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7/21/2019 Immediate Function and Esthetics in Implant Dentistry
1/114
Edited by
Peter MoyPatrick PalacciIngvar Ericsson
&Immediate Function
Esthetics in Implant Dentistry
Quintessence Publishing Co. Ltd.
London, Berlin, Chicago, Tokyo, Barcelona, Istanbul, Milan, Moscow,
New-Delhi, Paris, Beijing, Prague, So Paulo, Seoul, and Warsaw
7/21/2019 Immediate Function and Esthetics in Implant Dentistry
2/114
Peter Moy Patick Palacci lngva Eicsson
1 ction
Esthetics in lmpla strv
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u i
h l r1 Publicaton D
M. K
Im J e implan
. D s
I T II l Ecc r
616'93
ISBN-13: 97850
Al tradenms k, includgk Proea, Tthi-H TUie owes.
gt 20
by Qen C L
T work i _ A !i rgt w ts prhbd z he ls pa l 10 f d o ad o n lv
P Bi: fb pis
SBN: 7 8857--
n G
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v
General technical developments, especially in the
area of computers, have led to new and fascinating
tools becoming available for medicine and den-
tistry.
Contemporary methods within radiology, such as
computerized tomography and medical imaging,
have made patient information available for
diagnosis in a totally new way. Furthermore,
ongoing development has made these technol-
ogies less costly and therefore more readily avai-
able for doctors and patients.
Guided surgery is an example of a technology that
has developed in this way. The utilization of new
powerful technologies has to be conducted in
close consultation with experienced clinicians. The
technology is just a tool, no matter how powerful.
This book describes and documents how to use
NobelGuide in various clinical situations. It is
based on long-term clinical ambitions, thorough
knowledge of the development of this technology,
and the ambition to strive for what is the best for
the patient.
Matts Andersson, DDS PhD
Chief Scientist, Nobel Biocare AB
Gothenburg
Foreword
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vii
Professor Per Ingvar Brnemark first introduced
the concept and principles of osseointegration to
North America during the Toronto Conference in
1982 after years of research and clinical trials. The
protocol presented at that time recommended a
non-loaded healing period of between 3 and 6
months for dental implants. These recommenda-
tions were made from experience using a machine-
smoothed-surface titanium implant. Publications by
other investigators reported very high implant
success rates in completely edentulous jaws, as
well as predictable prosthetic reconstruction when
the delayed loading protocol as advocated by Prof.Brnemark was followed. These articles were fol-
lowed by publications indicating similar success
rates with partially dentate cases.
The demands and expectations of patients to
complete dental implant treatment sooner and
faster have forced clinicians to find new clinical
solutions. Fortunately, improvements in technology
and understanding have provided the means for
clinicians to meet these demands. Thus, with
improvements in implant surfaces, thread patterns
and implant body designs, loading concepts haveevolved into the early loading of implants. Early
loading is the application of load on implants
sooner than the 3- to 6-month healing period, and
immediate loading is the application of load within
48 hours. Early and immediate loading of dental
implants requires clinicians to change their proce-
dural protocols and patient management. To opti-
mize treatment for their patients, clinicians must
take advantage of all available improved technol-
Prefaceogies and clinical techniques, including CAD/CAM-
generated surgical templates and prosthetic
restorations, computer software programs that
permit accurate diagnosis and treatment planning,
and the use of minimally invasive surgical and
prosthodontic techniques.
This textbook introduces the concept of Nobel-
Guide, a complete and practical approach to man-
aging the implant patient who expects immediate
loading and function. The authors take the reader
through the diagnostic process, with a detailed
description of the necessary workup and
generation of the radiographic guide for a CATscan. This allows the clinician to complete the
workup using a specialized computer software
program that shows the available hard and soft
tissues, vital anatomic structures and ideal loca-
tions for tooth/implant positions based on the
prosthetic design. From this planning stage, a sur-
gical template is generated for implant placement,
allowing minimally invasive surgical techniques
while assuring accuracy of implant placement
without the reflection of a soft tissue flap. With
knowledge of implant positions prior to the surgicalplacement, the prosthodontic specialist can fabri-
cate the desired prosthesis before the actual
surgery, thus providing the patient with a function-
ing prosthesis immediately after the implants are
placed.
These new concepts and protocols are
presented in a manner that allows clinicians to pro-
vide their patients with practical and predictable
immediate function.
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Peter K Moy, DMD
Dr Moy received his dental degree from the Uni-
versity of Pittsburgh, a certificate in General Practice
Residency from Queens Medical Center in Hono-
lulu, Hawaii, and completed his surgical training in
oral and maxillofacial surgery at UCLA Hospital in
1982. A Professor in the Department of Oral and
Maxillofacial Surgery at UCLA, he is also Director of
Implant Dentistry at the Straumann Surgical Dental
Center and Nobel Biocare Surgical Fellow Program.
He is a Fellow of Pierre Fauchard Academy and the
Academy of Osseointegration, where he currently
serves as Vice President. He is an associate editorfor the International Journal of Oral and Maxillofacial
Implants and a member of the editorial board for the
International Journal of Oral and Maxillofacial
Surgery, Clinical Implant Dentistry & Related
Research and Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontology. Dr
Moy maintains his private practice, the West Coast
Oral & Maxillofacial Surgery Center, in Brentwood,
California.
11980 San Vincente Blvd #503Los Angeles CA 90049
USA
Tel: 001 310 820 6691
e-mail: [email protected]
viii
Editors
Peter K Moy
Patrick Palacci
Ingvar Ericsson
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Patrick Palacci, DDS
Dr Palacci received his dental degree from the
University of Marseilles, France; he completed his
periodontal training at Boston University, MA, USA,
where he was appointed as a Visiting Professor. He
is currently in private practice at the Brnemark
Osseointegration Center, Marseilles, which has
mainly been involved in esthetic implant treatment,
developing several techniques related to precision
in osseointegration treatment as well as soft tissue
management, including the papilla regeneration
technique. He has written a number of scientific
articles as well as two textbooks, published byQuintessence, and a chapter related to esthetics
and soft tissue management in Professor Per-
Ingvar Brnemarks textbook From Calvarium to
Calcaneus, also published by Quintessence.
Brnemark Osseointegration Center
8-10 rue Fargs
13008 Marseilles
France
Tel: 00 33 (4) 91 57 03 03
e-mail: [email protected]
Ingvar Ericsson, DDS, Odont PhD
Prof Ericsson obtained his DDS degree in 1966;
Specialist License in Periodontology in 1977, in Pros-
thetic Dentistry in 1990; and Odont doctorate
degree (PhD) in 1978 at the Faculty of Odontology,
Gteborg University, Sweden. He worked at the
Department of Periodontology in Gteborg from
1973 to 1994, and as Professor at the Prosthodontic
Department, Malm University, from 1994 to 2003.
In addition, he has been working as a private
practitioner in Gteborg since 1967 and as a
consultant at Nobel Biocare since 1993. Prof.
Ericsson has published around 100 original articles,25 review articles and several chapters in textbooks.
He has been an invited speaker at approximately
200 scientific meetings and presented courses
internationally. Prof. Ericsson has vast experience of
the Brnemark System both from a surgical and a
prosthetic point of view. He has been one of the
clinical developers of the Teeth-in-an-Hour concept,
together with the group under Dr Matts Andersson
at Nobel Biocare.
