ALL On X / All on 4 /All on 6 Concepts.pptx

Get to know about the introduction and concept of ALL ON X and the complete protocol in a stepwise manner

1. ALL ON X by Dr.Suresh ALL ON X Department of Prosthodontics and Crown & Bridge Guided by Dr. K. Prabhu MDS Head of the department Dept Of Prosthodontics Presented by Dr. K. SureshKumar 2nd year PG Dept of Prosthodontics

2. CONTENTS INTRODUCTION ALL ON X by Dr.Suresh BIO MECHANICS PATIENT SELECTION TREATMENT PLANNING RATIONALE BASIC CONCEPT OF ALL ON X SURGICAL PHASE ALVEOLOPLASTY / REDUCTION GRAFTING PROTOCOLS IMMEDIATE PROVISIONALISATION RESTORATIVE PHASE COMPLICATIONS MAINTENANCE CONCLUSION REFERENCES

3. INTRODUCTION The full-arch implant rehabilitation protocol is one of the newest innovations in implant therapy to treat the edentulous or nearly edentulous patient. Atrophic Edentulous Arches Conventional dentures Implant supported Removable dentures Implant supported fixed Prosthesis Conventional Approach with axial Implants Rehabilitation with tilted implants ALL ON X by Dr.Suresh

4. BIO-MECHANICS ALL ON X by Dr.Suresh

5. ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

6. Advantages of tilted implants Increased Implant Length Increased Osseo-Integration Greater Primary Stability Increased anchorage in multiple cortical bone layers Reduced cantilever forces Increased force distribution across the arches Elimination of bone grafting Reduced Morbidity ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

7. AP SPREAD the distance measurement between a line measured from the center of the anterior-most implant and a line measured from the distal of the distal-most implants cantilever distance can be 1.5 times the interfixture distance , as determined by English et al Branemark protocol was 2.5 times the A-P spread Lyndon Cooper proposes that 10mm can be used as a rule of thumb for distal cantilever length on an All-on-X prosthesis ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

8. PATIENT SELECTION Chief Complaint Medical History Dental history Patient expectations Extra & Intra oral examinations Radiographic analysis Conditions which affect the treatment outcome o r Surgical procedure Habits like bruxism and clenching Condition of existing teeth Caries Occlsuion Photographic evaluation OPG CBCT scans ALL ON X by Dr.Suresh

9. LIP SUPPORT & BONE AVAILABILITY In the absence of teeth, the maxillary ridge becomes narrower and shorter. mandibular ridge becomes wider and shorter. Both resorb in a posterior fashion WITHOUT PROSTHESIS WITH PROSTHESIS ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

10. TRANSITION LINE & SMILE LINE the facial interface between the prosthesis and natural tissues Successful transition line Esthetic failure ALL ON X by Dr.Suresh

11. RESTORATIVE SPACE ALL ON X by Dr.Suresh the space between the platform of the dental implants and the incisal edges of the teeth of that same arch at least 15mm of restorative height for every ALL ON X prosthesis The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

12. HOW TO MEASURE RESTORATIVE SPACE In a dentate patient, measure from the incisal edge toward the ridge in the patient’s mouth Measurements can be done in CBCT – Best method In an edentulous patient you will need to mount the casts on an articulator or utilize an existing set of complete dentures with radiographic markers in a CBCT ALL ON X by Dr.Suresh METHODS TO GAIN HEIGHT Increase the VD Perform alveoloplasty The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

13. PROSTHETIC OPTIONS ALL ON X by Dr.Suresh

14. NUMBER OF IMPLANTS PLACEMENT KEY FACTOR – BONE QUALITY implant cumulative survival rates have been reported at 97.6% when four implants are used R eport by Parel and Phillips , noted that implant survival , was greatly improved when five or more implants were utilized in the maxilla MORE THAN 4 implants for the maxillary arch Fixed prostheses with three implants have been shown to be highly successful in the mandible since 1987 in 1997 showed three immediate load implants in the mandible to have a predictable implant survival rate after ten years in service THREE implants is a minimum needed for the mandible ALL ON X by Dr.Suresh MAXILLA MANDIBLE The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

15. TILTING OF IMPLANTS BEDROSSIAN’S ALGORITHM ZONE 1 ZONE 2 ZONE 2 ZONE 3 ZONE 3 ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

16. BEDROSSIAN’S ALGORITHM Bedrossian , E.A., Sullivan, R.M., Fortin, Y., Maló , P., & Indresano , T. (2008). Fixed-prosthetic implant restoration of the edentulous maxilla: a systematic pretreatment evaluation method.  Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 66 1 , 112-22 . ALL ON X by Dr.Suresh

