Implant Supported Bridges: Minimum Number of Implants?

This is a lot of questions. The jaw angle can determine if the patient will be a bruxer. We all want to know the minimum number of implants and it is predicated on so many variables that you need to know your patient and the occlussion. As far as the sinuses, it is and should not be a fearful thing to do lateral wall sinus lifts. I use Curasan with PRP and move the membrane with the "elephant toe" piezo followed by the sinus elevators. If there is enough bone I will place the implants at the same time(it keeps the membrane up) If the membrane perforates place a colagen membrane and proceed. Nobel is a great choice and your type of prosthesis will determine if it is screwed on (like a bar) or cemented (Crown and bridge). Ideally, The more implants the better. Charles English invented the term AP spread and the better this is the longer the cantilever and the stability of the teeth. I would not place only two implants in the upper and make a bar but I have placed as little as four and have had great success. This is based on my personal successes and not based on Carl Misch's book. At the time the dogma of six implants minimum on the upper was made, there were only 4mm wide implants. Now with the increase of size and surface coatings this dogma will change. Good luck.

First of all, the very fact that you are asking these questions leads me to believe that you may need to take an advanced course in implant treatment planning or attend supervised surgical training. These questions are the very core of training for dental residents in Periodontology, Oral Surgery, and Prosthodontics. After years of studying and reading and watching other surgeons operate and discuss on these topics, I doubt you will learn it in 15 minutes browsing this forum. If you think you will get the knowledge and know how from this forum, then you are sadly mistakened, and more importantly, causing harm to the patient. Isn't our role as clinicians clearly defined here? Please refer to a more experienced colleague and learn to walk before you run.

SFOMS: I'm glad to hear that your were absolutely sure of the answers to all these questions before you did your first sinus lift or full max case. I unfortunately do not always have the definitive answer for every situation after 20 years of very successful results. I missed that book. Alas, I will still ask questions at times. Dr B - yes, more is always better esp in the maxilla. Be sure your patient accepts the downside of any less than ideal treatment and accepts the risks associated with any treatment plan. You must have a firm concept in your mind of what is a minimally acceptable treatment plan and not offer options that you do not feel comfortable with. Lots of variables; smoker?, bruxer?, home care, medical hx, arch form, opposing dentition, patient expectation of prosthetic design and appearance, bone density, bone volume... Sinus grafts are highly successful with a variety of materials. IMO surgical technique is more important that type of graft. I favor Puros plus PRP yet do I do not see a difference yet in cases with or without PRP. Good luck

It is really sad to read a defensive post from climberdds. One should not be doing implant denistry,specially full arch rehab with sinus graft surgery, if one does not know difference between screw retained and cement retained,between cadaver bone and bovine bone,and simply no.of implants required for specific patient and ask for help without mentioning all the factors necessary to determine that. I agree with sfoms.This forum should not be used to learn implant dentistry. Dr B. If you are in New York send me e mail at sj18@nyu.edu, I may be able to help you to find better way to learn.

Consistently , most miss the most important part. Do a full wax/set up, Do a design first and see where the bone is Check the class of of bite Check the occlusal forces. Determine what is necessary from that The reason we do the implant is for the prosthetics You wouldnt build a house before knowing the lot size and foundation would you? Its real simple. You may even find that the risk increses and its not an implant patient.

Thanks Robert56, as a lab tech I restore hundreds of implant cases a year and most are not approached this way. The result is patients and restorative doctors are always working in a compromised position. On the question of how many implants I think I will stir the pot and mention Dr Malo's All-on-4 and say that this maxilla sounds like a prime candidate for this surgery. You can, and we do restore on 4 implants regularly and the 5 & 10 year studies support the success. Unlike Dr Malo I don't feel it is the answer to every patient but it offers an opportunity to restore maxillary archs that once were considered marginal or unrestorable and give the patient a fixed restoration without the sinus lifts and long recovery times.

