The Tall Tilted Pin Hole Immediate Loading (TTPHIL) concept has evolved from various ideologies in implantology: basal, pterygoid, and angulated/tilted implants under immediate loading.
To maximize the success of rehabilitation, the TTPHIL technique utilizes the use of long tilted bicortical implants. Longer implants have more bone to implant contact, thus, improving osseointegration.
By engaging the alveolar and nasal cortex, hard tissue augmentation procedures and vital structures in the premaxilla are avoided.
In the posterior maxilla, pterygoid implants are placed.
loading protocols in dental implants about indications and contraindications of conventional , immediate,progressive and delayed loading of dental implants
Implant Loading Protocols Journal Club-Comparative evaluation of the influenc...Partha Sarathi Adhya
This journal club deals with different loading protocols and comparative analysis among them. this basically deals with immediate and delayed loading protocols.
loading protocols in dental implants about indications and contraindications of conventional , immediate,progressive and delayed loading of dental implants
Implant Loading Protocols Journal Club-Comparative evaluation of the influenc...Partha Sarathi Adhya
This journal club deals with different loading protocols and comparative analysis among them. this basically deals with immediate and delayed loading protocols.
Esthetic considerations in implant placement Esthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placement
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.
differences between natural tooth periodontium and implant bone connection, biomechanics of implants, implant protected occlusion , occlusal principles for single tooth implant prosthetics and implant supported prosthesis on edentulous arch, shortened arch concept, therapeutic occlusion
Journal Club On Pre-extractive Interradicular Implant Bed Preparation: Case P...Shilpa Shiv
Journal Club On Pre-extractive Interradicular Implant Bed Preparation: Case Presentations of a Novel Approach to Immediate Implant Placement at Multirooted Molar Sites, IJPRD 2013.
Esthetic considerations in implant placement Esthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placement
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.
differences between natural tooth periodontium and implant bone connection, biomechanics of implants, implant protected occlusion , occlusal principles for single tooth implant prosthetics and implant supported prosthesis on edentulous arch, shortened arch concept, therapeutic occlusion
Journal Club On Pre-extractive Interradicular Implant Bed Preparation: Case P...Shilpa Shiv
Journal Club On Pre-extractive Interradicular Implant Bed Preparation: Case Presentations of a Novel Approach to Immediate Implant Placement at Multirooted Molar Sites, IJPRD 2013.
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
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.
Sinus lift with dental implants Placement.(with Clinical Photographs) Dr. ...All Good Things
Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!
Pterygoid implant insertion is an alternative to avoid sinus-lifting or other grafting procedures to treat the posterior maxilla.They are especially used in partial edentulism in order to avoid distal cantilevers.
The placement of a pterygoid implant requires surgical experience and expertise in the field of implantology.
Pterygoid implants have high success rates, to those of conventional implants, minimal complications and a good patient acceptance.
Dr Sachdeva's Facial Aesthetic and implant institute is one of the leading clinics in Delhi performing Pterygoid Implants in patients with bone resorption. So hurry up and book an appointment with us at Ashok Vihar, Delhi which has state of the art clinic and all the latest and advanced equipments.
To book an appointment contact:
Dr. Rajat Sachdeva
Director & Mentor
Dr Sachdeva’s Dental Aesthetic And Implant Institute
I 101, Ashok Vihar Phase 1, Delhi- 110052
Contact us at
Phone : +919818894041,01142464041
Our Websites:
www.sachdevadentalcare.com
www.dentalimplantindia.co.in
www.dentalclinicindelhi.com
www.dentalcoursesdelhi.com
Facebook- dentalcoursesdelhi
Youtube- drrajatsachdeva
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Instagram page- surgicalmasterrajat
This is a power point presentation on sinus floor elevation, describing the various techniques, biological aspects and clinical outcomes from a periodontist point of view. It also includes a brief review on the anatomy of maxillary sinus and management of complications.
