All on 6 Maxillary Implant Case: Mix Attachments?

I have a few cases where the anterior abutments needed to be cemented on custom abutments while the posterior implants were screw retained. Close to 10 years and prostheses seem to be ok. Not ideal but definitely effective.

Please don't try to mix removable and fixed attachments in the same case. Custom cemented abutments and screw retained should work fine as the case is tightly fixed retention.

Are you not able to use angled abutments? Seems 30 degree angles should correct the problem

Since this is a 6 implant case, is the final prosthesis a hybrid one piece, is it a Ti bar,acrylic? or all ceramic (Zirconia) or a Ti frame, Procera crowns? Mixing abutments, especially with all Zirconia which is more brittle to sheer than I think is talked about, may give short lived prosthesis. I wouldn't mix locators and fixed screws. If you don't have the 30* option of multi abutment ( or are you even using multi abutments); custom abutments; but I cant visualize success if the anteriors need more than 40 degrees. Please describe the implant trajectories and the degrees off center. What is age of patient, what is esthetic issues, if any, you may, if using acrylic/Ti bar, and the emergence is on buccal and you can mask with good resin fill, do that. If you are thinking all zirconia, I feel this will fail, zirconia does not do well in off angle abutment/occlusal conditions. Good Luck PS did you do the surgery? Did you inherit the patient; The issue you describe should not be happening with todays imaging and knowledge. If a surgeon was involved, what was the surgical plan, CT , Guided Surgery , pre maxilla bone grafting or reduction? Diagnostic wax up. Just information to think about; full arch cases are all about visualizing the final product with no compromises. Sincerely Leonard

Don't mix fixed and resilient attachments. Implants will take unequal loading and that is the primary goal with full arch maxillary cases: shared load distribution.

Isn't that what the angled (17/30 degree) multi unit abutments are for??

Have the prosthesis fabricated to cover all six abutments in the same manner. Use the two problem abutments for support (without screw access holes). The remaining four abutment screws will be adequate to retain this.

In the year on 15.07.2001 I inserted an implant in edentulous left upper 1st molar, to replace 1stmolar,2nd & 1st premolar and the canine (natural ) was taken as an abutment. The FPD served for about 14 years, even after 14 years the implant survived.

Please do not mix resilient, resistant and fixed attachments. It is a long-term recipe for disaster. If you can not get a one piece draw then use custom attachments on ALL of the fixtures. A good lab should be able to work this through with you. You might even consider going a bit "old school". Create a substructure that fixes the alignment issues and screw fixate a superstructure restoration onto that. Best of luck.

I'm afraid that if you do fixed on the posterior implants, it wouldn't really matter what kind of attachment you put in the anterior region, as most of the strain would go to the posterior implants anyway. The anterior part of the restoration will be practically "in the air", except, maybe, during protrusion. The long term result of this might be bone loss around the posterior implants. So you do need to have some anterior support. We had some similar cases in the past, with anterior implants inclined 40-50 degrees and more to the buccal. To restore these cases, we used telescopic abutments that compensated for the implant angle and were made completely parallel, with parallel walls and a definitive gingival shoulder. These abutments (by Abracadabra, Israel) enable fixing any angle - not only predefined ones (like the multi-units), but any angle at all. Then, like in the photo I posted here, if one of the anterior implants was too buccal or too much inclined, we would seal it with a flat-head screw and not use it eventually, as long as there were other anterior implants that were acceptably positioned. A telescopic case means a removable overdenture. In our case, the parallel walls provided excellent retention, so it is "fixed-yet-removable" - with the same type of abutments on all the implants in the case. A removable denture has its benefits - it's lightweight, the patient is able to better take care of it, and most importantly - you get mixed support from the implants and the jaw. In these telescopic cases, the level of support is well-thought-of, as we know the exact position in which the restoration will be completely seated at rest on the abutments, and can design the tissue-facing surface of the denture accordingly.

Has anyone mentioned the screws that allow angled screw retained restorative work. I use them quite often anterior cases multiunit cases where one implant angled etc. Most companies now have one, trilobe screw, smart abutments, I believe you can get upto 25 degrees,.

Thank you all for your input. This 70 yrs old female has been a patient for 35 yrs. I have made her many max dentures. She indicated to me she wanted implants and a fixed max denture. I considered her sinus augs and knife edged anterior ridge above my skill and training level. I sent her to my OS guys for a consultation. She went thru an illness and I lost her for awhile. One day I get a letter telling me her implants have been placed. She received 6 implants , all parallel and surrounded by mucosal tissue for the most part. She has no maxillary ridge what so ever. I must have had a senior moment on the 30 degree abatements. I will check them out. Cemented anterior abutments sound interesting. Is the appliance still removable?I would like to use all zirconia appliance. I am well aware I can not mix traditional locators with screw retained abutments. My question was can I use the new fixed locator attachments with screw retained. Zest says there is no movement in these fixed locators and it is acceptable. I wanted to consult the wet fingered guys and not sale people. Anyone have any experience with this system or observations? Thanks

You can just put telescopic copings on the anterior implants to redirect the line of insertion and use them for support You don't have to screw to every implant.

You don’t have to screw to each implant depending on the restorative material I am trying to save Dr Roadking some upset and refunding of big money. All zirconia as he said he wanted to use will fracture at the weak link. Any abutment not passively screw attached will fracture the bridge at That point. Ti frame and ti bar. Restorations are more forgiving. Any site left unattached is a fail point. Redo remake it is not the patients fault the doctors are not in communication Just a point of view Sincerely Lenard