Implants perpendicular to occlusal plan or cantilever?

Not sure of the adjacent and opposing occlusion. Is this a class two deep bite? The safest thing to do is a full lab wax up with the opposing occlusion to determine the implant placement. It appears there is enough bone but the splint seems to be to the palatal and in a cross bite. Implant placement is best along the long axis of the restoration. Just using a perpendicular to the existing occlusion will only give you orientation in one plane. With an ICAT there are views with the opposing occlusion. I still think there is only so much that can be done with a virtual placement vs a laboratory generated splint. That said I think the posterior placement is too far to the palate and the anterior need to placed with a slight flare keeping in the midline if the alveolus remember you are going around a corner transitioning from posterior to anterior. Another thing you may want to consider us downloading this case to 3DDX and get some expert advice or work with a Simplant rep. One can get disoriented using just one plane when re- establishing occlusion. Your CT is three dimensional, ask ICAT for referral. T

all looks fine. You may need to graft the labial concavity a little but follow the alveolar flare with the implant for maximum bone contact. Your restorative colleague can reorient the implants with custom abutments to correct the angulation. Saving grace is the low lip line.

There is inadequate bone at all sites to place implants of the proper length and diameter. There is no excuse for under engineering a case because the patient doesn't want a graft. The best time to prevent implant failure is when in the planning stage. we have learned that implants placed into healthy bone, in ideal positions and then restored reasonably will give many years of service. The rules are clear. Educate your patient on the need for grafting and most of them will make the right decision. The ones that don't want grafting should be offered other treatments. If you can't provide the ideal treatment, use your team of specialists to help you as needed. Everyone benefits in the end.

I had a thought for the poster, if you download this to 3DDX online they can help you place the implants correctly and generate a Simplant surgical guide. I have used them successfully over the years on more complicated cases. They will have a treatment planning conference online so you can express your concerns. It adds cost to the case but it is money well spent in avoiding problems.

I'm a restorative dentist. Just like the surgeons have seen challenges with non bone grafted sites, I have seen snafus with attempted bone grafting. I agree with most of the posters that a CBCT with simplant would be ideal (I use it myself and love it) but for the last 6-8 years have been treatment planning with the same software and cone beam surveys as are posted. What kind of dependable bone graft are you going to do? Ridge split? How dependable is grafting onto cortical bone (facial plate) as strictly an onlay graft? What material are you going to use? Biooss resorbs slowly, not particulary osteogenic? Does this material actually help in stabilizing an implant and add true living bone in apposition to the implant or just add bulk? How about mineralized or demineralized graft material? (I'm interested in my surgical colleagues input on grafting material, healing time, dependability etc, since I'm not a surgeon but please , saying "needs bone graft" doesn't give me or the poster much to go on). If the patient has a low lip line (which this one does) then gingival contours are not critical. Place 3.3- 3.5mm diameter implants into the areas that are thin, cantilever #5 if needed but have three implants distally and splint together for resistance to forces. There are restorative ways around bone grafting. Splint narrower diameter or shorter implants together. With the activated surface treatments the current generation of implants have, narrower and shorter implants are very successful. I agree, always better to over engineer than under engineer but we also have to look at all options, i.e. restorative and surgical. If we can dependably restore this individual with splinted crowns and not have to go after bone grafting then isn't that more desirable from a cost and predicability perspective?

As Einstein said we let our education interfere with our ability to learn . Things have moved and bone regeneration has too . I have stopped using autogenous material 12 years ago and only use fully bio-absorbable alloplastic materials since then as we need only host bone remaining to enable healthy turn over to occur for improved functional re-modelling and for long term bone retention as described by Wolff in 1892. This case is not complex as long as you understand regeneration and host ability to heal . Dr Johnson raises all the questions , we need to think. Peter

I realize that what I am about to say is thinking way outside the traditional implantology box. In cases where there is a thin ridge type a smaller diameter mini dental implant can be considered. When bone grafing is not considered an option due to patients desire or otherwise why not consider using an implant that fits the existing bone rather than risking perforation and implant thread exposure in the thin areas of bone. Mini dental implants have diameters ranging from 1.8mm ( not usually recommended for maxilla) to 2.9 mm) which is only 1mm smaller than the smallest traditional implant) and lengths from 10mm up to 18mm. Correctly following the protocol of mini dental implant placement achieving initial stability of at least 30ncm then splinting the crowns together in my experience offers the patient a minimally invasive alternative. Kind Regards Dr. A. Smith