Maxillary bone augmentation with calvarial bone graft for immediate full-arch rehabilitation: Insights from a 10-year proof-of-concept retrospective analysis

OBJECTIVE

Evaluate the long-term outcomes of full-arch rehabilitation using immediate dental implant placement and continuous functional loading with full-fixed dental prostheses (FFDPs).

MATERIALS AND METHODS

Fifty-six patients received temporary implants (n = 327) at maxillary augmentation with calvarial bone. A provisional acrylic FFDP was immediately loaded onto these implants. After 6 months, the temporary implants were replaced with definitive implants (n = 326) and immediately loaded with a second provisional FFDP (N = 55). Subsequently, a baseline radiograph was taken following a 6-month healing period. The second bridge was then substituted with a definitive FFDP. Primary outcomes included peri-implant marginal bone level (MBL) and definitive implant survival. Secondary outcomes evaluated provisional implant and prostheses survival, complications, and patient satisfaction.

RESULTS

The provisional implants had a survival rate of 97.9%. One patient was excluded from further analysis due to loss of temporary implants and first FFDP. The definitive implant survival rate after 10 years was 92.2%, with a moderate but significant decrease in MBL between baseline radiography and 10 years later (-0.08 ± 0.18 vs. -0.24 ± 0.44). However, large individual variations were observed, with 65.8% of implants showing no bone loss and 9.2% showing loss ≥0.5 mm. Sinusitis was experienced by 14.3% of patients upon surgery. Patient satisfaction was high or reported no issues after protocol completion (80%). One patient lost all six definitive implants and definitive FFDP 8.2 years after implant placement.

CONCLUSIONS

The described protocol can be regarded as a long-term, highly successful method for full-arch rehabilitation of atrophied maxillae while enabling continuous masticatory and speaking functionality.

Guided Full Mouth Implant Rehabilitation in Atrophic Alveolar Ridges Using TTPHIL ALL TILT® Protocol: A Case Report With Three Years Follow-Up

Computer-assisted implant planning has become a key diagnostic and therapeutic tool in modern dentistry. This case report emphasizes the possibilities in modern implantology combining virtual implant planning, guided surgery with surgical templates, and immediate function. A 75-year-old female presented with maxillary and mandibular dentures and wanted fixed replacement in minimal appointments. Diagnosis, decision-making, and treatment approaches were based on clinical findings and detailed virtual three-dimensional implant planning. Guided implant placement of six implants in each arch using Tall and Tilted Pin Hole Immediate Loading Technique (TTPHIL ALL TILT®), and immediate loading with a provisional fixed dental prosthesis (FDP) was performed fulfilling patient's functional and esthetic demands in a minimally invasive manner. The final computer-assisted design/computer-assisted manufacturing (CAD/CAM) FDP with a titanium framework and ceramic layering was delivered after six months. At the three-year recall, the implant-supported FDP was free of any complications. Uneventful osseointegration of the dental implants and a healthy peri-implant mucosa were observed. Computer-assisted TTPHIL ALL TILT® technique including three-dimensional virtual implant planning, guided surgery, and CAD/CAM fabrication of provisional and final reconstructions allowed for a concise treatment workflow with favorable esthetic and functional outcomes in this maxillary and mandibular full-mouth case without the need of multiple surgeries in a short treatment time.

Long-Term Outcome of Dental Implants in Immediate Function Inserted on Autogenous Grafted Bone

Background: There is a need for long-term evidence of immediate function dental implants inserted in grafted bone. The aim of this retrospective study was to investigate the outcome of full-arch rehabilitations supported by implants in grafted bone. Methods: Thirty-six patients (women: 24; men: 12; average age: 53.5 years) were included (225 implants). Primary outcome measure: to assess implant cumulative success rates evaluated through life tables. Secondary outcome measures: to evaluate implant and prosthetic survival, marginal bone loss, and the incidence of both biological and mechanical complications. Results: Twenty-five implants were unsuccessful giving a dental implant CS rate of 88.1% at 14 years and a 76.8% survival estimation (Kaplan−Meier) using the patient as the unit of analysis. No prosthesis was lost. Average MBL at 10 years was 2.01 mm. The incidence of biological complications was 36%, with smoking affecting it significantly (p < 0.001). The incidence of mechanical complications was 86.1% (45.2% and 54.8% in provisional and definitive prosthesis, respectively. Conclusions: The rehabilitation of atrophic maxillae through dental implants in immediate function inserted in grafted bone is a valid treatment alternative, despite the relevant rate of implant failures and incidence of complications.

