23

News No. 23 May 2010

Immediate Loading
in the Complete
Edentulous Maxilla-
A Clinical Case
- Using MIS Multi-Unit Abutments

Make it Simple
 2 News 23, May 2010

Immediate Loading in the

Complete Edentulous Maxilla
- A Clinical Case

1
Dr Jean Koskievic Saint Antoine Hospital (Paris)

The development of oral implantology has success rate 15 years later for the fixed of new treatment protocols. Under certain
allowed for the creation of a new discipline prostheses implemented on Brånemark conditions, these protocols reduce the number
pertaining to odonto-stomatology, with System® implants after osseointegration during of implants needed for stabilizing prostheses,
treatment procedures that are now well codified, 3 months10 in the symphyseal region. either provisory or definitive, and enable
predictable and reproducible with great success immediate implant loading with accuracy while
rates. These protocols involve implant loading The Hong Kong bridge11 reduces the number decreasing treatment time and costs. These
in a two-stage surgical procedure.1-3 of implants placed in the symphysis to 4 and protocols require a surgical template made
allows immediate insertion of the prosthesis. from a predefined prosthetic device.
The implant success rate is 98.3%. Other
1. studies12-14 confirm that immediate loading In 1994, the Matérialise® Company developed
Delayed Versus of 4 implants placed in the symphysis and a software program that could carry out
Immediate Loading made jointly liable to the mandible of complete scan-derived implant simulations, as well
edentulous patients, is a reliable, reproducible as a quantitative and qualitative study of the
Schnitman et al.4 proved that immediate and predictable method when using a implant sites. A surgical drill template (guide),
loading is a viable technique when applied rigid overdenture. which uses stereo-lithographical modeling
to the mandible. Surgical and prosthetic (SurgiGuide®), was then created. This resulted
success rates have been found close to that of A retrospective clinical study15 has been in a complete system of data analysis and
delayed loading. conducted on 44 patients and 176 implants execution of surgical templates compatible
using a new protocol of immediate loading with all implant trademarks (Simplant®). This
A protocol of immediate bi-maxillary loading (All-on-Four). This consists of inserting 4 long
has been described by Tarnow et al.5 Brånemark surgical template allows accurate repositioning
implants (2 distally angled) in the symphysis of the implants in the bone.
et al.6 published the first results of a new concept, by using several 40 N/cm in patients with an
the Brånemark Novum®. This concept enables edentulous mandible. By distally angling these In 2002, following the research of Verstreken
accurate pre-positioning, with the help of implants, the authors hoped to decrease the et al.18,19 and Jacobs et al.,20 Van Steenberghe
surgical templates. In the symphyseal region, 3 forces acting on the cantilevers of the acrylic et al.21,22 conducted a study on two cadavers
implants are placed pre-operatively in a three- complete mandibular prosthesis mounted and later on eight patients that proved that
space plane and connected between each on the rigid intrados and screwed to these the transfer of CT results to the patient using
other by a prefabricated rigid connection rod. implants by angled multi-unit pillars and computer-aided surfing, allows for extremely
A second rod, supporting a fixed prosthesis specific fixtures within less than 2 hours. A accurate development of a surgical drill template.
made of acrylic resin, is received in a second cumulative survival rate of 96.7% was recorded This procedure also enables positioning of a
stage occurring not later than 24 to 48 hours. for implants and a success rate of 100% for fixed prosthesis while limiting the freedom of
This study corroborated by another 18-month prostheses. In a later study16 by the same movement between the metallic pillars and
clinical research by Randow et al.7 concludes authors, a cumulative survival rate of 97.6% was cylinders incorporated in the prosthesis.
that this treatment is only reliable if the implants found for the maxilla. It has been confirmed
are positioned between both chin foramina. that the distal angulation of implants made In a prospective multi-center study conducted
In a 5-year study on 16 patients and 88 inter- jointly liable by a fixed prosthetic element on 24 patients with edentulous maxilla under
foraminal implants placed in the edentulous supporting a cantilever does not increase one-year follow-up, Van Steenberghe et al.23
mandible, Ericsson et al.8 have shown that the bone strains with regard to vertically proposed a new concept called "Teeth-in-One-
by using a rigid prosthetic device, the bone inserted implants.17 Hour". Its protocol, based on computer-aided
resorption rate around the implemented 3D planning, allows insertion of implants using
implants within 20 days is identical to that a surgical template with mucous support
of implants implemented at 4 months. The 2. (flapless technique) and implements a complete
first results at the end of the Novum protocol Computer-Aided Planning and trans-screwed rigid prosthesis immediately
presented interesting success rates. Van Implant Modeling after surgery. A 100% survival rate was shown
Steenberghe et al.9 conducted a study over for the implants and identical success rate for
Computer-aided, scan-derived planning and
a longer period and found an approximate the prostheses.
implant modeling established by stereo-
survival rate of 90% after 5 years vs. a 99% lithography have resulted in the development