Djupedalsgatan 2S-413 07 Gothenburg
Sweden
Tel: 00 46 707 615044
e-mail: [email protected]
ix
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x
ContentsChapter 1 Loading principles ........................................................................................................................ 1
Ingvar Ericsson
Delayed, early and immediate loading protocol...................................................................... 2References .................................................................................................................................... 8
Chapter 2 NobelGuide concept ..................................................................................................................... 11Peter K Moy
Background .................................................................................................................................... 12Prerequisites for successful implants ....................................................................................... 15Advantages of the NobelGuide concept ................................................................................. 16Surgical template .......................................................................................................................... 17Additional considerations ............................................................................................................ 20Conclusion ..................................................................................................................................... 21
References ..................................................................................................................................... 21
Chapter 3 Surgical planning ......................................................................................................................... 23Marcus Dagnelid, Jean Veltcheff
Computer-based surgery at a glance ....................................................................................... 24Procera system ............................................................................................................................... 24Computer-based workflow .......................................................................................................... 24Conclusion ..................................................................................................................................... 36References ..................................................................................................................................... 36
Chapter 4 NobelGuide in use ......................................................................................................................... 37
Part I: NobelGuide surgery ..................................................................................................... 38Peter K Moy, Patrick Palacci
Surgical procedure ....................................................................................................................... 38Fully edentulous patients ............................................................................................................ 40Partially dentate patients ............................................................................................................. 44Postoperative patient instructions ............................................................................................ 45
Part II: NobelGuide, zygoma implants and immediate function ...................................... 46Chantal Malevez
Introduction to zygoma implants .............................................................................................. 46Surgical standard protocol ......................................................................................................... 47
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Zygoma implants and NobelGuide .......................................................................................... 47Conclusion ..................................................................................................................................... 48
References ..................................................................................................................................... 49
Chapter 5 Esthetic considerations ............................................................................................................. 51Patrick Palacci
General principles ........................................................................................................................ 52Fully edentulous patients ............................................................................................................ 53Partially edentulous patients ...................................................................................................... 54Esthetic anterior maxilla classification ..................................................................................... 55Treatment planning ...................................................................................................................... 57Treatment options according to different classes ................................................................ 58Case presentations ...................................................................................................................... 62Further reading ............................................................................................................................. 76
Chapter 6 NobelGuide prostheses ............................................................................................................. 77Pelle Pettersson, Christer Dagnelid
General factors for quality assurance ...................................................................................... 78Preparations ................................................................................................................................... 78The radiographic guide .............................................................................................................. 78Postoperative care and follow-up ............................................................................................. 83Case presentations: a prosthetic approach ........................................................................... 83References ..................................................................................................................................... 89
Chapter 7 Avoiding complications when using NobelGuide ............................................................... 91
Peter K Moy, Patrick Palacci, Ingvar EricssonComplications during planning ................................................................................................. 93Complications during surgical procedure .............................................................................. 96Complications during prosthodontic procedure .................................................................. 101Conclusion ..................................................................................................................................... 102
Chapter 8 Conclusion .................................................................................................................................... 103Peter K Moy, Patrick Palacci, Ingvar Ericsson
Index ............................................................................................................................................................. 105
xi
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Chapter1
I ngvar Ericsso
1
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Chp 1 pcp
Delaved, earlv and immediate
protocol
Twstage surgery - delayed loading
n 1969. the origil potocol fo mpn isionws describe by Baemrk nd co-wokers
(Eerk e 969) Te pooco secfes
wo-sge sugicl ocedre, ie two-iece
is used d te imlt s submerged
rg 3 to 6mo eg perod (Fg 1
eree, be coeco s eore he
spr-costctio bicted d scew-reted
o e p illrs e pncile o osseo
egrto ws empszed: ' dec coge of
ipt by te oon o boy sse t e
boe imt inefce s observed he lig
mcroscopc eve
I 9 oowp resus of e tetet out
come of 235 edetos jws 28 mxills nd
07 bes wee presened Brerk et
9 e obsevio perod vred from 9
mohs o 8 yers Dt reveed t 85% o the
sucosrctons sed wee stble Sce
he g prectbity o mpt remet s
been demonsrted i log-ter foow- sudes
(55 yers o edetuous pes eg Ael e 990 Arvdsson e 996 998 nd or pry
ete ets (eg Leko e 999 ere
oe he l mehooogy s sceiic
odio for implt stbilty d edcbe
ongtem ccl success
Onestage sgey - delayed loadinge erk Syste fo nts ws oigy
esged to be wo-sge syse: dug te
til heig pse te mplns were subergedTs poc ws tken to mimie risk of
feco prevet pc mgron of mucos
epte og te tn surce d to m
me he rsk or ue ery og of te n
(erk e 969 9
However snce is deveopmen tere hs been
e-evo o e tdol wo-sge prooco
coeder e {976 97 93 sowed t
s ossibe to cheve rectble osseointegrtion
eve whe usig onestge techique e me
2
dtely foowg slio e imlt p s
eosed te orl cvy n eperent stdes
e pplico of onesge srgic pocedre
o oneece mlts Gotedse et 99
Abmsso e 996 o woece ns
Abhmsso e 996 rcsso e l 996 ssown good ress Tese observons e r
e cored i nuber of wel-coroe cini
c stes usng e Banek yste eg
ery Roseberg 994 en et 995
ecke et 99 icsson e l 99 Cot n
eruyn 998 iberg et 999 ogre e l
2003 occi et l 2003 gquis et l 2005
utemore rcsso et l 99 reored t e
ginl boe eve t tued plns lce
eroy he edetos mdible d su
pog fe sprconstructios s sble bet
ween 2 d 60 ots irespective o whee
pced ccordg to oe- or two-stge srgc
proocol
Becke e l 997 reoted o 35 Eerk
ured mts ced ccordng o e oesge
srgc oocol cobo wit elyed
oig e 36 ots of heng befoe odig;
g ) Imps were pce te xl s we
s i he mndibe demosg iy ete
condos e m surviv e ug the firstye o observto olowig lodig ws 9596%
A oewory fing ws t in is tcu
goup o ptes 32 sige oo elcemes
wee icde Becke e 99
or nd e Byn 99 reed 5
ptes or ptl = 35 o copee = 50
ndbulr eenulousess by mes o fed
surcostcos ete byrnerk tred
ms A otl o 330 is were ced
Of ese 330 mpts 2 were stled ccog o te oe-sge ooco (e 3 monhs o
helg beoe oig 9 ccordg to te
rdio wosge roocol A soewt ge
pecege of ires ws eoed or e tiy
suo h fo e comeely edenous stu
o rrespective o weter he mls wee
pced sng oe- o two-sge srgc p
poc he ove plnt svvl re durng e
u to ye observtio erod ws eoed to be
bo 95% e utors concuded one
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Delaved. ev and immediate loadi procol
I
Surg
Hlig Prid Ladig=Fuci
ehanical S
ab
l
ty
-
Boil Stbilit
Fig 1- Schema iustrationf te twstage ad ne-te prtl it deyai.
OSSEOINTGRAO is conept of bii
tage urgca approach wth omay ubmerged
ype Brneak ipa ca be a predcabe a
he cmo wtage cedre n the
cetey ad aay edetuou andbe'.
Herma ad coworke 1977 treated 3
paent fo edentim i te adbe uig
mant aced i a onage ugca cedue
The ow-up peod wa 3 yea ad te
cumative aie rae eaced te ige te
oerave ecique wa 9% I er wd, a
imia teatme ce wa obtaied or te
o-age tecnique a o the tadioa b
eged oe Bernad et a (995) paced 0 im
pan accordng to a ne-age ugca ecnue ve ede andbe Foowng e ta
3h eaing peiod he pa eved a
eainer or ovedeue N iat aie eier
peri-ia o or ard ue cocatio wa
eoed
Siar cica daa have bee reoted wi
e o ian neece i dieet tuai
(uer e a 997): i edeo mandibe
(ee et a 2 ad i ede maxia
(Beg vit e a 04 tee cnca die teant iar wee no oaded va a xed ura
ctruco unt 3 6 mont heang ad
paed er wd te treaet cocep o
oeage mat ntaain i cbian wt
deayed adng wa aied g urte
e, data o cnica de g Atra Tec
mat wopiece) uort the above-metoned
obeva eg Coper e a 999
a e cica tdie cied abve the iga
dee oe wee adjed ad reied by
a t tiue conditoer week owng
imat itaao to miimize avorabe
cta adng o te pa owever it
ud be aciated a pa itaed
accrdig a oeage ugca rcedre
durig te ia eag perd to ome exet, w
be direcy ad upedctaby oaded dng c
o via the adued and eed dere the
e uc oadig mght be uavabe or he
impat a te deorman aer o comee
deture bae aea dug cna condtio
can be coex and pedctabe (Ga and
Saord 983 Deite Bemak rned
an taed according t a ntage urgicaprocedure demoated he ame ucceul rae
a ideca ipat aed accodng he
rigia woage pocedue eg Eic e a
99 997 Berad et a 995 Becke et a 997a
Hea e a 99 ort ad e By 998
n her wod a niia ad dect oadig
mpant iercg te ucoa via te adjted and
reied dentue obiy doe t jeoparde a
roer eegatn o te ixe co e
a 99 Such a aement i i ageeme whcca data epored by enry ad Roenberg
99 ), w cncded hat coed medi
ae adg adeuatey intaed no-uberged
an, by reinert a mdiied dee doe
o aear o eoardie te poce o oe
tegraon i e aeo madibe urermore
Becer et a 99) caed tat oe-te
Brema ant ay be cdered a iabe
ateatve wotep a ccodg
Gant e a (9a 9b } avoabe adng
3
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Chapter 1 loading principes
conditos are achieved hough a rigid fixed spa
cosrucio ad, herefore t s reasoable to
belee ha a successu treatme outcome could
be reached aso we gid appaces are
coected o te red mpas eary foowng
stallao of the pats (i.e. ealy ctoal
loadig)The impoance of oa hygee has bee hgh
ghed especialy whe applyng the oestage sur
gcal potocol (Goedse e a 199 . Good oal
hygee codos w facate e foraton of a
pope soft isse seaa ie. te tsse porto
separag e oral cavy and te achorg boe.
e aos cocuded ta paque accumaio
o e pant plas resuted i: ( } eteded fl
tated coneie ssue ot oy a vecal t
aso a oizonta drecto; (2) log pocke ep-
4
Fig 1-2 a-c Mari bonelevel au mplats laceaodig o he o-ae al rooo wi ery loadn.() Coo i of a ) A 8 olow. c AI 60 llexaiao. d nd e) Mrlb l ou lslaed !oaded aord o oiil ol: ( io 18' olowu
exaiao ad ( a 5yaroow exaao
telm ad (3 acie boe resopo (e. pres
ece o osteocass of te magal boe cres
copared wth the codos a mplas witou
pesence o paque acculatos
Ostg surgy rly loig
About 20 years ago i was stated tha'.. preatureload o impats leads o te ormato of brous
tsse istead of he foaio of oe tsse (.e.
