A review of guidelines for implant rehabilitation of the edentulous maxilla

Recommendations for successful virtual patient-assisted esthetic implant rehabilitation: A guide for optimal function and clinical efficiency

OBJECTIVE

Complete arch implant rehabilitation necessitates meticulous treatment planning and high-level collaboration between surgical and prosthetic dental teams. Emerging virtual technologies hold considerable promise in streamlining this process. The aim of this article is to extend recommendations to clinicians venturing into the virtual patient-assisted esthetic implant rehabilitation workflow.

OVERVIEW

This article summarizes recommendations for virtual patient-assisted esthetic implant rehabilitation in the following five aspects: three-dimensional data handling and superimposition, occlusion and virtual articulator integration in creating virtual patients, streamlined face- and prosthetic-driven surgical planning, reuse of presurgical data ("Copy & Paste"), and final impression for passive fitting of final restoration. To illustrate these principles, a case with complete-mouth implant rehabilitation completed within six visits using this virtual patient workflow is presented.

CONCLUSION

The virtual patient workflow serves as an invaluable tool to perform treatment planning, enhance efficiency, and ensure predictable outcomes in esthetic complete arch implant rehabilitation.

CLINICAL SIGNIFICANCE

Virtual workflows are increasingly prevalent in esthetic implant rehabilitation. Nevertheless, these workflows necessitate a distinct set of knowledge and tools divergent from conventional dentistry practices. This article offers guidelines and recommendations for dental clinicians who are new to this field.

Comparison of the accuracy of implant position among freehand implant placement, static and dynamic computer-assisted implant surgery in fully edentulous patients: a non-randomized prospective study

The optimal implant position is a critical factor for long-term success in fully edentulous patients. Implants can be placed through conventional freehand, static computer-assisted implant surgery (CAIS), or dynamic CAIS protocols, but at present there is very limited clinical evidence on their accuracy in fully edentulous patients. This study was performed to evaluate the accuracy of implant placement using three protocols in fully edentulous patients. Thirteen patients received 60 implants with the freehand (n = 20), static CAIS (n = 20), or dynamic CAIS (n = 20) protocol. Postoperative cone beam computed tomography was utilized to evaluate the accuracy of implant placement in relation to the planned optimal position. The data were analysed by ANCOVA followed by Bonferroni analysis. The mean angular deviation (standard deviation) in the freehand, static CAIS, and dynamic CAIS groups was 10.09° (4.64°), 4.98° (2.16°), and 5.75° (2.09°), respectively. The mean three-dimensional deviation (standard deviation) at the implant platform in the freehand, static CAIS, and dynamic CAIS groups was 3.48 (2.00) mm, 1.40 (0.72) mm, and 1.73 (0.43) mm, while at the implant apex it was 3.60 (2.11) mm, 1.66 (0.61) mm, and 1.86 (0.82) mm, respectively. No difference in terms of accuracy was found between static and dynamic CAIS; both demonstrated significantly higher accuracy when compared to the freehand protocol in fully edentulous patients.

Prosthetic failures in dental implant therapy

Both fixed and removable implant‐supported prostheses are well‐established methods for replacing missing teeth in partially or fully edentulous patients. Numerous systematic reviews have been performed in recent years to evaluate the survival and complication rates of implant‐retained fixed dental prostheses and implant‐retained overdentures, displaying high 5‐year survival rates ranging from 97.1% for fixed dental prostheses to 95%‐100% for implant‐retained overdentures. However, the survival rates only represent the prostheses remaining in use for a defined follow‐up time, and do not account for the potential prosthetic complications that may have arisen and influence the general success of the implant treatment. The most common technical complications of fixed implant‐retained single crowns are crown fracture, fractures of ceramic implant abutments, and esthetic problems. The predominant technical complication at multiple‐unit, implant‐retained fixed dental prostheses is fracture/chipping of the veneering ceramic. Reported technical complications for implant‐retained overdentures are overdenture fracture or chipping of the veneer materials, whereas mechanical complications include implant fracture, attachment failure, and attachment housing or insert complications. To reduce the risk of such failures, a comprehensive pretreatment diagnostic work‐up is essential, including defining the prosthetic goal with the aid of a wax‐up or set‐up and the associated ideal, prosthetically oriented three‐dimensional implant position. Furthermore, selection of the ideal type of prosthesis, including the respective implant components and materials, is important for clinical long‐term treatment success.