1
Dr Jean Koskievic University Diploma in Pratical and Fundamental Implantology University Diploma in Advanced and Maxillomandibular
DDS, MMS, DUI, DUIA Reconstructive Surgery Implantology (Lille University Medicalschool, France) Associate Fellow of the A.A.I.D
Member of the French Association of Implantology Director of the "Certificat Hospitalier d'Implantologie Oral " at the Saint Antoine Hospital (Paris)
 3 News 23, May 2010

Today, three types of surgical be carried out. The crests should be leveled to Once the assembly is validated, it is sent to
templates are used: obtain a prosthetic groove in the anteroposterior the laboratory. A duplicate is made to use as
direction, wide enough to insert the implants. a radio-opaque template (Fig. 3).
-Surgical template with bone support: the Adherences are eliminated. Healing times
template is positioned on the patient's bone must be respected. The provisory PAC that
during surgery. It is intended for partially or Scanning
comes before the definitive prosthesis should
completely edentulous patients and allows for be fabricated. This will validate the occluso- During scanning the patient holds the radio-
observing the surgical procedure by relying prosthetic space needed for this type of opaque template and bites in centered
on the residual bone. This ensures better treatment, which requires implementation of relation (Fig. 4).
accuracy for template positioning. This surgery different components.
involves flaps. Examination and interpretation of scans,
Should the patient already and computer-aided implant
-Surgical template with mucous support:
be fitted with dentures: simulation (CAIS)
the template is positioned on the patient's
soft tissues during surgery. It is intended The prosthesis should be re-evaluated or The scan reveals the accuracy of the anatomic
for patients with completely edentulous replaced since the immediate loading protocol obstacles, and the quality and quantity of
mandibles or maxillas for a non-invasive in a complete edentulous maxilla-mandible the residual alveolar bone (Figs. 5a,b). In the
("flapless") surgery. depends on its validation. presented case, the Dicom files were sent
to the modeling center (Positdental®) for
- Surgical template with dental-mucous support: computer-aide simulation (CAIS) (Figs. 6a,b).
the template is positioned directly on the 4. Presentation Of The Clinical Case The CAIS plans the implant installation in 3D
teeth present on the arch during surgery. It and determines the number of implants and
A 67-year-old man consulted for complete
is intended for partial edentulous patients, their position in the three-space plane. The
rehabilitation of the maxilla and mandible. He
either unitary or plural, when flapless or other feasibility of the prosthetic device and selected
presented with a complete edentulous maxilla
surgery, is not desired. implants was viewed. The length, diameter,
for which no PAC compensation had been
made, and a partial edentulous mandible emergence zone and angulation of each
3. Indications and Contra-indications with three residual teeth (33, 34, 43) and an implant was recalculated (Figs. 7a,b). Upon
inadequate PAP. In the maxilla, the clinical request, the modeling center simulated the
Only ASA1 or ASA2 patients should be selected. examination revealed a keratinized, non- drill template and metal intrados supporting
Moreover, first selection relies on motivation inflammatory gum over the entire edentulous the provisory resin prosthesis that was made
and understanding of treatment planning, as ridge and the absence of residual roots and jointly liable to the provisory implant inlay
well as the strict respect of hygiene rules. The focuses of infection (Fig. 1). cores (Fig. 8).
patient should be informed of the proposed
treatment plan and of the required healing Residual, irrecoverable teeth (33, 34, 43) In the maxilla, 6 implants (MIS - Medical
periods and controls. were observed in the mandible. Panoramic Implant System) with internal hexagon, angled
radiographs in the maxilla revealed the at 30°, was distributed between both sinuses.
-Clinical extra- and intra-oral examinations presence of prolapsing sinuses extending Implementation of 6 implants allows support
are carried out to develop a treatment plan up to teeth 13 and 23, thus preventing any of the rigid resin prosthesis of the "cantilever"
preceding any surgery. Contra-indications for axial implant protocol in the posterior region. type, made jointly liable to the implants in a
an immediate loading protocol of this type are Pre-implant surgery was required. In the maxilla bone. This is often of mediocre quality,
the same as for loading in two surgical stages. mandible, strong bilateral posterior alveolar but brings a better distribution of forces, which
Residual bone volume in the edentulous region, resorption with emerging foramens of the remain within admissible physiological limits.
occlusion type, intermaxillary connections, and chin was observed in front of teeth 34-35 The implants were angled at 30° while placed
periodontium condition should be assessed and 44-45 (Fig. 2). along the sinuses so that their emergence
by the clinician. appeared in front of teeth 14 and 24. Four
After the patient was informed of the various additional implants (12, 11, 21, 22) were
The mouth opening should be examined treatment options, a functional aesthetic bi- also placed at 30° while relying on the hard
to ensure that the surgical template can be maxillary implant-borne rehabilitation was palate (Fig. 9).
anchored, that there is space for the use of chosen with immediate implant loading, and
instruments, and for implant insertion. In the simultaneous implementation of the trans- Resistance to the vertical tensile strength
flapless technique, a floating ridge may be screwed provisory prostheses. The decision was increased when these implants were
contra-indicated since it does not provide the was made to rehabilitate the maxilla first. In the crossed with the distal ones. The 6 implants
guide with good stability. Patients with significant second-stage, after extraction of the mandibular received "multi-unit" pillars (MIS - Medical
dysfunctions and parafunctions should be residual teeth and healing temporization, the Implant System) angled at 30°, designed to
excluded from this type of treatment. mandible was rehabilitated. straighten the emergence of the implant axes
and recover the parallelism of the titanium
-In the selected implant sites, the clinician should Today, implant simulation allows the use of trans-screwed provisory inlay cores. This
assess if residual bone volume and keratinized planning software programs to fit patients allows insertion of a transitory rigid prosthesis
tissue are present in sufficient quantity and with dentures on the condition that there is a from teeth 15 to 25, made jointly liable to these
quality. D4 type bone is contra-indicated to sufficient bone quantity. This rehabilitation is provisory inlay cores.
this type of treatment.24 subjected to protocol.
The transitory trans-screwed rigid prosthesis is
-Additional radiologic examinations (dental Aesthetic assembly of the toothless equivalent to an external fixative. It reduces the
panoramic examination, scanner) and maxilla (wax up) applied forces transmitted to the implants, which
computer-aided 3D simulation validate the are at the origin of harmful micro-movements
feasibility of the proposed treatment plan. The wax prostheses should be mounted before to the osseointegration, lessens the "cantilever"
the final functional aesthetic result. Before effect, and allows for an increased number
Should the patient still scanning, the practitioner should examine of teeth on the prosthesis while improving
be without dentures: the vertical dimension of occlusion, the inter- the aesthetic aspect. The CAIS was returned
maxillary connection and the occluso-prosthetic for validation.
Before implant surgery, extraction and curettage space to determine whether the mouth opening
of the focus of infection and transplants should is sufficient for a drill template to be used.
4 News 23, May 2010