Hybrid abutments consist of a titanium insert, which is connected to a ceramic mesostructure using a resin cement
These types of abutments have the advantages of both ceramic and titanium abutments, including improved esthetics, optimal biological response, and superior mechanical properties, with no adverse effects on the implant–abutment interface.
The benefits of implant dentistry can be realized only when the prosthesis is first discussed and determined. An organized treatment approach based on the prosthesis permits predictable therapy results. Five prosthetic options postulated by Misch are available in implant dentistry. Three restorations are fixed and vary in the amount of hard and soft tissue replaced; two are removable and are based on the amount and type of support for the restoration. The amount of support required for an implant prosthesis should initially be designed similar to traditional tooth-supported restorations. Once the intended prosthesis is designed, the implants and treatment surrounding this specific
result can be established.
The maxillary sinuses were first illustrated and described by Leonardo Da Vinci in 1489 and later documented by the English anatomist Nathaniel Highmore in 1651.
The maxillary sinus, or antrum of Highmore, lies within the body of the maxillary bone and is the largest and first to develop of the paranasal sinuses.
Shape- a pyramid-shaped cavity; base- adjacent to the nasal wall; apex- pointing to zygoma.
Size- insignificant until eruption of permanent dentition; average dimensions of adult sinus- 2.5–3.5 cm wide, 3.6–4.5 cm tall, and 3.8–4.5 cm deep; estimated volume of approximately 12–15 cm.
Extent- Anteriorly, extends to canine and premolar area. sinus floor usually has its most inferior point near the first molar region.
Reconstruction of a facial defect is a complex modality either surgically or prosthetically, depending on the site, size, etiology, severity, age, and the patient’s expectation. The loss of an auricle, in the presence of an auditory canal, affects hearing, because the auricle gathers sound and directs it into the canal.
Surgical reconstruction is preferable but prosthetic approach may be necessary in some circumstances such as the presence of complex or large defects, requirement of the recurrence control, local or general contraindications of surgery, damaged neighboring tissues due to the radiotherapy, general poor health, failed reconstructive attempts previously made, refusal of the surgery by the patient, high esthetic demands, the desire for a quick recovery and palliatively operated patients.
Nowadays, craniofacial implants are used to support and retain such prostheses. Studies have shown successful retention and stability of auricular prostheses anchored to the temporal bone with titanium implants.
The main concept of osseodensification technique is that the drill designing creates an environment which enhances the initial primary stability through densification of the osteotomy site walls by means of autografting of bone.
Digital Removable Complete Denture—an Overview.pptxNishu Priya
There is a great responsibility for a dentist and a dental technologist to fabricate high-quality removable complete
dentures. Factors, such as a meticulous diagnosis and treatment planning, a personal communication between the
involved persons, and a profound knowledge of the clinical and technical possibilities, should lead to an easy, simple,
cost-effective, and highly satisfying denture fabrication workflow.
smile designing. The terms ‘aesthetic zone’ and ‘smile zone’ are commonly used to denote the appearance
of the teeth and smile. This zone has been shown to influence significantly factors
such as social acceptability, self-confidence and professional prospects. It is paramount
to undertake a meticulous assessment of the aesthetic zone during patient examination,
so that you may best determine which features may require addressing while developing
the treatment plan.
Management of tmd symptoms with photobiomodulation therapyNishu Priya
Conservative approaches, such as soft diets, anti-inflammatory drugs and photobiomodulation therapy (PBMT) or low-level laser therapy (LLLT), have been used to manage TMD.
Lasers have proven to be successful in clinical settings and treatments of soft tissues, musculoskeletal pain, bone regeneration, dentinal hypersensitivity, and provide reduction in symptoms and improved function.
The mechanism of action in PBMT is via absorption of light, with deeply penetrating wavelengths ranging from 630 nm to 1300 nm, to stimulate tissues with direct irradiation to achieve analgesic and anti-inflammatory effects.
