Graftless Solutions for the Edentulous Patient
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Saj Jivraj
Editor
Graftless Solutions
for the Edentulous Patient
Editor
Saj Jivraj
Anacapa Dental Art Institute
Oxnard, California, USA
ISSN 2523-3327 ISSN 2523-3335 (electronic)
BDJ Clinician’s Guides
ISBN 978-3-319-65857-5 ISBN 978-3-319-65858-2 (eBook)
https://doi.org/10.1007/978-3-319-65858-2
Library of Congress Control Number: 2017964316
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Foreword
Implant dentistry has evolved tremendously over the last three decades especially
for the treatment of the fully edentulous patients.
In the recent past, implant dentistry, a form of “pre-prosthetic” surgery, included
large bone grafting procedures in preparation for the placement of the implants.
Generally, the implants were placed 6–12 months after the grafting procedures in a
2-stage, delayed load protocol.
The need to wear a removable prosthesis or at times to abstain from wearing any
form of dental prosthesis while the grafts were healing as well as the extended treat-
ment times and the multiple procedures needed prior to the placement of dental
implants to support a fixed prosthesis deterred patients from seeking care.
Today, the “graftless concepts” eliminate the need for grafting and long waiting
periods prior to the reconstruction of the edentulous or the patients with “terminal
dentition”. The ability to remove the patient’s failing dentition, place implants and
fabricate a fixed, immediate load prosthesis has changed the manner in which many
of our colleagues treat their patients in 2017.
The vast body of literature confirming that the graftless approach has the same or
at times better long-term outcome as compared to the 2-stage, delayed loading pro-
tocols has led to better patient care, higher patient acceptance of treatment while
still maintaining long-term success data.
It is prudent at this point in time to consider why such a change in paradigm and
treatment planning has occurred by reviewing the major research and development
findings over the last several decades.
In the 1980s, understanding bone biology and refining the surgical techniques for
the preparation of the osteotomy and placement of the implant was the focus in
research and development of implant dentistry. We were content if osseointegration
had occurred and referred the patient for prosthetic reconstruction of the implants
regardless of the number, angulation or distribution of the implants.
In the 1990s we began to understand the limits of functional loads placed on
osseointegrated implants. Attention to understanding the biomechanical limits of
the hardware improved the management of the functional loads placed on implants
resulting in more predictable, long-term outcomes.
In the 2000s, research focused on “graftless concept” using tilted implants as
well as distal site anchorage by using the Zygoma implant propelled treatment plan-
ning to an unprecedented level. The ability to treat a subgroup of patients declared
v
vi Foreword
as “untreatable” with the quad zygoma concept has certainly expanded the services
available for the treatment of our patients.
The authors of this text have outlined the treatment planning, surgical as well as
the prosthetic protocols and techniques for the treatment of the edentulous as well
as the “terminal dentition” patients. They have honoured and highlighted the objec-
tives advocated by Professor PI Branemark which include:
• Simplification
• Interdisciplinary management
• Predictable outcomes
• Patient-centred treatment planning
Congratulations to the editor, Dr. Saj Jivraj, for his leadership in collaborating
with experienced clinicians in producing this updated text for the treatment plan-
ning of the edentulous patients with a fixed, implant-supported prosthesis.
“…a decisive factor in patient care is simplification of treatment, which should
be based on identifying and utilizing the enormous capacity of existing original
anchoring tissues…”
Simplification, understanding and appreciating when a treatment option is ade-
quate vs. optimal.
In conjunction with my colleagues Drs. Zarrinkelk, Ferro and Yeung, we discuss
treatment planning using conventional “analogue” techniques. It is appropriate to
highlight that the appreciation of “analogue” planning is critical and crucial if the
clinician would like to transition using the digital workflow.
Drs. Pikos, Pozzi, Arcurrl and Moy comprehensively present the integration of
digital treatment planning into the contemporary implant practice.
Interdisciplinary management of every patient’s treatment plan resulting in a
predictable outcome, which can only be achieved by following documented and
evidence-based treatment options.
