Graftless Solutions for the Edentulous Patient (BDJ Clinician’s Guides)

Description

This book, designed to meet the needs of clinicians and now in an extensively revised second edition, clearly explains the rationale and technique for the rehabilitation of fully edentulous patients utilizing traditional graftless concepts as well as zygomatic implant strategies when posterior support cannot be achieved by the former means. Considerations relevant to treatment planning and the biomechanics of immediate loading and zygomatic implants are first discussed. The techniques for placement of traditional tilted and zygomatic implants and for immediate loading of a full arch restoration are then described step by step. Detailed information and guidance are also provided on the different materials available for full arch restorations, laboratory aspects of the definitive restoration, maintenance of restorations, and management of prosthetic and surgical complications. The book concludes with a helpful series of clinical cases. Graftless Solutions for the Edentulous Patient is designed particularly for clinicians with experience in placing and restoring dental implants.  Foreword 1 Foreword 2 Preface Acknowledgements Contents Contributors 1: Diagnosis and Treatment Planning: A Restorative Perspective 1.1 Positioning the Maxillary and the Mandibular Incisal Edge 1.2 Restorative Space 1.3 Lip Support 1.4 Smile Line and Lip Length 1.5 Contours and Emergence 1.6 Appropriate Tissue Contact 1.7 Occlusion References 2: Surgical Diagnostic Considerations in Graft-Avoiding Dental Implant Reconstruction of Atrophic Jaws References 3: Guided Surgery for Full-Arch Implant-Supported Restorations 3.1 Why Perform Guided Surgery as Opposed to Freehand Surgery or Using a Conventional Shell Surgical Guide? 3.2 Planning Software 3.2.1 Surgical Planning Software 3.2.2 Prosthetic Planning Software 3.2.2.1 Incorporating Prosthetic Planning into Surgical Planning Software 3.2.2.2 Data Required for Full-Arch Implant Restoration Surgical Planning 3.2.2.3 Dual-Scan Technique 3.2.2.4 Placing the Radiopaque Markers 3.2.3 Surgical Guides 3.2.3.1 Types of Surgical Guides 3.2.3.2 Fully Guided Surgical Guides The Indications and Benefits of the Fully Guided Surgical Guide What Data Do You Need to Prepare the Guides 3.2.3.3 Surgical Planning Considerations (Surgical, Prosthetic) 3.2.3.4 Surgical Systems Used with Fully Guided Surgical Guides How Do You Use the Guide During Surgery Options That Aid Immediate Provisionalization Limitations of the Guide 3.2.3.5 Pilot Guides The Indications and Benefits of the Pilot Guide Data You Need to Prepare Pilot Guides Surgical Planning Considerations (Surgical, Prosthetic) for the Pilot Guide Surgical Tools Used with Pilot Guides How to Use the Guide During Surgery Limitations of the Guide 3.2.3.6 Bone-Borne Guides The Indications and Benefits of Bone-Borne Guides The Data You Need to Prepare Bone-Borne Guides Surgical Tools Used with Bone-Borne Guides How to Use the Guide during Surgery Options That Aid Immediate Provisionalization Limitations of the Bone-Borne Guide 3.2.3.7 Stackable Surgical Guides The Indications and Benefits of Stackable Guide Systems The Data You Need to Prepare the Guides Surgical Planning Considerations (Surgical, Prosthetic) Surgical Tools Used with Stackable Guides How to Use the Stackable Surgical Guide During Surgery Options That Aid Immediate Provisionalization Limitations of the Guide 3.2.3.8 Robotic Surgery The Indications and Benefits of Robotic Implant