The output energy in PBMT does not affect skin temperature and is classified as a soft laser, which increases lymphatic flow, reduces edema and prostaglandin E2 (PGE2) and cyclooxygenase (COX) levels.
A systematic review for pain management reported placebo vs LLLT for practical and clinically relevant parameters using 700nm to 1200nm.
Prosthodontic rehabilitation of maxillary defect in a patientNishu Priya
Restoration of maxillectomy defects demand varied modifications in prosthesis fabrication, to make them lighter and well-tolerated by the patient.
Literature suggests the use of various retentive aids for the construction of conventional obturator to improve retention and oral function.
Fabrication of functional complete dentures for edentulous patients who have undergone hemimandibulectomy is a very arduous and demanding endeavor.
The most challenging situation encountered during this procedure is the deviation of the mandible to the resected side. The deviation of the mandible to the resected side is directly proportional to the loss of tissues in the area hemi-mandibulectomy has been performed.
In cases with Cantor and Curtis classes II, III, IV, and V, guide flange prosthesis would be a treatment modality. For guide flange prosthesis to be effective, the sufficient number of posterior teeth that are periodontally sound should be present in the opposite arch.
In patients where reconstruction is not done after resection of the mandible, scar tissue formation occurs over a period of time that stiffens the tissues and worsens prosthetic rehabilitation, leading to compromised treatment planning.
A successful prosthesis comprises an aesthetic restoration, having good functional qualities allowing comfortable and confident use. Absolute success however can only be considered if the histological and morphological normality of the mucosa and deep supporting tissues is maintained.
It is critical to understand the mucosal response to prosthodontic prostheses for the treatment outcome.
The anatomy of the edentulous ridge in the maxilla and mandible is very important for the design of a complete denture. Objective in fabrication of a complete denture is to provide a prosthesis that restores lost teeth and associated structures functionally, anatomically and aesthetically as much as possible with preservation of underlying structures and the knowledge landmarks help us in achieving our objective.
Sterilization and disinfection in prosthodonticsNishu Priya
Routinely dental care professionals are at an increased risk of crossinfection while treating patients. This occupational potential for disease transmission becomes evident initially when one realizes that most human microbial pathogens have been isolated from oral secretions. Because of repeated exposure to the microorganisms present in blood and saliva, the incidence of certain infectious diseases has been significantly higher among dental professionals than observed for the general population.
Introduction
CERAMICS : An inorganic compound with non-metallic prosthesis typically consisting of oxygen and one or more metallic or semi-metallic elements that is formulated to produce the whole part of a ceramic based dental prosthesis. – GPT 7.
The word Ceramic is derived from the Greek word “keramos”, which literally means ‘burnt stuff’, but which has come to mean more specifically a material produced by burning or firing.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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
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
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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.
4. TREY
research
• The discovery of osseointegration by Branemark in 1986 brought out the revolution.
• To improve the volume for the benefit of osseointegration process, grafting solutions have been in
use with methods like autogenous bone grafts, guided bone regeneration, allogeneic material, and
combinations of these procedures with delayed loading.
• Conventional crestal implants require ridge augmentations or sinus direct or indirect lifts for
placement and are severely limited when it comes to the resorbed maxilla.
Background
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5. TREY
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Basalimplants
• Basal implantology which is based on employing the basal
cortical portion of jaws for implant retention has been
used extensively in resorbed ridges
• The design of the implant used in this protocol has a
vertical shaft and a united implant abutment with a screw
apex. This shaft connected to the basal disk is elastic and
can be bent by 15–45°. On immediate loading, the
continuous functional loads remodel the bone which
adapts over the implant.
• However, there are limitations in the implant design,
surgical technique, prosthetic phase, and the
maintenance phase. This technique-sensitive procedure
may cause functional overload osteolysis and fracture of
the implant due to its design.
• It is also restricted to severely resorbed ridges, thus,
requiring multiple implants. In failed cases, retrieval of the
implant is very cumbersome compromising the bone
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The skeletal bone that remains after tooth loss and
complete resorption of the alveolar crest is termed basal
bone.