Prosthetic articulator-based implant rehabilitation virtual patient: A technique bridging implant surgery and reconstructive dentistry

This technique report describes a fully digital workflow to create a prosthetic articulator-based implant rehabilitation (PAIR) virtual patient for complete-arch or complete-mouth implant rehabilitation. This workflow uses a custom gothic arch tracer during the cone beam computed tomography (CBCT) scan and a 3-dimensional virtual facebow when superimposing data. The PAIR virtual patient possesses reliable centric relation and vertical dimension of occlusion and is compatible with virtual articulators. Computer-aided implant planning and a digital prosthetic design can be seamlessly integrated by using this virtual patient.

Implant rehabilitation of edentulous maxilla in digital dentistry: A case report utilizing CAD/CAM technologies

The replacement of missing teeth utilizing dental implants and digital dental technologies has gained significant popularity in daily clinical practice over the last decade. Partially dentate patients present more anatomical references to guide the implant position and prosthetic reconstruction as compared to completely edentulous arches. Therefore, the management of edentulous maxilla using implant digital dentistry represents a challenging clinical situation where a thorough treatment plan is paramount to achieve a final prosthetic result that meets both functional and esthetic requirements. This case report discusses the oral rehabilitation of an edentulous maxilla and partially dentate mandible using a digital workflow for both the surgical and prosthetic phases of the implant therapy. Protocols for clinical assessment, treatment planning, and restorative management are described to provide a predictable and prosthetic-driven treatment for implant-supported prostheses.

Technical Strategy of Bone Graft Augmentation in the Anterior Maxilla

Bone graft augmentation in the anterior maxilla has a high successful rate. However, suture dehiscence and consequent bone graft exposure can compromise and fail this procedure. Therefore, this article presents a new strategy of closure technique to guarantee the bone graft augmentation. The sutures occur in muscular and mucous planes to avoid suture tension, thus decreasing complications of bone graft augmentation in the anterior maxilla.

Innovative Solutions Using Zygoma Implants

The severely resorbed edentulous maxilla presents significant treatment challenges. The introduction of remote implant support using zygoma implants has provided a plethora of treatment possibilities for many patients. This article presents four very different sets of circumstances successfully treated using this protocol.

Restoration of divergent implants with a 2-piece screw-retained fixed, complete dental implant prostheses

Restoring a severely resorbed maxilla is challenging because of poor bone quality and the resorptive pattern that follows tooth loss. When bone augmentation is not possible, implants are placed in suboptimal positions, making the prosthetic rehabilitation more complex. This report presents the steps used to rehabilitate a severely resorbed maxilla with divergent implants, using an implant-supported 2-piece screw-retained prosthesis.

Attachment-retained gingival prosthesis for implant-supported fixed dental prosthesis in the maxilla: a clinical report

The rehabilitation of edentulous maxillae is a complex procedure due to the involvement of esthetic and functional requirements. A trial maxillary denture can be used to identify the need for adequate upper lip support when replacing removable complete dentures by implant-fixed dental prostheses. This clinical report describes the outcome of the rehabilitation of an edentulous atrophic maxilla with unfavorable maxillomandibular relationship and deficient upper lip support. A trial denture was fabricated and used to diagnose the need for a prosthesis capable of restoring the upper lip support. The reduced upper lip support was also confirmed by a lateral cephalogram. The patient was rehabilitated by an implant-fixed dental prosthesis associated with an attachment-retained gingival prosthesis. The case presented shows that when loss of upper lip support is detected and the patient does not wish to undergo further surgical reconstruction procedure, the retention of a gingival prosthesis using a ball attachment is a satisfactory treatment option.

Virtual implant planning in the edentulous maxilla: criteria for decision making of prosthesis design

OBJECTIVES

To evaluate prosthetic parameters in the edentulous anterior maxilla for decision making between fixed and removable implant prosthesis using virtual planning software.

