use of
viduals is predicted to be much higher and, there-
a removable prosthesis. The patient must be
fore, treatment of edentulism will be a daily
informed of the risks and benefits. Treatment
challenge to clinicians for many years to come.
alternatives must be discussed and written
With the increasing number of patients requir-
informed consents obtained. All patient con-
ing full-arch implant rehabilitation, clinicians
cerns must be addressed comprehensively
will need further training in the diagnosis, treat-
prior to embarking upon treatment. It is imper-
ment planning and clinical execution of these
ative that the patient understand the treatment
protocols. If the clinician feels they are not
protocols, treatment sequence and timing of
equipped to treat such patients, appropriate refer-
ral must be made. Many edentulous patients
S. Jivraj (*)
Anacapa Dental Art Institute, Oxnard, CA, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 517
S. Jivraj (ed.), Graftless Solutions for the Edentulous Patient, BDJ Clinician’s Guides,
https://doi.org/10.1007/978-3-031-32847-3_20
518
avoid pursuing treatment due to the misconcep-
tions cited above.
Obstacles to treatment include but are not lim-
ited to.
1. Fear of wearing a removable appliance:
Immediate loading of dental implants has
been shown to be very successful if attention
is paid to a myriad of details. The patient
should be reassured that this part of the proto-
col is very predictable.
2. Prolonged treatment time:
By simplification of the treatment process
and avoiding any unnecessary grafting
procedures, treatment time is drastically
­
reduced. An additional advantage is the
patient is able to receive fixed permanent teeth
the same day.
3. That treatment is painful:
There is some discomfort associated with
any surgical procedure. With the teeth being
implant-supported from day 1, the discomfort
is greatly reduced. It should be explained to
the patient that this prosthesis is different to
an immediate denture in that it does not move
and the surgical site is allowed to heal
undisturbed.
4. The procedures are unpredictable:
Multicentre studies (see previous chapters)
show the predictability of the procedure to be
in the range of 90–98% in experienced opera-
tors. The patient should be made aware of
their responsibility in the overall process. Soft
diet, hygiene and use of a night-time occlusal
guard are critical to a favourable outcome.
5. The treatment is very costly:
Cost is a concern for every patient, and
treatment may be broken down into phases to
accommodate the patient’s financial situation.
The patient should also be made aware that
the cost of doing nothing may be much higher
in the overall lifetime of the patient as this
particular treatment does have life-changing
repercussions.
The following patient presentations are of
patients who had all been told that dental implant
therapy was not possible unless major grafting
was undertaken.
In keeping consistent with the theme of this
text, patient presentations will be prosthetically
S. Jivraj
treatment planned based on the seven diagnostic
factors outlined in a previous chapter.
1. Incisal edge position.
2. Restorative space.
3. Lip support.
4. Smile line and lip length.
5. Contours and emergence.
6. Tissue contact.
7. Occlusion.
Surgically diagnosis and treatment planning
will address the.
1. Medical status of the patient.
2. Space requirements.
3. Spread of implant positions.
4. Stability of implants placed.
20.1 Patient 1: Re-treatment
of a Failed Implant
Rehabilitation
Surgical evaluation: All patients considered for
full-arch rehabilitation undergo a systematic
diagnosis and treatment planning process. First,
the patient’s medical status and history are con-
sidered for any contraindications to proposed
procedure and their possible management.
Secondly the patients’ overall health is consid-
ered for the determination of the appropriate
anaesthesia modality. The overall goal of graft-
less approaches to this class of patients is to make
the proposed surgical treatment accessible to as
many patients as possible. Therefore, avoidance
of more complicated anaesthesia modalities such
as in-hospital anaesthesia delivery is not condu-
cive to the accessibility goal and should be
reserved for the medically compromised patient.
Clinicians must develop the anaesthesia and sur-
gical skill necessary to treat this type of patients
safely and efficiently in office with the simplest
anaesthesia technique possible tailored to each
individual patient. Most patients can be effec-
tively and comfortably treated with profound
local anaesthesia combined with a mild sedative.
Patient 1 was a 73-year-old woman with no
significant medical conditions.
20 Clinical Patient Presentations 519

The patient’s clinical and radiographic data

were gathered to determine the appropriate
method to satisfy the three absolute surgical
requirements.
The patient presented with multiple dental
implants placed at another clinic within the past
2 years. The patient reported that the original
treatment plan was for a fixed hybrid appliance
but it was aborted in favour of an implant-­
supported removable appliance due to unknown
reasons (Figs. 20.1, 20.2, and 20.3). She reported
absolute dissatisfaction with the appliance and a Fig. 20.2 Implant and mucosa-supported removable
lack of confidence in the treatment process in gen- appliance
eral. She was frustrated with the previous care
provided and wanted a more definitive result with
a fixed appliance. She demanded that transition to
fixed appliance be completed with minimal time
spent in dental offices and without any grafting.
Clinical examination of the patient was per-
formed, and initial presentation showed four

Fig. 20.3 Poorly distributed implants, exposure of

implant threads

Fig. 20.4 Radiograph showing failing implants in both

maxilla and mandible

maxillary as well as three mandibular implants

Fig. 20.1 Patient presented with removable appliance,
relatively pleased with the aesthetics
which appeared to be failing (Fig. 20.4). All
implants showed significant bone loss with thread
exposure. The tissue support around implants
showed inflammation and superficial infection.
The soft tissue supporting the denture was very
inflamed and irritated. The initial radiographic
520
examination confirmed significant bone loss
around all existing implants and improper angu-
lation. Facial evaluation showed a pleasing smile
with appropriate teeth showing in repose and
smiling, there appeared to be sufficient lip sup-
port from the over-denture flange. The removal of
the denture showed significant lack of lip support
by the existing bony structures of the maxilla.
The edentulous ridge was not visible during smil-
ing with the denture removed.
Radiographic evaluation showed all implants
in the maxilla and mandible to exhibit significant
bone loss circumferentially. Restorative space
measured on a cephalometric film obtained from
CT scan was measured at 42 mm (Fig. 20.5).
Panoramic and cross-sectional images of the
maxilla and mandible were obtained and showed
significant atrophy of both the arches. The max-
illa exhibited large pneumatised sinuses occupy-
ing majority of the maxilla. There was significant
atrophy of the pre-maxilla with 7–8 mm of alveo-
lus remaining below the floor of nose. There was
minimal bone remaining in the molar and premo-
lar regions, zones 2 and 3 (Fig. 20.6). The man-
dible showed moderate amount of resorption
with 10 mm of bone above the inferior alveolar
nerve and with sufficient width throughout.
Fig. 20.5 Cephalometric radiograph used to measure
vertical restorative space between platform of implants in
maxilla and mandible. Forty-two millimetre of restorative
space was determined
S. Jivraj
Fig. 20.6 Panoramic radiograph showing very large
maxillary sinuses and severe atrophy of the maxilla; avail-
able bone support is highlighted. Mandible shows suffi-
cient vertical bone height for dental implant placement
20.1.1 Surgical Treatment Plan
(Patient 1)
1. Patient is a healthy 73-year-old with no abso-
lute contraindications for oral surgery proce-
dures. Mild sedation with profound local
anaesthesia was utilised to perform the proce-
dure in a safe and comfortable manner.
2. Space: The patient has undergone moderate
alveolar atrophy with perhaps alveoloplasty at
the time of the existing implant placement.
Forty-one millimetre of inter-arch space was
measured clinically. The patient was t­ reatment
planned for an acrylic resin titanium prosthe-
sis. There was sufficient space for the pro-
posed restoration. No further space creation
via bone reduction was necessary. It was
determined that due to severe atrophy of the
maxilla and superior position of the implants
an appropriate contour to the prosthesis can
be achieved to provide lip support without a
horizontal shelf formation; therefore, no fur-
ther bone reduction is necessary to place
implants.
3. Spread: The challenge in this case is the lack
of bone in all three zones of maxilla. The
removal of the existing implants will compli-
cate the reconstruction. The implant removal
defects will limit the options in positions
available for placement. Preplanning of
implant placement showed that an angled
implant configuration such as All-on-4™
would not be possible due to the extensive
anterior extension of the maxillary sinuses.
20 Clinical Patient Presentations
Both posterior implants would not be in max-
illary bone if the platform was kept in the
bicuspid regions or zone 2 and the implants
were angled no more than 45°. Furthermore,
the lack of anterior bone volume under the
floor of the nose did not allow axial implant
placement (Fig. 20.7). An alternative place-
ment scheme was devised with posterior sup-
port provided by bilateral zygomatic implants
and the anterior support by bilateral angled
implants in the pyriform rim or lateral nasal
wall. The mandible would be treated with
removal of the existing implants and alveolo-
plasty to create a flat platform for implant
placement. Two implants would be placed just
anterior of the mental foramen and two axial
implants in the anterior midline of the mandi-
ble (Fig. 20.8).
4. Stability: The zygoma is an extremely dense
bone structure that will provide excellent sta-
bility to the zygomatic implants. There is suf-
ficient ridge to allow for anchorage of the
crestal portion of the zygomatic implants. The
anterior implants would be placed with the
apical portion in the very dense lateral nasal
wall—pyriform rim of the maxilla.
Fig. 20.7 Planning of zygomatic implant treatment con-
cept with angled anterior dental implant placement
Fig. 20.8 All-on-4™ treatment concept planning tracing
showing lack of bone in posterior maxilla for angled
implant placement. Also showing lack of vertical bone
height in anterior maxilla
521
20.1.2 Prosthetic Evaluation
This patient presented having recently undergone
dental implant therapy but was unhappy with the
removable implant and tissue-supported over-­
dentures that were provided. The patient
requested a fixed prosthesis and was unwilling to
go through grafting procedures.
On clinical examination, the dentures lacked
retention and stability. The palatal tissues were
inflamed. There was an absence of keratinised
mucosa. The existing implants demonstrated
bone loss and were in unfavourable locations
(Figs. 20.9 and 20.10).
From a diagnostic perspective, the following
factors were evaluated:
1. Incisal edge position: The patient was rela-
tively pleased with the aesthetics of the exist-
ing dentures. The incisal edge position
appeared to be satisfactory. A diagnostic
Fig. 20.9 Inflamed palatal tissue indicating poor fit. Poor
distribution of implants
Fig. 20.10 Inflamed mandibular tissue and poor distribu-
tion of implants
522 S. Jivraj