6. TREY
research
The range of designs (single-, double-, and triple-disk
implants, horizontal plate-form implants secured with
osteosynthesis screws, etc.) allows management of the
diversity of anatomic situations and bone qualities.
7. TREY
research
• Engagement of basal bicortical bone is done
which is highly mineralized and least resistant
to resorption for achieving good torque.
Bicortical engagement of implants has proven
to achieve better stabilization with less
stresses on the crestal bone and implants.
• The use of flapless approach for this
technique offers the possibility of placing
implants in less time without tissue trauma
due to flap reflection and reduced
postoperative discomfort.
• It also has the advantage of maintaining the soft
tissue profile not compromising mucointegration
and osseointegration.
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All-on-4concept
• The revolutionary All-on-4 concept introduced by Paulo Malo (1996) followed the insertion of straight and tilted
implants between two cortical layers.
• The increased bone to implant contact provided improved primary anchorage. It has been universally accepted
with high success rates.
• Limitations: shorter lengths of implants used, open flap procedures, limited success in immediate loading, short
arch cantilever loads, expensive Malo bridge as a part of implant design, surgical technique, prosthetic, and
maintenance issues.
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9. TREY
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Zygomaticimplants
• Branemark came up with another alternative for
rehabilitation of severely atrophied ridges: zygomatic
implants.
• These were a boon especially in cases of oncological
resected maxilla greatly reducing the number and
size of grafting procedures and implants used via
predictable posterior anchorage.
• Disadvantages: invasiveness of the procedure and
the morbidity associated with it like sinusitis,
oroantral fistula formation, orbital penetration and
injury, nerve deficits, surgical edema and the load of
distal cantilever and the requisite for delayed loading
in zygoma cases
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Pterygoidimplants
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• Pterygoid implants were introduced by Tulasne which were intended to pass
through maxillary tuberosity, the pyramidal process of palatine bone and
engaging the pterygoid process of sphenoid bone.
• It overcomes the need for sinus lift procedures, grafting process, and, at times,
even the invasive zygoma implants. The success rates of tilted and pterygoid
implants for maxillary rehabilitation have been more than 98% and 94%–99%
as documented in the literature, respectively.
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Thetalltiltedimplants
11
• The Tall Tilted Pin Hole Immediate Loading (TTPHIL) concept has evolved from various ideologies in
implantology: basal, pterygoid, and angulated/tilted implants under immediate loading.
• To maximize the success of rehabilitation, the TTPHIL technique utilizes the use of long tilted bicortical
implants. Longer implants have more bone to implant contact, thus, improving osseointegration.
• By engaging the alveolar and nasal cortex, hard tissue augmentation procedures and vital structures in the
premaxilla are avoided.
• In the posterior maxilla, pterygoid implants are placed.
13. TREY
research
• The TTPHIL protocol improves force distribution through increased anteroposterior spread, increased implant
length in less bone, apical fixation in basal bone, and bypasses sinus; avoids bone grafting; reduces implant
number (only six implants) achieving good insertion torque—for immediate function with rigid splinting; and
allows engagement of dense bone with no crestal bone loss.
• On the prosthetic front, screw-retained solutions are provided by multiunit abutments and use of open tray
impression techniques for fabrication of rigid prosthesis. Better prosthesis hygiene maintenance is an added
virtue.
• Thus, the TTPHIL-ALL TILT™ technique, even though is a novel approach to placement of implants, is
derived from established schools of thought in implantology through the ages.
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• Mucointegration—
• Single-drill under preparation
• Self-drilling active threaded implant for bicortical basal
bone engagement
• Tall implants to engage cortical plates (16–57 mm)
• Tilted implants (15–65°) to have more bone implant contact
• Rigid splinting with screw-retained solution for retrievability
• Platform switching abutment with no micromovement at
implant abutment junction
• Flapless subcrestal placement (pin hole procedure)
• Immediate prosthesis within 3 days to a week time
Key features
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Indications
• All cases of edentulism, even in resorbed posterior maxilla.