Systems Data Necessary for Robotic Implant Placement Surgical Planning Considerations (Surgical, Prosthetic) Surgical Tools Used with Robotic-Assisted Surgery How to Use the Haptic Robotic Implant System 3.2.3.9 Real-Time Dynamic Guidance The Indications and Benefits of Real-Time Dynamic Guidance Systems Data Necessary for Real-Time Dynamic Guidance Implant Placement Surgical Planning Considerations (Surgical, Prosthetic) Surgical Tools Used with Real-Time Dynamic Guidance Implant Placement How to Use the Real-Time Dynamic Guidance Implant Placement 3.3 Conclusion References 4: Digital Workflows in Full Arch Implant Prosthodontics 4.1 Preliminary Digital Data Acquisition 4.2 Treatment Planning in Software 4.3 Surgical Execution: Guided Implant Placement 4.4 Definitive Data Acquisition 4.5 Functional Verification References 5: 3D Printing Protocols in Full-Arch Reconstruction: A Complete Workflow 5.1 3D Printing in Dentistry 5.2 3D Printing Resins 5.3 Surgical Study Models 5.4 Radiopaque Resin for Try-In prosthesis 5.5 Surgical Guide Resin 5.6 Hybrid Ceramic Resin 5.7 Pretreatment Planning for a Successful Digital Alignment 5.8 Edentulous and Dentate Workflows 5.9 Photogrammetry 5.10 Printed Conversion Prosthesis 5.11 Prototype Provisional Prosthesis 5.12 Case Presentation References 6: The Zygoma Anatomy-Guided Approach (ZAGA) for Preventing Complications Using Zygomatic Implants 6.1 Introduction 6.2 Technique Evolution 6.2.1 Original Technique 6.2.2 The Slot Technique 6.2.3 Exteriorized Technique 6.3 The ZAGA Concept 6.3.1 The ZAGA Classification 6.3.1.1 Group ZAGA Type 0 6.3.1.2 Group ZAGA Type 1 6.3.1.3 Group ZAGA Type 2 6.3.1.4 Group ZAGA Type 3 6.3.1.5 Group ZAGA Type 4 6.3.2 The ZAGA Minimally Invasive Osteotomy 6.3.3 The ZAGA Flat and ZAGA Round Zygomatic Implants: The Story of a Breakthrough 6.3.3.1 The Clinical Points to Solve 6.4 Conclusions References 7: Pterygoid Implants as Alternative to Bone Augmentation in Implant Dentistry 7.1 Introduction 7.2 Indications 7.3 Contraindications 7.4 Pertinent Clinical Anatomy of the Pterygomaxillary Region 7.5 Preoperative Planning 7.6 The Surgical Approaches for Pterygoid Implants 7.6.1 Description of the Technique: Pterygoid Implants with Osteotome Guided Technique (Fig. 7.11) 7.6.2 Description of the Technique: Pterygoid Implants with Drill Guided Technique (Fig. 7.13) 7.7 Prosthetic Considerations 7.8 Clinical Cases 7.8.1 Case #1: Trans-nasal and Trans-palatal Implants in Conjunction with Pterygoid Implants (Fig. 7.15) 7.8.2 Case #2: Hybrid Zygoma in Conjunction with Pterygoid Implants (Fig. 7.16) 7.8.3 Case #3: Quadruple Zygomatic Implants in Conjunction with Pterygoid Implants (Fig. 7.17) 7.9 Complications 7.10 Discussion 7.11 Conclusion References 8: Scientific Basis of Immediate Loading and the Biomechanics of Graftless Solutions 8.1 Defining Immediate Loading 8.2 General Factors in Immediate Loading 8.3 Specific Elements of Immediate Loading 8.4 Occlusion 8.5 Optimal Number of Implants 8.6 Axial vs. Tilted Implants 8.7 Vertical Cantilever Height: Crown-Implant Ratio 8.8 Medical Evaluation of the Patient 8.9 Medical Conditions That May Impact Immediate Loading 8.9.1 Diabetes Mellitus 8.9.1.1 How Does It Affect the Body? 8.10 How Does Diabetes Affect Implants and Immediate Loading? 8.10.1 Does Literature Support Immediate Loading of Implants in Uncontrolled Diabetic Patient? 8.10.1.1 Can Immediate Loading Be Done on Patients with Uncontrolled Diabetes Mellitus? 