d­ enture set-up was to be done to evaluate any

modifications in aesthetics (Fig. 20.11).
2. Restorative space: Due to the severe bone
resorption, restorative space would be avail-
able for any material combination. Due to
financial constraints, acrylic resin titanium
prosthesis was selected.
3. Lip support: The patient had a severe lack of
lip support and a concave facial profile when
the dentures were removed. This is one of the
factors that would pose a challenge in provid-
ing the patient with a fixed restoration. Due to
the fact that the patient was unwilling to go
through additional grafting procedures, alter-
native clinical strategies would need to be
evaluated such as alveolectomy and tilting of
the anterior implants so that the contour of the
restoration could be developed and so that it
was maintainable (Figs. 20.12 and 20.13).
4. Smile line: With the dentures removed, the
alveolar ridge was not visible, so hiding the
transition zone would not pose a problem.
5. Contours and emergence: The horizontal dis-
crepancy between the implant position and
where the patient desired the teeth aestheti- Fig. 20.12 Severe facial collapse on removing dentures
cally posed a significant challenge. Using
shorter implants, tilting the anterior implants
and starting the emergence profile higher up
would help create some space for contour
development.
6. Tissue contact: The existing tissues must be
made healthy prior to any surgical procedures.
Soft relining of the patients existing denture

Fig. 20.13 If there is a discrepancy between lip support

and implant position, a horizontal shelf results

to be carried out to achieve this. Due to the

Fig. 20.11 Smiling view of patients existing denture
indicate approximate incisal edge position she is happy
with
extensive resorption and available space,
shaping the restorative contours for a convex
undersurface is attainable. This will allow the
patient to maintain the prosthesis.
7. Occlusion: Occlusion must be addressed in
the immediate load provisional to protect the
20 Clinical Patient Presentations 523

implants in the weakest quality bone from

excessive loads. In the definitive restoration,
occlusion must be organised to distribute the
loads over as wide an area as possible.

20.1.3 Surgical Procedure

The patient was anaesthetised with a mild seda-

tive combination of fentanyl, midazolam, diaze-
pam and morphine sulphate. Antibiotic medication
consisting of 1 g of cefazolin was administered Fig. 20.14 Removed implant defects visible in the max-
intravenously at the beginning of the procedure. illa. Zygomatic implant positioned within bilateral zygo-
After titration of the sedatives, infiltration and matic bone with crestal anchorage in the residual posterior
maxilla. Angled implants in the anterior maxilla with
block injections of local anaesthesia were com- appropriate multi-unit abutments placed
pleted to provide a profound local anaesthesia.
Ten minutes of time was allowed for the local
anaesthesia to take full effect. Crestal incision
was made in the maxilla with bilateral vertical
releasing incisions in the tuberosity region. The
maxilla was completely exposed. The existing
implants were removed utilising retrieval tools.
Trephine drills were not necessary. The nasal cav-
ities were identified and exposed allowing for
visualisation of the lateral walls. Openings into
bilateral sinus cavities were created along the but-
tress of the zygomatic bone using large round
burs. The Schneiderian membranes were lifted off
the interior of the sinus extending to the roof of
the sinus and exposing the medial aspect of the
zygomatic process. Using the zygomatic 2.9 mm Fig. 20.15 Coronal radiographic sections through ante-
drill the initial osteotomy was made through the rior maxilla showing angled anterior implants anchored in
very dense lateral nasal wall. Note proximity of the ante-
maxillary alveolus at the second bicuspid region. rior implants to nasal cavity and inferior turbinates
The long drill was extended thorough the maxil-
lary sinus to engage the zygomatic bone at its
thickest portion and exiting at the prominence of received a straight multi-unit abutment. The angu-
the zygoma (Fig. 20.14). Appropriate length lation of the two lateral implants was corrected by
implants were selected and placed. Next, two placement of 17° multi-unit abutments. In the
13 mm NobelSpeedy implants were placed in the mandible the previous implants were removed.
approximate position of lateral incisors and Bilateral mental nerves were identified.
angled to engage the lateral nasal wall. The place- Alveoloplasty was performed to create a level
ment of the angled implants in the anterior max- platform for implant placement. Posterior
illa allowed for placement of longer implants implants were placed by positioning the platforms
engaging the very dense areas of bone in lateral superior to the foramen, and the axis of the
nasal wall (Fig. 20.15) A 10 mm NobelSpeedy implants was tilted up to 45° to avoid injury to the
implant was placed in the midline maxilla. Multi-­ nerve. Two more NobelSpeedy implants were
unit abutments were placed on the zygomatic placed between the implant defects created by the
implants. The midline anterior implant also removal of the previous fixtures. All implants
524
were long enough to engage the very dense corti-
cal plates of inferior border of the mandible
(Fig. 20.16). All maxillary and mandibular
implants were found to be very stable. Multi-unit
abutments were placed on the posterior implants
to correct the angulation of the implants and
straight abutments were placed on the anterior
two implants (Figs. 20.17 and 20.18). All surgical
sites were irrigated and closed utilising chromic
gut sutures. The patient tolerated the procedure
well and was turned over to the prosthodontic
team for fabrication of the provisional prosthesis.
20.1.4 Prosthodontic Sequence
Immediate dentures at the correct vertical dimen-
sion were fabricated for a direct pick-up proce-
dure. Vertical dimension was determined prior to
implant placement and a record made.
Fig. 20.16 Mandibular implants placed according to the
All-on-4™ treatment concept. Defects from removed
implants are visible
Fig. 20.17 Panoramic radiograph showing completed
surgical phase with zygomatic implants and angled ante-
rior implants in the maxilla and mandible treated accord-
ing to the All-on-4 treatment concept principles
S. Jivraj
Fig. 20.18 Note the relationship of the zygomatic
implants to the orbital cavity and zygomatic bone
A direct technique for immediate loading was
employed. Vertical dimension, centric relation
and occlusal plane were verified. After protec-
tion of the surgical sites with rubber damn, tem-
porary cylinders were first picked up in the
maxillary prosthesis. The patient was guided
into centric relation and a similar pick-up of
temporary cylinders was performed in the man-
dibular provisional denture. The prostheses were
removed and transferred to the dental laboratory
where the prostheses were processed and fin-
ished. The prostheses were adjusted to leave a
1 mm space between the prostheses and the tis-
sue. Ten teeth were provided and no cantilevers.
Occlusion was adjusted for shimstock hold on
anterior teeth and shimstock drag on the poste-
rior teeth. Vertical dimension was verified on
delivery of the restoration (Figs. 20.19, 20.20
and 20.21).
Splinted open tray impressions, jaw relation
records and a trial restoration were inserted to
verify aesthetics and phonetics (Figs. 20.22 and
20.23).
The trial restoration was utilised to fabricate a
titanium framework using CAD software.
Computer-aided milling was performed.
The frameworks were tried in and checked
against the putty matrices to ensure sufficient
room for acrylic resin and tooth. A final try-in
was performed on top of the titanium frameworks
to verify aesthetics, phonetics, fit and occlusion.
20 Clinical Patient Presentations
Fig. 20.19 Smile view of immediate load transitional
prosthesis
Fig. 20.20 Patient happy with transitional aesthetics; lip
support was critical to establish
The wax prosthesis was processed to acrylic resin
under heat and pressure using injection moulded
techniques.
The prosthesis was delivered adjusting the
undersurface to ensure positive pressure.
Dynamic occlusion was adjusted for canine guid-
ance. Static occlusion was adjusted to ensure
shimstock hold on canines and premolars.
525
Fig. 20.21 Post integrations, health of tissue should be
evident
Fig. 20.22 Wax trial prosthesis to verify aesthetics and
phonetics
Fig. 20.23 Final aesthetic try-in
Shimstock drag on anterior teeth and no contact
on the cantilevers.
Screws were torqued according to the manu-
facturer’s instructions, and access holes were
sealed using Teflon and composite resin.
A night-time appliance was provided and
maintenance instructions provided (Figs. 20.24
and 20.25).
526 S. Jivraj

