This presentation has videos and more surgical aspects of recent advances in Implant dentistry.This is different from other presentations in this platform since it is stuffed with most recent articles and informations

1. Recent advances in Dental
Implants
Presented by
Dr.AkhilSankar
2nd yearMDS

2. Contents
◉Introduction
◉Advances in Diagnostic imaging
◉Recent advances in extraction techniques
◉Advances in Implant Design
◉Recent advances in Implant Abutments
◉Implant -Abutment connection
◉New concepts in Implant rehabilitation
zygomatic implants
Pterygoid Implants
All-on-4
◉References

3. Introduction
◉As like any other treatment modality in medical science, Dental implants have also
undergone numerous improvements and modifications ever since its introduction.
◉With each improvement and advancement made, implantology has proved to be a
boon in disguise to the patients

4. Advances in
Diagnostic Imaging

5. Imaging
Phase 1:Pre-
surgical implant
imaging
Phase 2: Surgical
and interventional
implant imaging
Phase 3:Post-
prosthetic implant
imaging
Determines the
•Quantity, quality, and
angulation of bone;
•Relationship of critical
structures to prospective
implant sites
• The presence or absence of
disease at the proposed
surgical sites.
Evaluates the
surgical sites during
and immediately
after surgery
Evaluates the long-term
change
• Crestal bone levels around
each implant
• Changes in mineralization or
bone volume.

7. PANORAMIC ZONOGRAPHY
◉panoramic x-ray machine is modified for making sectional
images of the jaws.
◉provides precise imaging of pre selected areas of interest with minimum
radiation exposure
◉spatial relationship between the critical structures and the implant site can be
assessed.

8. Limitations:
 Tomographic layers relatively thick .
 Adjacent structures blurring and superimposition.
 Not useful for determining the differences in bone density

10. Tomography
◉Tomography is the generic name formed by the greek words ‘tomo’(slice)
and ‘graphy’(picture).
◉by blurring other regions above and below the site of interest Enables
visualization of a section of patient’s anatomy .
◉high quality complex motion tomography is required in dental imaging.

11. Computed tomogramphy
• a computerized x-ray imaging procedure in which a narrow beam of x-rays
is aimed at a patient and quickly rotated around the body,
• 1 to 2 mm thickness of images enable evaluation of implant site and 3D
appearance of alveolus
• sectional thickness of 0.25 mm can be obtained with latest

12. The advantages of CTbased systems
◉Uniform magnification
◉High contrast image with well-defined image layer, free of blurring
◉Easier identification of bone grafts or hydroxyappatite materials used to augment
maxillary bone in sinus region
◉Multiplanar views
◉Three-dimensional reconstruction
◉Simultaneous study of multiple implant sites
◉Availability of soft tissue for image analysis

13. Disadvantages
◉Higher dose of radiation
◉Lack of usefulness for implant interface follow-up because of metallic artifacts
◉Expense

14. The big concept!
Cone Bean Computed Tomography

15. Cone Beam Computed Tomography

16. ◉Software programs incorporating sophisticated algorithms including back-filtered
projection are applied to these image data to generate a 3D volumetric data set, which
can be used to provide primary reconstruction images in 3 orthogonal planes (axial,
sagittal and coronal).
◉CBCTis devoted to maxillofacial area to scan and visualize jaw bone lesions especially
cancellous bone
◉It gives all the information of a CT but, at 1/8th the radiation dose and at a lower cost

17. ◉CBCTis categorized into large, medium, and limited volume units based on the
size of their field of view (FOV)
Large (FOV)
• Orthodontic
use
• TMJ diseases
Medium FOV Small FOV

18. Advantages of CBCT
◉X-ray beam limitation
◉Image accuracy
◉Rapid scan time: 10–70 seconds
◉Software can be made available to the user
◉Dose reduction :Effective dose is 80% smaller than conventional CT
◉Reduced image artifact

19. DENTASCAN
A software visualization tool which provides oblique and panorex real time
reformation.
Axial,panorex and oblique views remain cross referenced o n the screen
When the cursor is moved on one view the remaining two views are refreshed
to correspond
Intented to use in presurgical evaluationin implants

20. Interactive computed tomography(ICT)
•This technique enables transfer of the imaging study to the
clinician as a computer file.
•The clinician’s computer becomes a diagnostic
radiologic workstation with tools
•An important feature of ICT is that the clinician and radiologist can
perform “virtual surgery” (vS)

21. •With an appropriately designed diagnostic
template, VS can be performed to develop the
patient’s treatment plan electronically in 3
dimensions.
•Transfer of the plan to the patient at the time of
surgery can be accomplished by production of
the computer generated, three-dimensional
stereotactic surgical templates

22. Microtomography:
Modification of CT, it is specially useful in acquiring serial sections of bone
implant interface.

23. Multi slice helical CT:
The helical CTscan takes continuous pictures of the body in a rapid spiral motion,
so that there are no gaps in the pictures collected.