8.10.1.2 Alternatives to Immediate Loading in a Diabetic Individual Complete Denture Strategic Abutments Provisional/Transitional Implants 8.10.1.3 Patients on Dialysis 8.10.1.4 Can Immediate Loading Be Done on Patients with CKD and Dialysis? 8.11 Osteoporosis 8.11.1 Why Is Osteoporosis a Problem in Immediate Loading? 8.11.1.1 Can Immediate Loading Be Performed in Osteoporotic Patients? 8.11.2 What Are the Potential Medical Complications Associated with Osteoporotic Patient? 8.11.3 Precautions for Immediate Loading in an Osteoporotic Patient? 8.11.4 What Postoperative Care Should One Take When Doing Immediate Loading in an Osteoporotic Patient? 8.11.4.1 Medications 8.11.4.2 Can Immediate Loading Be Done in Patients Taking SSRIs? 8.12 Patient-Related Factors 8.12.1 Bruxism 8.12.1.1 How to Diagnose a Bruxer? 8.12.1.2 What Are the Problems of Doing Immediate Loading in a Bruxer? 8.12.2 Can Immediate Loading Be Done in Bruxers? 8.12.3 Are There Any Practical Guidelines When Attempting Immediate Loading in a Bruxer? 8.13 Case Report 8.14 Smoking 8.14.1 What Are the Problems of Doing Immediate Loading in a Smoker? 8.14.2 Can We Perform Immediate Loading in Smokers? 8.15 Case Report 8.16 Clinician Related 8.17 Conclusion References 9: FP1 Concepts in Rehabilitating the Edentulous Patient with Implant-Supported Restorations 9.1 What Is an FP1? 9.1.1 Stage 1: Data Capture 9.1.2 Stage 2: Facially Driven Digital Wax-Up 9.1.3 Stage 3: Superimposition of the Initial Situation, the Digital Wax-Up, and the CT Scan 9.1.3.1 Choosing Individual Implant Positions 9.1.3.2 Evaluating Pontic Sites 9.1.3.3 An Overall View of the Case 9.1.4 Stage 4: Periodontal and Prosthetic Planning 9.1.4.1 Maintain the Current Hard and Soft Tissue in an Extraction Socket 9.1.4.2 Augment the Soft Tissue around Pontic Sites 9.1.4.3 Augment the Hard Tissue 9.1.4.4 Manipulate and Augment the Soft Tissue to the Prosthesis at Either the Implant or Pontic Site 9.1.5 Stage 5: Implant Planning 9.1.5.1 The Multifunctional Guide 9.1.5.2 Pontic Design for the Multifunctional Guide 9.1.5.3 The WeldOne Shell 9.1.5.4 Guided Surgery 9.1.5.5 Stackable Guides 9.1.5.6 Freehand Placement 9.1.5.7 Fabrication of the Provisional Restoration 9.1.6 Stage 6: Fabricating the Final Restoration 9.1.6.1 The Digital Workflow Appointment 1: Digital Impression Using the Triple-Scan Technique Appointment 2: Try-in and Verification Pickup Method Printed Verification Jig 9.1.6.2 Using an Analogue Workflow 9.1.6.3 Laboratory Bonding Protocol 9.1.7 Stage 7: Fitting the Final Restoration 9.1.7.1 Patient Cleaning and Maintenance References 10: Graftless Surgical Protocol: Diagnosis to Delivery 10.1 All-on-Four™ Surgical Protocol 10.2 Treatment Planning 10.2.1 Radiographic Evaluation 10.3 All-on-4 Standard: Non-guided Surgery 10.3.1 Surgical Protocol: Step by Step 10.3.2 Implant Placement 10.4 All-on-4 Standard: Guided Surgery 10.4.1 Patient Examination 10.4.2 Preparation of the Radiographic Guide and CBCT Scan 10.4.3 Computer Planning 10.4.4 Surgery Protocol 10.5 All-on-4 Standard: Navigated Surgery 10.6 Conclusions References 11: Surgical–Anatomical and Prosthetic–Biomechanical ZAGA Criteria to Determine the Zygomatic Implant Trajectory 11.1 Introduction 11.2 The ZAGA Zones 11.2.1 The Zygomatic Implant Critical Zone 11.2.2 The Antrostomy Zone 11.2.3 The Zygomatic Anchorage Zone 11.3 Biomechanics in the Context of Tilted Implants 11.4 The ZAGA Criteria to Establish the Zygomatic Implant Trajectory 11.4.1 Identify the ZICZ 11.4.2 Establish the AZ 11.4.3 Perform the Antrostomy 11.5 Interim Prostheses 11.6 The ORIS