Immediate Loading of Maxillary Implants in a Full ...

Dr. Mariano A. Polack

earned his dental degree in 1995 and his specialty training in Prosthodontics and Master of Science

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degree from the University of Minnesota in 2000. He maintains a full-time private practice focused in prosthodontics in Gainesville, Virginia. In addition, between 2002 and 2004 he was a guest researcher at the Ceramics Division of the National Institute of Standards and Technology where he was involved in several research projects on dental porcelain. Dr Polack is a reviewer for various journals and has published more than 40 abstracts and papers on implants, esthetics and dental materials. He also lectures nationally and internationally, including presentations at the Academy of Osseointegration and American Academy of Implant Dentistry. He is a member of the International Team of Implantology, Academy of Osseointegration, American College of Prosthodontics, American Dental Association and a founding member of the Gainesville Study Club, a multi-specialty study club in Gainesville, Virginia. In 2010 Dr. Polack and Dr. Arzadon won the Roxolid Clinical Cases Award.

Dr. Joseph Arzadon is an oral, maxillofacial, and facial cosmetic surgeon in Northern Virginia.

He graduated summa cum laude

from The University of Maryland Dental School in 1991, earned his Medical Degree, General Surgery Internship and OMFS residency

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certificate from The University of Connecticut Health Center in 1996. He maintains a full time private practice at the Northern Virginia Surgical Arts and Medical Spa in Arlington, Gainesville, and Manassas Park. He is also a clinical instructor at the Washington Hospital Center OMFS Residency program. Dr. Arzadon is a reviewer for the Journal of Oral and Maxillofacial Surgery, past moderator at the Annual OMFS meetings, lectured and presented at various local and national meetings, and member of various professional organizations including the International Team of Implantology and Academy of Osseointegration. He is board certified by the American Board of Oral and Maxillofacial Surgery and Fellow of the American Association of Oral and Maxillofacial Surgeons, American College of Oral and Maxillofacial Surgeons, International Association of Oral and Maxillofacial Surgeons, and American Academy of Cosmetic Surgery. In 2010 Dr. Arzadon

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and Dr. Polack won the Roxolid Clinical Cases Award.

Immediate Loading of Maxillary Implants in a Full Mouth Rehabilitation

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Introduction Implant therapy can effectively restore the decimated dentition (Polack & Arzadon 2010, Albrektsson et al 1981). Immediate placement and loading protocols can help accelerate treatment, decrease discomfort, cost, and increase patient’s satisfaction. The literature supports the efficacy and efficiency of these protocols (Roccuzzo et al 2009, Cornelini et al 2005, Attard & Zarb 2005). The following case report describes the restoration of the maxillary implants with immediately placed and loaded implants, followed by their definitive restoration approximately three months later, in conjunction with conventionally loaded posterior mandibular restorations.

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Case Presentation: A 65-year old male presented in good general health at the prosthodontist’s office for the development of a comprehensive treatment plan (Figures 1 – 7). The patient was dissatisfied with the esthetics of his smile and overall function. The maxillary arch presented incisors with fractured porcelain veneers, which had been repaired with deficient 10

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composite restorations, and two long-span fixed partial dentures (FPDs) restoring the posterior quadrants. The maxillary right FPD was supported by an implant on site #1 and natural tooth abutments #4 and #6. The maxillary left FPD was supported by teeth #11 and 15. The buccal surface of tooth #15 presented almost 100% attachment loss and gingival recession, and its immediate extraction was recommended to the patient. The mandibular arch presented with ill-fitting full-coverage restorations on teeth #20-21 and #28, and teeth #17, 18, 19, 29, 30, 31 and 32 were missing. The patient had lost his mandibular precision removable partial denture several years prior to the consultation. A referral was made to the oral maxillofacial surgeon (OMS) for surgical evaluation and immediate extraction of tooth #15. A preliminary treatment plan was made to replace only the posterior maxillary teeth, as well as ramus block graft reconstruction of the severely narrow edentulous mandibular posterior regions, followed by placement of implants on sites #19, 28 and 30 after graft healing (Figures 8 - 10). Tooth #15 was extracted. To satisfy the patient’s esthetic request and his desire to avoid a removable prosthesis, the FPD