otogeess Aetsso e al 986. We
plats are paced accodng o he oestage
poocol e implats os liely wl e exposed to
a certa oad immedatey folowg placemet
iporta prereqsie for obtaig a pe
dcae heag process of mpats (osseote
gato} s hat icoio i.e the moeme a
te eace betwee he oe ad he ipa
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g 1- Teae pproh by Sh d cworkrs( 1997). Fve to x mplan wr pac n tl1e nemadibl )\w th oami. a o of hs impas t th 1di was xpsd ab umnt cnnci
immdiatly fllowing iso Raiig s wsubmrgd ames w od 3 4 mosaer. I ao, s o e exit o d bove e ee-vesse bundle, oe short impla w paced billy usinga -stag urg1ca chiq Tus r iplan wr e i al aviy wih w med!ey ccelt ini ixd pa dt T mths !,t mat fid pa enue was bae d -tachd be implts
face i limied (Camero et a 973 Bk
1992, 1999. Plla 995. S0a t a ( 993
port hat t t volv proal w
accept cooo amo to 55 m
Ftoe Bk (99) eporte at c
oto of approxmael m a cote a
treod vae o tre mpla rface o
ootrat poprl
avoal oa codo ca acvd
o e coc o each ot va a d fxe
paal ee Gaz e al 984a 198 How
ever dva mpa plar ae accodto the oeae rcal pocedre ae mot ie
expod to precal loa mmdae after
aato Tro aoal o a
ta plat ave o e jo tothe va a
cocto a oo a pole olow pace
e Mcooto at e erace ewee oe
ad plat rac wl e lmte ad hopel
wi a accpta lvL h acltat h
al poc (ootrao
Rcet oo a prcae el o mplat teame have e epoe the lteate
we mpla ae expoe to eal fcoa loa
the ateo ade e Eco e a
Chow t al 2 e e a25 h rco
t al vaat ocom of oa
ehaltato of eetlo ma fxe
pacorcto coect o e re
ar pla aed accor o ete a
oeae rcal procedre a mmedate
oad, o ora wo-a a
Delaved. earv and immediate loading protocol
loadi protocol w the wok hpothei that
the o frec wee wo mtod
cocr tam otco A total of 88
te mpat 16 pae we plac acco
to e oeae poocol a oade va afxe
applacew da Impat pace accor
o he oial poocol wee loae ao
mo olow pat italao O dive of
th x appace al patt w raoraph
call xae; xamato wa pae at
8 a 6mo' ollow p Aa of te
adoaph reveaed that the e ovato peiod he mea lo o oe ppot
aotd o e a m ao the pat
pctv of whhr a oad o ot 1
Al pa at al oevao tval w o
to ccal ae he aor cocle that t
poie o ccel loa itam etal
plat earlfolow talao va a pemaet
coarch pra-corcto
cl a 25 pod a rto
pectv d he ppoe wa o valat ear l o oae a arl load
a lae op o pate Data ota were
copare wt oe o a fro he ame
cc app the oal potocol e twoa
ad dlad oad h ahor coc a
olow: h pee veao how a h
copar wh h clac wotae ch
qe oewat lowe cmave rvva ae
(CS afe ea o e oea ece
(CS 975% v 997% epcvl
5
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Chapter 1 loading principes
gained pominence (Karlsson et a 1998, Cordoi et
a 200, Gofese e a 200 Gotfredsen an
arsso 201 ). To create such a srface the
cca can fo exape bast i appy itaim
pasma spa o perom a aoc oiao of the
suface Hal an Lasmaa 200). Epereta
sties have sown hat he oepa cotact
s ige fo a TUneM anoxize [aoica
oxde] srface compare wh a macie oeAbrektsso et a 200 He e a 20 Rocc et a
3 Zeche et a 3; a observatio whc s
n ageee wt huma soogca fdings
ece repoed Rocc e a 202 Ivaoff e a
23 Schpbach et a 205 Ths is poss e
o oseocodcive propees o he iten
suface. aito Rope et a 00)
emosrated sg a og moe hat a-oiie
UneM pas w antan he pimar
stait beter ta machine ones s observatos suppote cinica ata reported Gause et
a. 2001 eefoe t seems reasoae to state that
Te pats are we ste to exposre to
medate cioa oad oher wods a
paraigm shft as occre regaing te oadg
cocep o deta impats. oda, it s ot o
posse to oa te impats he da of istaao
va a i povisiona spaconstcto bt aso o
arcate te na oe eore pacg he pas
Nobede cocep B usig spa coptere
8
ig 16 Virtua panning ocer: thr-dimnsioa (ft ddd ad w-dimioarigh)
toogap coveed scag ata ad a
avanced via panng proga t s possbe to
... pace te mpats n teir es positon te
jawoe' beoe the rea sger is peormed Fg 1
6 is book w ea wih ts topc o via
panig or mpat srge
References
Ab I Bgnd T, Wnstor J id The
ri had d sf issus at ifft mplant
ssms A aiv udy Jog. Ci Oa
pa R 1996;7:2-219.
Ad R Eiksson B Lk U na - J T. A on
r fw-up udy d ipa i
ay du jw l J a xiac
Ipa 1990534359.
Ark T Za G, Wrhi P rsson RA. e l
ter icay uy ued da ip a evwd oos criia o scss. nt J Ol Mia
Ipa 9825
Abtsson T. Ja C d AK, Sui Y Gottow Jximn sdi on oidz A islom
ra! d iaia ly l Oi
g R 21 2-2
Arvid yd H Fryl A Fivy flwp
h Ara Da Ip y tai
dnu p w J D 199G759(A.
Avd Byd H Fro A nw L Lu E iv
ya iv wp p th A T a
Impt Sys i h a duu ad.C Ora la Rs 99894
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Blsi J Woger GJ Imedte lodg of Bemrkpas in edentous adibles a prelimy repotIpnt De 99768-88.
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Bekvist G Slho S Nile Lind C. Iplnt-sporedfix sthss i dtuos mailla. A yar nal addologial olow of tretn wit nosberged ITimas Cli Oral Ipas es 00
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Chapter 1 loading principes
manswih difeent srfae caractersts: a expeiental sudy in rabits i Imant Det Reat Res 2000;27077
Goredsen K Kalssn U A prospetive 5-yea sdy f ixedatia rosess spored y implants wit cneand O basted srace. J rostodtis 20002-7
Ha ausaa Proeresf a new rous ide srace oitanium plans. Apl Osseogatin Res 2000 1 5-8.
Hatan N. Te Mas New. A ov -day teie f fxedvidalied ilantsupoed psthesis i eedentulus madible usg Bremark Sys impantsApl Osseoegraion Res 001 03
Hee S Karsson U Ale Brune S Astrad Nn-sumerged mplat in the treate of the edenosower jaw a 5-yea rspetve ongtdina dy of ITIow crews mpat Dent Relat Res 200 3:20-2.
Henry Reberg Sgesge sugey for rehabiltati ohe edeous adile. Pelimiary results. Paceriodt Aeset e 19946-8
Hery P, Tn A Aen B Hl Johanssn C eov oquecoariso f iUit ad td p1as in
greyund dog andible Apl Ossintgraon Rs000 1.
ermas M du r. ea Maeve C A singe-sepoea ive ech que sg e Bea system Arospectiv study in te edes mandile. Orampas Res 78437(Asact
Ivanff C da G Jhansso C Wenne)eg Astolgic evaatin f oe resse t oxidized ad
rned nu ic-impas in ma jwne t Oral Mfc Ilants 20031834-34.
Kasson eds Olsson C A 2-yar repo axillry and adiba fed patial enues prtedy Ara Tech dena implants. A comparison f 2 impats
Clin Oral mpants Res 99:342Kasemo B ausmaa J Aspts f sae pysic o iani
mplans Swed De J 188{Sppl)9-6Kasem B ausaa J Biomaeria ad implat surfae
sciece: a srface sene apach Ora MaxllfacIpls 884247-25
Kireterp Anesen Ude . Repacee of exaedne teeh y edately laded el ace Seec HAcoaed las An neyear flw-p o 35 pates ApOssetegat Res 200234043.
ass C T irface betwen ad ilants wiert suce ide ptis. Appl OsseintgraiRs 0001914
Lekl U Gne J eny P gi K Linden U Begstr Svival f e Bear impan in patiay edenuos jaws: a 0-year prospectve mlticee stdy. t Jral Maxlfa Ilats 191463-65.
Mal ibeg B olzz G Gualii Vgagen T, Rage Bedate ey fncon f Break pns pcein te esthetc ze: a -yeapspecie cical ltcetesudy. Clin at et elat es 20035Spl 1 )3746.
Pilliar R\ Qne valuai o the eect oveet aa pros cated lant-boe erfae. avis EJ ed.The ebomaterial ierae ooto Uivesity oTrnto ress 9303
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Rci A Marigoi M Senerby L Gottlw J eiatelading Brnek Syste imlat with te nitesrfae stlogial evuo fe 9 mont1s . Aplssenei es 20023:25-28
cc A gn M gos M ttlw J Seerby Histogy retrieved medey ad ey ladedidized ats: lgt mcscopc bservatios ater 5 o
9 ts of oadig n 1e posterio adile. Cin Implatet Retat Res 2003a(Spp t :8898
Rci A Margi M Gw J Imedate oadig oBremak system wi TiUie ad achined sfaces inthe sterir madible: a radozed oennded al Ilat Dent Rela Res 2003b5(Spp 1)57-3
Rmpe , aSilva D Lungen AK Gttlw J Seerby Saility easeens of a dobe-readed ttamilant design w une oidzed su face. Anepeietal esonnce fequency nyss sdy edog madile Apl Osseegation R es 200 01 8-20
Scn P Whrle PS, Resen JE a Sva WangNH Ten ye rsults or anemk impants idiately
loadd with e prseses at plat laeent. JOa axillofac Implants 199; 14903.
Sched A ler 0 Ster Gewebseaktion auf ein Titylinderlmplantat it TitaSpi-sctobeche.Sweiz Monatschr Zaheilkd 76673727
Scder A Sch H Sraua Stter be deAngeng Oseoceet a ee eseen mpatatkbe Scwez oaschZne 1788051-058.
Scde A Mgli B Sue F as I-lzyinderipantaty F z Po1eseneen bei zanlsen Kieer.Sweiz Monsc ahilk 198393720733
Schpa P ase R R artgani Seerby undgen AK e an idzed tianium ilant
ierface a ligt crspi sang eectrnirospc lakscaer scaing eecro scopic,and energy-dispersive X-ray sdy of clicay etrieveddentallants lin Implant Den Relat Res 2005;7(Spl1 ):6-43
Sale K Hase ES ockse-susse H. Bger .e efets f stepross ne defciecy, ne gaftingand mcoon fixati pousce ydrxye-coed implas : esi RG aley lT (eds}.Hydrxypate oatigs in rodic sery. New Yrk:Raven ress, 1993 0'3.
va Senbere My Jacbs R Vandeerckhve Buirynen M N I Te imdiate eaban y
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Weeerg A. n srace rugess and implat ncpraion [ tess. Depatmet BioaterialsHadica esearc tebog Uversity Sweden. 6.