Immediate loading of a fixed full-arch prosthesis on four template-guided implants

BACKGROUND

Treatment of the edentulous maxilla with a fixed full-arch prosthesis on four immediately loaded implants has been discussed as a treatment option, although generally five implants are recommended for that indication. The precise transfer of the virtually planned position by 3D-guided implant placement is an essential prerequisite for delivering the prefabricated temporary restoration at the time of surgery. Three-point support on the teeth or implants ensures that the template for the guided surgery is soundly seated during the operation.

CASE PRESENTATION

In the described case, the three-point support was carried out by teeth and temporary implants in the molar region inserted prior to the CBCT. The virtual implant planning determined the best prosthetic implant position while using the available bone to avoid extensive augmentation. Following this, a metal-reinforced provisional restoration was prepared using a drilling template. Four implants were placed in the planned position with the aid of a tooth-/implant-supported guide. The prosthetic axis of the angulated distal implants is balanced by 17-degree angled abutments. After transferring the implant position to the dental laboratory, the prepared restoration was finalized. The remaining teeth were extracted and the temporary restoration was delivered 3 h after implant placement. The definitive fixed full-arch zirconia restoration with micro layering was placed 9 months later in a stable situation.

CONCLUSION

The remarkable accuracy of the implant placement with a surgical template generated from preoperative virtual implant planning ensures a relatively short treatment time and an uneventful and fast recovery with minimal discomfort. The immediate prosthodontic rehabilitation is a benefit, not only for the patient but also for the dental team. Micro-layered monolithic zirconia seems to be a promising option for screw-retained full-arch prostheses.

The 10 Year Outcomes of Implants Inserted with Dehiscence or Fenestrations in the Rehabilitation of Completely Edentulous Jaws with the All-on-4 Concept

Background: There is a need for a long-term evidence of implants placed in challenging conditions. The aim of this study was to investigate the outcome of full-arch rehabilitations with the All-on-4 concept for implants inserted with dehiscence or fenestrations. Methods: This retrospective cohort study included 123 patients (dehiscence, n = 87 patients; fenestrations, n = 28 patients; both conditions, n = 8 patients), with a total of 192 implants in immediate function presenting dehiscence (n = 150), fenestrations (n = 40), or both conditions (n = 2). Primary outcome measures were cumulative implant survival (CSurR) and success (CSucR) rates. Secondary outcome measures were prosthetic survival, marginal bone loss, and incidence of biological complications. Results: CSurRs were 94.1% (overall), 95.6% (dehiscence), and 88.1% (fenestrations) at 10 years using the patient as the unit of analysis. Smoking affected implant failure significantly (p = 0.019). Implant-level CSurRs and CSucRs at 10 years were 96.2% and 93.5% (overall), 97.2% and 94.6% (dehiscence), and 90.0% and 87.6% (fenestrations), respectively. Average bone resorption at 5 and 10 years was 1.22 mm and 1.53 mm, respectively. Biological complications occurred in 18 patients (n = 18 implants). Conclusions: Implants inserted with dehiscence or fenestrations demonstrate good long-term outcomes with overall high success and survival rates and low average marginal bone resorption, despite an inferior outcome in implants with fenestrations and smoking’s negative effect.

Immediate occlusal vs nonocclusal loading of implants: A randomized prospective clinical pilot study and patient centered outcome after 36 months

Background

Immediate provisionalization reduces chair time and improves patient comfort.

Purpose

To analyze immediate functional loading vs nonfunctional loading with restorations in the posterior mandible for marginal bone defects, implant success/survival, and patient satisfaction.

Materials and Methods

A randomized controlled clinical trial was designed to assess these parameters based on 20 adult patients who underwent implant surgery, followed by immediate delivery of screw‐retained or cemented single or splinted restorations in full occlusal contact or in infraocclusion (test and control group). A questionnaire with visual analog scales was used to assess patient satisfaction.