Drs. Tunkiwala and Kher in collaboration with Mizuno and Torosian discuss the
intricacies of the final prosthesis, which was envisioned in the treatment planning
stage. They underscore the concept of “begin with the end in mind” in their step-by-
step discussions of the various stages for the fabrication of the planned definitive
prosthesis.
The ability to prevent as well as manage complications is essential for both the
surgical and the restorative care provider. Drs. Bongard, Powel and Dawood discuss
the various techniques and algorithms for the management of complications with
the graftless concept.
Long-term success in treatment planning for the fully edentulous patients is
strongly linked to the ability to control the occlusal forces. Our colleagues must
recognize that recall appointments must be pragmatic. Not only should the recall
appointment address the patients oral hygiene but documenting the stability of the
abutment and the prosthetic screws is absolutely critical.
“…the continuous cross arch rigid connection of the prosthesis to the implants
by ensuring tight abutment and prosthetic screws is essential for long term
success…”.
Foreword vii
Drs. Moldovan and Jivraj communicate these important considerations in their
discussions in the Chapter 16 of this book.
The time and the passion invested in continuing education and discussions with
our colleagues enriches the hearts and minds of all involved in treatment planning
and executing the various treatment options for the edentulous patients.
In the immortal words of PI Branemark,
“Listening to the needs and the demands of the patient and executing treatment
plans in the best interest of our patients is paramount.”
San Francisco, CA, USA Edmond Bedrossian
Foreword
Dental implants are one of the most significant developments in the treatment of
patients who are missing teeth. When the method to place and restore these implants
was presented to North America at the Toronto Conference more than 30 years ago,
a strict protocol was adhered to.
Over time, researchers and clinicians have taken advantage of better imaging,
CAD/CAM technology, newer materials and implant designs to innovate and
develop methods of shortening treatment times while obtaining predictable out-
comes for patients.
These methods and materials have been used and reported on by multiple authors
and some of these authors have collaborated on this book. Collectively they have
contributed to this particular method of restoring edentulous patients and elucidated
not only the mechanics of placing and restoring implants but more importantly man-
aging atypical situations, patient selection and management of complications.
Readers of this book will clearly understand a clear treatment protocol that will
lead to predictable outcomes for their patients. In addition this body of work can
help clinicians decide on whether this mode of treatment is suitable for their patients
and help them to avoid any complications that may occur. This information will also
allow the clinician to decide when it is appropriate to refer a patient to more experi-
enced colleagues.
I have known Dr. Jivraj personally for over 15 years and can attest to his dedica-
tion to patient care and using a solid evidence base to make treatment decisions.
Rest assured he has taken the same care in assembling this experienced group of
clinicians and teachers to share their experiences and knowledge on this focused
subject.
Winston Chee, D.D.S., F.A.C.P.
University of Southern California
Los Angeles, CA, USA
ix
Foreword
Dr. Saj Jivraj has assembled in this textbook a quintessential team of talented world-
renown surgeons and restorative dentists who extensively share their vast knowl-
edge in the latest innovations in Implant Dentistry. In order to address the
ever-increasing magnitude of patients in need of extensive implant treatment, graft-
less implant solutions must be combined with an in-depth knowledge of surgical
and restorative procedures through a rigorous and well-coordinated interdisciplin-
ary approach.
This textbook displays in an effective and methodical manner the modern foun-
dation for the diagnosis and graftless treatment of edentulous patients with fixed
implant-supported prosthetics. It provides clear and understandable concepts
through basic and advanced implant principles that are required in the initial com-
prehensive diagnosis and digital workflow all the way through the interdisciplinary
teamwork necessary to manage tilted and zygomatic implants, and ultimately pro-
duce high-quality full arch implant supported restorations.
We have greatly benefited over the past years at Augusta University from the
great teachings of Dr. Jivraj and we trust that this important work will be enjoyed
worldwide as a reference textbook in modern implant dentistry.
Gerard J. Chiche
The Dental College of Georgia
Augusta, GA, USA
xi
Acknowledgements
As the years pass, the things that become important really come into perspective. It
is to these important aspects of my life that I wish to dedicate this book.