25. Advances in Extraction Technique

27. Root Preservation technique
1961 Bjorn
• Completed to create pontic site beneath conventional FPD, now implant
supported FPD as root submergance.
• Requires root to be free of apical pathology, or endodontic treatment must
first be completed.
• Tooth is decoronated at level of bone crest and coronal portion of root
prepared to mimic the ovate form of the future pontic
• Soft tissue closure by primary intention – either attached gingiva advanced
and sutured or soft tissue graft (more preferable).

28. Socket-Shield Technique
 in 2010 Dr. Huerzeler et al
 Tooth planned for extraction at immediate implant placement site (typical in
anterior maxilla)
 Decoronated at 1 mm above bone crest level
 Tooth is then sectioned in a mesial-distal manner, creating buccal and
palatal halves
 Palatal root section removed and any pathology at root apex, along with it
 Buccal half of root is then concaved slightly
 Implant is then placed palatal to the ‘socket-shield’

29. • With extractions, the collapse of hard and soft tissue can create poor sites for ideal
placement of implant or FPD
• Bundle bone arises from functionally loaded PDL and, therefore, is lost when the
tooth is extracted
Paertial Extraction Treatmets do show promising effects in management of post-extraction ridge

30. EASY XTRAC SYSTEM
The Easy X-Trac is used to perform a minimally invasive tooth extraction on single and
double rooted teeth.
By Dr. Hans-Peter Hornig and Dr. Thomas Offerman.
The system allows for immediate implantation after extraction, and eliminates all
rotary/pulling movements, post traumatic swelling, and need for bone restoration.
Narrow root and vertical fracture

32. PHYSICS FORCEPS
Dr. Richard Golden and misch
1st order lever
ADVANTAGE
No squeezing/rocking motion is required.releases hyaluronidase in shorter period due to steady
force
Light gentle pressure directed buccally serves its purpose.
Minimal force requirement with maximum output
DISADVANTAGES
It has a learning curve, so if excess force is applied,fracture of tooth crown or bone might happen
Also, this instrument is much costlier to its conventional counterpart

34. On comparing all of the aforementioned parameters, they have found that the utility
of the physics forceps is better in comparison to the conventional forceps

35. BENEX SYSTEM
INDICATION
specifically designed for single-rooted tooth below the marginal gingiva
DISADVANTAGE
Cannot be used in the cases where there is inappropriate root morphology and in
grossly carious teeth where retention of screw is not possible.
Dr. Benno Syfrig
The Benex®-Extractor represents an innovative system allowing gentle, secure and
easy extraction of the root of the tooth

37. A minimally invasive extraction technique using Benex Extraction System in flapless
immediate implant placement in anterior teeth.
Ren et al 2016
25 implants osseointegrated successfully. The marginal bone resorption was (0.21±0.23)
mm after loading for 1 year. The mean extraction time was 6.87 minutes and the VAS
was 3.32. All patients were satisfied with the final esthetic outcomes and felt comfort
during surgery.
CONCLUSIONS:
Benex extraction System is a convenient, atraumatic and predictable technique during
flapless immediate implant placement in anterior teeth.

38. Extraction using Implant Drill

39. Successful osseointegration and complete bone healing were observed for all patients. The new
extraction technique by using implant drills to section the tooth was found to be effective in
immediate implant cases in order not to damage the thin plate of buccal bone.(Implant Dentistry:
December 2009 - Volume 18 - Issue 6 )

40. SONOSURGERY
• sonic instrument for bone surgery (SIBS) and various inserts was developed by Dr.Ivo
Agabiti,
• can also be used for sectioning teeth and separating the periodontal ligament
• 2000-6500 cycles per minute

41. ADVANTAGE
• Sonosurgery provides better tactile control
• preserving the integrity of the osseous walls of the extraction socket.precise
and controlled movement
• reduce the surgical timE
• The average heat generated by the SIBS was close to that by conventional
rotary cutting instrument (2.54 to 3.29°C),
DISADVANTAGE
• risk of tips fracture is very high.
• Impairs function of older cardiac pacemakers
• water spray from handpiece creates a contaminated aerosol

43. Piezoelectric handpiece uses a voltage deflection to produce a mechanical force
(microvibratory movement)

44. Professor Vercellotti in 1988
MORPHOLOGICAL-FUNCTIONAL CLASSIFICATION
Sharp inserts-osteotomy,osteoplasty,bone chips harvesting
Smoothing inserts-osteotomy access to delicate structure
Blunt inserts-for soft tissue,schneiderian memb lift & nerve lateral