was sectioned distal of #12, effectively transforming it into a 2-unit cantilevered prosthesis supported by #11. The patient was strongly advised against this procedure. Two weeks later, tooth #11 fractured and was removed (Figure 11). The patient’s dentition was then temporarily restored by means of an interim removable partial denture. Due to the periodontal involvement of the remaining dentition, the patient was referred to a periodontist for a comprehensive periodontal evaluation. The periodontist confirmed that the prognosis was poor to hopeless on all the maxillary teeth, fair for #28 and good for all remaiming teeth. The patient completed hygiene instruction and reinforcement, scaling and root planning in his mandibular arch, and regenerative therapy on tooth #28. A diagnostic waxup was done, and a comprehensive treatment plan was proposed to the patient, which included extraction of all remaining maxillary teeth, with immediate implant placement in sites #s 3, 4, 5, 6, 8, 9, 11, 12, 13, and 14, followed by immediate provisionalization. In the mandibular arch, implant placement and restoration in the

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Figures 1 - 7: Preoperative presentation demonstrates missing teeth, inadequate esthetics and periodontal involvement of the remaining teeth. Fig 2: Fig 1:

Fig 3:

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Fig 7: Fig 4:

Fig 5:

Fig 6:

Fig 8:

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Figures 8 -10: Ramus block graft of posterior mandibular sextants is carried out.

Immediately after the surgery, the patient was referred to the prosthodontist for fabrication of the provisional restoration. The healing abutments were removed and closed-tray impression posts were connected to the implants in positions #3, 4, 5, 8, 9, 11, 12 and 14 (Figure 16). As already noted, the implants in sites #6 and 13 were not immediately loaded due to the need to graft the significant HDDs which had been present following Volume 2 • 2013

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8 & 9, so that the implants…apical to the gingival margin of tooth #11, to improve the final esthetic result

Provisionalization:

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Study models were obtained, and a diagnostic wax-up was carried out. The diagnostic wax-up was shared with and accepted by the patient. Using the diagnostic wax-up and clear polymethyl methacrylate, a surgical guide was fabricated. Instructions were given to the surgeon to reduce and contour the edentulous maxillary ridge anteriorly, to allow proper depth for implant placement while generating adequate soft tissue scalloping. The surgeon was to reduce the alveolar bone crest at sites 8 & 9, so that the implants in these sites could be placed 3-4mm apical to the gingival margin of tooth #final esthetic result.

The maxillary teeth were removed by elevating buccal and palatal flaps, except at tooth #6, so as to maintain intact gingival margins. A moderate buccal bony defect was present at the #5 site. It was therefore decided to place the implant in the position of #5 more palatally than usual. The buccal bone at the #9 site was scored horizontally with a #701 bur to mark the level of the buccal gingival margin of #6. Tooth #6 was removed, The buccal plate remained intact. A flap was then elevated at the site of tooth #6, to expose the crestal bone and allow for better access of the #7 site. A periodontal probe was used to measure 3-4 mm apically from the horizontal mark at site #9. A mark was made at this location, representing the most apical position of the future buccal alveolar crest. Reduction osteoplasty, with scalloping of the alveolar crests at sites #8,9 was carried out, followed by the same therapy at the #7 and 10 sites (Figures 12, 13). The surgical guide was used to confirm the adequacy of the performed osteoplasty, and to create 2.8 mm diameter osteotomies. Site #5 was palatally modified(Figure 14). 2.8mm guide pins were placed in osteotomysites, and the final osteotomies were completed without the surgical guide (Figure 15). Type 3 bone was encountered. The following

Straumann SLActive Bone Level implants were placed using the handpiece adapter set at 35nCm: sites #3,14 - RC 4.1 x 12mm; sites #4, 5, 6, 8, 9, 11, 12, 13 -RC 4.1 x 14mm. Primary stability was attained in all instances. Following implant placement in sites #6 and #13 , horizontal defect dimensions (HDD) were present, which required additional bone grafting. Therefore, these implants were not attached to the immediate provisional restoration.. The buccal osseous defects and HDDs were grafted with Bio-Oss, and 4mm healing covers placed. The thick gingival tissues posteriorly and palatally were also reduced. The wounds were reapproximated with 4-0 chromic sutures. Post-op instructions were given. The patient was instructed to return to the office of the OMS for follow up care.

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Presurgical Planning:

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positions of teeth #s 19, 28 and 30 was planned, in conjunction with full coverage restorations on teeth #s 20, 21, 28. The patient was referred back to the OMS for evaluation of the maxillary arch for immediate placement of implants to support the planned restoration. It was decided that implant #1 would remain, as it could be utilized if needed to help support a provisional FPD during the course of treatment. An immediate full arch maxillary provisional restoration would be delivered within 24 hours of implant placement. The maxillary surgery was planned for 2-3 months after the mandibular block graft surgery.