To My Family
First and foremost and without hesitation I would like to thank my beautiful wife
Dilaz. She is my life, my inspiration and a wonderful mother to my two beautiful
children Sara and Zain. You said “yes” to everything which should have been “no”;
you allowed me the time to become professionally what I dreamed about as a young
graduate. You persevered when times got tough and gave up everything moving with
me to the USA. For the countless hours I did not spend with you and the kids, for
the unconditional love, friendship and unwavering support I thank you. To Sara and
Zain, words cannot express the profound love I have for you. You have taught me to
appreciate life in ways I thought were not possible, the little things you do and say
make me a better person, husband and father. I will always be by your side to sup-
port you in anything you do. Work hard and dream big and believe in the
impossible.
I would also like to dedicate this book to the memory of two exceptional women,
Mrs. Amina and Rukiya Jivraj, who were taken from this world far too early. Not a
day goes by when I don’t think of you. I feel your presence in all the important deci-
sions that I make. I miss you both dearly and wish we could have created more
memories together. When people say, “Life is too short”, I now understand what
that means. I do know we will meet again, and it is that day to which I look
forward.
To My Colleagues
I’d like to thank Drs. Winston Chee and Terry Donovan who believed in me and
who provided me with the opportunity to complete my Prosthodontic education at
the Herman Ostrow USC School of Dentistry. I will be forever grateful.
This journey began with Dr. Hooman Zarrinkelk over a decade ago. I would like
to thank him for taking the road less travelled with me. He has pushed me to be the
best I can be. I admire his attention to detail and commitment to excellence. A lot of
the patients you see in this text are the result of our collaboration. There are very few
in our profession like him and I am grateful for having had the opportunity to work
with him and to see a professional relationship turn into a lifelong friendship.
xiii
xiv Acknowledgements
Without my co-authors this text would not have come to fruition. I would like to
thank Dr. Ed Bedrossian, Dr. Michael Pikos, Dr. Bobby Birdi, Dr. Sundeep Rawal,
Dr. Sanda Moldovan, Dr. Steven Bongard, Dr. Glen Liddelow, Dr. Graham
Carmichael, Dr. Alessandro Pozzi, Dr. Arcuri, Dr. Udatta Kher, Dr. Ali Tunkiwala,
Dr. Stephanie Yeung, Dr. Andrew Dawood, Dr. Peter Moy, Dr. James Mcanally, Dr.
David Powell, Dr. Susan Tanner, Dr. Ana Ferro, Dr. Joao Botto, Dr. Mariana Alves,
Dr. Armando Lopes and Dr. Paulo Malo for their contributions to the text.
The laboratory section was graciously written by Mr. Kenji Mizuno and Mr.
Aram Torosian. I truly appreciate the countless hours they spent documenting the
lab phase and putting it into a format that is practical.
I would like to acknowledge all the students and faculty involved with the
advanced Prosthodontic programme at Herman Ostrow USC School of Dentistry
from whom I have learnt so much and still continue to do so.
I would be remiss if I did not thank my team at Anacapa Dental Art Institute.
They make coming into work each day enjoyable and always go the extra mile for
our patients. Their dedication and commitment is second to none and I want to let
you know I appreciate everything you do.
I would also like to thank Melker Nielsson for his friendship and advice over the
years. It was through his guidance and support that I pursued graftless solutions as
an option for my patients.
To My Patients
Who make each and every day enjoyable for me. Thank you for allowing me to
compile these clinical photographs. It’s caring for these patients that makes my
profession so rewarding and makes me look forward to the next day.
To God
Who has made everything possible. His guidance has allowed me to pursue my
dreams and realize them.
Saj Jivraj, B.D.S., M.S. Ed.