45. C L I N I C A L C H A R A C T E R I S T I C S O F P I E Z O S U R G E RY
C U T T I N G
Rise in temp 18.1 dc
Time consuming
Cost is very high
tips will abrade and to be
replaced oftenly

46. POW ERED P E R I O T O M E
Dr.Simon Johns.Dental tribune Daily US edition 2012

48. Recent Advances
in Implant Design

49. MINI IMPLANTS
◉Are sometimes referred to as SDIs (small diameter implants), as well as NDIs
(narrow body implants).
◉Diameter: 1.8mm to 2.9mm (less than 3mm)
◉Various lengths: 10, 13, 15 & 18 mm’s
◉ fused abutments provides additional strength

50. ◉The MDI are available with either an O-ball head or a square head
◉The body connects the tip with the prosthetic head.
◉The body can be a parallel sided cylinder or a progressively tapered cone
◉A small pilot drill is used to create the opening for the implant to be threaded into the
bone.
◉The definitive implant supported crowns are usually delivered within 2 weeks of
surgery

52. • Typically inserted directly into the bone through
the overlying gums
• No need to surgically incise and raise flap
• A minimally invasive surgery is needed for insertion
of MDI implants
• Immediate loading done due to self tapping design.
• Each of the tiny implants is held in finger driver
that inserts the implant and also acts as screw
driver.
• Next a winged thumb wrench is used to tighten
the implant then implant wrench
• Possible to provide mini implant treatment in single
dental office visit.

53. Advantages
◉Immediate loading is possible
◉Can be inserted in minimal tissues without relying on grafting techniques
◉Minimally invasive procedure
◉One-stage denture stabilization
◉Does not require osteotomy
◉Cost-effective
◉Can be placed with in patients with ridge too narrow for conventional implants
.

54. In conclusion, the survival rate of MDIs in the maxilla was 82.7%. Patients experienced
minimal postoperative pain and did not have to undergo disruptive augmentation

55. The study concluded that the survival rate of more mini –implants are same as that of
conventional implants. The incidence of marginal bone loss is more in conventional
implants when compared to that of mini-implants.

56. TRANSITIONAL IMPLANTS
◉ absorb masticatory stress during healing
phase of definitive implants
◉Used for proviosionalization
◉Specifically designed Narrow Diameter implants
◉ranges -1.8 to 2.8 mm
◉Length -7mm to 14mm.
◉Fabricated with pure titanium in a single
body with treated surface.
◉They should be placed at least 1.5 mm from
adjacent teeth and the distance between any
transitional implant and a definitive implant
must be at least 1.5-2 mm

58. ◉The abutment head generally has a 5 degree taper, which makes
it optimal for retention of cement retained prostheses.
◉Only one drill, a 1.5 mm or 2 mm twist drill is required for
placement of the implants.
At least four systems are currently available
The Immediate Provisional Implant, [2.8 mm in
diameter and 14 mm long]
 the Modular Transitional Implant,[1.8 mm in diameter
and varies in length]
the Mini Dental Implant,[1.8 mm in diameter and also
varies in length]
the Bicon Temporary Implant[2.0 mm in diameter and
come in8 mm, 12 mm]

59. Advantages
• Provisionalisation of fully and partially edentulous jaws
• Undisturbed healing of bone grafts
• When Immediate loading not possible with definitive implants but patient
insists for fixed transitional prosthesis
• Effective way to generate aesthetic transitional appliances
• Allows evaluation of phonetics and function.
• Cost effective.

60. One – Piece Implants
◉The implant is machined from a piece of titanium that incorporates both the
implant body and an integral fixed abutment in a single component.
◉diameters -3.3,3.5,3.75,4.0, 4.3, 4.75 and 5 mm
◉ 4 lengths -10, 13, 15 and 16 mm
◉ More strength as a united component
◉ Minimal surgery(1 stage surgery)
◉ Good esthetics

61. DENTAL SUPPLEMENT, Lento D, Avantaggiato P, Baldoni M, Di Girolamo M.. J
Biol Regul Homeost Agents. 2020;34(1 Suppl. 1):125–131.
Sample size:84 one piece implants placed in 21 patients
Follow up done after 1 year
Conclusion: One-piece immediate loading implants has no difference in
survival rate respect to two-piece implant and delayed loading for
rehabilitation of totally edentulous mandibles. one-piece immediate loading
implant is a reliable device for edentulous jaw rehabilitation.
Oral rehabilitation of edentulous jaws with one-
piece implants: a case series

64. INDICATIONS
• The long-term treatment of missing tooth.
• More esthetic regions like anteriors
• Immediate loading of prosthesis
• Implant supported fpd
• Also used for full mouth rehabilitation

65. Short DentalImplants
◉A dental implant with length of 7 mm or less. (Friberg et al. 2000)
◉Any implant under 10 mm in length referred to as a ‘‘short’’
implant (Griffin TJ, Cheung WS. 2004)
◉A device with an intra-bony length of 8 mm or less. (Renouard
and Nisand 2006)
Indication :
Atropic Jaw
Proximity to vital structure
Single crowns
Overdentures

66. Advantages:
1. Bone grafting for height often unnecessary
2. Less treatment cost, pain, and time prior to restoration of the
implant.
3. Simplified bone surgery unlike the augmentation procedures.
4. Implant insertion easier.