Results

Following 36‐month data were evaluable for 9 patients (21 implants) in the study group (immediate functional loading) and for 10 patients (31 implants) in the control group (immediate nonfunctional loading). One implant in the control group was lost, hence the overall implant survival and success rate was 98.2%. Marginal bone defects were consistent with previous studies and comparable in both groups. Periotest values did not significantly change from baseline and the 12‐month follow‐up (Friedmann test). Patient satisfaction was high and did not involve any significant intergroup differences (Mann‐Whitney U‐test).

Conclusions

Both types of immediate provisional restorations are viable in selected patients. Larger randomized controlled trials are needed to establish immediate functional loading as a standard treatment for partially edentulous jaws.

The All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: A longitudinal study with 10 to 18 years of follow-up

BACKGROUND

There is a need for studies evaluating the long term outcomes of the All-on-4 treatment concept.

PURPOSE

To evaluate the long term clinical and radiographic outcomes of the All-on-4 treatment concept in the mandible.

MATERIALS AND METHODS

This retrospective longitudinal case series study included 471 patients (women: 286, men: 185, average age = 57.7 years) rehabilitated with 1884 implants in immediate function supporting 471 fixed full-arch mandibular prostheses and followed for 10 to 18 years. Primary outcome measures were prosthetic survival and implant success and survival (estimated using life tables). Secondary outcome measures were marginal bone loss (MBL) at 10 and 15 years, biological and mechanical complications. Multivariable analysis was used to estimate potential risk indicators for implant failure (Cox regression to estimate hazard ratios and 95% confidence intervals (95%CI)), MBL > 3 mm at 10 and 15 years, biological and mechanical complications (binary logistic regression to estimate odds ratios [ORs] with 95%CI).

RESULTS

Twenty-seven patients deceased (5.7%) and 149 patients (31.6%) were lost to follow-up. The cumulative prosthetic survival rate was 98.8%; the implant cumulative survival and success rate was 93% and 91.7%, respectively up to 18 years of follow-up. Previous biological complications (HR = 4.43) were significantly associated with implant failure. Average (95% CI) MBL at 10- and 15-years were 1.72 mm (95%CI: 1.59, 1.85) and 2.32 mm (95% CI: 1.98, 2.66). Smoking (OR = 2.72), previous failure of a contiguous implant (OR = 3.89) and biological complication (OR = 8.11) were associated with MBL > 3 mm. The incidence of biological complications was 11.8% at implant level, with previous failure of a contiguous implant (OR = 5.56), smoking (OR = 1.75), and systemic condition (OR = 1.65) were significantly associated. The incidence of mechanical complications was 36.7% with male gender (OR = 1.67) and type of prosthetic material used in the restoration significantly associated (metal-acrylic OR = 0.30; metal-ceramic OR = 0.22)).

CONCLUSIONS

Considering the implant, prosthetic and MBL outcomes it is concluded that the All-on-4 is a viable treatment option validated in the long term. Nevertheless, biological and mechanical complications can occur.

Immediately restored full arch-fixed prosthesis on implants placed in both healed and fresh extraction sockets after computer-planned flapless guided surgery. A 3-year follow-up study

BACKGROUND

The treatment of patients by the use of immediate implant placement in post-extractive site is a challenging procedure.

PURPOSE

A 3-year clinical and radiological study of post-extractive implants placed using flapless guided surgery and immediately functioning.

MATERIALS AND METHODS

Thirty-two patients (23 females and 9 males), aged between 44 and 73 years (a mean age of 59.5) were treated with immediate full arch restorations and flapless implant surgery in fresh extraction and healed sites. A double-guide technique stent in conjunction with the NobelGuide system (Nobel Biocare AB, Göteborg, Sweden) was used.

RESULTS

A total of 285 implants over 32 patients were assessed. The patients were clinically and radiologically followed for 3 years. One hundred and ninety-five implants were placed in the maxilla and 90 in the mandible. Eight patients received implants in both arches. One hundred and ninety-seven implants were placed in extraction sites (137 maxilla, 60 mandible) and 88 in healed sites (58 maxilla and 30 mandible). The overall cumulative implant survival rate (CISR) was 97.54%. Two implants failed in maxillary healed sites (CISR 96.55%), three in maxillary extraction sites (CISR 97.81%), and two in mandibular extraction sites (CISR 96.66%). No implant failed in healed mandibular sites (CSR 100%). All fixed prostheses maintained stability and good functionality during the follow-up, accounting for a cumulative prosthesis survival rate (CPSR) of 100%. The overall marginal bone level (MBL) was -0.52 mm (SD -0.18) after 6 months, -0.88 mm (SD -0.20) after 12 months, -1.05 mm (SD -0.21) after 24 months, and -1.32 mm (SD -0.41) after 36 months.