Contents
1 Diagnosis and Treatment Planning: A Restorative Perspective���������� 1
Saj Jivraj and Hooman Zarrinkelk
2 Diagnosis and Treatment Planning: A Surgical Perspective���������������� 15
Hooman M. Zarrinkelk and Saj Jivraj
3 Guided Surgery: Treatment Planning and Technique�������������������������� 25
Mike A. Pikos and Saj Jivraj
4 Comprehensive Integrated Digital Workflow
to Guide Surgery and Prosthetics for Full-Arch
Rehabilitation: A Narrative Review ������������������������������������������������������ 45
Alessandro Pozzi, Lorenzi Arcuri, and Peter Moy
5 Surgical and Prosthetic Biomechanical Considerations
When Using the Zygoma Implant���������������������������������������������������������� 69
Edmond Bedrossian, Edmond Armand Bedrossian, Spencer
Anderson, and Chan Park
6 Scientific Basis of Immediate Loading and the Biomechanics
of Graft-Less Solutions���������������������������������������������������������������������������� 85
Bobby Birdi, Saj Jivraj, and Komal Majumdar
7 Graftless Surgical Protocol �������������������������������������������������������������������� 99
Ana Ferro, João Botto, Mariana Alves, Armando Lopes, and Paulo
Maló
8 Surgical Protocol for the Placement of the Zygomatic Implant:
A Graftless Approach for Treatment of the Edentulous Maxilla�������� 133
Edmond Bedrossian and Per-Ingvar Brånemark
9 Rationale for Immediate Loading���������������������������������������������������������� 159
Stephanie Yeung and Saj Jivraj
10 Material Considerations for Full-Arch
Implant-Supported Restorations������������������������������������������������������������ 189
Saj Jivraj and Sundeep Rawal
xv
xvi Contents
11 Clinical Steps for Fabrication of a Full-Arch Implant-Supported
Restoration: Metal Ceramics, Zirconia, Acrylic Titanium������������������ 213
Udatta Kher, Ali Tunkiwala, Saj Jivraj, and Aqeel Reshamvala
12 Speech and Facial Aesthetic Considerations for the Contour
of Fixed Prostheses���������������������������������������������������������������������������������� 243
Glen Liddelow and Graham Carmichael
13 Laboratory Fabrication of Full-Arch
Implant-Supported Restorations������������������������������������������������������������ 261
Kenji Mizuno, Aram Torosian, and Saj Jivraj
14 Prosthetic Complications with Immediately Loaded,
Full-Arch, Fixed Implant-Supported Prostheses���������������������������������� 321
Steven Bongard and David Powell
15 Management of Failure and Implant-Related Complications
in Graftless Implant Reconstructions (for Atrophic Jaws)������������������ 333
Andrew Dawood and Susan Tanner
16 Maintenance of Full-Arch Implant-Supported Restorations,
Peri-implant and Prosthetic Considerations ���������������������������������������� 355
Sanda Moldovan and Saj Jivraj
17 Clinical Patient Presentations ���������������������������������������������������������������� 367
Saj Jivraj and Hooman Zarrinkelk
Index������������������������������������������������������������������������������������������������������������������ 429
Contributors
Mariana Alves, D.D.S., M.Sc. Oral Surgery Department, Malo Clinic,
Lisbon, Portugal
Spencer Anderson Department of Oral & Maxillofacial Surgery, University of the
Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, USA
Lorenzi Arcuri University of Rome Tor Vergata, Rome, Italy
Edmond Bedrossian American Board of Oral & Maxillofacial Surgery,
Chicago, IL, USA
Department of Oral & Maxillofacial Surgery, University of the Pacific Arthur
A. Dugoni School of Dentistry, San Francisco, CA, USA