Zece W ang! S Fst G eper G ams vala .Osseus eag charastics three dffee ilanttys. A togcal d sopec sdy in minipgs. C Oal plats Rs 2003140
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23 Cnial ptgrah of e failin ef central icisor( 9).
tradtonal teamet prooco Patens who ave
fxed esoatos eqg a emovabe osess
owg o oss o key abutment eet ae deadg
masoed esoatons ta wl e the
to avod sng a emovable dete Ts s esec
aly e o ates wth a sgle mssg oot
the estec zoe hat has a alng boded bdge
(Fg 23 ese paents wl not wa to wat p o
6 oths to ave a ed cow paced to e
edeos sace
o meet e deads o aste eatet tmes,
clcas ave aempted o eose ats
eae ad soe saces pace medatepovsonal esoatos o an mpa hat was js
placed sg emoay comoets g 24 s
aoac has bee sccessl Scnma et a
1990 Bals e a 1997 ece et al 0 b s
vey tme consmg ad demadng o e
estoave secals It also paces te mlat a
s o osg s al sablty og tgheng
and ooseng of messo cogs ad os
thetc coonents o to he lant {g 5 e
NobeGde syse was seccaly deveopedto mee tese demands laced o te clcan
gves the actoner bete coo o the esto
ave coecto to he mpa mmedaely ate
pacee ad t es he aa mal
ao eed to delve the osess by avng
the estoaon abcated o to at lace
en Usg ths system clcans ca edee
e e deal ocato ad oso o mpas)
based on the demands o te detve estoao
fo al clically edelos staons Fg 2-6).
Backrun
a
2-4 () Cusom-fabicaed, emray aumen ahas ee cnneed mmedael afe ia laee.b Pvisina resans sre byear a-e.
Kowng wee e mlas w be ocaedafe paceme wh a high degee o accuacy te
aboatoy eccan ca abcae the defive
esoao g 7) o o mlan sgey ad
ave avalable o delvey medatey ae he
mpas ae laced Ths the maoy o e pos
todoc/laboaoy wo s comleed pooe
F 2- Rc thn tempray cth gngvl mrgn f butt.
13
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Pqt for succeful implan
Fg 2-8 (a) Mxillry surgicl tempe fed in osio wih hoizontal acor ins. (b dulr srgic eple wi l
iplns pe o pedeere loons.
Prerequisites for
From ealy studies on immedae oadg (Hey e
a 20, Gause et a 201 Osso e a 2003
Roci e a 20) iporat preequsites wee
idenied fo mpans o be scessf we
paced o imediate fuo Ivanof e a 0 .
Aheving tia man saby minmzg
ana mapaon o he pant a was jus
paed and onroing imedae oadg foces
diected o e mpa ae sevea o te eiees dentied Esabshng ia stabiy oe of
the ost mpoan eeusites is aheved
thogh ioeaa ieokig of he ima
to e surodng boe g 2-9: hs s necessay o
preven ooion a e ntefae drng eay
oe heaig oer aco beieved o nuece
oe eaig ad a staty ove e s e
ipan suace caateriis ad texe g a.
To otze e iia bioog esose eseciay
i staios wih ow oe desty s as he posteo axia a modfed a srface iUeM
Nobe Biocae as bee shown to enae
pimay ia saiy g 21 oug ts
ogheed sface ad o acieve seconday
saiy earier han mached sfaes thogh a
hegheed eay oe eag espose o he
sface Wenerberg 996 Lasson 200
Spah e a 205
noe enei of medate fnon s
aon o aua oces paed o e ian
dg e itia eaing peiod te fs 2 o 4
wees s eod o me s ccia o eay cot
omatio ad the ogessve aaon o the
cot ito oseod tisse s a peiod s ofen
vioated i other immedate oading oeps
were e restoration is abrated ae e impan
aeet T ese techiques eue e pace
et ad eova of autes and messon
coings ofen o the second o thd day afe
man acee srgey s pota e of
Fg 2-9 Cose o bewee ere ree oe
i r of l1 iml.
15
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Chapter 2 NobeiGude concept
Fig 2-10 a The rougened iUte sface f a NobelBiocare implan.
g 210 (b) A traducer ro e Oell uni aa1e tothe mplan easure inial stabity.
ISQ 7
g 210 c An implat stabty qt radng fm thOss ni, dii xclln saby
16
24 to 72 hous te implan pceen fo he
rsfoao o bood clot o oseod isse
reqires tt e clot s le nistre d tt
mi oq o oioa srain be pc o
impl o voi movmt (Camo 193,
Brski 992) Ths ms t ny du nig of plns or copones ieaey afe
placemet sold e elimed nl te boe
eig pocess as mred sficiety to a
stiy o t implt
Antages of theconcePt
h NoGie cocpt povies t cic
with th aiiy to corol t loadig forcs ppd
o e plat d elminae te gly aagig
lateral oces trog feqet ispecto o he
occso n coc beig me o th sto
to Hvg t resorto plc idtey
atr iplat pacn prmis th cnca to
cck accrly fo y cotacs durig latrl
excsiv ovees nd o iiize verical co
c we e ptet coses nto centic occlsio.
h se o peiced srgcl tept fogidd srgy d a flapess srgic tchniq
gaty cs e im ird fo plat sr
gy d sof an hr iss r sbjcd to
mnil rma wile periig precse mpt
plcement d acieving igh degee o ptet
satscon by provig te ptiet with imete
cio sg ie posesis Fig - )
T obGd syst difs ro or
ciqus a sgc ppocs y coservg
o e cc's ad prosthodoiss ime admnmizg he cair ime reqie o coplete e
posthec rm te ipnt plcet. Oe
imeite loig chis qui resor
tv spcis to spe sigiic pio o tm
f t mps ar pcd to povi t pt
wit te fe esorton. is may e dig o
e restorive speclist s well as te pten
specily wi e tme eqirmens iedtey
oowig sugic procde o liver e esto
atv prosss oGd avods d fo
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ig 2-1 (a) Facial viw of dnitive prosthesis ade riort mplant sugry. (b) Ligual viw of dhntiv prsessog pg i rr oitio T fii-tiv t t t l
estoraive mnipulto by hvig the estoraion
fbrted pior to he ul plceet of impns.The li y hs delive e postesis mme
dately afe the impls are paced ther tha
hvg e paient rern o e restotive c
a's oe imedatey aer sgery to ave e
poshess aed
template
The NoeGude cocept was also deveoped o
assis te clnin i png mplns witot ele
vig a sgil flap e i focs s plaed o
te faico of a very cate surgical tepe
acounig fo e natomi varaios nd locaio
o critil aatomy, wih wil dre the inicia to
pae plans he exc prplned octos
sng a mimaly invasve sgil enique here
are wo metods to create a prese surgcl
tempe: a mode-ased nd a compue sotwre
Surgical tempate
plnig approa Te wo pproaes ave
nique nd deen eqreens he ed rests te sae eio of surgica empate ha wil
gde te cnica o pce ipns no he desred
positions Folowng s rie descpion of te wo
mehods of pnnig. or moe deied ifoio
o compuerbsed plnnig see Cpte 3.
Mode-based panig
A acrate impession s reired to abricae asudy ode whi will peri plcement o
impn anlogs into the edentlous spces he
tickess o te gngval tsse over he edenuos
se is mesued in the paens out sg a
mppig gude nd tanseed o e mase st
(g 212) Seven ponts o measureens ae pe
fomed three on e cal rea three o the
lingpalat ad one o e mdes o the
veolar dge Fig 13}. Measuements are tns
ferred to e secioned model wee seve
1
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Chapter 2 NobelGuide concept
18
Fig 2-13 (a) Use of a sharp probe placed through the map-
ping guide to determine the thickness of gingival tissue in
one of the three sites on the buccal area. (b) Three mapping
sites on the palate for two implants.
Fig 2-14 (ac) Seven measurement points per implant site
are transferred and marked on master model.
Fig 2-12 A mapping guide fabricated on the master model
showing seven sites of measurement: three on buccal area,
three on palatal and one mid-crestal site.
c)
b)
a)
a)
b)
Computer-based planning
Computer-based planning requires an accurate
radiographic guide, duplicating the dimensions of
the definitive prosthesis as closely as possible. This
diagnostic approach employs a dual computer-
ized-tomography (CT) technique where the
points are connected and the exact thickness of
the gingival tissue is removed from the stone model
(Fig 2-14). Once the stone is reduced, the indexed
segment is replaced back on the base and a
gingival tissue mask is poured onto the trimmed
model to duplicate the exact condition of the
patients edentulous ridge (Fig 2-15).
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scanned images are taken at half-a-millimetre cuts
to create a highly accurate, computerized model of
the patients oral anatomy. The first scan is taken
with the patient wearing the radiographic guide
with an occlusal index to place the guide in the
ideal vertical dimension of occlusion during
scanning (Fig 2-16). It is important to establish and
maintain the proper vertical dimension of occlusion
because the surgical template, which is essentially
a duplication of the radiographic guide, generated
from the software planning will be seated intra-
operatively to this vertical dimension. A proprietarysoftware program, Procera, converts the CT data
by superimposing the two scans, aligning the radi-
opaque markers so that the prosthesis will be
visible over the available osseous anatomy (Fig 2-
17). This permits the clinician to plan the appro-
priate implant position and angulation in the avail-
able bone (Fig 2-18).
The planned position of implants is captured in
a very precise surgical template (Fig 2-19), which
is produced from a computer-aided design/com-
Surgical template
19
Fig 2-15 Model is trimmed to remove the thickness of
stone that mimics the thickness of gingival tissue.
Fig 2-16 Patient is scanned with the radiographic guide
and occlusal index in place.
Fig 2-17 (ac) Procera software planning aligns the
radiopaque markers in the radiographic guide and the
scan showing the patients bone structure.
a)
b)
c)
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Conclusion
Advanages of the NobelGude sysem o-
pared wih othe imedate-loadig oepts are: educed sgca te becase of te minimally
invasive, flapess sgey ore accae pacee of ipants o desed
oatons usg a guded surgial templae redued healig te, possurgcal swellng .
and dsoot im ized rsk ad complicao ecase f
gded sugey ad accuate identcain o
vta srures o CT reduced prosetc ar e and esoatve
apuaton aer pant paeet owg o
arao o e poshess pror o he surgical
pocedre imediate estecs, as he deeed pshesis
is idenical to the sade cl ad contos of
e pevos appoved resorave seup a ota ad uque sste that provdes a
omplete oa onsuve souton or a
cliical statis.
ReferencesBash TJ, Wofnger GJ Imeate oa of Breark
pats in eeuls abes: a prenry rep.
