Prosthesis is one of the most important component of an implant. There are various prosthetic factors that must be considered for a successful implant. Few of them include prosthesis type and material, the connection between abutment and prosthesis, occlusal factors, etc.
Impression tecnique for implant supported rehabilitation/ dental coursesIndian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
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Prosthesis is one of the most important component of an implant. There are various prosthetic factors that must be considered for a successful implant. Few of them include prosthesis type and material, the connection between abutment and prosthesis, occlusal factors, etc.
Impression tecnique for implant supported rehabilitation/ dental coursesIndian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Indian Dental Academy: will be one of the most relevant and exciting training
center with best faculty and flexible training programs for dental
professionals who wish to advance in their dental practice,Offers certified
courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry,
Prosthetic Dentistry, Periodontics and General Dentistry.
All on four implants are the most sophisticated way of replacing the teeth.Traditionally, the procedure had been performed in two steps. The dentist began by installing the implants, which were left for three to six months to heal and integrate with the jawbone. The permanent teeth were fitted in the next stage. During the healing period the patient was given a temporary denture that has been shown to be a potential cause for bone loss around the implants, thus avoiding a loose temporary denture with an immediate fixed bridge as with All-On-4 Plus® is a step towards a better outcome.
Biomechanics of dental implants/dental implant courses by Indian dental academyIndian dental academy
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
the dental implant design from the point of view of dental biomaterials and the effect of force factors on choice of implant design in correlation with bone defects and anatomical anomalies
Over time, progressively shorter implants have been placed such that short implants are now available that are less than 6 mm in length. The viability and high success rates seen with short implants can be explained by osseointegration, the macro geometric design of the implant, as well as physics and the distribution of forces. This paper was aimed to review the stability and survival rate of short implants under functional loads. Numerical and clinical studies were reviewed. Keywords: Short dental implants, sinus augmentation, factors affecting bone regeneration in dental implantology
Split ridge and expansion techniques are effective for the correction of moderately resorbed edentulous ridges in selected cases.
Transverse expansion is based on osseous plasticity obtained by corticotomy. It progressively allows for an adequate transversal intercortical diameter large enough to insert one or several dental implants.
The gap created by sagittal osteotomy expansion undergoes spontaneous ossification, following a mechanism similar to that occurring in fractures.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Indian Dental Academy: will be one of the most relevant and exciting training
center with best faculty and flexible training programs for dental
professionals who wish to advance in their dental practice,Offers certified
courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry,
Prosthetic Dentistry, Periodontics and General Dentistry.
All on four implants are the most sophisticated way of replacing the teeth.Traditionally, the procedure had been performed in two steps. The dentist began by installing the implants, which were left for three to six months to heal and integrate with the jawbone. The permanent teeth were fitted in the next stage. During the healing period the patient was given a temporary denture that has been shown to be a potential cause for bone loss around the implants, thus avoiding a loose temporary denture with an immediate fixed bridge as with All-On-4 Plus® is a step towards a better outcome.
Biomechanics of dental implants/dental implant courses by Indian dental academyIndian dental academy
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
the dental implant design from the point of view of dental biomaterials and the effect of force factors on choice of implant design in correlation with bone defects and anatomical anomalies
Over time, progressively shorter implants have been placed such that short implants are now available that are less than 6 mm in length. The viability and high success rates seen with short implants can be explained by osseointegration, the macro geometric design of the implant, as well as physics and the distribution of forces. This paper was aimed to review the stability and survival rate of short implants under functional loads. Numerical and clinical studies were reviewed. Keywords: Short dental implants, sinus augmentation, factors affecting bone regeneration in dental implantology
Split ridge and expansion techniques are effective for the correction of moderately resorbed edentulous ridges in selected cases.
Transverse expansion is based on osseous plasticity obtained by corticotomy. It progressively allows for an adequate transversal intercortical diameter large enough to insert one or several dental implants.
The gap created by sagittal osteotomy expansion undergoes spontaneous ossification, following a mechanism similar to that occurring in fractures.
Immediate Implant Placement And Restoration With Natural Tooth In The Maxilla...Abu-Hussein Muhamad
Anterior tooth loss and restoration in the esthetic zone is a common challenge in dentistry today. The prominent visibility of the area can be especially distressing to the patient and requires a timely and esthetically pleasing solution. Immediate single-tooth implantation followed by immediate provisionalization is becoming an increasingly desirable treatment that offers numerous benefits over conventional delayed loading. Provisionalization for immediately-placed implants using the patient’s existing tooth can enhance the final aesthetic outcome if certain steps are
followed. If the natural tooth is intact and can be used as a provisional, the emergence profile can be very similar to the preoperative condition. This article outlines a technique to use the patient’s natural tooth after extraction to provisionalize an implant.
