Treatment planning algorithm for patients with a terminal dentition.

This article discusses the variables that affect the diagnostic process in patients with a compromised dentition and addresses the clinical decision of whether to extract or maintain teeth. A decision tree algorithm is proposed to guide clinicians in planning complete arch rehabilitations.

Novel "All in 4-4-4" Hybrid Prosthesis: Bridging the Affordability Gap.

A strong body of scientific evidence indicates that a four dental implant-supported prosthesis is well suited for a full-arch rehabilitation. Yet, countless edentulous patients who could benefit from this established concept are left untreated because of high costs. This article describes a novel workflow that enables the fabrication of a metal-resin fixed hybrid prosthesis supported on four implants, with a variable cost for parts and material of around $400 and a (laboratory) production time of approximately 4 hours. This approach allows for the possibility of delivering a final or long-term provisional restoration on the day of implant placement. Because of the relatively low cost and the feasibility of in-house production, this workflow can potentially allow more patients to access high-quality full-arch implant care.

Reverse scan body: The scan pattern affects the fit of complete-arch prototype prostheses.

PURPOSE: To assess the effect of different scan patterns on the fit of implant-supported complete-arch prototype prostheses fabricated via a complete digital extraoral protocol with a reverse scan body. MATERIALS AND METHODS: A mandibular cast with four multi-unit abutment (MUA) implant analogs with adequate antero-posterior spread served as the reference cast, simulating a common clinical patient situation, and a polymethylmethacrylate interim screw-retained prosthesis was fabricated on it. Novel reverse scan bodies were connected to the interim prosthesis on the intaglio of the MUA abutments and extraoral scanning was performed with a white light intraoral scanner (TRIOS 4; 3 shape) and three different scan patterns: starting from the occlusal surface of the interim prosthesis (O-group), starting from the intaglio (I-group), and helix pattern (H-group).  The resulting STL files from the three groups were then imported to computer-aided design (CAD) software and after the digital design, the STL files were exported to a computer-aided manufacturing (CAM) milling machine which generated a total of 15 CAD-CAM milled prototype prostheses per group. Two clinicians assessed the fit of each digitally fabricated prototype prosthesis on the reference cast, utilizing the screw-resistance test and radiographic evaluation. Fisher's exact test was used to test the difference between the three groups, and Cohen's k-score was used to assess the inter-examiner agreement. RESULTS: Out of the three different groups, the O-group scan pattern led to 100% prosthesis fit, while the prototype prostheses generated from I- and H-groups had 80% and 53% fit, respectively. The results were statistically significant (p = 0.008). CONCLUSIONS: Occlusal scan pattern leads to fitting milled prototype prostheses after extraoral scanning with reverse scan bodies without intraoral implant data acquisition.

The Reverse Scan Body Protocol: Completing the Digital Workflow.

Recently developed extraoral techniques have allowed for an alternative approach for the digital acquisition of implant positions in fully edentulous patients. The "reverse scan body protocol" digitally simulates the traditional back-pouring technique long utilized in analog workflows. This article presents two cases in which an extraoral scanning technique was used to capture implant positions, design a prototype, and fabricate the definitive monolithic zirconia full-arch prosthesis.

Treatment of Periodontal Diseases With Laser: Assessing the Evidence.

The treatment of the moderate to advanced resorbed edentulous maxilla with a fixed prosthesis is complicated due to the presence of pneumatized maxillary sinuses posteriorly and the nasal aperture in the premaxilla. To treat patients with this condition using endosseous implants to support a functional prosthesis, grafting procedures have been advocated. The multiple surgical steps involved in the reconstruction of the resorbed maxilla, however, can be a significant barrier to patient acceptance of grafting treatment protocols. The success of graftless concepts using tilted and zygomatic implants has led to a higher case acceptance as the treatment can be accomplished in one appointment. Over the past two decades, the experience clinicians have gained using zygomatic implants has resulted in a redesign of the implant aimed at addressing the challenges associated with the treatment of patients with moderate to advanced resorbed maxillae to better serve these patients.

Fundamental Principles for Immediate Implant Stability and Loading.