Ipan De 19976:83-8 8 Becke W Beker BE Huffsee S ay funioa oa
a 5 ays o remak ipas pae o
edeuous adies a pospeve, opeeded, o
udina sdy J Peioool 200;7495-
nak -1 asso 80 Al R e a Osseoinra
ipas in e ea of e deulos jw Expri
e o a 10yar piod Scad J Pls Rcsr SugSpp 19:2
Brs J. Becaca acs aecng e bedeap nerfce C Maer 992-201
ameo H ar V Macnab I Te eec of ovement o
e bg prs ea o oe J Bome Mae es
197330-11
Referenc
Gase R oma M RtJhsaer Lre AK
Hamere CF Goow J ab easueens oimeaey oade aied ad odize mps
e posero maa A ompaaive inia sdy usin
esonae fequeny anayss App Osseoineaio es
200 ;227-29
aser R Ludg A oow nnrby , oan
usa P nrne ousal oadin o 3nekTUn mplas cd pedonany n sof bo: 1ya
ress o prsecve cca sy Cn pa1 D
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Chapr3
Surgical planningMarcus Dagnelid, Jea Vetchef
2
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Chapter 3 Surgical planig
I he area of implanoogy geat advaces have
bee ofeed by compterzed toography (CT}
Reectg a ucopeosea ap ad dlng adpacig a pat wee ee s boe o adequate
volue ad alty s stll he coo surgca
pocedure e poshetc par o te teaten
w cosideratos or te foces eg o te bte
and p sppo w be based o tat surgca
est
W he NobeGde cocep Verseke e a
1996, Van Seebege e a 2002, 2004, 2005},
he clca ca ceae he opa poshetc
est: wi C the cican can pace te mpas
wtthe g eg and aglaos accoding to
the perfec functona ad eshetc outcome C
also gves the clcan gy accae ad detaed
foraton regadng anaocal adarks sch
as he sns foo asal oor ad olne o eves
ad vesses Wl 00).
moder mpatoogy s portat to ana
yze ad pa every eaten accordng to each
pates codto Alhoug te obel Gude
concept ofers a ne opporty for medae
oadg shod aso be see as a sopstcaeddagosc ad plang ool Wong n a te
dmesoal 3D envrome enables te cinca
o pace mpants an opma poso eve
bone wt poor qaty ad quany ad he
cnca ca sseqety wo wt ealy o
deayed loadg
Procera svem
Pocea software s he ool sed whe wokg
wih Nobe Gude. Tis sofwae is o ony a
telgen syse or copte-based sgey t
aso ncdes feaues reatg to he aoatoy
work sch as designg rocera copgs ad
abutes and a rocera mpan Brdge
e software has bee desged to ae ts
se as smpe and sagowad as posse y
creaig a une toolbar based on seve cons
24
ClncP
[!& L1 2 3 4 5 7
Fig - Procer softwae tb, hi guides the liin
trouhh sv stps ofth NbGui o.
te copeased sgey s smpfed Fg 1 }
Te clnca can easily access e sowae at ay
te ad ca beef rom sgical plang a
Cbased 3 evroment
hs chape expoes pates' aatoy
reveaed ew dmensos t aso deonsates
ta the se o rocera software o dfct cases
asssts te clca i ndig e bes implan
pacee ecause o te wde ange of possibl
tes rocera sotware t ca be sed as a
pang too aoe wto ceatg a sgcal
gude f a adoa pooco s prefeed
Capes 2 ad 6 descre te wokfow w
te obel Gude concept. eore comecig
copebased surgca plag tese fuda
entas ad perequises us be fly understood
n orde o succeed ad ave a successl
treate outcome e preplanning phase s as
poant as any dea eamet ad t s theoly way to identy te possble cadidae for the
obeGude cocept
o the pupose of expag and nepetg
te woe obel Gde treaent concept ts
chapter pesents case eports ese wll deo
state e geea worklow and aso e dfeen
toos ad fctos te software
wolow
rocera software se egs by denyg te
posse cadidate o obe Guide Depedg o
wethe he paent s sngle partal o fly ede
tos te detist hen pepaes te rado
gaphc gude see Cape 2} om ts po he
clcia w access te rocera sofware ad
beg he treate accordg to te Noe Gde
cocept
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Te worklow is based on seven steps epe
sented by icos o the sowae:
1. egise and edi aie iomaio
2. sa Pocea sowae C ile covete apli
catio
3 oen ocea sowae plaing ogam -sugica plang
4 impot anig nto oea opueaded
desig (CAD) design
5 ceae sgcal eplae
6 vefy sgica emae
7 veiy odcs dils, ses etc) and pt
opeao speiaton docuens; ode sugca
telate ad sgicalaboaoy odcts
I he clician's a is to use e sowae as a
anig oo te ast o steps ae ecded
Te adiogapc guide can still be au
acued to assst e cliica in lacing te imlat
sateg osios and i a avoable agaon
ahough it s o eeded
is aspec wil be coveed n oe o te case
epos wee he boe quany ad ualy was
nitiy deeied o be iscie ad tis
siede teae ito a aditioa potoco
1. Register and edit patient infoaon
Oce te adogahic guide s pepaed te
atie s egsteed witn te sotwae Tis w!
auomacally eate an e eae denti
ication ) nube based on a eix onneced o
ha se and a nmbe o eac patien
l ipoat omao sc as dae o bt
ad esosible cliician o poshodotis wll
oly be seen by a use e D olows the patethogo te whoe eaent ad apeas o
e sgia emplae a a lae sage Nobel Boae
can easily tace om wc cliica a cope
anig has bee se
Most contes ave esictions egadig
atie daa communicaed ove te iene e
eaet enses ta data ase adhees to
sch gdeies
e umbe ceaed s ten sed i e
ied aet eeal o te adioogis s e
Computer-bad w
coept spees e atie w big to e adi
oogis te eaed adogahic gide ad an
occlsa nde beoe udegoig C wh a
dobesca ecne Cae 2) s pocess
s descbed beow
Double-scan technique
e Nobe Guide oncept ses a doblesan
eche. Tis meas a wo seaae scans ae
made e adoogca examao ( 1 e s
sca s ade o e paet wih he adogahc
gide and occusa de pope poso e
gide eeses bo he mssig teet ad so
sse wile the ide eses he igt bte and
oe osiion duing he sca ) he seond
scan is made o e gde aoe ataced o a pape
bo o a secied oam maea
The densty o e patens sot tissue esembes
e adogapic gude theeoe it is poat to
ave a eac age o e gide oside he
aiens moh
s esseal ta he adioogis as a basc
undestandng o the concept beoe ndeaig
e scanig pocede C canot be poey
peomed wito a coect adogahic gide
ad idex t is also stated a he adoga
gide ms coa a se ube o inseedgutaecha makes woking as eeece pos
he sowae ses te wo mages accodg o
ese oits, ts givig te te poso o he
guide i the mou
The omatio geneated by CT s omosed
o wodimesioa axal sces ese ae bogh
o he cnica n CM oma saved o a C
disk o eom he coptebased sgey i a
vita eviomen the slces mst be conveed
to 30 models
2 Procera soare CT le conveeapplicaon
Conveso o te data deived o CT is he
seond sep i e oea sotwae A intve
mbe o aplaos wll bg e clca om
aial sices o shed 3 odels beoe saig
e acal sgcal anig Fig 3
25
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Chapter 3 Surgical planig
Fig 38 Proea sftwae enbles he ciican to plae m-pts i ee aguio d pos1o oig !O eriogp guide Ts esres good posioig or-
e sposron referr n e prs.
In a uy eeuos pae it is impoan to pace
he access os o te guide abumets in a coec
positon. Te ccan ca choose beween a screw
eaied o cee spraosco (Fg 3-8As entione earler, s impoant o se
Pocer soware as an avaced paning tool n
a aspects of impla teatme ig 3-9). e se
of hs type of surgica gide generates a safe and
ore exac drllng w no wobblg and opmal
se o e paien's boe. s possibe o place e
mpans a e wok w common impresson
ecqes a impla or abtme leve
he aim s o pace the pats as parllel as
possibe splifyig nstallao o a xe paalenture. fter he nsaato of a plan he
poson accoding o impora srcres is easly
vee by rotaig e 30 oel a scrolling
torog diee sices. uteore exposre o
impant theads o either he bucca or e paaal
aspect can be vsaize in the same mane.
I e axla the extenso o he maxillary
sns asal caviy a incisor caa creae bore
lies acilatig placeent plang o impas
Panig i e mandible is even more ened
28
wen t coes o avodng neeence wi ealy
impora srctures. Several oos witi e sot
ware can be se o ghligh or revea ese
sctures Mag he ouie o e nero ave
oa canal a s mesia oop s a proity o cn
icas: ts sowae oe o ess eiates teisks o damaging e neve vessel bue g -9).