Clinical Replacement Therapy and the Immediate Post-extraction Dental ImplantAbu-Hussein Muhamad
Immediate dental implants have greatly reduced the treatment time and the number of surgical intervene tions. Recently it has been noted that this treatment modality can be used in aesthetically demanding cases especially the anterior maxilla. The aim of this article is to describe a clinical case in which a fractured maxillary canine was replaced by an osseointegrated implant using a simplified technique in a patient who was a smoker and presented poor oral hygiene. The technique adopted permits a reduction of the number of implant components and consequently a lower cost of treatment, while at the same time maintaining acceptable aesthetic and functional outcomes.
Congenitally Missing Bilateral Incisors with Single-Tooth Implants: Clinical ...Abu-Hussein Muhamad
Agenesis, the absence of permanent teeth, is a common occurrence among dental patients. The total incidence of tooth agenesis is about 4.2% among patients that are seeking orthodontic treatment and with the exception of third molars, the maxillary lateral incisors are the most common congenitally missing teeth with about a 2% incidence . Esthetically correcting congenitally missing maxillary lateral incisors is a common challenge that every orthodontist and dental team will face, and dentists must consider the treatment options that are most appropriate for each patient.
This paper describes the therapeutic use of osseointegrated implants to replacε congenitally missing upper lateral incisors. Highlighting the importance of the Orthodontic/Restorative interface.
Minimally Invasive Extraction and Immediate Implant Placement with Single-Sta...Abu-Hussein Muhamad
This case report describes extraction of a fractured left maxillary lateral incisor tooth, followed by immediate placement of a dental implant in the prepared socket and temporization by a bonded restoration. Materials And Methods: The tooth was extracted with minimal hard and soft tissue trauma and without flap reflection. The socket was prepared to the required depth and a Implant was inserted. An impression was made 4 months after implant insertion, and a definitive restoration was placed. Results: The atraumatic operating technique and the immediate insertion of the Implant resulted in the preservation of the hard and soft tissues at the extraction site. The patient exhibited no clinical or radiologic complications through 12 months of clinical monitoring after loading. Conclusion: The dental implant and provisional restoration provided the patient with immediate esthetics, function, comfort and most importantly preservation of tissues.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Implant placement in posterior maxilla by Dr. Ajay SinghAjay Singh
Implant placement in posterior maxilla. Dental implant therapy into the posterior
maxilla has always been and continues to be a
challenge due to various limitations in this
region such as poor bone density, sinus
pneumatization, lateral and vertical bone
resorption, high occlusal forces and area of
limited access. Further, if the implant is
placed into poor density posterior maxilla,
the bone which forms around the osseointegrated
implants does not show very high
bone to implant surface contact (BIC) percentage,
thus in several cases the implant even
after successful osseointegration may fail
once it is restored in function.
Immediate Implants Placed Into Infected Sockets: Clinical Update with 3-Year ...Abu-Hussein Muhamad
Dental implants can be placed immediately into healthy extraction sites with high success and survival rates. It has been suggested, however, that immediate placement of implants into infected extraction sites is contraindicated due to the pathology interfering with osseointegration resulting in decreased implant survival and success With many potential implant sites presenting with a preexisting periapical or periodontal infection, treatment protocols have been advocated for immediate placement of implants in these infected sites. Advancements in surgical techniques and implant surface technology have made immediate placement of implants a more predictable and accepted treatment option; however, there is still debate about whether infected extraction sites should be used for immediate implant treatment approaches. The purpose of this clinical update is to report on the success and survival of implants placed immediately into infected extraction sites.
Atrophied Edentulous Mandible with Implant-Supported Overdenture; A 10-year f...Abu-Hussein Muhamad
Abstract: Severe atrophy of the inferior alveolar process and underlying basal bone often results in problems with a lower denture. These problems include insufficient retention of the lower denture, intolerance to loading by the mucosa, pain, difficulties with eating and speech, loss of soft-tissue support, and altered facial appearance. These problems are a challenge for the prosthodontist and surgeon. In this case report, patient with resorbed edentulous mandible was successfully rehabilitated using two dental implants placed in the interforaminal region with ball abutments opposing conventional maxillary complete denture. Key Words: dental implants; dental prosthesis, implant-supported; resorption,
Indications of orthognathic surgery and surgical proceduresMaherFouda1
this explains indications of performing orthognathic surgery.It also explains different surgical procedures for different severe forms of malocclusion .
