It requires highly meticulous diagnostic investigations, which should routinely include conventional computed tomography (CT) or cone beam computed tomography (CBCT) with a custom template. One problem in the posterior maxilla is that very little bone tissue is often left after teeth are lost, and that this tissue also offers little retention for implants due to its cancellous structure. In accordance with the SimPlant planning, five implants were inserted into the augmented bone on the left side (Fig 6-12r). Immediate loading of definitive implants with NobelGuide. After this, the template can be stabilized further with the direction indicators, which prevent it from rotating (Fig 6-2d). Above all, this means resolving the question of how the masticatory forces in the molar region (the center of occlusal force) are to be absorbed. The follow-up radiograph after 4 years of functional use shows a stable bone situation around the implants (Fig 6-3k). In the SimPlant program, the maxilla can be visualized in three planes: axial, panoramic or cross-sectional, and also as a 3D reconstruction (Fig 6-1d). The distal locking attachments hold the palateless denture securely in place (Fig 6-6h). Originally, this female patient with an extremely atrophied maxilla had experienced a lot more problems with a loose denture in the similarly atrophied mandible; the right side was particularly badly affected. Fig 6-3h Parallel direction of insertion for the prosthesis. 1.Bilateral sinus floor elevation, implant placement and lateral augmentation, 2.Exposure and widening of the zone of attached gingiva. A long-term provisional to be supported on the nine osseointegrated implants was fabricated according to the “Progressive Bone Loading” concept (see page 387; Fig 6-5c). Närhi TO(1), Geertman ME, Hevinga M, Abdo H, Kalk W. Author information: (1)Department of Prosthodontics, Institute of Dentistry, University of Turku, Turku, Finland. For early restoration or loading in the partially dentate maxilla, the ITI Consensus recommended a fixed prosthesis: “Implant number and distribution are dependent on patient circumstances, including bone quality and quantity, number of missing teeth, condition of Fig 6-11e Stable insertion of the implants on the left side despite the narrow jaw. The uniform distribution of thicker bone around the implant ensures a better supply of nutrients to the tissue. The thermoplastic foil, which had been prepared in advance, was tried in. For the treatment course, see pages 473–479. Moreover, the implants had to be placed further palatally than originally planned (Fig 6-7e). The condition of the prosthesis is also satisfactory (Fig 6-6j). Fig 6-11u Check panoramic radiograph with the impression posts. Fig 6-11g Palatal augmentation was also necessary. This female patient with an edentulous maxilla was having problems with her complete denture, particularly with the fact that it covered the palate (Fig 6-3a). Comprehensive evaluation of the edentulous maxilla is further complicated by the fact that both bone and soft tissue loss can begin before tooth removal as a result of generalized periodontitis—which often causes the appearance of “long teeth.” Edentulous patients may present with intact alveolar bone volume, missing only the clinical crowns. After 5 years in situ, the front view of the denture is satisfactory, apart from the visible metal parts (Fig 6-5g). Fig 6-11h Augmentation material stabilized with the membrane. The healing period was uncomplicated and the implants were exposed 10 months after the first operation (Fig 6-11j). To enable the relative positions of the occlusion rim to the template to be verified, vertical lines were drawn on both with a marker pen (Fig 6-9g). The postoperative panoramic radiograph shows the positions of the implants and the extent of sinus elevation (Fig 6-11i). Fig 6-11s Wider gingiva on the right side. To ensure that the template remains uncluttered, the author prefers to place the drill holes in positions 1, 3, 5, 6 and 7 (Fig 6-1c). This staggered placement also ensured better distribution of the masticatory forces over the prosthetic superstructure. Fig 6-12s Implants placed on the palatal and buccal sides of the crest. Fig 6-4d The distal gingival deficits have filled with granulation tissue. See: Any structure resembling a bent bow or an arc. Fig 6-2e Checking the prepared implant beds. This procedure was repeated on the left side (Fig 6-11e). After only one operation, the patient was able to leave the clinic immediately with a fixed restoration. Following the CT and panoramic radiograph analysis, the implant positions were established according to prosthetic aspects and taken into account in a custom-made template (Fig 6-5a). Fig 6-11m Attached gingiva gained from the palate at the time of implant exposure. However, if the old restoration does not meet the expectations of either the patient or the dentist, the teeth will need to be set up again according to the principles of full mouth rehabilitation and also duplicated, to allow the optimal implant positions to be determined. This female patient had an edentulous maxilla and wished to be fitted with a fixed restoration right from the start. In most patients with a Class I maxilla, who have lost their teeth with minimal bone loss, the labial bone has an irregular contour. Provided the tooth set-up is correct, this prosthesis can be used as a basis for fabricating the implant template. Fig 6-9i Inserted implants following removal of the template. 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