Fig 10:

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implant placement. Radiographs was taken to confirm seating, a rubber-dam was placed to protect the wound, and a polyvinylsiloxane impression was taken. A facebow and occlusal registration were obtained. The impression posts were connected to their respective analogs and replaced in the impression (Figure 17). The healing abutments were replaced and the patient was dismissed. The laboratory technician poured a soft-tissue model and prepared provisional abutments to the gingival margins. These provisional abutments were used to support a one-piece, full-arch polymethylmethacryllate provisional restoration (Figure 18). The following morning, the provisional abutments were torqued to 15 Ncm in their respective implants. PTFE tape was used to seal the access holes, and the provisional restoration was tried in, adjusted and cemented with a small amount of provisional cement. Care was taken to carefully and completely remove all excess cement. The patient was given postoperative instructions, which included a soft diet for eight weeks. A follow up at the OMS office

Fig 11: Tooth #11 fractured shortly after the extraction of tooth #15.

was carried out two days after the surgery to assess the soft tissue response, which was within normal limits. No mobility of the implants or the provisional restoration was noted, and the patient was comfortable and pleased. At 10 weeks postoperative, the implant sites were found sensitivity to be healing well (Figure 19). No implant mobility, inflammation or patient sensitivit were encountered. The maxillary implants were determined to be ready for final restoration at the 12-week (3 months) healing period. The block grafts were also ready for implant placement. It was therefore decided to wait an additional 6 weeks until the mandibular implants #19, 28, and 30 were ready for final restoration. The patient was referred back to the prosthodontist. Final Restoration: The provisional restoration, healing and provisional abutments were removed. An implant-level final impression was made with

Fig 12: A buccal view of the anterior maxilla after flap reflection. The coronal position of the crestal bone is evident on sites #8 and 9, demonstrating the need for alveolar reduction. A horizontal mark is made at #9 corresponding to the buccal gingival margin of #6. Removal of bone 3-4mm apical to this mark represents the future buccal crest.

Fig 15: An occlusal view of the guide pins inside the prepared osteotomies in the maxillary arch.

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closed-tray impression posts (Figure 20). A double-cord technique was used to impression teeth #20, 21 and 28. A soft-tissue master model, facebow and occlusal registration were obtained, and UCLA custom abutments were fabricated. The abutments on teeth #6, 8, 9 and 11 were designed with lingual set screws to allow for retrievability of the screw-retained FPD from #s 6 to 11. Gingival colored ceramics were used to achieve adequate tooth proportions in the esthetic zone (Figure 21 24). The posterior maxillary and mandibular restorations were designed as cemented individual units. The restorations were tried in, and their adaptation, occlusion, interproximal contacts and esthetics were evaluated and adjusted as needed. The abutments were torqued to 35 Ncm (Figure 25, 26) and the screw-access channels were sealed with PTFE tape and composite resin. The lingual set-screws on the anterior FPD were torqued to 10 Ncm. The posterior implant crowns were cemented with a small amount of provisional cement (Figure

Fig 13: Crestal bone reduction has been completed. The modification of the bony architecture will allow for a more esthetic result.

Fig 17: The impression posts are connected to the analogs and replaced in the impression.

Fig 16: Immediately following implant placement, an impression is made to adapt the provisional restoration in the laboratory.

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Fig 19: Ten weeks postoperatively, implant sites and soft tissues demonstrate adequate healing with no inflammation or sensitivity

Fig 14: The surgical guide is positioned on the maxillary arch during implant placement

Fig 18: 24 hours after surgery, the provisional abutments and full-arch provisional restoration are delivered.

Fig 20: A final impression is taken with closed-tray impression posts.

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Figures 21–24: Facial and lingual views of the completed maxillary restorations. Gingiva-colored ceramics were used to maintain adequate height:width ratios in the esthetic zone. Teeth #6 – 11 were designed as a lingual screw-retained prosthesis, and the posterior restorations as cemented single units.

Fig 22.

Fig 23.

Fig 21.