• Immediate loading cases, where avoiding cantilever is necessary, rescue option in grafting failures, aid in
zygoma implants, and short implants.
• Patients, in whom grafting procedures or zygomatic implants would be morbid or medical conditions
wherein such invasive surgical procedures are contraindicated that can undergo the TTPHIL technique.
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Contraindications
Severely debilitating systemic disease. Consideration needs to be given to the mouth opening of the
patient, enough to access posterior regions.
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CLINICALTECHNIQUE:THETTPHIL-ALLTILT™PROTOCOL
Preoperative Workup
• As TTPHIL-ALL TILT™ technique is a flapless single-drill placement of implants, a thorough radiographic
evaluation of the prospective patient’s jaws is indicated.
• These studies include panoramic films, CBCT for digital planning, and fabrication of stereolithography models
and surgical guides. The dicom image files are converted to STL files on which the surgical planning is done
using specific software (BlueSkyPlan, United States).
• The ideal angulation and the length of the implant in the sagittal view and coronal view and the point of entry
(Point A) and exit (Point B) of the implants are also marked (keeping in mind the borders of the maxillary sinus)
which are then reproduced onto the stereolith model. In this way, planning and data transfer occur with a goal
of transferring the same to the patient for clinical benefit.
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Cone beam computed tomography (CBCT) data for surgical planning of six tilted implants; (D) Final
placement (point of entry and exit
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• The fabricated stereolith model is used to study the anatomy specific to the patient, with the point of insertion
and exit of the implant marked per the virtual planning.
• These models can be used for mock surgery, patient education, and fabrication of surgical templates.
• The surgical guides are incorporated with sleeves to guide the direction of the drill while performing the
surgery or a metal guide template with a central pin that can be used on which the point of entry and
angulation of the drill or implant are marked or transferred per the plan from the stereolith model
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Surgicaltechnique
Armamentarium
diagnostic instruments
surgical instruments
physiodispenser unit
drill kit-pilot drill, short & long drills
stepped osteotomy drill
hex drivers
surgical guide, or ALL TILT metal
template.
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• Under aseptic precautions (flapless
approach), crestal anesthesia is given at
the planned surgical sites.
• The ALL-TILT metal template on which the
pilot drill entry is marked using the stereolith
is placed intraorally against the alveolar
ridge with the central pin anchored at the
midline.
• The first anterior implant is placed anterior
to the maxillary sinus wall (entry point at the
junction of the floor of the maxillary sinus
and anterior wall).
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• The pilot drill of 1.2 mm is inserted through the
mucosa into the alveolar bone using the metal
template as a guide for the point of entry to a depth of
6 mm, perforating the crestal cortical plate.
• A portable radiovisiography (RVG) is taken to visualize
the direction of the drill into the bone and its relation to
the anatomic structures, especially the sinus walls and
also to check mesiodistal tilt of the initial drill.
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• Once satisfied, drilling continues with the template
or the guide in place, until the required cortical
engagement is reached.
• It is vital that the physiodispensing unit is run at
lower speeds of 400–600 rpm for a better tactile
feel or proprioception of the drill as it enters the
cortical plate (nasal). The single-drill concept is
followed, i.e., long stepped drill with a diameter of
1.4–2.2 mm is used with enough coolant.
• Under-drilling, wherein the diameter of the drill is
less than the implant to be placed for better
anchorage, is done.
• The direction of the drill would be distal to mesial,
toward the nasal cortex.
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• The selected implant (tapered 3.75 mm or 3.5 mm diameter with a length of 18 mm or 20 mm or 22 mm) is
then mounted on the implant driver and driven into the channel slowly until it engages the nasal cortex.
• The concept of osseodensification occurs, i.e., the expansion of cortex while insertion.