Whe pannng o eigboing eet a parti
ay edenos pae he sotware enabes te
useo mak e oline o the roos a crows by
aing pos As escibe in te sectio on C
fe coversion step ). amagam ilngs a crowns create disturbaces in e axial sices. o
geeate a sabe 3D oel o e paient ese
wl be c away and is some cases wl ean
excg inorato abo the crowns o e ee
e ser can stil access e oiginal sices a use
tese fo fnig the correct ote g -.
ered bone uality/esy ca be measued
accoding o Honsiel is; howeve i shod be
oe a he onsied ui s no a dee vae.
e clncan so aso consie a the values
given by peomig t1e geea eamnaio o each
paet riogapc evaaion palpato grae of
bone esopto ad geera heal facors Ding
sugey te inserio oe s peraps e most
impoan vale or boe ay W he advanageso cen iplan sraces an iUie pacular,
ig pimay stabiy ca also be acieve even in
paets wt vey soft bone
a of te NobeGde concept is te stabil
izatio o te sgca gie by means o hozontal
anco pns ependng o e eve o eenls
up o ee pns so be pace hs is ade in
the same sipiied ae as fo placing iplats
but i can oly be perored wt a pope een
son of te aiogapic gide n te vesblmlacement o acor pns wit peetaon to te
liga aspec n he manible o palaay i e
maxilla is absoluely cotaicate Rpte o
arteries n tese egions ca i a wost case
sceao create ireversbe bleedig ad be e
teateg for e patien.
soe cases, te aount of boe can be a
liatio o conainicao. vace esopon
w minal aon a aliy o boe can guie
te clicia nto a raiona pocedure wh
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Compur-basd w
Fig 39 (a-h) Diferet stware tools used t ilit mpt tc lnrks. I ts se te e lveo s sz bh by hgg !sc h s y kg he cg diferent ss T
gt th sgl eml g l sop. s or lss ts t sk g$g th ssl -
29
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Chapter 3 Surcal plan
refleon of a fap The Poea sotwae a e
use as a diagnost oo eveag he aeas wee
one an be fou
Cse 1: emle 3 yers o e
he atie ame to te ii afe any yeas of
asee fo eta teate Se had peviosyoy ee eae y eas o naoss an
aghig gas, an n eenty was eevig
edatio to eat depesso. Te paie was
wig to begin eament an eplace eeth os
hog aies ad ifections Raogaphs
s1owed poes ay i the seon ad hi
quadrant (Fig -11a-): oo 6 was severey deaye ad ad apia
esio: e patet aso had an extra- ad na
oa edea fom te netio
30
Fig -0 (ac) A pay detae tien whee facs by orli-uomt rn v bn xlu h ei Ie timol mo! o e
e Th l ll e e gil i ih diee .
ooth 26 1ad apica esios ad was aso
iosse to save owing to exensive carie hee wee soe aed figs ad seo
dary aes esos
peiodoa isease was in vais stags
athogh oe han exete o a patient at
ha ageEaios of tee wee ae a a emovae
aia ee was deivee (Fig -1 ).Peoonta isease was reaed at e dea
ygienist, a hn igs were peormed Impat
spote estoaios wee ae he seond
ad h qaa
he patie's sbjetive ees was o epae
e teeh os e e axia for esthe easons
an eonomi fatos, which made t possibe o
g treamen aso i te mande. Becase o
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Fig 3-1 (ac) Proprtv ntrorl dohs nt
n suo wh s es lsons of e 26 d 36,s ll s tr flls oJontl os.
h vious anxty ad xm a of dnal
ams, a was o nmz he srgical
auma ad also m sp n cha;
theefoe, a NbGuidera was laed.
A adiogaphc gude was anufaued ad
h lowg do CT was pfmd Usig 3D
csucon Pocra soa,
was apaha good voum and quay w s
s Fig 10W annng for aaly dnous pans
s oe pan o redue the rgnal for
atio in h aal scs xcld dsuancs
sch as PM cwns ad aagam gs I hs
acua cas pr was cad y h
PM xd ara dn n h rs quadanDspt ducg aco desbed the CT-
overson sep e shae of h cwns ad he
Compurbasd w
i 1 Oroom k fr 6 o o
hl
xnson oos can vsazd singos
in h Pca swar.
Th mpla sod avd rfrc with any
s Aso ipora s e sace ndd or h
suga gide or, mo pcsy h sv (ig 311eg
n h go of oo5,
h va sgcal
nvmn ad poss a long mpla ha
orgaly thog Fg h)By turnng e 3D d ad analyznghe pe-
pendcla e-sice he nca coud see tat
n was prs laal o h rd o h
maxiay ss Ths gav coc o a apd
mpa: NoRpac aprd RP 1 mm. hclncan ca aso vy a ccal anchoag o
the imat n posi 26 by ookg no aua
sinus regon (Fig 3 i -k).
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Chapter 3 Surgical planig
Fig - e-g I P w l l viSJliz oos wl w f ni9borng Tisu f ug 1 ug i fuid l i uic
32
g (h) By i Pce f-wae ad e ute f e adiapi
gd plnig d a lg i igil ug i poin25. Inti Nl
RT
pedRP 13
mm ilnNtice a he eaulio adpiti d dgpigd
g - i I digp postaiv .igi i f lt l i P fw Hg un w cd d mlan l eg peid o 3 mt.
g and k) Intraoral adiograpafer 3 ths' ealiwig u d w y-i. dvdu Pzironi bmns w d w P iconia w
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chance of fidg optmal postons o plans, and
o usng e ee eig ad wdt o the boe
avaiabe (Fig 3-12i).
Prosthetic consideraios
Accodg to e Nobe Gd oep e prerequsie or sccessful teaen is proper prereat
et of each paie Exactos ifecions s as
apa lesos and periodota dets sod be
poply had bor sding th patit o C
Haig ms b vrifid by oopatomogra or
peeaby by itaoa adogaps
Gag pocedures o educo o fabby
idges mst be pefored i advane I a ado
gapi gude is fabaed before bo e
odlig and so issu alig as ourd
ss o is rasrd to sgia gud
Ts wl aso ceae a false vale o so tiss thik
ness n Proera softwae geneatig prope
pa paement ad poste ocoe e
lnia ms peo a impesson or a ard re
ig by th dnta thiia
Sgica pang w gards to t supa
consucto is te optma hoce In sew-ead
cosrons a acess oe ca easily be paed
for exampe te oclsa aspect f a very ag
ated positio of a mpla mst be used tecliia a prdt h d of an aguad
abn ad rby so th tan pas
ad smpiy th clia's commnaton.
e oigina oncept o eeh-i-a-our o
wh e obel Gde oept ognates is fo
a proshei poi of vew te opima aet
Cotrollig t plamt of ass hoes and
os importay didig t shi ad
onal oucome advance provide eoros
gas eshes me cofot ad qaly of iefor paties. e spng ad stabzao o te
mpats in a igd supacosto ae me
da oading possb.
t sod b od ta ob Guid is a op
sys: op in e aspect o plaing ly edetu
ous patal o sgle ases Te supracostco
can be provsoal o fial sew retaned o
eened The possby reas o plae ealg
abtts aeth aplss sugy ad wo wt
mprssios o mpan o abtmt v
Computer-bad w
Intactiv commuicatio
n a ids of teatme pope fomaton is te
ey to a scessl teamen ouome so n
ass wh a pait is pssng hsao
detaild noatio abou a spcf pod
a overome insecurty ad aiey e patieoera sofwae i self a be used as a tool o
clde the patiet in the panng phase Te
lia an easy show e pai the flow of e
opt with ompbasd pag Sapsots
a b tan as wl as movi lps planing
phase sg as mateial or omniatio
I mode detisty the am is also to develop
ad widen he omuao bewee e
a ad detal tea. Difent versons o
roa softwar a b usd saig paning
fls and rang a ou fo boh srgal and
postec discussons e esetic ad functonal
oome s a dect rest of ths cose colaboation.
he commnation beween te prosthodonis
ad ia s also a impoa facto fo a
sssl tatt oto ga bot pas
a acss t plag va smia vrsions of t
Pocea software dscussig possible plan
positions ad aglatons ad e infuece ese
wil ave on te poste teamen
41mpon plaig to P
ompled srgc plang s savd a designated
folde o eah pate hs plag wll be mpoed
o e ompeadd dsign sysem and wll
pvid a iniial olin o surgia tmpat
5.ceate surgl templa
his step w geerae te ished sugial em
pla I hr s a ro whi h sga pa
g g osio btw iplas pats and
aco pis o nterence wit te supra-o
srcon he an can return o sgica pla
g (step 3 i te sowae n te surgica pla
g sep te reqed age ca be ade; stps
4 ad 5 will ga th prop otln o t w
sgal pat
35
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n II NobeiGude, zgoma m
Chapter4
Part 1: NobeiGude suge
Peter K Moy, Patick Palacci
ad mmedateChanal Malevez
3
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Chapr 4 Pn 1: NobeiGude sue
Pan I: surgery
Sie the ioduio of Tee-n-a-Hour i 203
o the ompetely edenuos paiet, e technque
has evolved into one ta a be used for ay
clca sitato: te competey edetos paient(oiuhi e al 2000). e paay denate Gase
et a 201 and e sgle-mssg oo Ersson
et a 201 ah edentulos stuaton reqres
slg odifiatos i te presugia workup ad
he sugca approach e specfc dagosic
workup for ea o the three varetes o edetis
s discssed n deai ! Cape 6.
hs aper otes te surgal echue o
ea sate of edes e poedue is
descred or te competely edentulos paien
ten varatos srgcal ehque used fo
patets wo are paraly denae and ave a snge
mssing oo are discssed
Surgical
Whe usg he NoeGude tehiue he
seqece of twst dis ad suga oponets s
e same o a edentulous ial siatonsWhe te srgca epae is erned rom he
aboraoy, te rst tg tat e clinica soud
g
=
-
-
=w
_
-
_
.
=
-
k -
.
..
i=:_ -
=
,
_
_
.
Fig (a) Order sheet fom NoeGude planning po-ram wit1 Ihe patien1's eaen deificaon number
38
do s perfom a geeral specion to ensue tha
te idetfato nber o e tepate ates
tat of the pang detiaion me assged
to hat patent e ciicia sod eck at the
ofgrato o he gude seeves ad paed
er of pants he srga epae aredeia to te operato iforaon sheet o
te paning softwae Fgs 4-1 ad 4-2 e
teplate sould aso e nspected o ensue tere
s o warpig o daage to he aryc or gude
seeves wthn he tempate
he cican sould one te aboratoy
fabated sugia oclsa dex to te sugical
teplate and esue at te f s eac The sur
ga de st also have a tigt f o the dentio
e opposg denta arc g 3 e preise
ft of te srga oclusal inde esres tat he
sugca empate wl be secred to the denta arc
n e prope vertica dmensio o occusio g
4 I te srga e pae is no paed a te
prope verica dmeso duig e srgey he
plas paed tog e tempae wl o e
seated o te poper vetca poston w te
alveola dge ad the xed parta detue at wi
e coneed afer impant paeet will ete
e nfra- o hyper-ocluso
The sugia poedre is saed y adsering oa aestei wt are o avoid
ecessve dspacee of e ggiva tsse tus
g b) Suia empae w1 pent' rcJeiao uber {;ppe et conr i typially pldby the patal vault of te mxiay teplate and e ingalae te maJiblar teate.