69. B A S A L I M P L A N T
• “Basal Implant” term used in reference -principles of utilizing basal bone areas
• The load bearing tolerance of the cortical bone is many times higher than that of the spongy
bone
• Dr. Jean-Marc Jullietin

70. There are four basic types of basal implants available-
I. Screw Form
a. Compression Screw Design (KOS Implant)
b. Bi-Cortical Screw Design (BCS Implant)
c. Compression Screw + Bi-Cortical Screw Design (KOS Plus Implant)
II. Disk Form
Basal Osseointegrated Implant (BOI) / Lateral Implant-.
1) According to basal plate design.
I. Basal disks with angled edges.
ii. Basal disks with flat edges .
2) According to number of disksi.
I. Single Disk.
ii. Double Disk.
iii. Triple Disk.
III. Plate Form
a. BOI-BAC Implant.
b. BOI-BAC2 Implant.
IV. Other Forms
a. TPG Implant (Tuberopterygoid)
b. ZYGOMATIC SCREW

71. NOVEL HYBRID DENTAL IMPLANT

72. Advantages of Basal implant
Single/ monobloc unit
Utilizes basal cortical bone for support.
Efficiently used in atrophic and compromised bone conditions.
Better distribution of masticatory forces.
Lesser peri-implantitis evidence.
Better results in medically compromised patients
Syncrystallization
Indications of Basal Implant
multiple teeth are missing or have to be extracted.
When a bone augmentation procedure has failed.
thin ridges –
bone height is insufficient.3
Contraindications of Basal Implants
Medical conditions like recent myocardial infarction, cerebrovascular stroke,
immunosupression.
Patients on chemotherapy and antiplatelets.

75. ADVANCES IN IMPLANT
MATERIAL

76. Zirconia implants
Zirconia (Zr02) is a type of ceramic material used in implantology because:
◉Biocompatibility(bio inert)
◉Esthetics (because its colour is similar to the teeth), and
◉ Mechanical properties, which are better than alumina.
◉High resistance to corrosion, flexion, and fracture
◉Contact with bone and soft tissue similar to that observed in titanium implants
◉It can be used to produce a entire implant or as a coating.

77. Advantages of Zirconia Dental Implants
◉No dark colour of the metal showing through the gums
◉No corrosion of the zirconia as with titanium
◉No galvano-electric currents between dissimilar metal in
the mouth
◉It is thermally non-conductive
◉Greater BIC (Bone –Implant Contact)
◉20% more bone apposition than titanium implants
Zeynep O¨ zkurt ,Zirconia Dental Implants: A Literature Review Journal of Oral ImplantologyVol. 37(3)2011

78. ◉RTQ (removal torque testing):
Gahlert et al evaluated the RTQ values of machined zirconia implants, sandblasted
zirconia implants, and SLA titanium implants. The mean RTQ for machined zirconia
implants was 25.9 N/cm, the mean RTQ for zirconia rough implants was 40.5 N/cm, and
the mean RTQ for SLA titanium implants was 105.2 N/cm
◉Stress analysis:
Kohal et al observed the stress distribution patterns of zirconia implants,which were found
to have low, well distributed, and similar stress distribution compared with titanium
implants

79. Conclusion:
The results from our study suggest that zirconia implants with modified surfaces
display features of osseointegration similar to those of titanium implants. These results
are promising in using zirconia implants for dental application in the future.

81. PEEK implants (poly etheretherketone)
◉Semi crystalline linear polycyclic thermoplastic material
◉Youngs modulus is very close (5-7gpa) to bone (14) when compared with Ti(110) which may
cause inadequate stress shielding and implant fracture
◉Superior to titanium for regeneration of bone
◉These implants are available in three fundamentally different designs;
◉TAU (1 piece): Diameter -4..8 mm ; lengths :10 , 12.5 ,15 mm immediate loading
possible in D2, D3, D4
◉THETA: Similar to TAU but D1 bone
◉IOTA: It is a 3mm diameter implant (10 and 12 mm) used in narrow ridges

82. Advantages:
◉Good strength,fracture resistance and bioinertness
◉Promotes human oseteoblast cell growth
◉X-Scattered radiation
Disadvantages:
◉Faintly radiopaque –difficult for post-op evaluation
◉Lengths and diameters range is restricted