Fig. 1 Fig. 2

Fig. 3 Fig. 4

Fig. 5A Fig. 5b

Fig. 6a Fig. 6b

Fig. 7a Fig. 7b

Fig. 8 Fig. 9
 5 News 23, May 2010

Physical validation were interposed between the implants angled of guidance systems is recommended.
at 30° and the provisory inlay-cores. The
The drill template and the provisory resin multi-units are composed of an anti-rotational However, according to Komiyama et al.28 there
prosthesis mounted on the metal intrados apical part that is screwed in the implant and are surgical and technical complications in the
were produced by the modeling center and a trans-mucous coronary part angled at 30° ""flapless" technique. In 29 patients, 176 implants
sent to the surgeon who physically validated that allows implant emergence axis to be were inserted using the "Nobelguide"TM protocol
the computer-aided 3D simulation from the adjusted. The angled multi-units are provided and immediately applied with a prosthesis
stereo-lithographic model (Fig. 10). The surgical with a prehension rod that enables insertion prepared in advance (21 in the maxilla; 10
steel templates and fittings were sterilized by into the angled implants while controlling the in the mandible). Within 2 to 18 months, 19
autoclaving before surgery. parallelism. After placement (Fig. 20), titanium implants were lost, with a success rate of
inlay cores were trans-screed in the multi-units 92% in the maxilla and 83% in the mandible.
Implementation of the implants (Fig. 21). Parallelism was completely controlled Surgical or technical complications were
on the maxilla and the flaps were sutured. found in 42% of the treated patients. It was
concluded that the surgical flapless protocol
A main ridge incision that was moved forward was still not scientifically validated.
to the palatal and two vestibular incisions for Implementation of the
unloading, in front of teeth 15 and 25, allowed trans-screwed prosthesis In the flapless technique, the reliability of the
for mucoperiosteal detachment of the areas The provisory resin prosthesis (Fig. 22), mounted protocol depends on several factors, which
to be implanted (Fig. 11). The drill template on the rigid intrados, was made jointly liable are not always under the surgeon's control.
is usually stabilized on the residual alveolar to the provisory titanium inlay-cores using a Parameters which could be sources of errors
bone using lateral osseosynthesis screws. cold self-polymerizable composite. The whole are accuracy of the baryta duplicate, scanning
However, in this clinical case, the strong was unscrewed, the intrados of the provisory quality, and reliability of the CAIS. A study29
undercut presented by the vestibular alveolar prosthesis trimmed and repolished, and then confirms that computer-aided navigation
bone naturally stabilized the drill template (Fig. re-screwed on the implants using the multi- may be a source of errors (average deviation
12). At implant sites 12 and 22, pre-drilling was units (Fig. 23). The occlusion was examined less than 1 mm from the drilling and average
achieved using a pointer, the non-working part (Fig. 24) and adjustment made using the deviation less than 4º from the implant axis),
of which was fitted with a centering washer radiograph (Fig. 25). but that these errors have no impact in the
with stop (Positroll®) inserted in the bushing flapless technique.
of the drill template. Suture removal and The lack of visibility with this technique requires
The drill template was supported on the ridge radiographic examination great caution, as well as a technique guided
using self-drilling screws with external irrigation, with bone support that allows for the control
Sutures were removed at 21 days. Cicatrisation
mounted on a counter-angle and guided by of the procedure. This seems to be a more
was controlled. The prosthesis was rebased if
the centering washer inserted in the bushing reliable approach until consensus is reached.
needed and the occlusion was re-examined.
at implant sites 12 and 22. This locked the drill Implementation of angulated implants, with
A panoramic radiograph revealed the proper