Implant Surgical Training, University of the Pacific Arthur A. Dugoni School of
Dentistry, San Francisco, CA, USA
American College of Prosthodontics, San Francisco, CA, USA
Bobby Birdi, M.D., M.Sc., F.R.C.D.(C) University of Minnesota School of
Dentistry, Minneapolis, MN, USA
Private Practice, Vancouver, Canada
João Botto, D.D.S., M.Sc. Oral Surgery Department, Malo Clinic,
Lisbon, Portugal
Per-Ingvar Brånemark, M.D. The Brånemark Osseointegration Center (BOC),
Gothenburg, Sweden
Graham Carmichael, BSc, BDSc Hons, DClinDent Consultant Prosthodontist,
Craniofacial Unit, Princess Margaret Hospital, WA, Australia
Consultant Prosthodontist, Maxillofacial Department, Royal Perth Hospital, Perth,
WA, Australia
Senior Clinical Lecturer, School of Dentistry, University of Western Australia, WA,
Australia
Andrew Dawood, M.R.D., R.C.S.(Eng.), M.Sc. Department of Head and Neck
Surgery, University College London Hospital, London, UK
xvii
xviii Contributors
The Dawood and Tanner Specialist Dental Practice, London, UK
Edmond Armand Bedrossian Department of Prosthodontics, University of
Washington, Seattle, WA, USA
Ana Ferro, D.D.S., M.Sc. Oral Surgery Department, Malo Clinic, Lisbon, Portugal
Saj Jivraj, B.D.S., M.S.Ed. Herman Ostrow USC School of Dentistry,
Los Angeles, CA, USA
Eastmann Dental Institute, London, UK
Private Practice, Oxnard, CA, USA
Udatta Kher, M.D.S. Private Practice, Mumbai, India
Glen Liddelow, BDSc, MScD, DClinDent Clinical Associate Professor, School
of Dentistry, University of Western Australia, Perth, WA, Australia
Consultant Prosthodontist, Craniofacial Unit, Princess Margaret Hospital, WA,
Australia
Armando Lopes, D.D.S., M.Sc. Oral Surgery Department, Malo Clinic,
Lisbon, Portugal
Komal Majumdar, B.D.S., D.I.C.O.I., D.I.S.O.I. Diplomate of the International
Congress of Oral Implantologists, Indian Society of Oral Implantologists,
Mumbai, India
Paulo Maló, D.D.S., Ph.D. Oral Surgery Department, Malo Clinic,
Lisbon, Portugal
Kenji Mizuno, C.D.T. Oxnard, CA, USA
Sanda Moldovan, D.D.S., M.S., C.N.S. Private Practice, Beverly Hills, CA, USA
Peter Moy, D.M.D. Oral and Maxillofacial Surgery, Restorative Dentistry, UCLA
School of Dentistry, Los Angeles, CA, USA
Surgical Implant Dentistry, Los Angeles, CA, USA
Chan Park, D.D.S., M.D. Department of Oral & Maxillofacial Surgery, University
of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, USA
Mike A. Pikos, D.D.S. Private Practice, FL, USA
David Powell, D.M.D., M.Sc., FR.C.D.(C) Chrysalis Dental Centres, North York,
ON, Canada
Alessandro Pozzi, D.D.S., Ph.D. Oral and Maxillofacial Surgery, Restorative
Dentistry, UCLA School of Dentistry, Los Angeles, CA, USA
International Center for Oral Rehabilitation, Rome, Italy
Contributors xix
Sundeep Rawal, D.M.D. Private Practice, FL, USA
Aqeel Reshamvala, B.D.S., M.D.Sc. Dept. of Prosthodontics, MGM Dental
College and Hospital, Navi Mumbai, India
Steven Bongard, D.D.S. Chrysalis Dental Centres, North York, ON, Canada
Susan Tanner, M.R.D., R.C.S.(Eng.), M.Sc. The Dawood and Tanner Specialist
Dental Practice, London, UK
Aram Torosian, C.D.T., M.D.C. A.S. Ronald Goldstein Center for Esthetic and
Implant Dentistry, Dental College of Georgia at Augusta University, Georgia
Ali Tunkiwala, M.D.S. Private Practice, Mumbai, India
Stephanie Yeung, D.D.S. Private practice, Santa Monica, USA
Hooman Zarrinkelk, D.D.S. Diplomate, American Board of Oral and Maxillofacial
Surgeons, Chicago, IL, USA
Fellow, American College of Oral and Maxillofacial Surgeons, Washington,
DC, USA
Private Practice, Ventura, CA, USA