CONCLUSIONS

Computer-guided surgery using double-template technique (DTT) shows a predictable outcome in the medium term, decreasing treatment timing and patient discomfort.

Clinical and radiographic outcome following immediate loading and delayed loading of single-tooth implants: Randomized clinical trial

BACKGROUND

Immediate loading of single implants is generally considered a reliable procedure.

PURPOSE

The objective of the present prospective randomized clinical study was to compare the overall treatment outcome following immediate loading (IL) and delayed loading (DL) of single implants after 1 year of follow-up.

MATERIALS AND METHODS

Patients with a missing maxillary tooth (15-25) were randomly assigned to IL or DL. The protocol included implant installation in healed sites, immediate loading, delayed loading, temporary screw-retained restoration, and replacement with a permanent single implant crown. Outcome measures were implant survival, marginal bone level, soft tissue changes, papillae index, pink, and white esthetic score (PES and WES), patient judged aesthetics, and oral health impact profile (OHiP-14).

RESULTS

Implant survival rate was 100% and 96% for IL and DL, respectively. Implant success rate was 96% and 88% for IL and DL, respectively. Statistically significant lower papilla index scores were found in the IL group at temporary crown and definitive crown placement. An overall statistically significant improvement after 12 months for PES, WES and OHIP-14 was found.

CONCLUSION

This prospective randomized study showed that single implants in the maxilla can present satisfactory results with respect to either immediate loading or delayed loading after 12 months.

Five-Year Results of a Randomized Controlled Trial Comparing Patients Rehabilitated with Immediately Loaded Maxillary Cross-Arch Fixed Dental Prosthesis Supported by Four or Six Implants Placed Using Guided Surgery

PURPOSE

To compare the 5-year clinical and radiological outcomes of patients rehabilitated with four or six implants placed using guided surgery and immediate function concept.

MATERIALS AND METHODS

Forty patients randomly received four (All-on-4) or six (All-on-6) immediately loaded implants, placed using guided surgery, to support a cross-arch fixed dental prosthesis. Outcome measures were survival rates of implants and prostheses, complications, peri-implant marginal bone loss, and periodontal parameters.

RESULTS

No drop-out occurred. Seven implants failed at the 5-year follow-up examination: six in the All-on-6 group (5%) and one in the All-on-4 group (1.25%), with no statistically significant differences (p = .246). No prosthetic failure occurred. Both group experienced some technical and biologic complications with no statistically significant differences between groups (p = .501). All-on-4 treatment concept demonstrated a trend of more complications during the entire follow-up period. A trend of more implant failure was experienced for the All-on-6 treatment concept. Marginal bone loss (MBL) from baseline to the 5-year follow-up was not statistically different between All-on-4 (1.71 ± 0.42 mm) and All-on-6 (1.51 ± 0.36 mm) groups (p = .12). For periodontal parameters, there were no differences between groups (p > .05).

CONCLUSION

Both approaches may represent a predictable treatment option for the rehabilitation of complete edentulous patients in the medium term. Longer randomized controlled studies are needed to confirm these results.

All-on-4® Treatment Concept for the Rehabilitation of the Completely Edentulous Mandible: A 7-Year Clinical and 5-Year Radiographic Retrospective Case Series with Risk Assessment for Implant Failure and Marginal Bone Level

BACKGROUND

Studies are needed to evaluate long-term outcomes of the All-on-4® treatment concept (Nobel Biocare AB) for rehabilitation of edentulous mandibles by assessing marginal bone levels and risk indicators for implant failure.

PURPOSE

To evaluate 7-year clinical outcomes and 5-year radiographic outcomes of the All-on-4 treatment concept.

MATERIALS AND METHODS

This retrospective case series included patients admitted for implant rehabilitations in the mandible, who were followed for 7 years clinically and 5 years radiographically. Primary outcome measures were cumulative prosthetic and implant survival using patient as the unit of analysis (Kaplan-Meier product limit estimator). Secondary outcome measure was marginal bone level (MBL) at 5 years. Variables associated with implant failure were analyzed using the Cox proportional hazards regression model to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Binary logistic regression was used to compute odds ratio (OR) with 95% CIs for variables associated with MBL ≥2.8 mm at 5 years.