template (Fig. 13). The drilling sequence was the angle multi-units being introduced into
position of all pillars.
resumed using the pointer in front of sites 11 the market, allows for the development of
and 21, continuing with 3 mm (diameter) and accurate indications, trans-screwed prostheses
Implementation of the definitive
8 mm (length) drills, always fitted with the implant-borne prostheses which can accept cantilevers according to
centering washer with stop that guided the the type of bone found, the length and the
drilling and ended according to the length and At 3 months, after control of the osseointegration number of inserted implants, and the type of
diameter selected for each implant. Implants of the implants, the definitive maxillary prosthesis implemented prosthesis.
for sites 11 and 21 were placed and locked was implemented (Fig. 26).
Forces applied on angled implants do not
in the template (Fig. 14).
lead to higher bone loss at the marginal bone
The implant holders were dismantled and a 5. Discussion level than vertically inserted implants. It is now
tightening key, with 6 marks matching the 6 recognized that 4 implants are sufficient in
It is possible to insert implants while applying
sides of the internal hexagon, was inserted corticalized bone, such as the mandible. In
a flapless technique with extreme accuracy
in the implant neck. This key is guided by the maxilla, a greater number of implants
and using a CAIS-prepared drill template.21,22
a calibrated cylinder matching the bushing may be desired for this type of rehabilitation.
The research is corroborated by a comparative
diameter, thus avoiding any deviation during Then the quality of the residual alveolar bone
4-year retrospective multi-center clinical study,25
final tightening of the implant (Fig. 15). When is important.
which shows that the use of CAIS allows for
one of these marks match the open window
the insertion of implants using a flapless
of the bushing, the desired implant positioning
is recovered in the required axis and the latter
technique, with success rates identical to 6. Conclusion
those of any conventional technique. Another
is placed. Another set of calibrated cylinders With the development of the computer-aided
study26 has shown that the flapless technique
lock the drill template at implant sites 11 and simulation and 3D modeling, treatment protocols
encourages vascularization of the peri-implant
21 (Fig. 16) while the operation is renewed for for patients suffering from a complete edentulous
mucous membrane around the implant. In an
implants 14 and 24, which are installed in turn maxilla and/or mandible have advanced. It is
in vitro study, Van de Velde et al. 27 indicate
(Figs. 17a,b). The last drilling sequence allowed now possible to carry out immediate implant
that without a drill template, there is drilling
positioning of the implants in spaces 12 and loading under certain aesthetic functional
deviation when implants are implemented
22 (Fig. 18). After all implants were placed, the rehabilitations with reduced time and cost.
across the mucous membrane. Deviations
system was dismantled (Figs. 19a,b).
were found in 59.7% of the patients (43/72),
The guides with bone support offer greater
which could lead to a loss of implant stability
Implementation of parallelization of the safety for both patient and surgeon. With
with phonetic and aesthetic consequences. It
multi-units and provisory inlay-cores implant development and adapted fixtures,
was concluded that despite the advantages
this immediate loading technique is open to
The parallelization of the 6 provisory inlay-cores of the flapless technique, from the viewpoints
all types of implants and implant-connecting
needed to insert the prosthesis successfully of pain, morbidity and diminution of surgical
technology. It allows for a quicker prosthesis
presents some difficulty. To solve this problem, operation time, it is necessary to have a more
implementation with immediate recovered
6 multi-units (MIS - Medical Implant System) accurate measure of the soft tissues. The use
comfort and aesthetics for the patient.
6 News 23, May 2010