83. Recent advances in
Implant Abutments

84. Ceramicabutments
◉Densely sintered high-purity alumina (al2o3) ceramic
◉Yttria (Y2O3) -stabilized tetragonal zirconia polycrystal
ceramics
Alumina abutments :
◉Flexural strength of 400 mpa
◉ A fracture toughness value between 5 and 6 mpa ⁄m0.5
◉ Modulus of elasticity of 210 GPa

85. Advantages
◉Easier to prepare intraorally
◉Highly esthetic in appearance
◉Less plaque accumalation
The problems
◉Radioopalescence at the time of radiographic examination
◉Weak resistance to fracture
◉costlier

86. ◉Indications
1. An implant placed too superficially,resulting in exposed Ti at
the buccal aspect
2. An implant with excessively buccal placement & thin peri- implant mucosa
-"shining-through" effect of the Ti abutment
3. A slight disangulation of the implant, resulting in a need to correct the
direction of the implant pillar to create a harmonious embrasure &
anatomy of the crown restoration

87. Angled Abutment
 In the mandible, molars are inclined lingually, anterior teeth slant labially and premolars are almost
vertical. Placement of implants in the posterior areas may be off the horizontal plane as follows:
• second premolar region, 10˚;
• first molar region, 15˚;
• and second molar region, 20˚ to 25˚.
 The width of bone can be a limiting factor as to how great an angle at which the clinician can place the
implant.

89. • Angled abutments result in increased stress on the implants
and adjacent bone, usually are within physiological
tolerances.
• Use of angled abutments has not decreased the survival rate
of implants or prostheses in comparison with that of straight
abutments
• Angled abutments, in comparison with straight abutments,
do not appear to be associated with additional screw
loosening.
• On the basis of the limited clinical trials reported in the
literature it is acceptable to use angled abutments to
achieve parallelism between implants or adjacent
structures.

90. UCLA castable Abutments
 invented by Dr John Beumer at the University of California Los Angeles in 1988
 thus the name "UCLA
 The unique aspects of the UCLA abutment were :
1. The abutment screws directly into the implant without the use of a transmucosal abutment cylinder*
2. The abutment is made from a castable material - in most cases plastic or plastic with gold base.

91.  Advantages:
1. The lab can make a patient specific collar
2. The lab can make a patient specific angulation to address
implant fixture angulations issues.
 Limited interocclusAL Distance
3.Strength6
 Stronger than custom zirconia abutments
 4.Esthetics
 Color/opacity of ceramic addition can be customized for patient
 5.Versatility
 Can be used with any implant system regardless of implant size

92. Drawbacks
 Cost
 The UCLA abutment is an expensive piece that then requires a significant amount of
work by the technician to wax, cast and bake.
 Technically demanding
 When adding and firing the ceramic for the sub-gingival emergence to support the tissue
shaped with the implant provisional, the ceramic shrinks. This requires multiple
additions and firings to help ideally support the soft tissue.

93. Osseotite Certain, 3i Implant Innovations,
◉The internal connection implant design incorporates an audible
and tactile “click” when the components are properly seated.
◉Reduces the need for radiographs
◉This internal connection design incorporates a 6-point hex
and a 12-point, double-hex internal design.
 The 6-point internal hex -straight abutments.
The 12-point, double-hex -machined preangled abutments to
correct the off-axis emergence of the implant
Israel M. Finger et al The evolution of external and internal implant/abutment connections; PractProced
Aesthet Dent 2003;15(8):625-632

94. Advances in
Implant –Abutment
Interface

95. External Hex Internal
Hex
Morse Taper
•External hex-0.7mm standard
hexagon
•Interchangeable in regular
size platform
•Screw loosening
•Mechanical failure
•Rotational misfit
•1.7-mm-deep hex below a 0.5-
mm– wide, 45° bevel
•Distribute intraoral forces deeper
within the implant to protect the
retention screw from excess
loading,
•Reduce the potential of
microleakage
•Superior strength
• Tapered
abutment post is
inserted into the
nonthreaded shaft
of a dental implant
with the same taper

96. The internal hex implants, particularly Morse Taper, showed better stability in these
cases when used for single restorations.

97. Platform switching
CONCEPT OF PLATFORM SWITCHING
• The concept of "platform switching" refers to the use of a smaller-diameter
abutment on a larger-diameter implant collar.
• This connection shifts the perimeter of the implant-abutment junction (IAJ) inward
toward the central axis (i.e. the middle) of the implant.
• It is likely that moving the IAJ inward brings out bacteria more internally and, therefore, away
from the bone crest this would explain the limitation in bone resorption

98. Conclusion :platform switching showed positive impact on the marginal bone level around the dental implants.
Thus this concept must be taken into consideration in clinical practice.