RESULTS

A total of 324 patients (194 women, 130 men, average age = 58.9 years) were rehabilitated with 1,296 implants supporting 324 full-arch fixed immediately loaded mandibular prostheses. Sixty-four patients (19.8%) were lost to follow-up. Prosthetic survival was 323/324 (99.7%), and 14 patients lost 18 implants, with an estimated cumulative survival rate of 95.4% at 7 years. Variables associated with implant failure were smoking (HR = 5.28; 95% CI: 1.33, 20.91]) and the learning curve effect (0.69 < HR < 0.33 for more experienced levels). Mean MBL at 5 years was 1.81 mm (95% CI: 1.70, 1.92), and smoking was associated with MBL ≥2.8 mm (OR = 2.4; 95% CI: 1.02, 5.62).

CONCLUSIONS

The high implant and prosthetic survival rates and excellent MBL outcome confirm the predictability and safety of the All-on-4 treatment concept over a longer term than previously reported.

Double Full-Arch Versus Single Full-Arch, Four Implant-Supported Rehabilitations: A Retrospective, 5-Year Cohort Study

PURPOSE

To report the 5-year outcome of the All-on-4 treatment concept comparing double full-arch (G1) and single-arch (G2) groups.

MATERIALS AND METHODS

This retrospective cohort study included 110 patients (68 women and 42 men, average age of 55.5 years) with 440 NobelSpeedy groovy implants. One hundred sixty-five full-arch, fixed, immediately loaded prostheses in both jaws were followed for 5 years. G1 consisted of 55 patients with double-arch rehabilitations occluded with implant-supported fixed prostheses, and G2 consisted of 55 patients with maxillary single-arch rehabilitations or mandibular single-arch rehabilitations occluded with natural teeth or removable prostheses. The groups were matched for age (±6 years) and gender. Primary outcome measures were cumulative prosthetic (both interim and definitive) and implant survival (Kaplan-Meier product limit estimator). Secondary outcome measures were marginal bone levels at 5 years (through periapical radiographs and using the patient as unit of analysis) and the incidence of mechanical and biological complications. Differences in survival curves (log-rank test), marginal bone level (Mann-Whitney U test), and complications (chi-square test) were compared inferentially between the two groups using the patient as unit of analysis with significance level set at p ≤ 0.05.

RESULTS

No dropouts occurred. Prosthetic survival was 100%. Five patients lost 5 implants (G1: n = 3; G2: n = 2) before 1 year, rendering an estimated cumulative survival rate of 95.5% (G1: 94.5%; G2: 96.4%; Kaplan-Meier, p = 0.645, nonsignificant). The average (SD) marginal bone level was 1.56 mm (0.89) at 5 years [G1: 1.45 mm (0.77); G2: 1.67 mm (0.99); p = 0.414]. The incidence rate of mechanical complications (in both interim and definitive prostheses) was 0.16 and 0.13 for G1 and G2, respectively (p = 0.032). The incidence rate of biological complications was 0.06 and 0.05 for G1 and G2, respectively (p = 0.669).

CONCLUSIONS

Based on the results, rehabilitating double- or single-arch edentulous patients did not yield significant differences on survival curves. The incidence of mechanical complications was significantly higher for double-arch rehabilitated patients but nevertheless, these mechanical complications did not affect the long-term survival of either the prostheses or the implants.

The NobelGuide® All-on-4® Treatment Concept for Rehabilitation of Edentulous Jaws: A Prospective Report on Medium- and Long-Term Outcomes

BACKGROUND

There is a need for long-term studies on complete edentulous flapless rehabilitations.

PURPOSE

This study aimed to evaluate the long-term outcomes of the rehabilitation of completely edentulous jaws for immediate function with the All-on-4® treatment concept using a computer-guided surgical protocol (NobelGuide®, Nobel Biocare, Göteborg, Sweden).

MATERIALS AND METHODS

This prospective clinical study included 23 totally edentulous patients rehabilitated between February 2005 and May 2006 with 92 implants with the All-on-4 treatment concept using NobelGuide. Outcome measures were implant survival, marginal bone loss at 1, 3, and 5 years, and the incidence of mechanical and biological complications. Survival was calculated using life-table analysis.