• Torque ratchet is used for the final placement and the resistance of the implant is checked against torque and
reverse torque forces of 30–50 N cm.
• The primary stability of the implant is, thus, checked with the torque test to determine the loading protocol.
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• A post-insertion X-ray of the implant should be taken for the final
assessment. The next drill-implant fixture placement is done
parallel to the first anterior implant which engages the nasal
cortex using the surgical guide, followed by a check RVG.
• For the placement of the pterygoid implant (preferred a length of
22 or 25 mm), adequate crestal anesthesia at the planned
surgical site is injected.
• A pterygoid instrument is inserted and a check RVG is taken to
confirm the point of entry (junction of the floor and posterior wall
of maxillary sinus) and the initial path.
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Planned direction of pterygoid drill mesial to dista
Buccal to palatal
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• Using a physiodispenser speed at 400 rpm, the pilot drill is used next, and after palpation of the hamular
process, it is directed 5 mm laterally at approximately 45° to the occlusal plane.
• This process is a guide to identify the thickest part of the pterygoid pillar of the bone. The single stepped drill
encounters dense cortical bone of the pterygomaxillary suture area at 10–14 mm deep. Just after crossing
the pterygoid process, the drill is stopped.
• The direction followed is mesial to distal and buccal to palatal.
• A depth gauge is again used and a check X-ray is taken to finalize the length of the implant and to ensure its
path without perforating the posterior wall of maxillary sinus.
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25. TREY
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• The implant is now driven slowly using the implant mount with a long handle until subcrestal placement is
achieved.
• The same procedure of placement of the three implants is done on the other side.
• Multiunit abutments (30°, 40°, and 50°) are then placed at the correct angulations to compensate for the tilt of
the implants.
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• The surgical phase is followed by the prosthetic phase of impression making with transfer copings, Jig trial,
bite records, metal framework trial, bisque trial followed by placement of final prosthesis using computer
aided design and computer aided manufacturing (CAD CAM) technology for design, and fabrication within 2–
5 days.
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Discussion
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• The advantages of each school of thought were studied and analyzed, and, thus, TTPHIL-ALL TILT™
technique was developed.
• Short implants have failed to achieve longer durability and are associated with limited outcomes. Short
implants are of usually 5–8 mm in diameter requiring additional 2–3 mm bone all around, which is not found
in most of the resorbed ridges. Additionally, due to the increased crown to implant ratio, vertical cantilever is
usually seen.
• Delayed surgical healing, systemic co morbidities limitations, chances of graft failure, donor site morbidity,
and extra treatment expenses are not seen as favorable consequences of grafting procedures by the
patients and restorative dentists.
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• The buttress regions of the maxilla include the zygomatic, pterygoid, pyriform, etc., which have been the
areas of interest in maxillary rehabilitation.
• The presence of pterygoid region provides cortical stability to the implant when engaged, as the posterior
maxilla is made of poor quality spongy cancellous bone unfit for immediate loading.
• The nasal floor is of cortical nature and has been utilized even in the All-on-4 concept for achieving stable
fixation of implants in the premaxilla. The TTPHIL-ALL TILT™ technique was developed as an effort to
provide a graftless solution to the resorbed atrophic edentulous maxilla in a noninvasive way taking
anchorage of pterygoid, nasal floor and the lateral nasal walls.
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• Tilting of implants is done to avoid the limiting anatomical structures like the maxillary sinus. Success rates of
tilted implants in the literature ranged from 95.7 to 100%, which have been enhanced by bicortical
engagement.
• The All-on-6 implant design is limited in resorbed posterior maxillary edentulous ridges due to sinus
pneumatization. By adopting the All-TILT-6 design, 2 tall-tilted implants are placed engaging the pterygoid
pillar (junction of the palatine process of maxilla, pyramidal process of palatine bone and pterygoid process of
the sphenoid bone), thus, eliminating distal cantilever along with avoiding of sinus encroachment or any other
augmentation procedures in the posterior maxilla.