Atrophied Edentulous Mandible with Implant-Supported Overdenture; A 10-year f...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. mass generally found more toward the midline can be
taken advantage of, and, despite implant convergence
toward the midline, the holes perforating the inferior
cortex remain well distributed and relatively far apart
from each other, reducing the fracture potential. The
parasymphyseal area, where a mandibular fracture is
mostly likely to occur, is avoided altogether.32,33
Case Reports
CASE 1
A 72-year-old woman had worn dentures for longer
than 30 years and presented with severe mandibular
atrophy with 8 to 10 mm of alveolar height as viewed
on the Panorex (Fig 1). However, because of reverse
architecture only 4 to 5 mm of vertical dimension was
present in the mid-alveolar (axial) dimension. The
mental foramina were dehisced and relatively forward
in the arch. The nerves were partially exposed poste-
riorly.
A full-thickness crestal incision was made anteriorly
but only through the mucosa posteriorly to avoid
cutting the nerves. Using blunt dissection, the nerves
were located and deflected laterally, leaving the fora-
men free of neural tissue. Anteriorly, the mentalis
muscle attachment was left undisturbed to prevent
ptosis. The mandible appeared very fragile overall,
but it had been especially resorbed in the parasym-
physeal regions. Although all-on-4 fixture placement
had been planned on the computer, the surgical
placement criteria dictated placing the implant visu-
ally to not fracture the mandible. The first fixture was
placed directly into the right mental foramen (Fig 2A)
and angled forward 30°. The anterior implants were
evenly spaced and also directed toward the midline at
30° (Fig 2B). This created an overall V-shape place-
ment appearance on Panorex designated a “V-4” all-
on-4 placement (Fig 3). Additionally, the implant
placement angles were tilted anteriorly to avoid lin-
gual plate perforation (Fig 4). Finally, 30° abutments
were placed to compensate for implant angulation for
immediate prosthetic rehabilitation.
CASE 2
An 81-year-old female patient with a history of
wearing full dentures for 35 years who had been
FIGURE 1. Preoperative Panorex view of 72-year-old woman who
presented with severe alveolar atrophy.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
FIGURE 2. A, Using the all-on-4 technique, posterior fixture was
placed directly through mental foramen after deflecting dehisced
inferior alveolar nerve laterally. B, This was done bilaterally.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
1504 TREATMENT WITH MANDIBULAR V-4
3. taking an oral bisphosphonate (Fosamax; Merck,
Whitehouse Station, NJ) for 7 years for osteoporosis
presented for dental implant rehabilitation. The re-
sults from a fasting C-terminal telopeptide study were
satisfactory (315 pg/mL).
The mandible was highly atrophic with 3 to 4 mm
of vertical bone in the right symphysis and 5 to 6 mm
in the left. In preparing the implant sites, the vertical
available bone was a maximum of 5 to 7 mm (Fig 5).
After reflection of a flap, taking care to avoid nerve
injury and preserving the mentalis muscle attach-
ment, posterior implants were placed through the
foramen sites after deflection of the dehisced nerves.
Because the mandible resorbs, the mental foramen
often presents in a mid-crestal location. These im-
plants were placed at 30°, angling forward (Fig 6).
The front implants were well-distributed and
placed at somewhat less than 30° but still angled
toward the midline (Fig 7). The overall distribution
and display on the Panorex was a V shape (Fig 8). The
patient was immediately provided, after placement of
the 30° abutments, with a fixed provisional bridge.
Discussion
Patients who have worn dentures for 3 or more
decades may seek implant reconstruction because of
the pain from exposed inferior alveolar nerves owing
to complete alveolar loss from atrophy. Denture com-
pression of exposed nerves is best treated in this
setting by dental implants; however, the lack of jaw
bone height is a concern. Although a 10-mm vertical
height may be present mid-symphysis, the parasym-
physeal areas are often one half the height of the
symphysis. Also, in this setting, the mid-alveolar area
is often of a reverse architecture, such that the actual
mid-axial alveolar height is much less than seems
apparent on a Panorex. Although the lateral bone
height can be relatively high, it cannot be accessed for
implant placement; thus, often implants must be
placed where bone is relatively deficient. Therefore,
most experienced clinicians prefer to place implants
with a careful minimal torque technique but still per-
forating through the inferior border. Using this ap-
proach, an 8- or 10-mm fixture is still placed into a 5-
to 7-mm site.
The value of angulation of implants in a V-4 distri-
bution strategy is that bone grafting can be avoided,
because fixtures are favorably directed toward the
location of maximal bone mass. This approach is also
excellent to use without inferior border perforation if
somewhat greater bone mass is available.
The V-4 technique is biomechanically favorable in 3
ways: 1) mandibular continuity preservation; 2) a
greater length of implants; and 3) the V-shape is very
stable biomechanically.