RESULTS

Two dropouts occurred. The cumulative implant survival rate was 96.6% at 5 years of follow-up. Prosthetic survival was 100%. The average marginal bone loss was 1.7 mm (standard deviation 1.4 mm) at 1 year, 1.7 mm (standard deviation 0.9 mm) at 3 years, and 1.9 mm (standard deviation 1.1 mm) at 5 years. Seven patients experienced fracture of the definitive prosthesis (6 patients were heavy bruxers), and abutment screw loosening occurred in 2 patients. Two implants in 2 patients showed peri-implant pathology.

CONCLUSIONS

Within the limitations of this study, it is possible to conclude that this treatment modality for completely edentulous jaws is safe and predictable with good long-term outcomes.

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

PURPOSE

The aim of this preliminary study was to report on the short-term outcome of tilted implants with 20 to 25 mm of length in immediate function with bicortical anchorage for prosthetic rehabilitation of complete edentulous jaws with low-density bone.

MATERIAL AND METHODS

Sixteen patients (with 25 study implants and 43 nonstudy implants) presenting low-density bone were included in a prospective single cohort study to evaluate the short-term outcome of partial and complete edentulous rehabilitations using implants with 20 to 25 mm of length (NobelSpeedy Groovy, Nobel Biocare AB, Gothenburg, Sweden) in immediate function with bicortical anchorage (maxilla: alveolar ridge and nasal corticals; mandible: mandibular corticals). The patients were followed between 6 and 26 months (average of 14 months). Outcome measures were implant survival, marginal bone remodeling, biological and mechanical complications assessed at 10 days, 2, 4, and 6 months, 1-year posttreatment, and thereafter every 6 months.

RESULTS

Two patients with four implants were lost to follow-up after 6 and 11 months. There were no implant failures, rendering a cumulative implant survival rate of 100%. The average marginal bone remodeling was 0.50 mm (SD = 0.34 mm) and 0.86 mm (SD = 0.46 mm), after 6 months and 1 year, respectively. There was one mechanical complication in one patient (abutment loosening) 1 month post-surgery.

CONCLUSION

Within the limitations of this study, the short-term outcome of prosthetic rehabilitations of patients with low-density bone using implants of 20 to 25 mm in length in immediate function with bicortical anchorage is viable judging by the high implant survival rate, low marginal bone remodeling, and low incidence of complications. Long-term evaluation of these implants through studies using a prospective design is mandatory.

Extramaxillary surgical technique: clinical outcome of 352 patients rehabilitated with 747 zygomatic implants with a follow-up between 6 months and 7 years

BACKGROUND

The use of zygomatic implants inserted in immediate function through the extramaxillary technique needs validation.

PURPOSE

To report the outcome of rehabilitating 352 patients with complete edentulous atrophied maxillae using 747 zygomatic implants in immediate function inserted through the extramaxillary technique.

MATERIALS AND METHODS

Three hundred-fifty-two consecutive edentulous patients with atrophic maxillae were rehabilitated between 2006 and 2012 with 747 zygomatic implants and 795 conventional implants. Implant and prosthetic cumulative survival and success rates were estimated through Kaplan-Meier product limit estimator. Biological and prosthetic complications were recorded after 10 days; 2, 4, and 6 months; and thereafter every 6 months.

RESULTS

Forty-three patients (12.2%) dropped-out, one patient lost the prosthesis (cumulative survival rate = 99.7%), and four patients lost 7 zygomatic implants, rendering an estimated cumulative survival rate of 98.2% (Kaplan-Meier). Ten patients lost 17 conventional implants (patient-specific and implant-specific cumulative survival rates of 96.7% and 97.9%, respectively). Biological complications were observed in 80 patients (22.7%) and resolved in the majority of situations, rendering an estimated cumulative success rate of 94.4% at 7 years for zygomatic implants (Kaplan-Meier). Mechanical complications occurred in 156 patients (44%), with one-third of these complications occurring in patients diagnosed with bruxism before the rehabilitation.

CONCLUSIONS

The rehabilitation of atrophic maxillae with zygomatic implants inserted through the extramaxillary technique in immediate function, alone or in combination with standard implants, is a viable procedure. Until the biomechanical aspects are more predictable and also because of the complexity of the surgical technique, this rehabilitation approach is not ready for every implant clinician to begin using in practice, and prior special training is recommended.