She was seeking fixed implant-supported restora-

tions. The patient’s request was to avoid wearing
dentures in the interim phase and perform the pro-
cedure without grafting (Figs. 20.26 and 20.27).
On clinical examination, the following diag-
noses were made:

Fig. 20.24 Definitive acrylic resin titanium prosthesis

Fig. 20.26 Initial patient presentation; patient unhappy

with her smile

Fig. 20.25 Definitive smile

20.2 Patient 2: Implant

Rehabilitation
of a Periodontally Failing
Dentition with Moderate-to-­
Advanced Bone Loss

A 76-year-old woman presented with a terminal

dentition. She reported a history of periodontal dis- Fig. 20.27 Failing dentition of a 73-year-old patient
ease and gradual tooth loss over the last few years. desiring fixed implant restoration
20 Clinical Patient Presentations 527

(a) Caries.
(b) Periodontal disease with advanced loss of
bone support.
(c) Lack of posterior support.
(d) Partial edentulism.
The predominant factor in the above diagno-
ses that would impact the outcome of treatment is
periodontal disease. Treatment of these patients
usually begins with reducing the periodontal
pathogens by supportive periodontal treatments
such as scaling and root-planning even though
the teeth will be extracted. The literature shows Fig. 20.28 In the planning phase, it was decided to repo-
sition the maxillary incisal edge. This will have an impact
that the number of periodontal pathogens is on position of implant placement
greatly reduced when teeth are extracted and con-
verted to peri-implant sites. The literature also
shows that periodontal pathogens can exist in the
mouth up to a year after teeth have been extracted.
The implications of this pertain to maintenance
and recall of the patient. Patient motivation and
periodontal maintenance are critical to the long-­
term success because the progression of the dis-
ease cannot be ruled out.
From a diagnostic perspective, the following
factors were evaluated:
1. Incisal edge position: On clinical examination,
excessive display of the maxillary incisal edge
was evident. In planning the rehabilitation, the Fig. 20.29 Lateral view showing adequate lip support
incisal edge would need to be repositioned fur-
ther apically. Repositioning the incisal edge
would have implications on implant placement
as a transition zone is required between the
head of the fixture and the emergence of the
restoration from the gingiva. Alveolectomy
would be required and communicated to the
surgeon prior to implant placement. The
patient was informed that due to bone loss
pink prosthetics would be required (Fig. 20.28).
2. Restorative space: In periodontally involved
patients, the bone towards the crest is usually
quite thin. This often has to be reduced to cre-
Fig. 20.30 Patient presented with excessive gingival dis-
ate restorative space and a sufficient width of play due to over-eruption of maxillary anterior sextant
bone for optimal implant placement.
3. Lip support: The patient’s lip was oversup-
ported due to flaring of the maxillary anterior diagnosis for the excessive gingival display
teeth (Fig. 20.29). has to be made so that the appropriate treat-
4. Smile line: The patient displayed excessive lip ment option can be selected. In this instance,
mobility and a high smile line which dis- the cause of the excessive gingival display is
played an excessive amount of gingiva. A over-eruption of the teeth (Fig. 20.30).
528
5. Contours and emergence: Any reduction
planned should pay meticulous attention to
the contours of the restoration required to
develop an appropriate emergence profile.
6. Tissue contact: Following extraction of the
teeth and creation of adequate restorative
space shaping the restorative contours for a
convex undersurface is attainable. This will
allow the patient to maintain the prosthesis.
7. Occlusion: Occlusion must be addressed in
the immediate load provisional to protect the
implants in the weakest quality bone from
excessive loads. In the definitive restoration,
occlusion must be organised to distribute the
loads over as wide an area as possible.
Surgically diagnosis and treatment planning
will address the.
1. Medical status of the patient.
2. Space requirements.
3. Spread of implant positions.
4. Stability of implants placed.
Surgical evaluation: Clinicians involved in
care of the edentulous patient must realise that
the majority of patients in this classification will
be elderly with varying health status. Management
of the patient’s medical issues plays an important
role as surgical implant placement in the overall
success of the treatment. The patient presented
here suffered from multiple significant medical
conditions requiring extensive consultation and
intervention.
Patient 2 is a 76-year-old woman presented
with multiple periodontally compromised teeth
in both maxilla and mandible. She was deemed to
have a terminal dentition most appropriately
treated with removal of all teeth and prosthetic
rehabilitation. The patient had expressed a desire
to have a fixed appliance throughout the treat-
ment regimen. She had previously unsuccessfully
treated with removable partial dentures. She was
very insistent that no removable appliances be
fabricated. She suffered from significant pulmo-
nary disease that required multiple admissions to
hospital for acute treatment. She also exhibited
coronary vascular disease and hypertension.
Clinical examination of the patient revealed
an oral condition best characterised as ‘terminal’.
She had multiple teeth with severe bone loss
S. Jivraj
Fig. 20.31 Panoramic radiograph of terminal dentition
(Fig. 20.31). Her anterior teeth exhibited varying
degrees of gingival recession and root exposure.
There were multiple areas of cervical decay on
all incisors. Existing restorations were found to
be inadequate and failing. Facial aesthetic evalu-
ation showed extruded incisal position with
excessive tooth and gingival exposure in repose
and smiling. The patient showed approximately
5 mm of gingiva on smiling which will be critical
in surgical decision-making.
Radiographic exam showed severe bone loss
throughout the mouth. On initial view, she
appeared to have 10 mm height of bone in the
right maxillary alveolus beneath the maxillary
sinus. The left maxilla exhibited a different sce-
nario with extension of the sinus anteriorly and
inferiorly. There appeared to be insufficient verti-
cal bone dimension for implant placement in the
first molar position of left maxilla. The mandible
appeared to have adequate bone in both vertical
and horizontal dimensions.
20.2.1 Surgical Treatment Plan
1. Patient is a frail 76-year-old woman with mul-
tiple medical conditions complicating treat-
ment. Consultation with the patient’s
cardiologist and pulmonologist was made.
Pulmonary status proved to be the most diffi-
cult to optimise prior to surgery. The pulmon-
ologist was weary of general anaesthesia
requiring prolonged intubation and difficulty
weaning the patient off ventilation. The rec-
ommendation was made to perform the proce-
dure with conscious sedation and local
20 Clinical Patient Presentations
anaesthesia in two shorter surgical procedures
instead of attempting to treat the maxilla and
mandible in one general anaesthesia
procedure.
2. Space: Cephalometric radiographs obtained
showed that patients had adequate inter-arch
space due to extensive resorption of the man-
dible (Fig. 20.32). Approximately 26 mm of
inter-arch space was available with the current
vertical dimension of occlusion. However,
5 mm of gingival shows on smiling required
10 mm of maxillary vertical bone removal to
assure coverage of the transition line under
the upper lip. Therefore, 10 mm of bone
reduction in the maxilla and minimal man-
dibular alveolectomy was planned.
Fig. 20.32 Cephalometric radiograph of the patient pre-
sented showing approximately 26 mm of restorative space
available
Fig. 20.33 Planned alveolar reduction is marked on the
radiograph and implant positions are simulated showing
lack of adequate bone in the left posterior maxilla for
529
3. Spread: At first view of the radiographs, it
appeared that this patient may have sufficient
bone volume for either axial or tilted implant
treatment of the maxilla. The mandible had
sufficient bone above the nerve for axial or
tilted implant treatment protocols. However,
upon further investigation it became apparent
that due to the high smile line and the absolute
need to hide the transition line under the upper
lip, bone reduction will be significant. The
application of bone reduction to the maxilla
significantly reduces the volume of bone
available for implant placement. The right
side of maxilla becomes amenable to tilted
implant placement; however, the left side due
to the asymmetrical anterior extension of the
sinus and lack of sinus floor bone volume can
only be treated with the use of zygomatic
implant concept. The other available options
would be sinus augmentation and delayed
implant placement or pterygoid plate/tuberos-
ity bone implant placement. The anterior
maxilla in zone 1 retains enough bone after
reduction to allow placement of axial implants
(Figs. 20.33 and 20.34).
4. Stability: This is an elderly female patient with
suspected osteoporotic bone. Although osteo-
porosis is not an absolute contraindication to
implant placement, care should be taken to
avoid excessive damage to the bone and utilise
techniques and implants to counteract the lack
of stability in soft bone. Aggressive implant
design, engagement of non-alveolar or basilar
bone and modification of the osteotomy tech-
nique should be utilised.
angled implant placement. Anterior extension of the left
maxillary sinus is highlighted with the arrow
530 S. Jivraj