FIGURE 3. Placement of 2 anterior implants angled at 30° to midline
created a V shape for “all-on-4” placement, designated V-4.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac Surg
2009.
FIGURE 5. View of 81-year-old woman who presented with severe
mandibular atrophy with 5 to 7 mm of bone available in desired
implant sites.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
FIGURE 4. All implants angled slightly anteriorly to avoid perfo-
ration of lingual plate.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
JENSEN ET AL 1505
4. MANDIBULAR CONTINUITY PRESERVATION
A 4-mm hole drilled into the anterior tibia, a weight-
bearing bone, reduces bone strength by 40%.34
A
4-mm hole drilled into the mandible, especially into a
low-bone-volume atrophic mandible, may consider-
ably weaken the jaw, even though it is not a weight-
bearing bone.35
The placement of 4 holes through the
hoop of the mandible, especially if they are not centrally
placed, risks a discontinuity fracture intraoperatively36
or during the demineralization phase of healing.37
At
about 3 weeks after surgery, it is possible for a jaw
fracture to occur under normal functional loading38
ow-
ing to the relative weakening of the jaw caused by the
regional acceleratory phenomenon.39
However, the
area at the greatest risk of this is the parasymphysis,
which is avoided using V-4 angulation.
The implants should be placed using a screw tap
method, even using self-tapping implant protocols to
decrease insertion torque values and not overload the
bone.38,40
FIGURE 6. A, B, Posterior implants placed at 30° angulation.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
FIGURE 7. Anterior implants angled forward at approximately
30° such that adjacent implants are parallel to each other and do
not converge at inferior border.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
FIGURE 8. Overall presentation on Panorex was a V-4 display.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac
Surg 2009.
1506 TREATMENT WITH MANDIBULAR V-4
5. GREATER LENGTH OF IMPLANTS
What is important is not simply to have a greater
implant length, but also to have the implant primarily
fixated into compact bone.41
Bone grafting to gain
implant length is an alternative strategy; however,
vertical bone grafts are the earliest to fail under stress,
and implants secured mainly by bone grafts can some-
times fail with time.42
The incidental elevation of
inferior border periosteum to gain periosteal prolifer-
ative bone must also be considered as potential sec-
ondary support, although it does not always occur43
(Fig 9). Therefore, the most dependable bone for
long-term osseointegration is compact bone, more of
which is encountered by implant angulation using a
V-4 strategy.
These compromised sites should probably use
4-mm diameter implants or less rather than trying to
gain more surface osseointegration using shorter,
wider (5-mm) implants, which considerably increases
the risk of jaw fracture.
FIGURE 9. A, Implant insertion through inferior border. B, Periosteal bone apposition observed 6 months later. C, Panorex demonstrating
vertical bone growth of 2 to 3 mm compared with preoperative view after 6 months of function. D, Occlusal scheme with anteriorized
occlusion and posterior disclusion during 6-month provisional loading phase.
Jensen et al. Treatment With Mandibular V-4. J Oral Maxillofac Surg 2009.
JENSEN ET AL 1507
6. V-SHAPE BIOMECHANICS
The reason the V shape is favorable biomechani-
cally is the greater length of implants into more dense
bone. Also, the angulated implant pull-out strength in
a splinted configuration is intuitively greater for an-
gled implants. In the V-4 strategy, this is multiplied by
a factor of 4, although this has not been studied
experimentally. Finite element analysis of the tilted
implants that are splinted in a full-fixed prosthesis
revealed a decreased peri-implant “bone strain” com-
pared with vertical implants, supporting a cantile-
vered prosthesis and implying better load-bearing bi-
omechanics.44
The highly atrophic mandible in the elderly patient
can be treated with an all-on-4 technique without
bone grafting with an immediate loading protocol
by distributing the implants in a V shape, desig-
nated the V-4 technique. The V-4 is protective of
mandibular continuity, derives increased implant
length with acceptable insertion torque values, and
maintains a standard all-on-4 pattern of prosthetic distri-
bution despite the angulated placement. A splinted V-4
distribution has highly favorable biomechanics. Overall,
the V-4 permits the use of a conservative nongrafting
approach in what might otherwise require significant
bone graft reconstruction in a commonly elderly popu-
lation.
References
1. Cawood JI, Howell RA: A classification of the edentulous jaws.
Int J Oral Maxillofac Surg 17:232, 1988
2. Cawod JI: Reconstructive preprosthetic surgery. I. Anatomical
considerations. Int J Oral Maxillofac Surg 20:75, 1991
3. Chan MF, Johnston C, Howell RA, et al: Prosthetic management
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