A considerable number of studies in contemporary literature support the treatment of patients with edentulous arches using four or six implants with predictable outcome. As patients are increasingly being treated with full-arch implant-supported prostheses, clinicians need to understand the various fundamental principles for immediate implant placement and immediate loading. This article reviews these principles with regard to treatment planning, surgical execution, and prosthetic rehabilitation while describing a case of an edentulous patient seeking a fixed restorative option to re-establish form and function of her maxillary and mandibular dentition.

Treatment Planning the Edentulous Mandible. Review of Biomechanical and Clinical Considerations: An Update.

PURPOSE: This review article evaluated biomechanical studies, finite element analyses, and clinical papers on the prosthetic and surgical principles for the survival of implants when reconstructing the edentulous mandible, including the use of a three-implant-supported fixed prosthesis. MATERIALS AND METHODS: A comprehensive search of studies published from 1983 to December 2017 listed in the PubMed/MEDLINE databases was performed. Relevant studies were selected according to predetermined inclusion and exclusion criteria. RESULTS: The initial database search yielded 942 titles. After filtering, 157 abstracts were selected, with 68 articles considered relevant and included. Consensus among authors was identified in regard to the number and the distribution of implants; limiting or eliminating distal cantilevers; and the principles of biomechanical loading of a cross-arch splinted prosthesis. CONCLUSION: The result of this review suggests that reconstruction of the edentulous mandible with a fixed prosthesis using three, four, or six implants is a viable treatment option. However, when using three implants, wider-diameter implants are recommended for favorable force control.

Prevention and the Management of Complications Using the Zygoma Implant: A Review and Clinical Experiences.

PURPOSE: To review potential complications that may occur using the zygoma implant published in the literature as well as complications encountered by the primary author. Solutions for prevention as well as the management of such complications are also discussed in detail. MATERIALS AND METHODS: The authors have reviewed and outlined reports discussing the etiology as well as the management of potential complications associated with the use of the zygoma implant and have offered recommendations for the management of these complications. RESULTS: Predictable clinical solutions are offered for the identification of the cause as well as the management of complications, including orbital involvement, intracranial involvement, paresthesia of V2, subperiosteal infections, overextended apical extension, vestibular dehiscence, failed zygoma implant, fractured implant, and management of sinus infections. CONCLUSION: A comprehensive knowledge of the specific steps for the proper execution of this complex procedure will allow for a predictable outcome as presented by the systematic reviews of the zygoma implant, which have reported a cumulative survival rate of 96.7% to 97.8%. Understanding the cause, the prevention, as well as the management of potential complications is imperative for the contemporary surgeon using the zygoma implant.

Immediate stabilization at stage II of zygomatic implants: rationale and technique.

The severely resorbed maxilla presents a challenge for the maxillofacial surgeon and the restorative dentist planning implant restorations. The Zygomatic implant, as introduced by Brånemark, allows for the surgical placement of implants to restore resorbed maxillae without major grafting procedures. A minimum of 2 implants in the anterior maxilla are used in conjunction with 1 implant in each zygoma to support a prosthesis. Fabricating a passive bar to connect the implants at phase II surgery may require 1 to 2 days. With the adhesive abutment cylinder luting technique, a rigid framework can be delivered within 1 hour of uncovering the implants. This approach saves considerable time over conventional techniques and allows for the restoration of severely resorbed maxillae in an efficient and routine manner. The technique also eliminates the necessity for a technician to be available on-site for the procedure.

Veneer grafting: a technique for augmentation of the resorbed alveolus prior to implant placement. A clinical report.

Sixty-three patients with inadequate topography of the edentulous ridge were treated with mandibular ramus/body grafts to allow for the placement of endosseous implants. After 4 months of osseous healing, 187 implants were placed in the grafted sites. The mandibular ramus/body grafts remained viable regardless of the age or the extent of alveolar resorption in the patients treated. The ease of harvesting this graft in the office setting, its long-term resistance to resorption, and minimal postoperative morbidity makes this a viable intraoral donor site for horizontal alveolar augmentation.

Customized abutments to shape and transfer peri-implant soft-tissue contours.