99. How platform switching reduces crestal bone loss - A critical
analysis
The mechanism by which platform switching can contribute to maintain the crestal bone height could be due
to four reasons discussed below.
• Shifting the inflammatory cell infiltrate inward and away from the adjacent crestal bone.
• Maintenance of biological width and increased distance of IAJ from the crestal bone level.
• The possible influence of micro-gap on the crestal bone is diminished.
• Decreased stress levels in the peri-implant bone.

100. Newer concepts in
Dental Implants

101. O S S E O D E N S I F I C AT I O N
• A new concept for osteotomy called osseodensification (OD) has been at the
forefront of changes in surgical site preparation in implantology.
• Osseodensification (OD) is a new method characterized by low plastic deformation
of bone that is created by rolling and sliding contact using a densifying bur that is
fluted such that it densifies the bone.
• Standard drills excavate bone during implant osteotomy,
• These specialized burs allow for bone preservation and condensation through
compaction autografting during osteotomy preparation,
• thereby increasing the bone density in the peri-implant areas and improving the
implant mechanical stability.

104. Zygomatic Implants
◉In 1997,Branemark developed a specific implant called the zygomaticus fixture to
provide fixed solutions even when the conditions for implant insertion were poor in
the posterior maxilla.
◉zygomatic implants as self-tapping screws in commercially pure titanium with a well-
defined machined surface.
◉8 different lengths, ranging from 30 to 52.5 mm.
◉45 angulated head to compensate for the angulation between the zygoma and the
maxilla.

105.  Branemark initially developed zygoma implants for 3 primary reasons as his treatment modality for
(1) maxillary defect with post cancer (CA) resection,
(2) (2) trauma,
 (3) severe maxillary atrophy.
 The concept of the zygoma implants is to use available bone at a distant site when locally insufficient. The apex of the
implant gets engaged to the body of the zygoma, transversing the maxillary sinus and emerging from the first molar
position at a 45 angle.
INDICATIONS:
• posterior maxillary support in patients who are completely edentulous with
significant sinus pneumatization
• severe posterior alveolar ridge resorption
• combined with two to four anterior maxillary axial implants. (all on 4/All on 6)
• Unilateral cleft palate and generalized maxillary atrophy.
• Nasal reconstruction.

106.  Contraindications:
• acute sinus infection,
• maxillary or zygoma pathology and
• underlying uncontrolled or malignant systemic disease.
• chronic infectious sinusitis,
• the use of bisphosphonates and smoking more than 20 cigarettes a day.
• Any pathology of the maxillary sinus should preferably
According to Bedrossian et al. the maxilla can be divided into three zones:
zone 1, the premaxilla;
zone 2, the premolar area;and
zone 3, the molar area.

107.  Treatment recommendations based on the presence of bone in the different
zones of the maxilla (Bedrossian)

108.  the success seen with zygomatic implants is, a result of the engagement of four cortices
1. the lingual cortex of the maxillary alveolus, head of implants
2. the cortical floor of the maxillary sinus at the crestal portion of the implant and
3. the zygomatic bone cortices (2) at the apex of the implant.
 Corvello et al. evaluated the length of the holes drilled in the zygomatic bone of 18 dry adult skulls during the
placement of zygomatic implants using the original Branemark and the exteriorized (extrasinus) protocols.
 The exteriorized technique produced significantly longer drilling holes than the Branemark technique,
suggesting that the exteriorized technique may provide higher initial mechanical stability


109.  SURGICAL TECHNIQUE
 Anesthesia:
• According to the original protocol, general anesthesia.
• lidocaine with epinephrine to block the superior alveolar and the palatal nerves
 Recently, local anesthesia and oral or intravenous sedation. if the surgeon is experienced and the procedure is
expected to last for <1.5 h.
 simultaneous use of five different local anesthetic approaches, as follows:

 Normal infiltration anesthesia in the buccal sulcus from the central incisor to the third molar with lidocaine
with epinephrine and block of the posterior superior alveolar nerve,Gp and Infra-orbital nerve block by an oral
approach using lidocaine.
 Infiltration anesthesia around the zygoma area through the skin using about 3.6 ml of lidocaine with adrenaline
 In most of the surgeons’ experience, the procedure is well tolerated by the patient, and surgery is facilitated by
working on a conscious patient.