Fig. 20.34 Simulated

planning of implant
placement with use of
zygomatic implant in the
left posterior region

Fig. 20.35 Use of a bone reduction stent seated on the palate to determine the dimensions of reduction. Marks on the
bone highlighted with the arrows showing the amount of bone reduction to be performed

20.2.2 Surgical Treatment

Special attention was paid to the administration

of anaesthesia to this patient. She was treated in
office under close observation over 2 consecutive
days. The medical state of patient was optimised
as much as possible with the help of her physi-
cians. All efforts were made to avoid delays in
her procedure, so that she could be treated as
quickly and efficiently as possible, avoiding
excessive sympathetic response. Sedative anaes-
thesia was titrated to effect. She maintained spon-
taneous ventilation without any difficulty. Local
anaesthesia was infiltrated to achieve desired
local pain control. Use of vasoconstrictors was
minimised. All maxillary and mandibular teeth
were removed on the first day of surgery.
Maxillary mucoperiosteal flap was elevated and
previously fabricated bone-reduction guide was
used to mark the desired ostectomy. Bone reduc-
tion was completed quickly (Figs. 20.35 and
20.36). Osteotomy of the left zygomatic implant
was completed and an appropriate length zygo-
Fig. 20.36 Reduction of maxillary alveolus is completed
and flat plane is developed for implant placement. The
arrow shows the dimensions of reduction
matic implant was secured in place (Fig. 20.37).
An implant was angled up to 45° in the posterior
right maxilla just anterior to the anterior wall of
sinus as described in the All-on-4™ protocol.
Two implant osteotomies were completed in the
maxilla incisor region. All of the osteotomies
were performed in a modified underpreparation
technique where the apical portions of the oste-
otomies were underprepared relative to the crestal
portion. The extent of underpreparation was
20 Clinical Patient Presentations
determined by the quality of the bone. Regardless
of the modification of the osteotomy preparation
and use of an aggressive implant design, the left
anterior implant did not achieve sufficient stabil-
ity and was removed after multiple attempts.
Another osteotomy was performed slightly distal
to the initial osteotomy while maintaining A-P
spread, but that implant was found to be unstable
as well. Finally on the third attempt a distally
angled implant was placed engaging the anterior
sinus wall to achieve stability and was found to
be above 35 N of torque value (Fig. 20.38).
Angled and straight multi-unit abutments were
placed where appropriate and torqued tight to
prescribed torque values. Primary closure of the
incision was achieved. The patient was comfort-
Fig. 20.37 Position of the zygomatic implant in the left
maxilla posterior region. Note the position of the platform
in close proximity to the palatal root socket of the first
molar
Fig. 20.38 Radiographic evidence of position of
implants in the maxilla from left to right: (1) angled
implant with close proximity to the anterior wall of sinus.
(2) Right anterior implant engaging the nasal floor. (3)
531
able throughout the procedure, breathing sponta-
neously and maintaining stable vital signs. The
fabrication of the maxillary provisional appliance
was completed by the prosthodontist immedi-
ately following the surgical procedure. The fol-
lowing day the patient was seen in the surgical
office. The same anaesthesia technique was used
to treat the patient again. Alveoloplasty of the
alveolar ridge was completed and implants were
placed in the mandible following the All-on-4™
treatment protocol (Fig. 20.39). Mandibular pro-
visional prosthesis was fabricated. The patient
tolerated both days very well and healed unevent-
fully before the definitive restorations were made.
Learning points
1. Medical and anaesthesia management of
patient
2. Bone reduction due to excessive gingival
show and improper incisal edge position
3. Implant osteotomy modification due to soft
bone
20.2.3 Prosthetic Treatment Plan
The tissues were made healthy through scaling
and root planning and administration of an anti-
bacterial mouthwash.
A direct technique for immediate loading was
employed. Vertical dimension, centric relation
and occlusal plane were verified. After protection
Left anterior angled implant engaging the anterior wall of
maxillary sinus. (4) Left zygomatic implant engaging full
thickness of the maxillary bone
532 S. Jivraj