MATERIAL AND METHODS

CT- or DVT-scans of 43 patients (mean age 62 ± 8 years) with an edentulous maxilla were analyzed with the NobelGuide software. Implants (≥3.5 mm diameter, ≥10 mm length) were virtually placed in the optimal three-dimensional prosthetic position of all maxillary front teeth. Anatomical and prosthetic landmarks, including the cervical crown point (C-Point), the acrylic flange border (F-Point), and the implant-platform buccal-end (I-Point) were defined in each middle section to determine four measuring parameters: (1) acrylic flange height (FLHeight), (2) mucosal coverage (MucCov), (3) crown-Implant distance (CID) and (4) buccal prosthesis profile (ProsthProfile). Based on these parameters, all patients were assigned to one of three classes: (A) MucCov ≤ 0 mm and ProsthProfile≥45(0) allowing for fixed prosthesis, (B) MucCov = 0-5 mm and/or ProsthProfile = 30(0) -45(0) probably allowing for fixed prosthesis, and (C) MucCov ≥ 5 mm and/or ProsthProfile ≤ 30(0) where removable prosthesis is favorable. Statistical analyses included descriptive methods and non-parametric tests.

RESULTS

Mean values were for FLHeight 10.0 mm, MucCov 5.6 mm, CID 7.4 mm, and ProsthProfile 39.1(0) . Seventy percent of patients fulfilled class C criteria (removable), 21% class B (probably fixed), and 2% class A (fixed), while in 7% (three patients) bone volume was insufficient for implant planning.

CONCLUSIONS

The proposed classification and virtual planning procedure simplify the decision-making process regarding type of prosthesis and increase predictability of esthetic treatment outcomes. It was demonstrated that in the majority of cases, the space between the prosthetic crown and implant platform had to be filled with prosthetic materials.

Prevalence of complications after the oral rehabilitation with implant-supported hybrid prostheses

OBJECTIVES

Assess the main problems referred by the patients and observed by the professionals after the bucodental rehabilitation with an implant-supported hybrid prothesis.

PATIENTS AND METHODS

A retrospective study was carried out in which there were 43 patients included who were visited in the Department of Oral Surgery and Orofacial Implantology of University of Barcelona Dental School for one year. An oral rehabilitation with an implant-supported hybrid prosthesis was made to those patients. The following variables were registered: age, gender, number of inserted implants, type of implant and principal problems produced by the hybrid prosthesis.

RESULTS

The rehabilitation with an implant supported hybrid prosthesis was only performed in 43 of 116 cases treated in one year (January, 2006 to January, 2007). They were 26 men and 17 women of ages between 37 and 74 years, being the rate age of 56,5 years. The main complication recorded was the mucositis, associated frequently with a difficulty to carry a correct oral hygiene and to an overextention of the tail of resin of the prosthesis. Other observed problems were the peri-implantitis, the break of the acrylic teeth and the loss of some of the prosthetic screws.

CONCLUSIONS

The most frequent complication after the laying of an implant supported hybrid prosthesis was the mucositis, associated mainly with a prosthetic tail too long and to the consequent difficulty of carrying a correct oral hygiene. In spite of the high prevalence of observed complications, most of them were mild and resolved on subsequent visits.

Management of biomechanical complication of implant-supported restoration of a patient with combination syndrome: a case report

Combination syndrome (CS) is a pathologic condition of the stomatognathic system characterized by an edentulous maxilla with an atrophic anterior ridge, maxillary papillary hyperplasia, hypertrophic maxillary tuberosities, super-erupted mandibular anterior teeth, as well as atrophic mandibular posterior ridges. This condition can present a challenging situation to the clinician who needs to assemble evidence from all aspects of dentistry to formulate an appropriate treatment plan. One of the possible treatment choices for the fully edentulous patient with a CS is a full-arch implant-supported reconstruction for both maxilla and mandible. The purpose of this study is to illustrate and discuss a biomechanical complication-fractured maxillary meso bar in a patient with CS, and to present a description of how this complex case was corrected and successfully completed. The analysis of implant-supported and implant-retained full arch restorations in edentulous patients with CS is presented and treatment recommendations are given. A necessity of individualized approach for every implant reconstruction case, especially complicated with a CS, is suggested.

