L Fig 10-5 Pretreatment clinical examination. (0) Determination of the smile line.

(b) 'Evaluation of the available ridge height. (c) Evaluation of the available ridge width. (d) Evaluation of the patient's current removable denture.

The prosthesis is severel worn and cannot be used as a fixed provisional prosthesis.

Study casts: Preparation of the surgical guide The surgical guide is designed to conform to the prosthetic re!uirements" it helps the surgeon to position implants with precision. #n uncomplicated cases$ where the crest is large$ the surgeon is experienced$ and esthetics is not a primar factor$ the surgical guide is not restrictive" it does not have to determine exact implant positions (%ig &'()). *hen implant placement re!uires precision$ however$ the surgical guide is restrictive" it has to accuratel define the mesiodistal and buccolingual axes of the implants.

Surgical phase
Placement of implants
Selection of implant design and number of implants. *hile preparing the case$ the surgeon can choose

among various implant designs$ including standard parallel(walled$ conical$ or wide(nec+ implants with internal or external conne,ctions. %or the present case$ the simplest implant was used$ because an t pe should have been able to ensure good primar stabilit . ) %ive implants are often sufficient" in this case$ six were used. *hen anterior implants cannot be placed$ a greater number of posterior implants$ as man as eight$ are indicated to provide a good supporting base for the entire length of the provisional prosthesis. This can be achieved onl with a supporting metal frame (see %ig &'(-.e).

The vertical positioning of implants should be either supracrestal or level with the crest because esthetics considerations are not relevant in this indication. /ubcrestal positioning is also permissible if it increases primar stabilit . 0ll three possibilities are represented in %ig &'(1f Primar stabilit . #nsertion tor!ue$ 2sstell (2sstell)$ or Periotest (3edi4intechni+ 5ulden) measurements provide information about the level of primar stabilit . 6linicians can safel assume that the insertion tor!ue reflects a good approximation of the primar stabilit that can be obtained at a given site. This insertion tor!ue should measure -7 8cm or more for all implants. /et at -' 8cm$ the handpiece should stall before the full seating of the implant$ which is then completed with the tor!ue raised to at least 9' 8cm 5ood primar stabilit is especiall re!uired for the most distal and most anterior implants. :se of bone profiler. The guide pin is screwed in the implants and then the bone profiler is seated on the guide pin for removal of the bone around the implant nec+ (%ig &'(1g). This procedure is indispensable when the implant is in a subcrestal position. #t guarantees good seating of the abutment on the implant nec+. /election of abutments. ;ealing or transgingival immediate occlusal loading (#2L) abutments are placed at this stage$ before suturing. These prosthetic parts are placed b the surgeon$ which means that the surgeon must order them before surger $ after having agreed on their dimensions with the prosthodontist. Depending on the prosthetic option selected$ the surgeon will position either transgingival #pL abutments (%igs &'(1h and &'(1i) and their healing caps (%ig &'(1<) or healing abutments (see %ig &'( -.c). /uturing. The surgeon closes the mucosa vith simple sutures (%ig &'(1+). 6ontrol radiograph. Panoramic or periapical radiographs are ta+en to evaluate implant placement (%ig &'(1&). The will also serve as a baseline against which the clinician can evaluatethe status of the bone crest over time Transition from surgical treatment site to prosthetic treatment site. This critical phase$ which ma appear trivial$ is important to patients$ who need to be reassured that th= treatment team is focused on serving them. This transition is also a good indicator of how well coordinated the practitioner >amis. > ?efore the various prosthetic options available to treat this indication are discussed$ surgical management of a mandible that is becoming edentulous is presented.

Replacement of the complete dentition in mandibular extraction sites

0 woman who was missing man mandibular teeth sought total rehabilitation of her mandible ?ecause of

advanced periodontal disease$ the remaining teeth$ incisors$ canines$ and first molars$ had to be extracted. The patient wanted treatment to be completed as !uic+l as possible.

Presurgical preparation Clinical and radiographic examinations

Determination of the smile line (%ig &'(@a) Evaluation of the periodontal status of the teeth to be extracted and the possible p>esence of infection sites (%igs &'(@b and &'(@c) . Diagnosis that dictates extraction of all remaining teeth (see %igs &'(@b and &2(@c) Determination of the height and width of available crestal bone for implant placement with a 6T scan (%igs &'(@d and &'(ge)

Study casts: Preparation of the surgical guide.