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Pl nn
.
-
__
-
I
. .
.
.
-2 (a) Operati nfa shee ndcag tenube a szes of mplants. as wel as locaions i thevl rge.
3 (a The a eks e o 1e sgaltemplte t the surgicl dex. s well s the psttn
-4 (a) U o a 1.5 amee ws d toh ehna ge seeve Ne t1t gat s ape deyto he etrane of the ge leee of the sga eae.
ensug a optimal fi o he emplae o he
mcosal ssue. Te co-oeao of e aie s
cssay dig sag o sgca a
Surgil pocedure
(b) Infoatn fom the eato rashee s esnd exa to he sga emae
b) Fal et he o atigll pees. Ne the wel-ttg sa ne tpos t.
(b) Ion o th hozont h ostal zaton of the sgia tepae.
as te aet eeds o be gely o e surgical
ex o avo excesse comessio o e
cosa iss y sgcal ma Wn h
39
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Chapr 4 Pn 1: NobiGude sue
Fig 5 The orizntal ach ps assis i rerac l1e lp
surgical tempate s fly seaed, a 1.5 m diameer
ws dill s se hog e oizonta guide
sleeve an a oiontal aco p (Fg 4-4a) snseed o secue he sgca emplae ad
peve t fo otaig.
Fullv edentulous patiems
In he completey edenous stuaio hee hoi
ota acho pis ae sed wh oe pacedaoud e dle ad two posteo ea the
comssues of the lip Whe the aveola idge s
seveey esobed and he shape o te ge is fa
for anco pins ay be necessary to preven
movemen o te sugcal epae (Fig 4b). No
Fig 4-6 () Te s dll w mbies ssue pacJ eskg dll. s place dely nto e veialgde sleeve
oy o he anch pns preven oiona move
ent of the empae hey aso assist
etactg the lp (Fg -5).The fis wo mpants place ae kow as
'sabilato mplants as these estabs e
pope vetcal compesson of the sgica empae on he mcosal ssue The ses fo tese two
iplas ae the next o e most poseo
posios on e sugca epate ateally. Tt1e
drls se o pepae te implant se ae desgedo emove sowy an atauatcally soft sse
ad oe ad to avoid hea geneaio
he fs tws ll s he sta dr whc fnc
ios as a ssue punch an conerboe hs ll
is pace decly no te gue seeve (Fg 6a .A sbseqet ws ds wi have a
coespondig di guie ta wi i pecisey in
he gude sleeve (F 47a whc pevets h ws
dl fom woblng and over-preparng he recen
se. Afer he stat dr, a 2 mm iamete twst d
s sed wh a 2 dill gude Figs ?b c.
Foowng tis a 3 m daee tws dl is sed
a coespodg 3 m ll guie (Fig 8a b t
s poit i e boe s dense e cliican may
use a 2 m damete tws d n he 2 m dl
gde ad fialy a scewtap to enae e
osteooy site o pemi placeme o he mplantwithot overcopessg e oe. e ap oes
not eie a gide an is secenteg whe he
shan conacs e ge seeve The ecipient
bone se s now eady fo he implat
A specally esiged mpant ount is con
g 4-6 ) Ppe se of e s d eqes a heHage l1e dll akes ull ca ih e p l1e
gde sleee.
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Fg 41 Guided abutmens hve ee see ino heefinitive prosthesis. in prerai f cecin f epsess e plas
te surgica teplate is removed (Fig 4-11 ). Beorete teplae is eoved, a specal issue punc
(Fig 4-12) wich s desiged to ft ito te gude
sleeves s used o i excess ggival isse. Tis
w aow for easy seati of te prosthesis. Te
clca soud iset te posthetic estorao as
fast as possible because he suroding sof
tssue as a edecy o colapse which ca creae
proems fo poshesis inseio.
Afe a mpats ave ee seated ad excess
ggval tissue ed he prosthesis ca be
delveed. Ealer, the suica-posthodotic eashoud have deteied wic meber of e
team wl pace he posthess Ciica expeiece
suggests tat e clinica peoig surgery is
es sied o nser e ixed prsthesis. Te
clicia has deveoped a eel o he path o
iserto hroug he pacee o he sgca
tempate pacee of pas ad f of sugica
copoes he delivey of te poshess ad
tgeg o te prosec scews are peomed
i a sequenial fasio simlar o te pacee opats. Evey efot sod be made to avoid
seaing o overgeg e screws o oe side.e gided ames wok siiary o te em
pate abutes ere ae or wgs a the op o
te guided abmet tha expad as he abuten
scew s tihtee ito he mpla. Oce the wigs
o the abute screw expad tee s cion
agas he proshetc ame preeig he pos
thesis fro slidg veicay aog the legh of he
abume heeore te auten screws shoud
Fullv edelous pten
g 2 ! he gia tissue soun1 he e o theipa s s eved wi specaly esneJ ssue punc
g 3 The psess shou e cmpete seae one plas Oe his s nfire, e uided abutmensews are ene wi a a-e qe wren an
e csn in centr n aea exsns su e re k as own
e tgheed o where tte ip of the scew is jst
egagg the terna heads of he pat ce
al aben scews ae egagig he mplats he
pate is asked to cose dow genly o the pos
thess A ew tapping close movemes by thepatient wll assis i seag he postesis evely
ad locaig te pope erca esion o occ
sio o he paiet.
Whe a ame screws have ee ad
igteed a adiogaph sould e ake to com
tha a ide atets are seate completely o
to the ops o the mpats. Ae comao tat
e posess is copetey seated o he
mpans he abten scews are tgeedo 35
Ncm usg the aded toqe wrech
4
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Fg 416 T wdw wl lw, durng gyontl pee sing o 1e gal g
pemt the clnicia o vsaze ad esue a e
tempae s seaed compleey o o the eet (Fgs
16 ad 17) W mted esa-o-dsa spacg, f
ajace oot srucures ae cose to the edentuos
space o wen sng modelbased plang e
orota anco pn s o use. Ts s o avod
amagng oos or eucg e avaale boe o
suppot te pants Sabzao o the sugcal
tempate s aceved y egagng e atual
eo an w the saato plants Oertha tese vaaos om e pooco te sugca
seps ae essentally the sae fo he patay
entae sates as or te competey edeuous
e clncan may wat to chage one aspec of
gded sgery wen opeatg n e esetc
oe of paay enae pates We ggva
boype s t e tsse pc o a fapess
approach sod e avoe A mallap po
ceue s se o avod uese removal of
tssue; ts appoac aso contols excessvecoaco a ecesso o e argal ssue
aoud te meae loae pant ad e
aace aa eo. A nalap poce
e allows o ee conto of e epostoed
lapo place e atace sse wee s eeed
soe clca satons a na-lap poce
e eaes re-esashme of eproma
papa see Capter 5 for a scusson of e
papae egeeaio tecque Wen ggval
cotos ae dece o o poo ggva botype
Postore paent instctios
g 7 T ml g pla: g l - a'>l. d for e opimal ti o be conolledhugh e wdw
the se of guded srgey e esec zone s
corandcae e cca mst e eay to
pefo ope-flap sgey ad ake oe poso
oc eases o povde e paten wth e
ae oang the esetc oe
Postoperaive aien insmcons
e paet so be nsce o ea on a
soft 'ocewg de o a mnmm o 2 wees
By ocsg on a o-cewg de te patent w
e acutey awae of e nee o avod cewig w
the ewy pace pant ad estorao Ohe
oute post-srgca nstcos a soul e
gve ae use of ce o mme swellg wam
sale nses an ora ygee srctons e
olowup scee s exemey pora A eac
post-sgca vst specto of occlson wtatclatng paper sol e peormed Occluso
cages amatcaly oce te local aesetc as
wo of ad e pate sas o fee cooabe
wt e fed esoave postess as ee s
typcay vey ttle pa o dscomfo Drng ths
crcal peo eavy occusal cotacs ms e
ece an mos poatly aeal efe
ences elnated Latea premattes ae te
mos deea oce o meae oa plats
and lea o ealy are o e mplan
4
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Chapter 4 Pan I: NobeiGuid, zoma mpla ad mmediate fuctio
Pn II:ad fuco
troducto to zoma implatsOral ehabiltaion wth impants s we docu
ented and any proocols ave ee deveoped
o siply pocedres for he clincan, e poso
dontst ad e atent May sotions ave been
povided o ehace he estetc ad fctoal
asects of recostrco o the maxla.
xidized srface o pas promotes aster
boe ormaion (Glase et al 22 Ivao et al
203} icreasig pary stay and respods
oe eectively to demadig suatios sc as
so or defcet boe in the axla Sevee resor
ion o e posterior axla ca jeopadize rehabi
ato o y edeos paents y means o
impants.
Good reslts ave een pulsed wit sho
impants placed n he poserior maxlla Reoard
ad Nsad 205
Neverheess reabilitato o te poserio
axla were boe vome s isficien i.e. less
a m reans a calege. Poor achorageowng o isciet heg or wdh o oe has
previosy ed o te eed or addioa teapies
sc as apostion bone gaftng ss gra ad
osteogeesis dsacon Jensen 206)
ns gag is a well-kow and opla
pocede. Despite his oe agmetation and
Fig 418 zoa rplnt wth TUie 5ufc.
te nseo of iplans w o wtot mediae
loadg ofers sccess rates etwee 60 ad 98%
Wallace and From 2003 Usig implats wit
oxided sraces cosdeably iproves e sc
cess aes of hese rocedres Ludgre and
Brechter 202). However some aties may berectan o dergo sch pocedues.
To avoid bone graig ote solos ave
bee proposed: lted pats placed i te ber
osy or e pterygod plae, and plas olowig
te aerio sis wal dimnsng he caeve
appled to the fxed proshess Aaco e al 201
202 Caladreo and Toas 205
sertng pas n te perygod rocess s
demandig becase tis ecniqe as bee
associaed w he s o casng iury o te
descedg maxllary vascare Choi and ar
20)
To address he roe o very poo boe
volme zygoa plas ave roven o e sc
cessl n spporng fxed rosteses wito
bone gratg edrossian e al 202 Maleve e
a 204) e se of ygoma implants come
saes for insficieces in poo axllay suctres
by a acoage n e zygoa.