Reconstruction of edentulous maxillary and mandibular arches with implant-supported fixed restorations using a digital treatment planning technique: a clinical report

This article reports on the treatment of edentulous maxillary and mandibular arches with implant-supported fixed partial dentures. Treatment planning and surgical and restorative techniques are reviewed. Preoperative computerized tomography was obtained and computer software was used to determine the final position of the implants and restorations. The outcome has been favorable both for the patient and the clinicians.

Treatment planning complications and surgical miscues

It is critical to have an accurate understanding of the educational limitations of dentists because of a lack of formal training with implants. It is not a unilateral problem, as it can be easily discerned from the cases illustrated in this article. The team must pay attention to specific direction as to the number, location, depth, angulation, spacing, and distribution of implants in their patients. More and more experienced restorative dentists are incorporating implant treatment in their practice. There is more awareness and concern at having simple restorative cases turn into very complex undertakings that require extra chair time and additional laboratory expenses. To avoid treatment planning complications and surgical miscues the following is recommended: 1) always complete a detailed restorative and surgical examination; 2) do not place implants without a restorative prosthodontic workup; 3) refer the patient to an experienced dentist for the workup; 4) insist on a diagnostic wax-up; 5) insist on a radiographic and a surgical stent and use it during placement; 6) determine that the entire treatment team has the knowledge and experience to complete the case; 7) as a surgeon, be sure you understand the exigencies of fixed and removable restorative care; 8) make sure that team members have the same treatment vision; and 9) communicate. Never take anything for granted. Communicate.

Smoking interferes with the prognosis of dental implant treatment: a systematic review and meta-analysis

AIM

This systematic literature review was performed to investigate if smoking interferes with the prognosis of implants with and without accompanying augmentation procedures compared with non-smokers.

METHODS

A systematic electronic and handsearch (articles published between 1989 and 2005; English and German language; search terms "dental or oral implants and smoking"; "dental or oral implants and tobacco") was performed to identify publications providing numbers of failed implants, related to the numbers of smokers and non-smokers for meta-analysis. Publications providing statistically examined data of implant failures or biologic complications among smokers compared with non-smokers were included for systematic review.

RESULTS

Of 139 publications identified, 29 were considered for meta-analysis and 35 for systematic review. Meta-analysis revealed a significantly enhanced risk for implant failure among smokers [implant-related odds ratio (OR) 2.25, confidence interval (CI(95%)) 1.96-2.59; patient-related OR 2.64; CI(95%) 1.70-4.09] compared with non-smokers, and for smokers receiving implants with accompanying augmentation procedures (OR 3.61; CI(95%) 2.26-5.77, implant related). The systematic review indicated significantly enhanced risks of biologic complications among smokers. Five studies revealed no significant impact of smoking on prognosis of implants with particle-blasted, acid-etched or anodic oxidized surfaces.

CONCLUSION

Smoking is a significant risk factor for dental implant therapy and augmentation procedures accompanying implantations.

Oral rehabilitation of a completely edentulous epidermolysis bullosa patient with an implant-supported prosthesis: A clinical report

This clinical report describes the rehabilitation of a completely edentulous 29-year-old man diagnosed with recessive dystrophic epidermolysis bullosa (EB). Four implants were placed in each arch, and metal-resin implant fixed complete dentures were fabricated for both arches. This treatment option appears to be favorable for EB patients, compared to other options involving removable prostheses, in that it causes less mechanical irritation to the oral mucosa.

Length determination of zygomatic implants using tridimensional computed tomography

Considering the potential of tridimensional computed tomography (3D-CT) as a predictor of real bone dimensions, nine dried human skulls with maxillary edentulism were evaluated using images obtained by 3D-CT, prior to the installation of zygomatic implants, in order to obtain the measurements of the implants. In the analysis of correlation between the two 3D-CT examiners, a 75% agreement was found, and no correlation was found between them and the surgical measurement. The worst result was the surgical one, possibly because an inaccurate probe was used. Based on the obtained data, we concluded that the probe used is inaccurate, suggesting that the surgical probe be changed in its measurement scale. Agreement between surgeon and radiologist could possibly be obtained by using insertion guides, since what might have possibly caused the discrepancy in the results is the fact that the 3D-CT examiners and the surgeon used different implant insertion points. It is also possible that a larger sample might produce a more accurate evaluation, thus improving the results.