0 surgical guide without precise implant positioning is prepared. #t will allow the surgeon to adapt to whatever specific osseous situations the advanced periodontal disease ma have created (%igs &'(&'a and &'(l2b).

Surgical phase Extraction of teeth with poor prognosis

?efore the teeth are removed$ the clinician carefull removes tartar from the root surfaces and orders a course of antibiotic therap to begin - da s before the surger . 0lthough the radiographic examination in this case (see %ig & '(@c) showed that one or two teeth could be retained$ all mandibular teeth were extracted to permit the fabrication of a complete(arch implant(supported prosthesis The surgeon removes the teeth atraumaticall $ being careful to conserve the buccal cortical plate as much as possible. #n this patient$ all implants were placed in extraction sites between the foramina (%ig &'(&'c).

Placement of implants
/election of implant design and number of implants. 0s in the previous case$ an implant could be used according to the surgeon's inclination$ because an t pe should easil obtain good primar stabilit . #n some situations onl five anterior implants are re!uired$ but for this case it was decided the prosthesis should be supported b eight 9( and 7(mm(diameter implants placed in anterior and posterior segments (see %ig &'(l2c). 0ccess to bon sites. 0ccess can be obtained directl through the soc+et without raising a flap or after raising a flap. Placement of an implant without flap elevation is possible when the 6T scan shows no concavities or other specific osseous obstacles (see %ig &2(ge). 0 flap is elevated when anatomic obstacles are present or when a large gap around an implant must be filled with a bone substitute material 5ood visual access to the anatomic structures is a surgical necessit for these cases. %igure & '(&& illustrates a case where a flap was raised to fill the gap that remained after implant placement in a large canine soc+et Drilling se!uence. The classic drilling se!uence was followed in this case because the bone t pe was normal. The soc+et was drilled - to 7 mm be ond its apical limit to increase primar stabilit . The central sites were prepared first$ the most distal sites were prepared next$ and the sites between the two extremes were prepared last Parallelism of the implants was chec+ed b placing directional indicators in all the prepared sites -D positioning. The mesiodistal axis is specified b the surgical guide (see %ig &'(&'b)" in this patient$ it coincided with the alveolar axis. The surgical guide is also used to establish the buccolingual axis$ which controls the buccal envelope of the planned rehabilitative prosthesis. The buccolingual axis also generall follows the alveolar axis or is lingual to it #mplants are$ preferabl $ placed supracrestall or level with the crest The can also be placed subcrestall $ as was the case in the previousl described healed edentulous mandible$ where a variet of osseous configurations were encountered (see %ig &'(1). *hen a flap is not raised$ the surgeon places the implant in a blind techni!ue in which no landmar+ is visible. 0 graduated implant driver tip helps to place the implant nec+ - mm below the marginal gingiva. Primar stabilit . The insertion tor!ue should be greater than or e!ual to -7 8cm for all implants$ especiall for the central and most distal implants
#

:se of bone prafiler. The use of this instrument is indispensable for the perfect seating of the abutment on the implant nec+ when the implant is completel or even partiall subcrestal

126
!" Fig I 0-1 I Extraction sites approached with flap elevation. (0) 6linical view before extraction of the teeth. (b) Preoperative periapical radiographs. The advanced bone resorption full <ustifies extraction of all

remaining teeth. (c) 0traumatic extraction of the remaining teeth. (d) /urgical app"oach to the bone with the elevation of a full(thic+ness flap. 8ote the substantial gap in the bone (arrow) left b extraction of a bulbous canine and placement of an implant in its alveolus. (e) ;ealing caps and sutures in place. The prosthetic ph$ase can now begin. /uturing. *hen the alveoli are filled with an implant$ its abutment$ and a healing cap$ the do not re!uire sutures (see %ig &'(&'e). Extraction sites that do not receive implants are closed with simple sutures. 6ontrol radiograph. 0 panoramic or periapical radiograph is ta+en to evaluate the implant placement (%ig &'(& 2f). This radiograph will serve as the baseline against which the status of the bone crest can be evaluated over time.

Transition from surgical treatment site to prosthetic treatment site. The clinicians should prepare this move in advance to assure the patient that the treatment team is functioning efficientl .