Fig. 20.39 Completed surgical treatment of the maxilla

and mandible

Fig. 20.41 Mandibular immediate load; occlusion placed

from canine to canine

Fig. 20.40 Direct technique for immediate loading of

maxilla

of the surgical sites with rubber damn, temporary Fig. 20.42 Maxillary acrylic prototype for zirconia pros-
cylinders were first picked up in the maxillary thesis against mandibular trial set-up
prosthesis. The patient was guided into centric
relation and a similar pick-up of temporary cylin-
ders was performed in the mandibular provisional
denture. The prostheses were removed and trans-
ferred to the dental laboratory where the prosthe-
ses were processed and finished (Figs. 20.40 and
20.41). The prostheses were adjusted to leave a
1 mm space between the prostheses and the tis-
sue. Ten teeth were provided and no cantilevers.
Occlusion was adjusted for shimstock hold on Fig. 20.43 Prototype displaying minimal cutback to
anterior teeth and shimstock drag on the posterior combine aesthetics of ceramics and strength of zirconia
teeth. Vertical dimension was verified on delivery
of the restoration.
Splinted open tray impressions, jaw relation A maxillary acrylic prototype was verified
records and a trial restoration were inserted to against a mandibular wax try-in. The maxillary
verify aesthetics and phonetics. acrylic prototype was cutback to allow for
The definitive restorations included a mini- 0.8 mm ceramic on the buccal surface for aesthet-
mally layered zirconia-based maxillary restora- ics. The restoration was designed to provide
tion and an acrylic resin titanium restoration. static and dynamic occlusion in polished mono-
lithic zirconia (Figs. 20.42 and 20.43).
20 Clinical Patient Presentations
Fig. 20.44 Laboratory view of completed maxillary zir-
conia restoration against mandibular acrylic resin
titanium
The prototype and the master casts are
scanned, digitised and copymilled from zirco-
nia blocks. A cement space was to be incorpo-
rated into the zirconia framework to achieve a
passive fit and compensate for post-sintering
distortion.
The milled frame was characterised using
metal oxides, and the frame was then dried and
sintered.
The areas of cutback were veneered with feld-
spathic ceramics. It is important that the coeffi-
cient of thermal expansion is matched.
The final phase was the luting of the titanium
inserts within the zirconia framework. This was
accomplished using a phosphate-based resin
cement.
533
Fig. 20.45 Definitive restorations intraorally
A titanium framework was fabricated for the
mandibular restoration over which acrylic resin
was processed.
The prosthesis was delivered adjusting the
undersurface to ensure positive pressure.
Dynamic occlusion was adjusted for canine guid-
ance. Static occlusion was adjusted to ensure
shimstock hold on canines and premolars.
Shimstock drag on anterior teeth and no contact
on the cantilevers.
Screws were torqued according to the manu-
facturer’s instructions, and access holes were
sealed using Teflon and composite resin
(Figs. 20.44, 20.45, and 20.46).
A night-time appliance was provided and
maintenance instructions provided.
534
Fig. 20.46 Before and after of patient
20.3 Patient 3: Treatment
of a Periodontally Failing
Dentition
A 59-year-old man presented with a terminal
dentition and was seeking fixed implant-­
supported restorations in both maxillary and
mandibular arches.
A thorough clinical examination was
performed.
The following clinical observations were
made:
1. Periodontally failing dentition with periodon- 3. A graftless option with implant placement and
tal pocket depths in the region of 7–10 mm in
multiple sites.
2. Over-erupted mandibular anterior teeth.
3. Caries in multiple teeth.
4. Signs of excessive force on the dentition.
5. Lack of posterior support.
A number of options were discussed with the
patient, which included:
1. Scaling and root planning to reduce bacterial
load. Hygiene visits are emphasised from the
S. Jivraj
outset so that the patient understands the
importance of regular recall.
2. Staged implant placement and fabrication of
tooth-supported provisional restorations
whilst the implants were integrating. In this
approach, 6–8 implants would have been
placed. Placement of additional implants
would allow the clinician to segment the pros-
thesis and fabricate implant-supported crown
and bridgework. In this instance, the clini-
cians felt this was the best option for the
patient. The patient declined this option.
immediate loading.
20.3.1 Prosthodontic Diagnosis
1. Incisal edge position: On clinical examina-
tion, there was insufficient display of the max-
illary incisal edge and excessive display of the
mandibular incisal edge. The mandibular inci-
sors had over-erupted because of the anterior
20 Clinical Patient Presentations
tooth relationship. The maxillary incisal edge
required repositioning more apically in order
to correct the occlusal plane and minimise
vertical overlap of the anterior teeth. In order
to do this, thought had to be given to implant
position in relation to the mandibular incisal
edge. In patients with periodontally involved
dentitions, often the teeth have over-erupted
bringing with them an alveolar complex
which is of inadequate buccolingual width to
place implants. Thought had to be given to
alveolectomy prior to implant placement
(Figs. 20.47, 20.48, and 20.49).
2. Restorative space: The patient was treatment
planned for maxillary and mandibular mini-
mally layered zirconia restoration. The maxil-
lary arch would be treated as a tooth-only
defect. The mandibular arch would require
some pink prosthetics.
3. Lip support: The patient’s lip was well
supported.
4. Smile line: The patient had a low smile line
and insufficient display of his maxillary ante-
rior teeth. Often in patients who are conscious
of the appearance of their teeth, the smile line
is low. The clinician should be aware that
once teeth are replaced the patient is likely to
have a much higher smile line. At the diagnos-
tic phase, the patient should be forced to have
an exaggerated smile line.
5. Contours and emergence: Any reduction
planned should pay meticulous attention to
the contours of the restoration required to
develop an appropriate emergence profile.
6. Tissue contact: Following extraction of the
teeth and creation of adequate restorative
Fig. 20.47 Preop of periodontally failing dentitions
535
space shaping, the restorative contours for a
convex undersurface are attainable. The pro-
visional restoration was to be used to com-
press the tissue and create a concave tissue
surface.
7. Occlusion: Occlusion must be addressed in
the immediate load provisional to protect the
implants in the weakest quality bone from
excessive loads. In the definitive restoration,
occlusion must be organised to distribute the
loads over as wide an area as possible.
Surgically diagnosis and treatment planning
will address the.
1. Medical status of the patient
2. Space requirements
3. Spread of implant positions
4. Stability of implants placed
Surgical evaluation: Although most patients
presenting and considered for full-mouth reha-
bilitation are elderly, there are at times younger
adults in need of treatment that present differ-
ent challenges. Very often the challenge to be
considered is the efficiency of treatment for an
individual with limited time and busy life. One
must also consider and discuss with the patient
the longer future use of the prosthesis and its
associated maintenance. Our patient presented
is a healthy 59-year-old male individual with
very limited time. The patient is very healthy
and has no contraindications to the procedures
considered.
Clinical evaluation of the patient revealed
multiple areas of calculus deposits. Caries was
present on multiple teeth. There was poor hygiene
noted with associated periodontal disease and
attachment loss. Interocclusal space was ade-
536
quate. Smile evaluation showed a hypomobile
upper lip resulting in minimal tooth display. On
maximal smile, the maxillary teeth were not vis-
ible. The patient displayed an excessive display
of his mandibular incisors.
Radiographic examination showed carious
teeth, bone loss and a class I skeletal relationship
Fig. 20.48 Preop smile, patient showing hesitation in
smiling
Fig. 20.49 Full mouth periapical radiographs showing bone loss
S. Jivraj
between maxilla and mandible. There was avail-
ability of bone in zones 1–3 (see previous chap. 2
on Surgical Treatment Planning).There was evi-
dence of sufficient inter-arch space. The patient
exhibited typical sinus development. Both maxilla
and mandible had sufficient alveolar bone volume
in both height and width for implant placement.
20.3.2 Surgical Treatment Plan
1. Medical status of the patient was unremark-
able. He was healthy with no contraindica-
tions to implant surgery.
2. Space: The interocclusal space was measured
to be 20 mm. The proposed definitive restora-
tions required an interocclusal space of 26 mm
from the head of the fixture. This space would
be obtained by restoring the vertical and per-
forming alveolectomy in the mandibular arch
to lower the mandibular incisal edge level.
The desired dimensions for a biomechanically
sound prosthesis are 12 mm per arch. Lack of
upper lip mobility and low smile line as well
as the vertical position of the maxilla was to
our advantage in this case. The excessive
show of the mandibular teeth requires removal
of more bone from mandible than the maxilla.
This approach allows fabrication of a prosthe-
sis with correct positions of the maxillary and
mandibular incisors relative to lip line.
3. Spread: The patient exhibited adequate bone
for placement of implants in the molar posi-
tions as well as the anterior of the jaws. In this
instance, there was no need to tilt implants
20 Clinical Patient Presentations
and there was sufficient bone to place six
implants in the maxilla and six implants in the
mandible.
4. Stability: The patient is young and adequate
bone is present. Osteotomies were performed
in a manner to ensure stability. Type and
design of implant system will be considered
in this case. A self-tapping implant with pros-
thetic flexibility is the best option.
Surgical procedure: The patient was treated
surgically and prosthetically in one day. Deep
sedation with profound local anaesthesia was
used to remove all teeth except the ones needed
for stability of bone reduction and surgical stent.
A tooth-supported surgical guide was provided to
ensure accurate three-dimensional placement of
implants in the maxilla Alveolectomy was com-
pleted in the mandible to provide appropriate
restorative space and correct the mandibular inci-
sal edge position. Acrylic surgical guides were
fabricated by the prosthodontist. The surgical
guides were stabilised on retained teeth and oste-
otomies of the anterior implants were performed.
Six implants were placed in the maxilla and six in
the mandible. Multi-unit abutments were secured
and soft tissue closure was achieved. The patient’s
provisional immediate load prosthesis was fabri-
cated on the same day as implant placement. He
tolerated the procedure well and healed
uneventfully.
Fig. 20.50 Provisionals and surgical guides fabricated from an intraoral scan
537
20.3.3 Prosthetic Treatment Plan
Scaling and root planning were performed, and
the patient was advised to use an antibacterial
mouthrinse.
The patient was scanned using an intraoral
scanner, and provisionals for the immediate load
process were milled. Tooth-supported surgical
guides and abutment orientation guides were also
printed/milled. Vertical dimension was deter-
mined prior to implant placement and a record
made (Fig. 20.50).
A direct technique for immediate loading was
employed. Vertical dimension, centric relation
and occlusal plane were verified. After protection
of the surgical sites with rubber dam, temporary
cylinders were first picked up in the maxillary
prosthesis. The patient was guided into centric
relation and a similar pick-up of temporary cylin-
ders was performed in the mandibular provisional
restoration. The prostheses were removed and
transferred to the dental laboratory where the
prostheses were processed and finished. The
prostheses were adjusted to leave a 1 mm space
between the prostheses and the tissue. Twelve
teeth were provided with no cantilevers.
Occlusion was adjusted for shimstock hold on
anterior teeth and shimstock drag on the posterior
teeth. Vertical dimension was verified on delivery
of the restoration (Figs. 20.51 and 20.52).
538 S. Jivraj