With the functional successes of implant therapy being realized, the emphasis is shifting to the creation of tooth-like esthetics with implant therapy. Dental implants are placed after careful planning and site preparation, which may include bone and soft tissue grafting. The final soft tissue appearance is enhanced through the early use of provisional restorations. A combination technique is described to fabricate provisional healing abutments for cement-on prostheses and to transfer the individualized peri-implant soft-tissue contours to the dental laboratory. This technique will allow the practitioner to deliver highly customized implant care with familiar techniques and readily available materials.

Banked fascia lata as an orbital floor implant.

Synthetic orbital floor implants carry the risk of infection, rejection, anterior migration with prolapse, and posterior migration with optic nerve compression. Banked irradiated homologous fascia lata has been used as an orbital floor implant in the repair of 18 patients with surgically indicated orbital floor fractures. All patients had improvement in diplopia. There was no infection, anterior migration, or posterior migration of the implant. There was no reported transmission of communicable diseases. Early results suggest that banked irradiated fascia can be used effectively and safely as an orbital floor implant in selected cases.

HIV and banked fascia lata.

Concern over the transmission of communicable diseases through donor tissue has recently increased. Nine hundred and fifty-nine pieces of banked homologous irradiated fascia lata have been distributed to ophthalmic plastic surgeons nationwide over the past 3 years since the establishment of the Wills Eye Hospital Fascia Lata Bank. Safeguards taken against the transmission of disease include strict donor selection; negative antibody testing for human immunodeficiency virus (HIV), rapid plasma reagin (RPR), and hepatitis B surface antigen (HbsAg); heat treatment; and radiation sterilization with 4 million rads of cobalt-60 gamma radiation. To date, no cases have been reported of the transmission of HIV through surgical implantation of banked irradiated homologous fascia lata.

Corneal perforation in patients with vitamin A deficiency in the United States.

An emaciated alcoholic 52-year-old white woman presented with an old left corneal perforation and bilateral conjunctival and corneal xerosis. The serum vitamin A level was 0 mumol/L. Laboratory and radiologic findings were consistent with the diagnosis of a fat malabsorptive syndrome secondary to chronic alcoholic pancreatitis. Histopathologic evaluation of her enucleated globe revealed conjunctival epidermidalization, corneal perforation with prolapse and loss of intraocular contents, retinal detachment, and massive choroidal hemorrhage. A second patient presented with bilateral conjunctival xerosis, corneal ulcers, and a low serum vitamin A level. Corneal perforation of one ulcer ensued during her hospitalization. Medical investigation revealed hepatic metastases of an unknown primary source. Causes of vitamin A deficiency and its ocular complications as well as medical and surgical management options are discussed.

Considerations in placement of implants through existing split-thickness skin graft vestibuloplasty: a case report.

Many edentulous patients who previously have undergone vestibuloplasty with split-thickness skin grafting to improve denture stability and function seek additional help with dental implants. Problems encountered following the placement of four endosseous root-form dental implants in one such patient are presented. The anatomic and surgical considerations as well as methods available to circumvent these problems are discussed.

HIV and banked fascia lata.

Banked irradiated fascia lata is used in many ophthalmic procedures. Along with its increased popularity has come concern over protection from the AIDS virus. Banked fascia lata is protected against the AIDS virus by donor selection, antibody testing and irradiation sterilization. With the knowledge that fascia may also be heated as additional protection, this study was performed to determine if heat treatment weakens the fascia. Results suggest that heat treatment does not clinically or statistically weaken banked homogenous fascia lata.

Evaluation of orbital injuries.

Trauma to the orbit is evaluated with a careful history, a thorough physical examination, and specific radiographic studies. Orbital trauma involves a wide range of conditions, including soft tissue adnexal injury, orbital contusion, optic nerve damage, ocular injury, intraorbital foreign bodies, and orbital fractures. This article emphasizes the importance of an accurate history and a comprehensive examination. It highlights relevant questions to ask, discusses the meaning of pertinent complaints, describes steps in the examination, discusses the diagnostic importance of the physical findings, and recommends specific radiographic studies for accurate identification and localization of orbital fractures and intraorbital foreign bodies.

Isolated neurofibroma of the orbit.

In a 66-year-old woman, a large solitary neurofibroma arising in the right infraorbital nerve extended into the maxillary antrum and the orbit. Following extirpation of this rare tumor, bony defects of the right orbital floor and inferior orbital rim were repaired with a biplanar supramid implant.