Treatment of a severely atrophic maxilla using an immediately loaded, implant supported fixed prosthesis without the use of bone

grafts: A clinical report:

Sherry J S et al J Prosthet Dent 2010;103:133-138

Introduction
Implant therapy and restoration - severely resorbed edentulous maxilla -difficulties -surgeon -restorative dentist. In the past -particulate autogenous bone, with barrier membranes and stabilizing tacks and screws or large autogenous iliac crest block grafts. Other bone grafting options - allograft, xenograft, monocortical blocks,or iliac crest grafts.

Introduction
Grafting -resorbed situations-2-stage implant protocol. 1yr multiple surgeries-complications - donor site morbidity.
(Schnitman PA, Whrle PS, Rubenstein JE,DaSilva J, Wang NH. Ten-year results for Brnemark implants immediately loaded with fixed prostheses at implant placement.Int J Oral Maxillofac Implants 1997;12:495-503.)

Difficulty-immediate loading-max-type 3 or type 4 bone-sinus.

(Friberg BS, Jemt T, Lekholm U. Early failures in 4,641 consecutively placed Brnemark dental implants: a study from stage I surgery to the connection of the completed prostheses. Int J Oral Maxillofac Implants 1991;6:142-6.)

Introduction
Pterygomaxillary zygomaticus regions viable Rximmediate implant placement.
(Davo R, Malevez C, Rojas J. Immediate function in the atrophic maxilla using zygoma implants: a preliminary study. JProsthet Dent 2007;97:544-51.)

Median palatal bone- dense bone- Rx.

(Wehrbein H. Bone quality in the midpalate for temporary anchorage devices. Clin Oral Implants Res 2009;20:45-9).

Purpose.
To provide the patient with an immediately loaded, functional maxillary fixed prosthesis without bone grafting surgery in a single visit, demonstrating that even the most severely resorbed maxilla can be restored and functionally loaded when the pterygomaxillary and zygomatic regions are used for implant support.

Clinical report
69 old woman- controlled type II diabetes. Cc - max denture. Prostho Rx options- bone grafting, implant placement,and delayed loading. Fixed, screw-retained maxillary and mandibular prostheses-immediate loading.

 Maxillary fixed implant-supported acrylic resin provisional prosthesis. 3 months - definitive ceramic prosthesis. A mandibular immediate fixed prosthesis- 1yr before. Pt evaluated clinically,radiographically

 CBCT-prosthodontic Rx. Prior to scanning-max denture. 14 uniform-perforations-guttapercha. DICOM formatted files -CBCT scan - (3-D) format virtual implant planning.

 The software - implant locations-pterygomaxillary, lateral-nasal, midpalatal, and zygomaticus areas.

 1 implant each - pterygomax and lat nasal areas. 2 implants each - zygomatic region. Single short implant midpalate. Virtual planning-data uploaded-surgical template.

 Pt draped and prepared implant surgery. Anaesthetist-G.A-nasal intubation-L.A. (8 carpules of bupivacaine 0.5% with 1:200,000 epinephrine and 4 carpules of lidocaine 2% with 1:50,000 epinephrine). L.A administered high into vestibular areas to avoid changing the volume topography of the palate at the beginning of the surgery

 Surgical template aligned intraorally-surgical index. 1.5mm drill osteotomies- 6 anchor pins. 1 anchor pin-palate-engage palatal and septal bone.

 Surgical guide removed. Soft tissue removed- crestal bone profiled-guided counter bore drill. 2mm followed by 3mm guided drill- osteotomies.

Following implants placed A midpalatal implant 4 x 7-mm implant.  Right and left pterygomaxillary implants 4 x 18 mm.  The right and left lateral-nasal sites received 3.75 x 15-mm implants.  Zygomatic implants-removal-surgi-guide.  Premolar and 1st molar areas- each side.

 Conical abutments-lat nasal implants. Low profile abutments-pterygomax implants. 33o angled conical abutments and long guide pinszygomatic implants.

A maxillary acrylic resin screw-retained provisional prosthesis with a cast, midpalatal strut-before surgery.

 The palatal acrylic resin of the maxillary provisional fixed prosthesis - relieved - zygomatic implants unobstructed placement of the prosthesis onto abutments - pterygomaxillary - lateral-nasal implants. To convert max prov fixed prosthesis-implant supported-rubber dam. Trimmed-marked-ink stick-position-implant abutments

 Copings - rubber dam - prevent acrylic resin locking -undercuts during the coping luting process - underlying tissue. Prosthesis fully seated 4 implants. Prostheis screwed. Acrylic resin mixed,loaded flowed-zygomatic prosthetic cylinders-join-fixed prostheis.

 Provisional removed and polished. Tissue sutured. Placed implants could support immediate function without the palatal implant, so the metal strap that was fabricated was removed. Cover screw-palatal implant.

 Completed provisional acrylic prostheis-screwed-15Ncm. 3 months later-provisional removed. All implants stable. Provisional replaced-long guide pins-open tray impression. Max provisional-impression template.

 Heavy body impression material syringed-acrylic resin max implant prostheis-pick up impression. Abutment replicas-placed-temporary cylindersprovisional prosthesis. Soft tissue definitive cast-separated from provisional. Max and mand casts articulated-provisional-occlusal registration.

 Definitive maxillary fixed prosthesis fabricated custom-milled titanium framework. Individual alumina ceramic copings and individual porcelain crowns fused to copings designed-mutually protected occlusion.

 The patient cleans the prosthesis twice each day using a toothbrush and irrigation device. All implants have remained in function over the past 30 months, and the patient follows her prescribed professional hygiene recall schedule.

Summary
Combined computer-guided and freehand implant surgical techniques improve surgical precision, efficiency,and treatment outcomes in the atrophic maxilla. Even patients with the most severe forms of alveolar atrophy of the maxilla can be candidates for treatment with an immediately loaded,fixed, screw-retained prosthesis with trained, skillful use of the pterygomaxillary and zygomatic regions. This treatment can be accomplished without bone grafts.

References

Schnitman PA, Whrle PS, Rubenstein JE,DaSilva J, Wang NH. Ten-year results for Brnemark implants immediately loaded with fixed prostheses at implant placement.Int J Oral Maxillofac Implants 1997;12:495503. Friberg BS, Jemt T, Lekholm U. Early failures in 4,641 consecutively placed Brnemark dental implants: a study from stage I surgery to the connection of the completed prostheses. Int J Oral Maxillofac Implants 1991;6:142-6.

 Davo R, Malevez C, Rojas J. Immediate function in the atrophic maxilla using zygoma implants: a preliminary study. JProsthet Dent 2007;97:544-51. Wehrbein H. Bone quality in the midpalate for temporary anchorage devices. Clin Oral Implants Res 2009;20:45-9.

Balshi TJ, Wolfinger GJ, Petropoulos VC.Quadruple zygomatic implant support for retreatment of resorbed iliac crest bone graft transplant. Implant Dent 2003;12:47-53.