Fig. 20.51 Implants placed; day of immediate loading of maxillary and mandibular arch

Fig. 20.52 One-week postop of immediate load provisional restorations

Fig. 20.53 Additional set of provisional restorations fabricated to optimise aesthetics, phonetics and soft tissue
contact

Splinted open tray impressions, jaw relation
records and tooth try-ins were performed.
Additional provisional restoration was fabri-
cated. Aesthetics, phonetics and soft tissue con-
tours were further developed in the provisional
restoration (Fig. 20.53).
Minimally layered zirconia restorations were
fabricated for both maxilla and mandible.
Occlusion was provided on polished zirconia.
Tissue-contacted surface was designed in pol-
ished zirconia (Fig. 20.54).
The prosthesis was delivered adjusting the
undersurface to ensure positive pressure.
Dynamic occlusion was adjusted for canine
guidance. Static occlusion was adjusted to
ensure shimstock hold on canines and premo-
lars. Shimstock drag on anterior teeth and no
contact on the cantilevers (Figs. 20.55, 20.56,
and 20.57).
Screws were torqued according to the manu-
facturer’s instructions, and access holes were
sealed using Teflon and composite resin.
20 Clinical Patient Presentations 539

Fig. 20.54 Minimally layered zirconia restorations

Fig. 20.55 Day of delivery of definitive zirconia restorations

Fig. 20.56 Pre- and postop of implant rehabilitation

Fig. 20.57 Panoramic radiograph

540 S. Jivraj

A night-time appliance was issued and main- we as dentists should be preserving. Extraction of
tenance instructions provided. a tooth or all of the patient’s teeth should be based
on sound clinical examination, and patients must
understand the risks and benefits.
20.4 Patient 4: Retreatment A 42-year-old woman presented requesting
of a Failed Implant improvement in the aesthetic appearance of her
Rehabilitation teeth.
On clinical examination, the following was
This patient presentation illustrates the impor- observed:
tance of appropriate treatment planning. The 1. Caries beneath existing maxillary porcelain
practitioner often has some very difficult deci- veneers.
sions to make in regard to keeping or extracting 2. Missing veneer on maxillary right canine.
teeth. Despite the success rates of graftless full-­ 3. Missing lower-left molar.
arch implant solutions, teeth are always pre- 4. Gingival inflammation.
ferred, and, if they can be maintained predictably, 5. Unrestored dental implant in maxillary right
this should be a first choice. This decision is first molar position.
based on both medical and dental histories and The following treatment plan was proposed to
the clinical acumen and expertise of the provider. the patient:
Often teeth are extracted in favour of dental 1. Caries control and hygiene.
implants, and the patients are not aware that den- 2. Evaluation of existing root canal therapy by
tal implants may not be lifelong solutions with- endodontist and retreat as necessary.
out problems. A very different proposition exists 3. Full periodontal evaluation.
when treatment planning full-arch implant resto- 4. Restorative treatment would include a combi-
rations. Often as practitioners we may extract nation of full crowns, veneers and implants
healthy teeth due to a variety of clinical reasons. crowns.
The reasons to extract teeth may include but 5. Maintenance.
are not limited to. The patient moved out of state and chose to
1. Over-eruption of teeth and the patient denies pursue treatment elsewhere.
orthodontics. The same patient presented a year and a half
2. Patient is on multiple medications and is later with a broken maxillary implant-supported
xerostomic. provisional. On questioning, the patient commu-
3. Teeth of guarded prognosis exist in between nicated that her dentist had advised her to remove
the sites dental implants are being planned. teeth in favour of dental implants. The reasoning
4. The only sites of available bone are where the for this was that it would be a more cost-effective
existing teeth are and the patient is lacking solution which would be problem free for the
bone in other sites. remainder of her life.
To treatment plan a patient with a healthy den- From a diagnostic perspective, the following
tition for full-mouth implant-supported restora- was recorded in regard to her existing full-arch
tions is unethical. Patients often present provisional restoration:
requesting removal of their teeth because of pre- 1. Incisal edge position: On clinical examina-
vious dental experiences. It is the practitioner’s tion, there was excessive display of the maxil-
responsibility to explain to the patient the value lary incisal edge. The maxillary teeth on the
of teeth and maintenance. It is the practitioner’s provisional were flared forwards and there
responsibility also to explain to the patient that was significant vertical overlap with her man-
dental implants are not without their problems dibular anterior teeth. The position of the
and in a worst-case scenario the patient may even teeth was a result of inadequate implant
end up with a removable denture. Despite placement.
advances in implant dentistry, teeth are still what
20 Clinical Patient Presentations
2. Restorative space: The patient’s request was
to obtain restorations that did not stain or
break frequently. Zirconia-based restorations
were planned. In order to correctly position
the teeth, the maxillary plane would have to
be lifted by 2–3 mm.
3. Lip support: The patient’s lip was well
supported.
4. Smile line: The patient had a low smile line,
and this would not pose a problem in hiding
the transition zone. Once again when patients
are conscious of their teeth, they do not smile
so wide and this must be evaluated with both
photo and video.
5. Contours and emergence: Space creation to
develop appropriate contours and emergence
was required.
6. Tissue contact: There was poor tissue contact
with spaces beneath the existing provisional
restorations. This would be addressed in the
new provisional restorations.
7. Occlusion: Occlusion was heavy on the ante-
rior teeth, resulting in fracture of the provi-
sional restoration.
20.4.1 Surgical Evaluation
The position of the implants was too shallow and
flared forwards. It was deemed that these implants
would be unusable. CT imaging also revealed
atrophy of the bone in the anterior maxilla with
inadequate buccolingual dimension for precise
implant placement.
20.4.2 Surgical Treatment Plan
Medical management of this patient does not
present as an obstacle. She is healthy without any
absolute contraindications to procedure. Plan is
to perform the procedure under intravenous seda-
tion and local anaesthesia in an office setting. A
treatment plan discussing grafting of the anterior
maxilla was discussed with the patient. The
patient denied grafting and preferred a graftless
approach. The patient was informed that pink
541
prosthetics may be required to improve propor-
tions of the teeth.
Space: Sufficient space would need to be cre-
ated to reposition the maxillary incisal edge. The
implants would need to be placed deep enough to
allow for a 17° multi-unit abutment. This would
allow emergence of the central incisors with a
favourable emergence profile.
Spread: The goal in the determination of pos-
terior implant location in a tilted implant protocol
is to have the platform of the tilted implant no
farther anterior than the second bicuspid while
avoiding the maxillary sinus. In this case, there is
bone available in the maxillary left second bicus-
pid location.
Stability: This case is complicated by the lack
of bone width in critical locations. In this case, it
is imperative that the implants placed in the only
areas of bone available be very stable. Existing
implants are to be removed that will create bone
defects. For that reason, an aggressive threaded
implant design is desirable. Also the osteotomies
will be underprepared and widened as needed to
assure stable implants. The anterior implants will
be engaging the dense nasal cortical bone for
stability.
Surgical treatment: The patient was sedated
utilising intravenous medications, and local
anaesthesia was infiltrated to achieve profound
anaesthesia. Intravenous antibiotic and steroids
were administered as well. A mucoperiosteal flap
was elevated, and the maxilla was exposed. The
existing malpositioned implants were removed.
The surgical stent was indexed on the remaining
implant in the upper-right maxilla. The maxillary
left implant was angled up to 45°. Four implants
were inserted and were found to be stable. Angled
multi-unit abutments were placed on all tilted
implants both posterior and anteriorly and torqued
to appropriate values. The bony defects caused by
removal of implants were grafted with a mixture
of autogenous and xenograft. Primary closure was
obtained. The patient’s provisional restorations
were fabricated and inserted on the day of surgery.
The patient tolerated the procedures well and
healed unremarkably. Final restorations were fab-
ricated 6 months postoperatively.
542 S. Jivraj