Treatment variant with flap elevation

The surgical approach of choice for placement of implants in extraction sites is directl through the alveolus. #n some cases$ access to the osseous sites is supplemented by elevation of a flapAif a 6T scan has revealed the presence of anatomic obstacles or if the surgeon needs good visual access to fill in large gaps left after implant placement with bone substitute material. %igure &'(&& shows this approach. The surgeon elevated a flap because the extraction of a globular canine had left a substantial gap that re!uired filling after implant placement.

Technical difficult

Esthetic re!uirements

Team coordination
Extra costs Treatment time

Bis+ assessment

#
>
l:$i

8umber of implants

C 5-8

Documentation

Fig 10-12 Key information for treatment option I. 0fter the surgical phase is completed$ the prosthetic aspects must be considered. The three possible treatment options available for rehabilitation of an edentulous mandible will be reviewed in detail.

Prosthetic phase:Treatment option I

Scre -retained pro!isional prosthesis placed ithin 2" hours after surger#$ the prosthesis is attached to the pro!isional c#linders in the laborator# %con!ersion of a remo!able denture to a fi&ed prosthesis'. (eminder)
This option is selected when the principal determinant of treatment is the comfort of the patient The patient is reluctant to sit through a protracted, combined surgical and prosthetic appointment that could last from 3 to 5 hours . The treatment is carried out in two sessions of reasonable length, over I or days.

Key information for treatment option I

*echnical difficult# is a!erage
%igure &'(&. summari4es the +e aspects of prosthetic treatment in accordance with treatment option &. Difficult is considered average because the laborator bonds the prosthesis to the c linders and the prosthodontist is spared the burden of doing it chairside. During the surgical phase$ the implants must be placed with good parallelism$ and the access holes for the screws must be sufficientl lingual to the buccal surfaces of the involved dental units. 0fter the clinician has ta+en an impression with the implants and abutments in place$ the laborator bonds the prosthesis to the c linders. 0fter seating the prosthesis$ the clinician will have to ad<ust the occlusion. This tas+ increases the technical difficult enough to put it in the average range.

*eam coordination is moderate

The prosthetic phase does not follow surger in a single session. ;owever$ it begins immediatel after implant placement when the prosthodontist ta+es an impression that is sent to the laborator .

The laborator technician starts wor+ing immediatel after surger and bonds the provisional prosthesis to the provisional c linders. This is a relativel clear(cut procedure with few complications and no urgenc because there are no critical esthetic or functional demands to satisf It can be easil performed within ). hours

*reatment time is a!erage

The prosthetic phase does not follow immediatel after surger $ whose length is unchanged. The prosthetic phase comes later and is shorter than that of option .$ where the prosthodontist attaches the prosthesis to the c linders at chairside. The time needed for the two steps is average . to - hours for the surgical phase and & to . hours for the prosthetic phase. The latter is divided into two stages$ the first for preparation of the impression after the surger and the second for attachment of the prosthesis to the implants and ad<ustment of the occlusion.

+umber of implants) 5 to 8
%ive to eight implants are used. 6linicians ma want to use more than the average number of five or six implants used for a h brid prosthesis if the mandible is to be rehabilitated with a completearch prosthesis supported on anterior and posterior implants$ if bone !ualit is poor$ or in the presence of patient ris+ factors such as diabetes$ bruxism$ and addiction to smo+ing.

,sthetic re-uirements are lo

or none&istent

?ecause there are no esthetic concerns in most cases of complete rehabilitation of an edentulo>s mandible$ the strict rules for -D implant placement do not appl ..

,&tra costs are substantial

The provisional prosthesis re!uires specific$ expensive prosthetic components$ which cannot be reused in the final prosthesis. The laborator can attach the prosthesis to the c linders .with relative ease$ and chair time is spared. This ma+es it possible for costs to be reduced below the level of option .$ where the prosthodontist attaches the prosthesis to the provisional c linders at chairside

.dditional ris/ is lo
2btaining primar stabilit $ which is enhanced b the splinting effect of the immediatel loaded prosthesis$ should not pose an particular problem. /uccess rates are high and comparable with those of dela ed(loading protocols D

0ocumentation in the literature is e&tensi!e

This indication for immediate loading is the one best documented in the literature #mmediateloading procedures that involve posterior implants are not nearl as well documented.