Treatment planning of the edentulous maxilla

The predictability of successful osseointegrated implant rehabilitation of the edentulous jaw as described by Branemark et al., introduced a new era of management for the edentulous predicament. Implant rehabilitation of the edentulous maxilla remains one of the most complex restorative challenges because of the number of variables that affect both the aesthetic and functional aspect of the prosthesis. Among the prosthesis designs used to treat the edentulous maxilla are fixed or removable implant-supported restorations. Since the aesthetic requirements and preoperative situation of each patient varies, considerable time must be spent on accurate diagnosis to ensure patient desires are satisfied and predictable outcomes are achieved. The purpose of this article is to compare the treatment options and prosthesis designs for the edentulous maxilla. Emphasis will be placed on diagnosis and treatment planning. Criteria will be given to guide the practitioner in deciding whether a fixed or removable restoration should be placed. This objective will be accomplished through the review of cases with regard to varying design considerations and factors that influence the decision-making process.

Immediate Fixed Restoration of the Edentulous Maxilla After Implant Placement

Immediate loading of the edentulous maxilla is possible when sufficient bone is available to provide primary stability of implants located in positions congruent with an ideal prosthesis. Treatment planning, implant placement with immediate provisionalization, and final prosthodontic rehabilitation are best integrated by a process that uses the immediate provisional prosthesis as a surgical and restorative guide. Designating the planned tooth position is a prerequisite step to the identification of possible implant positions. The cervical contours of the planned prosthesis are critical determinants of this relationship. Defining the planned tooth/residual alveolar bone relationship aids in selecting both the possible type of prosthesis and implant locations. When the treatment plan is transferred directly from the tomographic template to the surgical template to the conversion prosthesis used for immediate loading, the surgical and prosthodontic management of this procedure is well defined.

One-Stage Surgery and Early Loading of Three Implants for Maxillary Overdentures: A 1-Year Report

BACKGROUND

Maxillary implant overdentures opposing mandibular two-implant overdentures are an underused treatment option for edentulous patients. Fewer implants, simple surgery, and short healing periods may increase patients' acceptance of this treatment concept.

PURPOSE

To determine implant success, after overdenture loading, of three narrow-diameter roughened-surface implants placed in edentulous maxillas, using a one-stage surgical procedure, a 12-week healing period, and opposing mandibular two-implant overdentures.

MATERIALS AND METHODS

Forty edentulous participants with mandibular two-implant overdentures were allocated to two groups with similar implant systems. Each group had three narrow-diameter roughened-surface implants placed into their edentulous maxillas in a one-stage surgical procedure. Standardized intraoral radiography and implant stability tests were performed sequentially at surgery, at 12 weeks (prior to loading), and at 64 weeks (after 1 year of loading with maxillary overdentures).

RESULTS

One hundred seventeen implants were placed in 39 participants. After 1 year of loading, 15 implants had failed in 11 patients, 4 implants have been "put to sleep" in 3 patients, and 1 patient has died. Data on marginal bone loss and resonance frequency analysis showed no significant differences between the implant systems. The mean marginal bone loss was 1.30 mm (+/- 0.44 mm) from surgery to 12 weeks and 0.32 mm (+/- 0.48 mm) between 12 and 64 weeks with loading. The mean implant stability quotient and resonance frequency values showed a statistically significant improvement over time, at 56.05 (5,891 Hz), 57.54 (5,981 Hz), and 60.88 (6,167 Hz) at surgery, 12 weeks, and 64 weeks, respectively. The overall success rate for all implants combined was 81%, and the cumulative survival rate was 84.61%.

CONCLUSION

In patients with mandibular two-implant overdentures, three narrow-diameter roughened-surface implants can be placed in the edentulous maxilla, using a one-stage surgical procedure, and can be loaded within 12 weeks with overdentures for 1 year.

A histologic study of bone response to bioactive glass particles used before implant placement: A clinical report

This clinical report describes the microscopic analysis of the postextraction bone response to bioactive glass particles used prior to titanium implant placement, after a healing period of 6 months. The clinical and radiographic follow-up were performed over a 3-year period after implantation.