110.  The original protocol (sinus slot technique)
 Earlier,a vestibular horizontal incision is used, the current protocol attempts to expose the area via a mid-
crestal incision and vertical releasing incisions along the posterior part of the infra-zygomatic crest
 The anterior border of the zygomatic arch is always identified.
 second landmark is the lateral orbital border, as interference with the orbit must be avoided.
 A mucoperiosteal flap is raised,
 exposing the central/posterior part of the zygomatic complex, the lateral wall of the maxillary sinus and
the alveolar crest.
 A bone window, around 10 mm wide on the lateral aspect of sinus.
 The sinus membrane is carefully dissected, freed from the sinus walls .
 A series of drills is used to penetrate the alveolar process and the zygomatic bone

111. The estimated length of the zygomatic implant is
selected using a depth gauge.
The self-tapping zygomatic implant is placed with
the aid of a motor or manually, using an implant
mount
the apex of the implant penetrates in the
intersection of
• the upper margin of the zygomatic arch
• the temporal margin of the frontal process of the
zygomatic bone
Care should be taken not to enlarge the palatal hole
during insertion, which is especially important in
patients with thin alveolar/basal bone.

112. Modifications of the original protocol: The Zygomatic
Anatomy-Guided Approach:
 In patients with pronounced buccal concavities on the lateral aspect of the maxillary sinus, the use of the
original technique results in excessive palatal emergence of the implant head.
 the new approach promotes the placement of the zygomatic implant according to the anatomy of the patient.
 The new approach categorizes patients anatomy into 4 types
 Ie; ZAGA TYPE (0-IV)
 According these anatomic types the placement position of implant is decided

115. The provisional prosthesis is extremely
important for patients treated with zygomatic
implants.
The goals for such prostheses are to provide
acceptable aesthetics as well as masticatory and
speech function during the healing process, and
also to explore the occlusal and aesthetic
position of the teeth and soft-tissue substitutes.

116. The most common complication was maxillary sinusitis,
Other less frequent complications –
◉ Minor sinus membrane perforation
◉Gingival infections
◉Fistula
◉Lip laceration
◉Paresthesia
◉ Implant
◉Fractures of prosthesis
◉43.8 degree&50 degree
◉The weighted average success is 97.05%, and maxillary sinusitis
was the most common complication, ranging from 1.5% to 18.42%

117. Conclusion:The low complication rate and 100% implant survival and stability indicate
that zygomatic implants offer a viable treatment option when performing graftless
restoration of severely resorbed maxilla, including immediate loading protocols.

118. PTERYGOID IMPLANTS
• "Pterygoid implants" have been defined by the Glossary of Oral and Maxillofacial Implants (GOMI) as "implant placement
through the maxillary tuberosity and into the pterygoid plate“
Length:-16-22mm average length of pterygomaxillary area is 22.4 ± 4.8 mm
Diametre:-3.75-4.5 mm
 I N D I C A T I O N S .
 Severe bone loss in maxillary artery
 Pneumatization of maxillary sinus
 Patients who cannot undergo GA for zygomatic implants
 To avoid bone augmentation procedures

119.  Surgical procedure
 2 different anatomic locations where pterygoid implants are placed:
 The pterygoid process
 The pterygomaxillary region
 The implant is anchored in the pterygoid plate of the sphenoid bone, through the maxillary and palatine
bones
 with distal angulation between 35° and 55 °, depending on the maxillary sinus floor
 The internal maxillary artery crosses 1 cm above the pterygopalatine suture as it enters the pterygopalatine
fossa. the distance from the artery to the lower end of the pterygomaxillary suture is 25 mm.
 bleeding in this region will be from the veins of the pterygoid muscle, can be stopped quickly once the
intraosseous fixation is done.

120.  Implants in the pterygomaxillary region are placed within the maxillary tuberosity, near or
 parallel to the posterior wall of the sinus
 difference being the use of curved instead of straight osteotomes
 The angle should 10º to 20º degrees to simulate the proper angulation of the third molar
 Contraindicated in the presence of an impacted maxillary third molar obliterates access to the pterygomaxillary region
 trismus
 COMPLICATIONS
 One of the major surgical risks that may occur during the surgery is bleeding,
 Another complication is lack of primary implant stability which can be solved through underpreparation drilling protocols

121. All on Four
◉By Dr.Paulo Malo in 1998
◉Four implants in edentulous jaws,: two straight ;two tilted .in the premacilla or
anterior mandible supports fixed full arch prosthesis
◉Maximizes the use of available bone by tilting the posterior implants by up to a
maximum of 45º
◉Benefits of Angled posterior implants:
•Help avoid relevant anatomical structures and can be anchored in better quality anterior
bone
• Offer improved support of the prosthesis by reducing cantilevers.
•Reduce the need for bone grafting by maximizing the use of available bone

123. • Angulation of distal implants provides numerous biomechanical and clinical advantages for fixed restorations
 Biomechanical advantages of “All-on-4” design
 1. Implants follow a dense bone structure
 2. Longer implants can be placed by tilting them posteriorly
 3. Tilting improves A-P spread of implants
 4. A-P spread enhances load distribution for prosthesis
 5. Marginal bone height of implants is maintained with rigid prosthesis
 6. Tilted implants have similar success rate as traditional implants when splinted together

124. • The angulation also provides the opportunity for longer implants to be placed while moving the implant
support posteriorly and enhancing load distribution.
• The rigidity of the prosthesis along with improved load distribution helps minimize any significant movement
and negates coronal stress at the marginal bone level.
• Angulation of distal implants in a 30º to 45º position relative to the occlusal plane allows the final prosthesis
to have 10 to 12 teeth per arch.
 most would advocate the use of additional 2 maxillary implants for patients
when encountered with certain risk factors ie,
• poor bone quality,
• opposing natural dentition,
• and men with parafunctional habits).