However, it is still necessary to improve the

procedures of computer-aided implant simulation
(CAIS), of template manufacturing, and supra-
implant connecting technology to validate
immediate loading in a complete edentulous
maxilla with terminal atrophy of the alveolar
bones in the posterior region.
The guides with mucous support reinforce
the therapeutic arsenal that is available for
Fig. 10 Fig. 11 the practitioner. The surgical intervention is
certainly improved while evading the post-surgical
problems (pains and edema) but, to our mind,
there is the disadvantage, of being committed
to a particular implant system.
Immediate loading of the edentulous maxilla with
a drill template, using either a flapless or flap
procedure, requires specially trained qualified
surgeons for this kind of technique.

Fig. 12 Fig. 13

Fig. 14 Fig. 15 Fig. 16

Fig. 17a Fig. 17b Fig. 18

Fig. 19a Fig. 19b Fig. 20

Fig. 21 Fig. 22 Fig. 23

 7 News 23, May 2010

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G, van Steenberghe D, Suetens P. An image-guided planning
system for endosseous oral implants. IEEE Trans Med Imaging
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Fig. 24 Fig. 25 Fig. 26

 MIS’s Quality System complies with international quality
standards: ISO 13485:2003 - Quality Management System
for Medical Devices, ISO 9001: 2008 – Quality Manage-
ment System and CE Directive for Medical Devices 93/42/
EEC. MIS’s products are cleared for marketing in the USA
and CE approved.

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