Sequence and timing of steps for treatment option I %igure

&'(&- illustrates the treatment chronolog for option &E The laborator participates before and after implant placement ?efore surger $ the technician prepares the surgical guide$ the removable denture$ and the individuali4ed impression tra . 0fter surger $ the technician attaches the prosthesis to the provisional c linders and finishes the preparation of the provisional prosthesis. The implants are placed in the usual wa The prosthodontist ta+es an impression immediatel after surger . The prosthodontist completes the intervention in a second distinct session that ta+e= place - to ). hours after surger $ depending on the accessibilit and availabilit of the laborator . 0fter a .( to 9(month period to allow osseointegration to ta+e place$ the clinician verifies the clinical stabilit of the implants. The construction of the final prosthesis begins in the conventional wa .

r- 128

,dentulous mandible) 1ption 1

- da s

IIIIIIIII!I

I*
A(DD

- months

9 months
$&&

i,"#laceh$ent% of i"t"pl,ants&

>

#lacement of final prosthesis

Impression

#lacemen"' of pro!isional
prosthesis Impression

>

2on!ersion prosthesis3 attached to pro!isional c#linders in laborator#

> Surgeon

#ros"'hodontist

Checklist of materials required for treatment option I

Fig 10-1 4 (e)uence and timing of steps for treatment option I, * different color is used to identify the interventions of each team member: surgeon or surgical phase +red,- prosthodontist or prosthetic phase (yellow); and laboratory technician (blue).

Prosthetic components prepared b# the laborator# before surger#

/urgical guide %unctional removable denture that will be converted #ndividuali4ed impression tra #nterocclusal relationship /toc+ of acr lic resin from the same lot used to ma+e the prosthesis so that retouched areas will blend in acceptabl

5aterials re-uired for the surgical and prosthetic phases

#mplants designated for the procedure as well as longer and wider implants in reserve in case the bone t pe encountered re!uires them (surgeon) Transgingival #2L abutments of the estimated length and their healing caps as well as additional abutments of var ing lengths in case the pretreatment estimate of height has not been accurate (surgeon) Provisional titanium c linders (laborator ) Tr (in screws (laborator ) 5old screws (prosthodontist) /crewdriver to fix the provisional c linders in place (prosthodontist and laborator ) Extensions$ if needed (laborator ) ;exagonal screwdriver to attach the healing caps to the abutments (surgeon and prosthodontist) #mpression copings for the #2L abutments for a pic+(up .impression (prosthodontist) #2L abutment polishing protectors for use during polishing (laborator ) /econd set of artificial teeth for the converted prosthesis (laborator )

Immediate-loading protocol
Presurgical and surgical phases
0ll prosthetic options for rehabilitating an edentulous mandible share similar presurgical and surgical phases. 2ptions & and . differ in who attaches the prosthesi> to the c linders. #n the first option$ the laborator does it and in the second the prosthodontist accomplishes the tas+. The following case illustrates the prosthetic phase as it unfolds according to option &.

Case history
The radiograph in %ig & '(&9a shows the edentulous state of the mandible. #t was decided that the molar could be retained but the canine should be extracted during implant surger . 0s a rule$ posterior teeth whose prognoses are poor are left in place as long as possible until completion of the prosthetic stage and extracted afterward. These posterior teeth$ which are scheduled for extraction$ are temporaril left in place because the ;elp to determine the vertical dimension of occlusion %acilitate the various steps of impression ta+ing /erve as a landmar+ in the wax bite used to establish <aw relationships 0ssist the patient's sense of proprioception in control of the exerted masticator forces The removable denture this patient was wearing had to be remade because it was no longer functional. ;owever$ it was used to establish the vertical dimension and to determine the envelope of the mandibular arch. The occlusal surfaces were relined to obtain good vertical dimension (%ig & '(&9b). 0 tooth was added in the canine area to aid in preparation of a duplicate prosthesis F Two identical dentures were prepared so that a duplicate would be available if the denture used for the conversion prosthesis were bro+en during its transformation into a fixed prosthesis (%ig &'(&9c). The supplementar cost of this additional denture is small in proportion to the overall fee for treatment$ especiall in view of its great benefit$ if called into use$ in permitting treatment to continue on schedule. 0 surgical guide is molded from the new removable denture (%igs & '(&9d and & '(&9e). Designed not to be restrictive$ it does not dictate the position and orientation of the implants #n this case$ the section of the surgical guide that would cover the implants was opened (see %ig &'(&9e). The portion covering the remaining molar was left in place and reinforced with pattern resin. /ix implants and the corresponding transgingival #2L abutments were placed (%ig & '(&9f). Two of the implants were 9 mm in diameter and four were 7 mm in diameter. ?ecause the 9(mmdiameter of the abutments was smaller than the nec+ of &$he 7(mm(diameter implants$ an unintended platform(switching effect was obtained (%ig & '(&9f). 0fter sutures and healing caps had been placed$ the prosthetic stage of treatment was initiated.