SFOMS has hit the nail on the head. Climberdds, all he is doing is trying to save Dr. Bruce a lot of sleepless nights. You need to chill out. I second his statement. The questions Bruce is asking are not questions you would expect to see from some one about to do a case of this magnitude. There are many courses that would teach the answers to these questions. If you don't know the answers, how are you going to do the procedure? I would suggest Bruce enroll in a course and use his patient in the hands on portion with some one there to teach and guide him. He could give the patient a discount and chalk it up as tuition. I think Bruce is in over his head on this one. You will make connections and friends that you can talk to to about these kinds of cases in the future.

Im driving a Ferrari on the highway passing all the other cars How do I apply the brakes and pull over ...? WHY are you driving the Ferrari ..if you dont know where the brakes are?? I am all for discussing differences of opinion on these forums but the answer to this question is to attend basic implantology courses read the litersture then attend more CE then observe others and then start with a standard case

dear docs, IN REAL ESTATE ITS LOCATION LOCATION LOCATION . IN IMPLANT DENTISTRY ITS EXPERIENCE EXPERIENCE EXPERINCE. so the experienced docs know like BO

While courses are absolutely necessary, key is mentorship. You will need to watch a procedure several times, and be preferably guided before beginning independent surgery. At my centre, I actually supervise my junior colleagues for two years. However in reality most people may not have asimilar luxury of time so peer discussions are useful. To address your questions; the number of implants depend on the anticipated loading. In a dentate, signs of wear, abfraction are useful guides. In an edentulous, you will have to rely on the overall look and feel of his jawline (masseters clinically and angle of mandible radiographically) I routinely use 8 to 10 fixtures in a fully implant supported and retained restoration though I have used 5 fixtures successfully on a few carefully selected cases dating to about 12 years - i.e implants of larger diameter and well spread). If you place fewer than 6 fixtures try to get some additional support from the mucosa especially if you cannot get the implants well distributed. My preference is for cement retention using the Improv Provisional cement from the old Steri-Oss, now Nobel line of products. The discussion on "crew or cement retained prosthesis " is in itself a separate issue and not addressed here. Sinus lifting procedures increase the pain and risk factor so unless you have the confidence, experience and means to perform and support post-operatively, best to refer. Ironically it is easier to even do that than to manage an atrophic anterior maxilla. A CT scan using a dentiscan format or equivalent is mandatory and a template crucial. If you go ahead, then try bio-oss bovine alone or as a mix with ha. Note some patients have objectiions to use of animal products and should be informed. Note also you will need a membrane to covet the window and this is sometimes porcine (so should inform Muslims and Jewish and in fact all patients) Type of Implant - I use Replace Select internal connection but fundamentally all implants work. I would however caution against the exclusive use of mini-implants unless the patient is well informed that its longevity cannot be guaranteed. (I am expecting half a dozen proponents to flame me on this but do realise its limitaitons). Finally, it is a rather tough case, befriend a senior colleage nearby - will be useful. Issues like bone quality, quantity in 3 dimensions, ridge angulation, medical status, even gape of patients mouth will influence complexity of surgery. In addition, post-op medication, support and provisionalisation during healing period is critical. To address your

Experience is something you don't get until just after you need it.

you can use endopore in the maxilla posterior, but its better to send the patient to a specialist and go to learn advance courses in implantalogy.

Dr. B. Please do not take offense nor get discouraged by above comments. Everybody likes big cases including myself. But your question seems like you may not be competent to do such procedure, yet. With more cases under your belt and proper training, you will understand where we are coming from.

dear dr B since you decide to do the implants,did you set with the patient and agree on the treatment plan,did u discuss other solutions for his case else instead of implants,did he knows the cost of all,if so,and the implant is the choice ,my openion to you as follows: in the upper jaw be sure not to put less than 8 implants,and if u plan to do sinus lefting as u mentioned its better to do it with the implants at the same surgical procedure(be sure to have at least 4mm of bone length and adequate width for that)so it will one surgical procedure, for the lower jaw also not less that 6-8 implants, NOW to decide where to put all the implants ,i prefer if the patient has an old full dentures(upper and lower) i prefer to use them as your surgical guids,unless you have to do teeth set up and bite registration to locate the neutral zone of the patient bite, i prefer to use autologus bone ,but if not enough ,you can use a osteogenic induction type of bone and its good if you mix it with prp you can use any implant system you trust it and you can master in handling it,and the important is that the prosthetic parts of the implant system is easy ,(not many steps or parts) wish you luck and god be with you