20.4.3 Prosthodontic Sequence The definitive restorations included a mini-

mally layered zirconia-based maxillary restora-
A direct technique for immediate loading was tion with layered pink ceramics.
employed. Vertical dimension, centric relation The prosthesis was delivered adjusting the
and occlusal plane were verified. After protection undersurface to ensure positive pressure.
of the surgical sites with rubber damn, temporary Dynamic occlusion was adjusted for canine guid-
cylinders were first picked up in the maxillary ance. Static occlusion was adjusted to ensure
prosthesis. The patient was guided into centric
relation, and a similar pick-up of temporary cyl-
inders was performed in the mandibular provi-
sional denture. The prostheses were removed and
transferred to the dental laboratory where the
prostheses were processed and finished. The
prostheses were adjusted to leave a 1 mm space
between the prostheses and the tissue. Ten teeth
were provided and no cantilevers. Occlusion was
adjusted for shimstock hold on anterior teeth and
shimstock drag on the posterior teeth. Vertical
dimension was verified on delivery of the restora-
tion (Figs. 20.58, 20.59, 20.60 and 20.61).
Splinted open tray impressions, jaw relation
records and a trial restoration were inserted to
verify aesthetics and phonetics. A second set of
provisional restorations were fabricated to opti-
mise aesthetics. On discussion with the patient, it
was decided to incorporate pink prosthetics in the
definitive restorations to optimise the d­ iscrepancy
in tooth length and width (Figs. 20.62, 20.63,
20.64, 20.65, 20.66). Fig. 20.58 Postop facial view of patient

Fig. 20.59 Preop of patients presenting clinical situation

20 Clinical Patient Presentations 543

Fig. 20.60 Occlusal and frontal views of patient’s dentition

Fig. 20.61 Panoramic

radiograph

Fig. 20.62 Perapicals

demonstrating caries
around existing
restorations

Fig. 20.63 Panoramic radio-

graph of implants placed in incor-
rect positions
544 S. Jivraj

Fig. 20.64 Patient’s smile and intraoral view of inadequate provisionalisation

Fig. 20.65 Occlusal access holes demonstrating thinness of acrylic around temporary cylinders

Fig. 20.66 Implant indexed surgical guide and provisional ready for immediate load
20 Clinical Patient Presentations
shimstock hold on canines and premolars.
Shimstock drag on anterior teeth and no contact
on the cantilevers.
Screws were torqued according to the manu-
facturer’s instructions, and access holes were
sealed using Teflon and composite resin.
A night-time appliance was provided and
maintenance instructions provided.
This particular patient could have been treated
with conventional tooth-borne restorations without
the need for full-arch implant-supported restora-
tions. Tooth-supported restorations would have had
better longevity and provided superior aesthetics.
The practice of removing healthy teeth in favour of
full-arch implant restorations must be avoided.
20.5 Patient 5: Interdisciplinary
Care and Decision-Making
Between Graft or Not
to Graft
A 33-year-old man presented with a failing denti-
tion. He was on multiple medications that resulted
in a reduction in salivary flow. His request was to
obtain fixed permanent restorations on dental
implants. He had an important life event in
4–6 weeks and requested a fixed restoration on
dental implants during that time period
(Figs. 20.67, 20.68, 20.69, 20.70, 20.71, 20.72,
20.73, 20.74, 20.75, and 20.76).
A thorough clinical evaluation was
performed.
Fig. 20.68 Implants placed palatally to allow for as much buccal bone as possible. Multi-unit angled abutments used
to bring trajectory of implants within surgical guide
545
The following observations were made:
1. Pneumatised sinuses posterior to first
premolars.
2. Severe wear on his teeth.
3. Irregular mandibular occlusal plane.
4. Lack of posterior support.
5. Mandibular molars with vertical fracture and
of poor prognosis.
The key decision-making parameters in this
patient were the following.
1. How many implants should be placed in the
maxilla?
The patient presented with severe wear, large
masseters and a history of sleep apnoea. It is
the author’s opinion that adhering to a specific
treatment protocol involving placement of
four implants would not be insufficient in
terms of stress distribution and anteroposte-
rior spread.
2. Should the patient be grafted or should zygo-
matic implants be placed?
Fig. 20.67 Demonstration of anticipated tooth position
in relation to existing implants. Implants in correct posi-
tion will need to be higher up to provide transition zone
546 S. Jivraj

The patient is in his early 30s. Currently there is

sufficient bone to place implants utilising a
tilted protocol in the first premolars. This
would allow cantilever of one additional
tooth. In patients who have signs of excessive
force on their teeth, cantilevers should be
Fig. 20.69 Panoramic radiograph of implants placed
avoided. The decision to increase the AP

Fig. 20.70 Implants post-integration showing flattened tissue

Fig. 20.71 Provisional fabricated. Proportions of teeth not ideal

Fig. 20.73 Definitive zirconia restoration with pink

Fig. 20.72 Provisional with pink acrylic added ceramics
20 Clinical Patient Presentations 547

Fig. 20.74 Initial preoperative situation. Postop immediate load with implants in incorrect position. Definitive restora-
tion with pink ceramics