Pro!isional prosthetic phase

The patient arrived at the prosthetic phase with the healing caps attached to the transgingival abutments (%ig &'(&7a)

Impression
?efore the impression is ta+en$ the healing caps are unscrewed. Then the impression copings corresponding to the #2L abutments are screwed in the transgingival abutments (%ig &'(&7b). 0 control radiograph is made to ensure that the copings are properl seated$ a step that is especiall important for implants with external connectors (%ig &'(&7c). The impression tra is placed between the implants (%ig &'(&7d). #n this case$ the central portion of the individuali4ed impression tra was reinforced with a metal shaft embedded in the pattern resin The openings in the impression tra are routinel closed with a sheet of wax or with surgical tape so that the impression material will not fuse occlusall (%ig &'(&7e). 0 double(fllix putt wash(light impression techni!ue in pol ether was used for this arch 0fter the impression material sets$ the transfer screws are locali4ed and then unscrewed to free the impression (%ig &'(&7e). The impression is removed and shows the position of the transgingival abutments. 8ext$ the interocclusal relationship is recorded using the surgical guide" the remaining

#
%ig G 0-1" Presurgical and surgical phases of tre6ltmem. (0) Pretreatment radiogl(aph. 2nl two mandibular teeth remain$ a canine and a molar. The 'Ei$ninc will he reiT)uved and the molal( left in place to serve as a postenor bloc+ and a guide for# impression tEiling. H ., PrlEtreatment removable denture after r$$).IiD'caticri. #t was ad<I"tcd >) th> $ddition 0$# i&"D al $ificE"$Ee$)tE ' replace the extracted canine and some acr lic resin to reestablish a 62#Tect occlusal plane. #t can row serve as a basis for fabrication of the surgical $"ide and the prostnesis that will eventuall be cor$AcrterlEEo i'le #$x(#r% prosthesis. (c) Double set of provisional Plust'$e'es. #f the Gtest pros:lesls fractures 5r is coml$"f'6irni7r $d$me sl'&re prosthesis can be utili4ed to allow treatment to continue on schedule. (d) /urgical guide in an earl stage of fabrication. #t was made from the patient's refurbished prosthesis. The positions ofthe implants remain to be determined. (e) /urgical guide.The guide is not restrictive but rather leaves a simple open space. The reinfolTement of the occlusal surface over t'le remaining natural molar will facilitate registration of the interocclusal relationships. CD Postoperative clinical $ituation. /ix implants and their transgingival #2L abutments are #n place. 0fter suturing and positioning of the i $alirg caps$ the s:#(gical phase vvill be cEornpleted. (p$'2/the"is b Dr /. 3ollo )

molar serves as a stop. The guide is filled with impression material and the patient closes the mouth in centric occlusion (%ig & '(&7f). The impressions are sent to the laborator (%ig &'(&7g).

&easurement of anteroposterior distance

Thi/ information is nocossal< to deter'E'&ine how far&he E$((Jc"th'Ksis '*n extend distall . The anterop D>t$($ior dd(EncL> il' ti"( patierlt was & #I rnfll" "#'%"("re: %.:c!, "))e acceptable extension length was &.7 xl&.' L&M.7 mrn. 6onse!uentl $ the existing 1' mil, ion! E>xtension did not have to be shortened ar$d$ in fact$ a prosthetic extensicn going be ond the nEetll arm was possible (see %ig &'(&)f).

*.aboratory procedures
The analogs of the #2L abutments are placed in the i'l&pression while the plaster cast is poured /+-.s & '(&Ma and & 2 .. &Mb)N 0fter the 6.st has /PT. the c 'indOlfs are screwed in the abutment analogs (<Eiu'" & '(&Mc and &' ,&Md). ;oles are prepared in Frle pm$J$IloEEE.s E"' that the provisional c linders can #"l(( through it. The tas+ of attaching the prosthesis with prepared holes to the c linders is a straightforward procedure when performed in the lahorator " it is easil completed through the successive addition of resin la ers.