First let’s talk about the “best implants to use” part. At this point in time, all implants being the highly researched and mainstream or knock-offs are highly successful. That number is dependant upon the surgeon’s skill and his performance. I don’t believe that success depends upon “a system”. A one piece implant such as Straumann’s standard plus implant can be placed in the esthetic zone in a high smile and single tooth situation and be indistinguishable from the adjacent natural tooth if done properly. That is surgical understanding. As far as grafting the sinuses, all materials have been shown to be highly successful, with Bio-Oss having a slight edge, but not statistically significant. Obviously the implant needs to be properly positioned and that requires some level of pre-treatment planning. It is not wrong to want a complete wax-up and stents, but if the periodontist placing the implants has a good understanding that is not really necessary. The more complex the case, the more I tend to go base to base. There is no real reason to push each procedure (graft the sinus and place implants at the same time) to its limit. Time can be saved by planning. This saves a lot more time than re-doing.

Why are you guys even giving advise on this case? You need to tell him, he should not do it! Give me a break. No one in this crowd would let him do a case like this on one of your family members! Next topic please.

Dr .B do a computer guided surgery with the nobelguide..its real simple easy and the company helps you with all the planning step by step including lab support.

saying that I put 8 implants in maxillary arch location: 16,15,13,11.21.23.25.26. should i splint all together like horse shoe? or should i section to three bridges such as 16 to 13, 12 to 22, 23 and 26? I assume that if one piece is stronger but hard to repair if porcelain fracture, but three sections are slighter easy to remove to repaire. but if three bridges, do you suggest semi attachment at the distal of 13 and 23? min stephson

sorry, I think if i want to section to three bridge, I may have to change my implant positons to 1 bridge from 16 to 14 with 15 pontic, which is upper right first molar to upper first premolar 2 bridge 13 to 23 with 12 and 22 pontic, which is from upper right canine to upper left canine. 3 bridge 24 to 26 with 25 pontic, which is from upper left frist premolar to upper left first molar thanks

The rule of thumb that I use is a modified Anti's Law. It is as follows: Divide the # of teeth to be replaced and add one and that is a start for the # of rootforms to use. This will vary with subperiosteals and blades.

I do not usually segmest the bridges in the maxilla. I segment in the mand when using root forms, but not with blades.

Fixed is always harder and has more repair issues down the road. You may want to consider overdenture tx or a hybris from DAL, DUTTON or Glidewell. This will yield a nice asethetic, phonteic and hygienic result. You most likely will not have to graft the sinus and save you and your patient alot oh heart aches, not to mention saving your patient a few bucks.

Assumptions! Well every one assumes what Dr B knows and does not know! If you like to discuss the topic remain on this thread or there are other threads where you can give your advices on! Who is forcing you? A lot of dentists asking questions here know much more than they show, don't assume the worst!

Sometimes the best path is get your function, centric, aesthetics, etc. worked out on a full denture or partial removable denture. I can remove wisdom teeth and I can do lateral sinus lifts, but sometimes it's good to ask yourself, "Who do I want the patient to "hate"? i.e. If much swelling and post op discomfort is involved, let the specialists do the heavy lifting. That is why they are there. It is good to build a team going into significant reconstructions. It is better for you to establish your end goal at the start, share that with an oral surgeon, maybe even via stent or such. After the sinuses are built up, get another scan using your guide stent. And, as mentioned, take some courses or consult with an experience clinician on the final number and placement of implants and the fastening scenario that matches the patient's condition and desires and pocketbook. I am glad you were brave enough to ask and that all the responders seem to be earnestly trying to help you and the patient. John