Treatment of a Severely Atrophic Maxilla Using An

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Treatment of a severely atrophic

maxilla using an immediately loaded,

implant supported fixed prosthesis

without the use of bone grafts:

A clinical report:

Sherry J S et al

J Prosthet Dent

2010;103:133-138



Introduction

Implant therapy and restoration - severely resorbed

edentulous maxilla -difficulties -surgeon -restorative

dentist.

In the past -particulate autogenous bone, with barrier

membranes and stabilizing tacks and screws or large

autogenous iliac crest block grafts.

Other bone grafting options - allograft, xenograft,monocortical blocks,or iliac crest grafts.



Introduction

Grafting -resorbed situations-2-stage implant protocol.

1yr ± multiple surgeries-complications - donor site

morbidity.

(Schnitman PA, Wöhrle PS, Rubenstein JE,DaSilva J, Wang NH. Ten-year results for

Brånemark implants immediately loaded with fixed prostheses at implant placement.Int JOral Maxillofac Implants 1997;12:495-503.)

Difficulty-immediate loading-max-type 3 or type 4

bone-sinus.

(Friberg BS, Jemt T, Lekholm U. Early failures in 4,641 consecutively placed Brånemark

dental implants: a study from stage I surgery to the connection of the completed

prostheses. Int J Oral Maxillofac Implants 1991;6:142-6.)



Introduction

Pterygomaxillary zygomaticus regions ±viable Rx-

immediate implant placement.

(Davo R, Malevez C, Rojas J. Immediate function in the atrophic maxilla using zygomaimplants: a preliminary study. JProsthet Dent 2007;97:544-51.)

Median palatal bone- dense bone- Rx.

(Wehrbein H. Bone quality in the midpalate for temporary anchorage devices. Clin Oral

Implants Res 2009;20:45-9).



Purpose«.

To provide the patient with an immediately loaded,

functional maxillary fixed prosthesis without bone

grafting surgery in a single visit, demonstratingthat even the most severely resorbed maxilla can

be restored and functionally loaded when the

pterygomaxillary and zygomatic regions are used

for implant support.



Clinical report

69 old woman- controlled type II diabetes.

Cc - max denture.

Prostho Rx options- bone grafting, implant

placement,and delayed loading.

Fixed, screw-retained maxillary andmandibular prostheses-immediate loading.



Maxillary fixed implant-supported acrylic resin

provisional prosthesis.

3 months - definitive ceramic prosthesis.

A mandibular immediate fixed prosthesis- 1yr before.

Pt evaluated clinically,radiographically





CBCT-prosthodontic Rx.

Prior to scanning-max denture.

14 uniform-perforations-guttapercha.

DICOM formatted files -CBCT scan - (3-D) format

virtual implant planning.



The software - implant locations-pterygomaxillary,

lateral-nasal, midpalatal, and zygomaticus areas.



1 implant each - pterygomax and lat nasal areas.

2 implants each - zygomatic region.

Single short implant ± midpalate.

Virtual planning-data uploaded-surgical template.



Pt draped and prepared ± implant surgery.

Anaesthetist-G.A-nasal intubation-L.A.

(8 carpules of bupivacaine 0.5% with 1:200,000epinephrine and 4 carpules of lidocaine 2% with

1:50,000 epinephrine).

L.A administered high into vestibular areas to

avoid changing the volume topography of the

palate at the beginning of the surgery



Surgical template aligned intraorally-surgical

index.

1.5mm drill ± osteotomies- 6 anchor pins.

1 anchor pin-palate-engage palatal and septal

bone.



Surgical guide removed.

Soft tissue removed- crestal bone profiled-guided

counter bore drill.

2mm followed by 3mm guided drill- osteotomies.



Following implants placed-

A midpalatal implant 4 x 7-mm implant.

Right and left pterygomaxillary implants 4 x 18mm.

The right and left lateral-nasal sites received 3.75

x 15-mm implants.

Zygomatic implants-removal-surgi-guide.

Premolar and 1st

molar areas- each side.





A maxillary acrylic resin screw-retained provisional

prosthesis with a cast, midpalatal strut-before surgery.



The palatal acrylic resin of the maxillary provisional

fixed prosthesis - relieved - zygomatic implants -

unobstructed placement of the prosthesis onto

abutments - pterygomaxillary - lateral-nasal

implants.

To convert max prov fixed prosthesis-implant

supported-rubber dam.

Trimmed-marked-ink stick-position-implant

abutments





Provisional removed and polished.

Tissue sutured.

Placed implants could support immediate function

without the palatal implant, so the metal strap that

was fabricated was removed.

Cover screw-palatal implant.



Completed provisional acrylic prostheis-screwed-15Ncm.

3 months later-provisional removed.

All implants stable.

Provisional replaced-long guide pins-open tray impression.

Max provisional-impression template.



Heavy body impression material syringed-acrylic

resin max implant prostheis-pick up impression.

Abutment replicas-placed-temporary cylinders-provisional prosthesis.

Soft tissue definitive cast-separated from provisional.

Max and mand casts articulated-provisional-occlusal

registration.



Definitive maxillary fixed prosthesis fabricated

custom-milled titanium framework.

Individual alumina ceramic copings and individualporcelain crowns fused to copings designed-mutually

protected occlusion.



The patient cleans the prosthesis twice each day

using a toothbrush and irrigation device.

All implants have remained in function over the past

30 months, and the patient follows her prescribed

professional hygiene recall schedule.



Summary

Combined computer-guided and freehand implant

surgical techniques improve surgical precision,

efficiency,and treatment outcomes in the atrophic

maxilla.

Even patients with the most severe forms of

alveolar atrophy of the maxilla can be candidates

for treatment with an immediately loaded,fixed,

screw-retained prosthesis with trained, skillful useof the pterygomaxillary and zygomatic regions.

This treatment can be accomplished without bone

grafts.



References

Schnitman PA, Wöhrle PS, Rubenstein JE,DaSilva J,

Wang NH. Ten-year results for Brånemark implants

immediately loaded with fixed prostheses at implant

placement.Int J Oral Maxillofac Implants 1997;12:495-

503.

Friberg BS, Jemt T, Lekholm U. Early failures in 4,641

consecutively placed Brånemark dental implants: a

study from stage I surgery to the connection of the

completed prostheses. Int J Oral Maxillofac Implants

1991;6:142-6.



Davo R, Malevez C, Rojas J. Immediate function in

the atrophic maxilla using zygoma implants: a

preliminary study. JProsthet Dent 2007;97:544-51.

Wehrbein H. Bone quality in the midpalate for

temporary anchorage devices. Clin Oral Implants

Res 2009;20:45-9.

Balshi TJ, Wolfinger GJ, Petropoulos

VC.Quadruple zygomatic implant support for

retreatment of resorbed iliac crest bone graft

transplant. Implant Dent 2003;12:47-53.

Documents

Treatment of a Severely Atrophic Maxilla Using An