Zygoma implants are avaable n dfere
legts: 3 3 0 2 7. ad52.5 m. ee ae wo daeters 3.9 a he
top ad 46 m a he evel o he ala wee
as a angatio of 45 correspodg o te
aglao o te zygoa with te axilla ig 4
). hese iplas ae sed eve e axiay
eig s less han m.
y edeos axary siato can e
treated sig ygoma ipants e ygoatic
ancoage is vey strong ad ese ong pats
ave a igh sccess rae. Zygoa mpants ca belaced i addito to two tee or o anteio
stadard plats g 9.
the aeo reag maxllary boe s ess
ta 7 o ygoa implants ca aso e
sfcient o supportng a totally ixed rosthess
g -20).
Zygoa pas can also eneit imedate
loadg edrossa et al 206 s wit sadad
impas, teir oxded srace enaces osseo
itegatio
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Fig 419 Facial mage of two zygoma mplants ad twsaard mpans he cae rgin with a fixd PraImplant Brdg.
sandard protcol
The stndard potcl fo isetng zygom
pts vves opeig wide ucopeose
p ncve e mxi s we as e neio
sis w p e zygic icis Tis
ebes vewg e ot ss wa ad ygoa
(Fig -21 ).Athog te ssciaed pi is dete te
ptet c expeience sweig d dscfor dys owig te sgey Despite , pro
vsi psesis cn be nsed ediey;
s eapy eqres mpessio o be take t
e e srgey ad cae djste o te
ccsion Te ceti of a defiive prostesis is
s ered sme ts e Te de
pcemet of impns ad e eed iimy
vsve sgey e ceges t zyg
mps pvde pppiae soion
pefng mpt theapy
Zoma implant and NobiGuide
Fig 20 Placement of our zgma mplants r srt-
ig a xed roseSIS.
zvuoma and NobeiGde
Te NbeGide cncept ws isertio of
ipts wt gided srgey by eas pe
sgic cpezed prepi. e ee-n
H pocedre nvves setio o e
deve posess t te e e sgey s
pcedre s crety beig deveped zyg
ipts sng a speci sgica gde and d
wae for nserng te pts i te rg posoTis ebes imedite pceen the defntive
psess.
e copeied ogrpy p o e eve
e ygma togete w e adioogca gde
Pocer sfwre enbes vt pstinng of the
zygo mps d he eizain f a fied
psess oce Ipt Bidge) A speci
sgic gde s de or dg d iseti f
e ygom ipats Spec adwe w
seeves o deet diees is viae s
47
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Chapter 4 Pn II: NobeiGud, zoma mpla ad mmedate fucto
Fig 42 Te whole mucosa is refected, showng e axa p o p o 1e zyoa e d dcaes snsnw.
essetia ha zygoa mplas are aced with a
gude becase of eir length ad the eed o
preise osioing
After seo i he moh the sgia gde
is fxed wth ree o for is Dling sarts w
he stadard iplats ollowig e NobeGide
roocol. ext a 2.9 calbated dl serted
a speial sleeve s sed o reare e se of te
ygoa iplats ad e a second dr of
36 diaee ad a oteboe are sed
At he xilary eve o te ygoma ila twoopegs ae ade hrogh te osa: oe o
he mplat and one or vewing the scew o the
ogina e mot, whc wil dcate he eact
poso of e agaed ead
Te ygoa iat s te ed o a seond
xtue out whh s sewed o the first oe;
hs es o idae te oe whe iseo
sod be stoped he wde re o wl be
inseed a sleeve to gide te mplant p to the
op of te ygoaAte isetio o all the plats the surgial
guide s eoved and he proshess s seed It
is srewed o he atero implas ad eeted
o e poserior oes
Advatages o hs ocedure ae that there s
o isio o stces, o swelig ad treatet
e is soeed seo of the ats as wel
as he rostesis a be erored 1 o 15
ines ad mmediate tio s reaed by
eas o a defiive rosess
g 4-22 Ooanomoa 1 o os-se
No casde ipresso o bite egisaon s
requed aer e srgery as e osess is
prepaed beoread ad iserted durig surgey
Conclusion
The developet o ygoa ats used o
juo w the Nobeude oep igligts
the possbiy of ehabag paties wit otaedents and suie boe vole by eas
o nimally invasve surgery ad imediate eco
sruto o the asatory fucio (Fgs 4-22
ad 23)
g 423 Te osess aed on h da o se
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Fig 3 To deermine pecisely the e esu. e aialfage shod be eoved i he aero ego ro cuspio spid whe ryin he e. he ee i be probabypld i mor il poiio o ip sppo oop o h k o il f
obtained wih e esec model ase ad e fa
resu wit e ixed rostesis pace (Fgs 5-3
and 5-4).
The estei mode base us ave a ig labial
age to otain a ere fit ad o posito 1e
salizatio s o te srgca gde. is fage
wi pus e ssues abaly js eow te ose,
and te lip wil oseqely ollapse. If te ia
postio of e teet is sia to te ese odelase tere will e a sgnia ak o so o
the ip o avoid s omlaio te eseti
odel base sold e rst fariaed wtou e
abal lage ad e esetic sold e be
deeed at tis stage of he poedre.
One e oe positog as been o
fied e age s added o te odel ase and
te liian ollows e orma prooo. We
pacg te fxed atia dere esecally o e
axa some adatao oblems may occ. Aste atie s lelyo ae bee weaing a dere
previosly te atie a soees eeee
disomort airow and spee robems wi Us
ew osesis n ace
o avod ese copicatos te prosess
sod be fabiated wh a excess of acyic
eary ilg a te saes ewee e imlants
or at east a wee Fg 55).
Te aet will ten aomodae to tis ew
satio wi a xed prostesis and o aate
Funv edetulous pae
ig 5-4 Fa posess s ' plae, 1!usa a a abialae s no eessar o obai adequae ip suppo Posi-on o he ee is iil o esei sess
ig 5-5 (a and b) he eoa esoraio s abicaedwi an excess of aIi maeia a e rde ee.
53
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Chaper 5 Eetic conideration
5- Aer a week, te pink crylc is reshped ro
mote hygene ad o avo ee oblem. After 3 mots,e phei eoa is re-ealuae a e ebauere mdiied ccrdig he ndge remdeg.
Then te embrasues so be ceate o allow
e opal combiaion bewee maneace
ad ygiee an speec and eseics.
o avod copatios accog to e esthecs
an expeatons of he patets, ay be pefeable
in eain ases to begin wt a tepoay fxe es
oaio o ceck al e paamees (eshetics vei
cal diensio occlsio poecs hygiee ad
eegene prole) ad e seveal mos ae o
abricae a deiive Proea Implan Brge taig
o aot al o ese ators Fgs 5-6 o 5-8
ParalIV paten
obles reate to pataly eelous patets are
sgicay ore omplex ta or he fuy een-
Fg 7 T1e e l (a ee i Fg 5- nd5-G) owed i e lower The i prhei i w
rady o b paed
tos pae As impla posog a sof
tisse cono wl be deiive using NobeGe
specia cae s eee we reaing ese paes
All normatio sould be obaied beoe e ea
men sas s wil inue inoaton abo rige
sape an boe qaiy an qaly as wel as: nube, sape an posio o te ajacen an
opposig eet occsio so sse aly and aiy coo textre a shape o tissues presee o absence o pap< sle lie a p obily pesoal ees o te patet a psycologica
acos
A ese acors eed o be evauae as tis
sugey an be osiee efiitve if sig he
flapless tisse-pc teique
Wt two-sage srgery had a/o so tssue
anaomy can be oie sig difee addve
pocedres b ese ao be odiie we
oosig e obeue opon using te lapess
bas pooo
A tese faos ave o be evaluae a pe
implant srgey may be equied o acieve he
optimal estetic esulBeoe coecig reae e cnica
sold evaate w s te opimal teatme I
soe saes he rge sees aequae an a
tsse-pn techiqe ay be appopiae or
'
g 5 Cii view Proe I Bridge n 1e ue nd ower fter 1 ye
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esthetcs, or thee may be a lack of ssue bt e
esthec needs are not very hg (e.g. whe ere is
a low lip le and ow lip mobily}. I boh o hese
cae, the ovenoal proool may t1ae a sais
acory resul
n ote siuatons here can be sgfcan dgeesoto (hard ad/or so sse) I such cases
the clnca has o decde whch reate o
choose fom he followng opios A prelminay ad/so te agmeaio
andreame g NobeGude aer a ealg
eod Aplcato o the obeGde cocept wt a
modifed sca tecque sng a fa srg-
ca ech iqe togethe wh a papill egee-
ato tecque Avod teatg te patent si his tecnque
f or exae there is lmied space betwee
eeth o bewee eeth and plans Te seeve
o e gude ca be a limting faco ee is a
imied space i ei ad a imied space
bewee mplas; hee may be df iculy wih
Esthetic anteor m asscaon
sof sses. I is dvded no our classes accordng
to verca ad ozoal dmensos of hese two
tpes o isse.
Verca o lfg 5-91
Class 1: nact or slgly educed papill
lass II ted o of pal
(ess an 50% of papill lo
lass Ill severe loss of apll
Cass IV absence o apl edelous dge}
isei e gude, ad oma ipa place )
et may be comised Fo these easos
he followg for asecs shod be careflly
evalaed:
ad sse oft te
prothet eorato
esthec requremens.
o selec adeqae srgcal otons e classf
caio descibed by Paacci and Ercsson n 20
o great hepto he clican, pohodont ad
geea practione i deerng the comene
men and competo e o the deed rea
men. ollowng s a bref sma o e classcato o claiy he eame approac i reao
to esheics
Esetic anerior
Ts aneio axila casscaio s based o he
amount of veical ad ozoa los of hard ad
b
c
)