• The use of tall implants with bicortical engagement offers a primary stability which is a strong predictor of
implant success.
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• Previously, it has been manufacturer-driven implantology, i.e., clinicians were limited by maximum lengths of
16 mm as manufactured by companies, which was not suitable for bicortical anchorage in all cases. Thus,
practice-driven implantology now has evolved the dimensions of implants too due to which taller implants of
lengths 15–25 mm have come up.
• These aid in immediate loading of the prosthesis. Thus, better prosthetic rehabilitation can be achieved
satisfying the patient aesthetically and functionally. From a prosthetic point of view, screw-retained prosthesis
is provided under this TTPHIL-ALL TILT™ concept.
• Predictable outcome with reparability and easy maintenance and no deleterious cantileverage are the
advantages of TTPHIL-ALL TILT™ concept over All-on-4 and All-on- 6 concepts.
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Case : Partially Edentulous Maxillary Arch (Delayed Implantation)
• A 37-year-old female patient came with a chief complaint of missing teeth and wanted to get them replaced. On
intraoral examination, missing 15, 16, 24, 25, 27, root stumps about 17, 26 and badly decayed 11, 12, 13, 21
were observed. The patient was keen on having a fixed prosthesis.
• On detailed examination of the orthopantomogram, there appeared to be adequate width of the available bone
anterior to the maxillary sinus but the inadequate bone in the maxillary sinus region.
• Treatment plan for the patient was atraumatic extraction of root stumps and immediate placement of six
implants i.e. 14, 15, 27 (pterygoid implant), 25, 26, 28 (pterygoid implant).
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35. TREY
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• Under aseptic precautions, local anesthesia was
administered at the planned surgical sites and
atraumatic extraction of 17, 26 was done. Extraction
sockets were thoroughly debrided and inspected with
the help of periodontal probe for any defect or possible
perforation of the cortical plate.
• Six Bioline implants were placed in the regions of 14,
15, 17 (Pterygoid implant), 25, 26, 28 (Pterygoid
implant) .
• The dimensions of the implants were 3.75 mm × 20 mm
(14, 15, 25, 26) and 3.75 mm × 22 mm (Pterygoid
implant i.e 17, 28) respectively. The orthopantomogram
of post-implant placement was exposed.
• Multiunit abutments were placed at correct angulations
to compensate for the tilt of the implants. Final
prosthesis was designed and fabricated using CAD-
CAM technology
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38. TREY
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Conclusion
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This protocol is an amalgamation of evidence-based well-
practiced bicortical implantology, tilted implantology with
subcrestal placement, and flapless guided implantology
presented in a first of its kind novel way to deliver
permanent prosthesis in 2–5 days.
It can be utilized on a larger scale in the form of
prospective studies, highlighting the clinical and biological
advantages of distributed stress algorithms with this design
and framework.
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References
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1. Nag PVR, Dhara V, Puppala S, Bhagwatkar T. Treatment of the
Complete Edentulous Atrophic Maxilla: The Tall Tilted Pin Hole
Placement Immediate Loading (TTPHIL)-ALL TILT™ Implant Option. J
Contemp Dent Pract. 2019 Jun 1;20(6):754-763. PMID: 31358722.
2. Nag P, Venkat, Sarika, P Khan, Ruheena, Bhagwatkar, Tejashree;
TTPHIL-ALL TILT TM -An effective technique for loading of dental
implants: A comparative study of stress distribution in maxilla using
finite element analysis; JO - Journal of Dental Implants
3. Chiapasco M, Zaniboni M. Methods to treat the edentulous posterior
maxilla: Implants with sinus grafting. J Oral Maxillofac Surg
2009;67:867-7
4. P VenkatRatna Nag. Immediate ImplantPlacement and Loading With
Tall AndTilted Pinhole Immediate Loading (Ttphil)Technique. Guident
Sep 2017:26-27