Discussion:

Fig 25:

Figures 25–26: Occlusal and buccal views of the custom abutments

Calandriello et al 2003, Lazzara & Porter 2006, A provisional removable partial denture Balshi & Wolfinger 2003). is avoided, the number of appointments Prosthesis design is of great importance with and overall cost of therapy are reduced, accelerated implant protocols. Whenever and the gingival architecture is properly possible, a screw-retained provisional supported soon the teeth are extracted restoration should be used with immediately (Polack & Arzadon 2012). In addition, such a ,anterior and posterior implants in the present loaded implants. This provisional restoration therapeutic approach is often psychologically case, mandated the use of a cemented (please design prevents the possibility of leaving rewarding for the patient, due to the ability to add "in the present case") excess cement behind, which could negatively produce esthetically pleasing results in a short impact osseointegration. The number of period of time. implants, and different angulations between anterior and posterior implants, mandated Conclusion the use of a cemented provisional restoration. Additional considerations with immediate The replacement of maxillary teeth with implant loading include an occlusal scheme immediately placed and loaded implants with bilateral contacts, shallow anterior represents a viable treatment modality overbite, a reduced incisal guide angle that can reduce chair time and cost for the and reduced posterior cusp heights (Ghoul clinician, while increasing patient comfort, & Chidiac 2012). Distal cantilevers are satisfaction and esthetics. contraindicated. The advantages of immediate placement and loading of dental implants are numerous.

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Primary implant stability is critical to allow for immediate provisionalization of implants (Esposito et al 2009). Several methods have been proposed to verify such implant stability. One accepted method is implant insertion with a torque of 35 Ncm or greater. Such an approach is believed to keep micromovement below 150 um (Szmukler-Moncler et al 1998), thus permitting osseointegration to occur. A soft diet during the healing stages, and the use of implants with a platform-switched connection are also commonly recommended when performing such therapy (Romanos & Netwig 2009, Schnitman et al 1997,

Fig 26:

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27 - 34). The crowns on #s 20, 21 and 28 were adhesively cemented with a self-etching resin cement. The patient was evaluated at two weeks, one month and six months post insertion..

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Figures 27 - 34: A postoperative view of the final restorations. Function, esthetics and phonetics have been restored.

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Fig 28.

Fig 29.

Fig 30.

Fig 31.

Fig 32.

Fig 33.

Fig 34. Volume 2 • 2013

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Fig 27.

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References 1. Albrektsson T, Branemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthop Scand 1981;52:155-70.

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2. Attard NJ, Zarb GA. Immediate and early implant loading protocols: a literature review of clinical studies. J Prosthet Dent 2005;94:242-58. 3. Balshi T.J. & Wolfinger G.J. (2003) Immediate loading of dental implants in the edentulous maxilla: case study of a unique protocol. Int J Periodontics Restorative Dent 23(1): 37-45.

5. Cornelini R., Cangini F., Covani U. & Wilson T.G., Jr. (2005) Immediate restoration of implants placed into fresh extraction sockets for singletooth replacement: a prospective clinical study. Int J Periodontics Restorative Dent 25(5):439-47.

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4. Calandriello R., Tomatis M. & Rangert B. (2003) Immediate functional loading of Branemark System implants with enhanced initial stability: a prospective 1- to 2-year clinical and radiographic study. Clin Implant Dent Relat Res 5 Suppl 1:10-20.

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6. Esposito M., Grusovin M.G., Achille H., Coulthard P. & Worthington H.V. (2009) Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev (1): CD003878. 7. Ghoul W.E. & Chidiac J.J. (2012) Prosthetic requirements for immediate implant loading: a review. J Prosthodont 21(2):141-54. 8. Lazzara R.J. & Porter S.S. (2006) Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 26(1):9-17. 9. Polack M.A. & Arzadon J.M. (2010) Gingival aesthetics, bone remodeling, and implant reconstructions. Dent Today. 29(11):112, 114-8. 10. Polack M.A. & Arzadon J.M. (2012) Titaniumzirconium implants: Case report. Immediate provisional and restoration using a small-diameter system. Dent Today 31(12): 64, 66, 68-9. 11. Roccuzzo M., Aglietta M. & Cordaro L. (2009) Implant loading protocols for partially edentulous maxillary posterior sites. Int J Oral Maxillofac Implants 24 Suppl:147-57.

12. Romanos G.E. & Nentwig G.H. (2009) Immediate functional loading in the maxilla using implants with platform switching: five-year results. Int J Oral Maxillofac Implants 24(6):1106-12. 13. Schnitman P.A., Wohrle P.S., Rubenstein J.E., DaSilva J.D. & Wang N.H. (1997) Ten-year results for Branemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 12(4):495-503. 14. Szmukler-Moncler S., Salama H., Reingewirtz Y. & Dubruille J.H. (1998) Timing of loading and effect of micromotion on bone-dental implant interface: review of experimental literature. J Biomed Mater Res 43(2):192-203.