125. ◉Final restoration:
• Full-arch restoration with only 4 implants
• Fixed and removable final prosthetic solutions
• Flexible solutions
◉Efficient Treatment Flow:
• Immediately loaded for shorter treatment times and improved patient
satisfaction
◉Implant Placement Accuracy
• All-on-4 Guide assists with accurate placement of implants
•Can be combined with computer-aided diagnostics and treatment concept
NobelGuide

126. All-on-4” Variations
All-on-4: zygoma implants and quad zygoma
The zygoma implants are indicated where there is insufficient bone in the premolar
and molar regions,The implant configuration will be 2 axial implants in the anterior
position and 2 zygoma implants in the posterior region.
If there is absolutely no available bone in the maxilla, the Quad Zygoma uses 4
zygomatic implants to support a full-arch prosthesis

127. All-On-4”v-4”
All-on-4 “V-4”is indicated for patients with severe mandibular atrophy typically with 5 to 7 mm of
remaining native bone. These 4 implants are placed at a 30º angle to help support a full-arch prosthesis
All-on-4 shelf: Maxilla
• the alveolus topography is re-created by bony reduction, allowing implants to be placed strategically
within the premaxilla in an “M” configuration when viewed from the frontal aspect
• The anterior and posterior implants converge apically in a 30º angulation.
• The posterior site “S point” denotes the most anterior point of the anterior wall of maxillary sinus,
• and the “M point” denotes the maximum bone available at the pyriform rim just above the nasal floor

128. All-on-4 Shelf: Mandible
Flat alveolus ridge and proper interarch space, a minimum of 20 mm, are required for the
mandibular arch.
The implant configuration is identical to Dr.Paulo Malo’s “All-on-4” design,
 2 exceptions in regards to the posterior implants.
First, the 1:1 ratio represents the available bone height from alveolar bone to mental nerve (N
point) and the number of millimeters of distance gained by tilting the posterior implant in a 30
angle.
The second key point is that the posterior implant can be positioned behind the mental foramen
when sufficient bone is present, unspecified by the authors, above the inferior alveolar nerve via
a transalveolus fashion from buccal to lingual with engagement to the lingual cortex for better
A-P spread

130. CAD/CAM in implant
dentistryUses
◉fabrication of surgical stent
◉Used in designing of prosthesis
◉Used in milling /fabrication of prosthesis(framework)
◉For milling of abutments.
Advantages:
◉Superior fit
◉Less degree of rotational freedom so more accurate
implant abutment connection.
◉Cost effective
◉Time saving since technician does not need to wax up
..computer screen

131. DIGITAL IMPRESSION MAKING

132.  SURGICAL GUIDE
 A stent is an appliance used for radiographic evaluation of height and width of the available bone during
treatment planning for implant placement or during surgical procedures to provide site for
optimum implant placement
• Surgi Guides are computer-generated drilling guides that are fabricated through
the process of stereolithography.
• The SurgiGuide concept is based on the presurgical treatment planning using
SimPlant software for ideal implant positioning.
• These successive diameter surgical osteotomy drill guides may
be either bone, teeth, or mucosa-borne

133.  The fabrication of the surgical guide templates is then based on one of the following design concepts:
1)Nonlimiting design
 Nonlimiting designs only provide an indication to the surgeon as to where the proposed
prosthesis is in relation to the selected implant site. This design indicates the ideal location
of the implants without any emphasis on the angulation of the drill, thus allowing too much
flexibility in the final positioning of the implant.
(2)Partially limiting design
 first drill used for the osteotomy is directed using the surgical guide, and the remainder of
the osteotomy and implant placement is then finished freehand by the surgepn.
(3)Completely limiting design
 Completely limiting design restricts all of the instruments used for the osteotomy in a
buccolingual and mesiodistal plane. Moreover, the addition of drill stops limits the depth of
the preparation,

134. Conclusion
•With the advancements in bioengineering and biomaterials fields in
dental faculties, several innovation have made dental implant treatment a
highly successful option for patient.
•The incorporation of new tech. and methods has improved the specific
areas of conventional treatment procedures.
•Continued research in a modality will always play a good role in
reducing the complications and increasing the patients compliance

135. Reference
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138. Thank you!