Fig. 20.75 Final smile shot

Fig. 20.76 Transition of patient from initial dentition, poor provisionalisation, Removal of existing implants place-
ment of additional implants and provisionalisation. Definitive restoration
548
spread would require either bilateral sinus
lifts and bone augmentation or zygomatic
implants on each side. Both approaches would
be clinically acceptable. It was decided to pur-
sue the route of bilateral sinus lifts due to the
patient’s age. During the interim phase, a
fixed provisional could still be provided on
four implants, thus satisfying the patient’s
concerns.
3. How do we address the mandibular occlusal
plane?
The first molars were to be extracted in favour of
implant placement. Orthodontics to correct
Fig. 20.77 Preop clinical situation, showing missing teeth, bone loss and irregular occlusal plane
Fig. 20.78 Facial view of patient smiling showing insuf-
ficient display of maxillary incisal edge
S. Jivraj
the mandibular occlusal plane would be dis-
cussed with the patient to harmonise the ante-
rior guidance.
20.5.1 Prosthodontic Diagnosis
1. Incisal edge position: On clinical examina-
tion, there was insufficient display of the max-
illary incisal edge. The occlusal plane was
also canted to the patient’s right. Teeth in the
mandibular arch had over-erupted as a result
of no occlusal contact (Figs. 20.77 and 20.78).
20 Clinical Patient Presentations
2. Restorative space: The treatment plan
included a minimally layered zirconia
restoration.
3. Lip support: The patient’s lip was well
supported.
4. Smile line: The patient had a low smile line,
and this would not pose a problem in hiding
the transition zone.
5. Contours and emergence: Space creation to
develop appropriate contours and emergence
was required.
6. Tissue contact: Following extraction of the
teeth and creation of adequate restorative
space shaping, the restorative contours for a
convex undersurface were attainable. The pro-
visional restorations were to be used to com-
press the tissue and create a concave tissue
surface.
7. Occlusion: Occlusion must be addressed in
the immediate load provisional to protect the
implants in the weakest quality bone from
excessive loads. In the definitive restoration,
occlusion must be organised to distribute the
loads over as wide an area as possible.
20.5.2 Surgical Evaluation
Clinical evaluation of the patient showed exces-
sive wear, vertical cracks in the mandibular first
molars and lack of restorative space. The patient
had a low lip line and long lip. One millimetre of
Fig. 20.79 Cross-section of CT showing pneumatised sinuses in maxilla existing teeth
549
gingival show on maximal smiling was noted.
Gingival tissues were healthy.
Radiographic and CT evaluation of the patient
showed pneumatised sinuses posterior to maxil-
lary first premolars. Inadequate buccolingual
width in the anterior maxilla where teeth had
been extracted was noted (Fig. 20.79). The man-
dible showed sufficient bone in width and height
for implant placement in the mandibular molar
region.
20.5.3 Surgical Treatment Plan
Space: The lack of inter-arch space in this case
will have to be managed through minor bone
reduction in the maxilla. This is done to create
space for the zirconia-based restoration. Bone
reduction is also done to ensure there is an ade-
quate buccolingual width of bone for implant
placement. Bilateral sinus lifts and bone augmen-
tation would be done at the same time. The goal
was to provide additional sites for dental implant
placement. In the mandible, the first molars would
be extracted and implants placed immediately and
allowed to integrate prior to restoration.
Spread: Four implants would be placed in the
maxilla. The distal implants would be tilted to
maximise the anteroposterior spread as much as
possible.
Stability: The patient exhibits sufficient bone
volume in the anterior maxilla as well as mandi-
550
ble. There are no large defects noted; therefore,
underprepared osteotomies with gradual enlarge-
ment of the preparations will be undertaken. An
aggressively threaded implant design will be
utilised.
20.5.4 Surgical Treatment
The patient was treated in an office setting. Local
anaesthesia supplemented with a very mild seda-
tive technique was utilised. All maxillary teeth
except those indexed by the surgical stent were
removed. Surgical stent was indexed on the
remaining maxillary teeth, and bone was reduced
to allow for at least 12 mm of inter-arch space in
the maxillary arch. The remaining teeth were
removed, and the maxillary arch was reduced to a
flat plane. Bilateral sinus lifts were performed
and bone augmentation completed. First molars
were extracted in the mandible and single
implants placed immediately. All implants in the
maxilla were inserted at torque value of no less
than 35 N. Multi-unit abutments were placed and
primary closure was achieved. A provisional
fixed acrylic prosthesis was fabricated immedi-
ately following the surgical phase of treatment
and secured to the implants on the day of surgical
implant placement. The patient tolerated the
Fig. 20.80 Provisional restorations and guides for immediate load
Fig. 20.81 Immediate load prosthesis on day of surgery
S. Jivraj
anaesthesia and procedure very well and healed
uneventfully. Post-graft healing additional
implants were placed in the maxillary molar
region.
20.5.5 Prosthodontic Sequence
The patient was scanned and provisional restora-
tions and surgical guides were milled.
(Fig. 20.80). Provisional restorations were fabri-
cated at the correct vertical dimension for a direct
pick-up procedure. Vertical dimension was deter-
mined prior to implant placement and a record
made. Bone reduction guides were fabricated to
communicate restorative space required.
A direct technique for immediate loading was
employed, mounted and processed and finished
in the laboratory. The prostheses were adjusted to
leave a 1 mm space between the prostheses and
the tissue. Occlusion was adjusted for shimstock
hold on anterior teeth and shimstock drag on the
posterior teeth. Vertical dimension was verified
on delivery of the restoration. A soft nightguard
was provided post surgery (Fig. 20.81). The
patient was referred to an orthodontist to correct
the mandibular occlusal plane whilst the grafts
were healing and implants integrating.
20 Clinical Patient Presentations
Splinted open tray impressions, jaw relation
records and a trial restoration were inserted to
verify aesthetics and phonetics.
The trial restoration was utilised to fabricate
an acrylic prototype utilising CAD software.
Computer-aided milling was performed.
The definitive restorations included a mini-
mally layered zirconia-based maxillary restora-
tion with layered pink ceramics (Fig. 20.82).
The prosthesis was delivered adjusting the
undersurface to ensure positive pressure.
Dynamic occlusion was adjusted for canine guid-
ance. Static occlusion was adjusted to ensure
shimstock hold on canines and premolars.
Shimstock drag on anterior teeth and no contact
on the cantilevers. Single-tooth monolithic resto-
rations were fabricated for implants in the man-
Fig. 20.82 Minimally layered zirconia restorations
Fig. 20.83 Smile view of patient with definitive restorations
551
dibular first molar regions (Figs. 20.83, 20.84,
20.85, and 20.86).
Screws were torqued according to the manu-
facturer’s instructions, and access holes were
sealed using Teflon and composite resin.
A night-time appliance was provided and
maintenance instructions provided.
This particular case highlights diagnosis and
treatment planning. The clinician is faced with a
choice of grafting or graftless. Both approaches
would be acceptable. Grafting is still a useful
treatment modality and should not be ­disregarded.
Often clinicians espouse to a totally graftless
practice and will not graft under any circum-
stance. This approach should be avoided. The
patient deserves to be made aware of the treat-
ment options available, the advantages and disad-
552
Fig. 20.84 Zirconia-based restoration in situ
Fig. 20.85 Pre- and postop view of treatment
vantages, the longevity and possible complications
that may arise.
The clinician should be astute in diagnosis and
treatment planning to provide the patient with a
course of treatment that is rational, biomechani-
S. Jivraj
Fig. 20.86 Final panoramic radiograph demonstrating
implant placement
cally sound and has every possible chance of
success.
Acknowledgements The author thanks Dr. Hooman
Zarrinkelk for the surgical expertise in cases 1, 2 and 4.
The author also thanks Dr. Jonathan Gordon for surgical
expertise in cases 3 and 5.