Criteria to Evaluate the Results of the Zygoma Anchored Oral Rehabilitation 11.7 Conclusions References 12: Clinical Techniques for Immediate Loading 12.1 Rationale for Immediate Loading 12.2 Requirements for Immediate Loading 12.2.1 Patient Selection 12.2.2 Surgical Considerations 12.2.3 Restorative Considerations 12.3 Immediate Loading: Clinical Methods 12.3.1 Direct Technique: Direct Denture Pick-Up and Conversion 12.3.1.1 Conventional Approach 12.3.1.2 Technique for the Mandible 12.3.1.3 Digital Method 12.3.1.4 This Is a Sample Workflow 12.3.1.5 Technique 12.3.2 Direct–Indirect Technique: Impression with Denture for Conversion 12.3.3 Indirect Technique: Pick-Up Impression with Extraoral Conversion 12.3.3.1 Conventional Method 12.3.3.2 Digital Method 12.3.4 Direct Pick-Up Tooth-Only Immediate Load Restoration References 13: Material Considerations for Full-Arch Implant-Supported Restorations 13.1 Screw Access Trajectory 13.2 Restorative Space 13.3 Nature of Opposing Dentition 13.4 Aesthetic Demands 13.5 Cantilevers 13.5.1 Framework Cross-Sectional Area for Cantilevers and Around Screw Channels 13.5.2 Ease of Fabrication and Passivity 13.6 Acrylic Resin Bonded or Milled to Titanium 13.7 High-Performance Polymers: PEEK 13.8 Milled Cobalt Chromium 13.9 Zirconia 13.10 Monolithic 13.11 Minimally Layered 13.12 Hybrid Designs with Individual Ceramic Crowns 13.13 Hybrid Designs with a Primary Titanium Bar and Overlying Zirconia Framework Utilising Intraoral Scanning and CADCAM Protocols 13.14 Conclusion References 14: Clinical Steps for Fabrication of a Full-Arch Implant-Supported Restoration 14.1 Section I: Introduction 14.1.1 Step 1: Impressions 14.1.1.1 Impression Techniques Closed Tray Technique Open Tray Technique 14.1.1.2 Impression Materials 14.1.2 Step 2: Verification Jig 14.1.3 Step 3: Interocclusal Records [16, 17] 14.1.3.1 Conventional Complete Denture Bases on Residual Ridge Pros Cons 14.1.3.2 Screw-Retained Complete Denture Bases Pros Cons 14.1.3.3 Two-Piece Screw-Retained Bases Pros Cons 14.1.3.4 Using Aluwax on Healing Abutments/Final Abutments Pros Cons 14.1.4 Step 4: Teeth Set for Try-In 14.1.5 Step 5: Framework Trial 14.1.6 Step 6: Bisque Trial 14.1.7 Step 7: Prosthesis Delivery 14.1.7.1 Delivery of Screw-Retained Restorations 14.1.7.2 Delivery of Cement-Retained Restorations 14.1.8 Step 8: Postoperative Instructions and Follow-Up 14.1.9 Conclusion 14.2 Section 2: Fast-Tracking Implant Prosthodontic Protocol for Fully Edentulous Patients 14.2.1 Technique 14.2.2 Conclusion 14.3 Partial Extraction Therapy (PET) for Multiple Teeth and Full-Arch Implant-Supported Reconstructions 14.3.1 Challenges in Multiple Sites Treated with PET 14.3.2 Phase 1: Socket Shields and Tooth-Supported Provisional Restorations 14.3.3 Phase 2: Pontic Shield, Root Submergence Technique and Implant-Supported Provisional Restorations 14.3.4 Phase 3: Fast-Tracking to Final Restoration 14.3.5 Conclusion References References for Fast Tracking 15: Speech and Facial Aesthetic Considerations for the Contour of Fixed Prostheses 15.1 Incisor Position 15.2 Determination of Facial Support 15.2.1 Consequence of Jaw Atrophy 15.2.2 Lip Support 15.3 Summary of Clinical Advice for Orofacial Aesthetics 15.4 Speech 15.5 Summary of Clinical Advice for Speech Adaptation 15.6 Conclusions References 16: Laboratory Fabrication of Full-Arch Implant-Supported Restorations 16.1 High-Performance Polymer: PEEK 16.2 Laboratory Fabrication Process 16.3 Acrylic Resin Titanium Hybrid 16.4 Laboratory Fabrication Process 16.4.1 Zirconia 16.5 Ease of Fabrication 16.6 Restorative Space 16.6.1 Passivity of the Framework 16.7 Implant/Abutment Interface 16.8 Occlusion/Wear 16.9 Design of Framework 16.10 Veneering Porcelain 16.11 Aesthetics 16.12 Delivery/Retrievability 16.13 Laboratory Process 16.13.1 Full-Arch Zr-Implant Prosthesis 16.14 Conventional Analogue Concepts Challenged: Digital and Non-digital Workflows 16.15 Digital Fabrication Techniques: Advantages and Disadvantages 16.16 Full Digital Workflow in Producing Definitive Restorations 16.17 Design Assembly 16.18 Milling 16.19 Finishing 16.20 Delivery 16.21 Conclusion References 17: Prosthetic Complications with Immediately Loaded, Full-Arch, Fixed Implant-Supported Prostheses 17.1 The Nature of Complications 17.2 Diagnosis and Treatment Planning Failures 17.3 Position of the Maxillary and Mandibular Incisal Edge 17.4 Failures Pertaining to Restorative Space, Choice of Restorative Material and Number of Implants 17.5 Failures Related to Lip Support and Smile Line 17.6 Failures Related to Emergence and Contours 17.7 Failures Related to Tissue Surface 17.8 Failures Related to Occlusion 17.9 Failure Resulting from Inadequate Treatment Execution 17.10 Impression Making and Cast Verification 17.11 ­ Complications/Considerations with the Definitive Restorations 17.11.1 Insertion 17.12 Biological Failures 17.13 Mechanical Failures 17.14 Material Failures 17.15 Restoration Failures Require Removal of the Restoration and Laboratory Repair 17.16 Implant Failure 17.17 The Maintenance Phase 17.18 Conclusion References 18: Management of Failure and Implant-Related Complications in Graft-Less Implant Reconstructions (for Atrophic Jaws) 18.1 Introduction 18.2 Failure to Plan 18.3 Implant Failure 18.4 Removing Failing Implants 18.5 ‘Rescue’ Implants 18.6 Failure and Zygomatic Implants 18.7 Maxillary Sinus and Shaft-Related Complications 18.8 Apical Infection 18.9 Discussion References 19: Maintenance of Full-Arch Implant-Supported Restorations: Peri-Implant and Prosthetic Considerations 19.1 Patient Selection and Risk Assessment 19.2 Peri-Implant Considerations 19.2.1 Supportive Periodontal and Peri-Implant Therapy 19.2.1.1 Professional In-Office Maintenance Protocol 19.2.1.2 Patient At-Home Maintenance Protocol 19.2.2 Peri-Implant Biological Complications 19.2.2.1 Management of Peri-Implant Mucositis 19.2.2.2 Management of Peri-Implantitis 19.2.2.3 Management of Peri-Implant Recession 19.3 Prosthetic Considerations 19.3.1 Professional Maintenance Guidelines 19.4 Prosthetic Maintenance 19.5 Conclusion References 20: Clinical Patient Presentations 20.1 Patient 1: Re-treatment of a Failed Implant Rehabilitation 20.1.1 Surgical Treatment Plan (Patient 1) 20.1.2 Prosthetic Evaluation 20.1.3 Surgical Procedure 20.1.4 Prosthodontic Sequence 20.2 Patient 2: Implant Rehabilitation of a Periodontally Failing Dentition with Moderate-to-Advanced Bone Loss 20.2.1 Surgical Treatment Plan 20.2.2 Surgical Treatment 20.2.3 Prosthetic Treatment Plan 20.3 Patient 3: Treatment of a Periodontally Failing Dentition 20.3.1 Prosthodontic Diagnosis 20.3.2 Surgical Treatment Plan 20.3.3 Prosthetic Treatment Plan 20.4 Patient 4: Retreatment of a Failed Implant Rehabilitation 20.4.1 Surgical Evaluation 20.4.2 Surgical Treatment Plan 20.4.3 Prosthodontic Sequence 20.5 Patient 5: Interdisciplinary Care and Decision-Making Between Graft or Not to Graft 20.5.1 Prosthodontic Diagnosis 20.5.2 Surgical Evaluation 20.5.3 Surgical Treatment Plan 20.5.4 Surgical Treatment 20.5.5 Prosthodontic Sequence