17. BASIC CONCEPT OF ALL ON X Four to six dental implants to support a full-arch fixed Prosthesis 2. The use of tilted posterior implants to overcome bony deficits or avoid vital anatomical structures 3. Single-day treatment for extractions, implant placement, and possible provisionalization with a fixed Prosthesis 4. Immediate loading when possible ALL ON X by Dr.Suresh

18. THE SURGICAL PHASE PRE OPERATIVE PROCEDURES MARK THE VERTICAL DIMENSIONS OF OCCLUSION ADMINISTRATION OF LOCAL ANAESTHESIA DEEPLY ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

19. FLAP REFLECTION TECHNIQUE A crestal incision with a “hockey stick” releasing incision over the maxillary tuberosity Or mandibular ridge is made E D E N T U L O U S PARTIALLY E D E N T U L O U S ALL ON X by Dr.Suresh If any teeth are present, the crestal incision can continue as a intrasulcular incision on the buccal aspects of the teeth The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

20. TOOTH REMOVAL & BONE REDUCTION Conventional old extraction techniques Bone cut with a bur to the alveoloplasty line ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

21. TEMPORARY SUTURING OF THE FLAPS ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

22. ALVEOLO-REDUCTION / PLASTY Pikos Block Grafting Bur Kit Performed With Straight Handpiece At 1500RPM With copious irrigation Creates a flatter area for your implant drills Creates a wider ridge preserve buccal and lingual bone adjacent to the implant Gains space required for thickness of restorative components A flat, even alveolus can make hygiene easier for the patient ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

23. PROPER IMPLANT POSITIONING a clear denture can be extraordinarily useful ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

24. DRILLING SPEED Bone necrosis starts at 47 C/116.6 F Copious irrigation with sterile saline is a must Use the feathering technique when preparing the osteotomy Start with a pilot drill at 800 rpm and reduce your speed until you reach 300 rpm with your final drills Replace the drills according to manufacturer recommendations to make sure they are never dull ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

25. IMPLANT SITE PREPARATION Surgical guidelines MAXILLA MANDIBLE ALL ON X by Dr.Suresh

26. IMPLANT POSITIONING IN MAXILLA Posterior implants were placed first followed by anterior implants the precise location of the anterior wall of the sinus can be determined by using a round bur to create a small window in the anterior wall of the sinus cavity The clinician can shift the position of a posterior implant by tilting it approximately 30 degrees the anterior implants for maxillary rehabilitation are usually placed in the sites of the lateral or central Incisors The apices of the tilted posterior implants typically extend to the canine region , so the positions of the anterior implants must be carefully selected to avoid any conflict ALL ON X by Dr.Suresh

27. IMPLANT POSITIONING IN MANDIBLE the anterior implants are placed first, followed by the posterior implants vertical releasing incision 7 mm long should be made in the midline The two distal implants are placed at a 30-degree angle distally relative to the occlusal plane just anterior to the foramina and the anterior loops of the mental nerve The anatomy of the jaw guides the placement of the additional two anterior implants For anterior implants , the angle of the abutment s is between and 17 degrees F or the posterior implants, the angle is 30 degrees ALL ON X by Dr.Suresh

28. Considerations ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

29. GRAFTING THE GAP IN ALL ON X JUMPING DISTANCE described by Boticelli is the space exists between the inner wall of the extraction socket and the outer surface of the implant This is gap or "jumping distance“ must fill with bone in order to establish adequate bone to implant contact Recommendations for grafting Thin biotype , thin buccal plate, multiple extractions, traumatic exodontia, Flapped surgery . Choice of graft materials Allograts Alloplasts Xenografts (DBBM) Chen and Buser shows that autogenous bone , allograft and alloplasts , with and without the use of barrier membranes, were effective in promoting bone fill of the gap ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

30. MULTI UNIT ABUTMENTS Allow correction of an implant angle up to 30 degrees Raise the restorative platform to the gingival level They make the immediate loading procedure much easier ALL ON X by Dr.Suresh

31. AFTER IMPLANT PLACEMENT 1. Immediate loading of a temporary fixed prosthesis 2. Place healing abutments on the implants and reline the denture 3. Place cover screws on the implants and reline the denture Risks exist for poor osseointegration Very low insertion torque on any dental implants Risks exist for poor osseointegration Patient is less motivated for home hygiene patient is a heavy bruxer achieve at least 30 Ncm of insertion torque at each implant S ite There are no significant risk factors for poor osseointegration ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

32. IMMEDIATE PROVISIONALISATION The Conversion Technique Pre Recommendations Pre operative denture should be at the proper vertical dimension The heights of the healing abutments are chosen after suturing the crestal incision, 1 mm of the healing abutment is above the soft tissue line a 17° angulated abutments to increase the distance between the screw access hole and the cingulum of the anterior teeth, allowing for greater acrylic packing volume to support the teeth on the metal substructure ALL ON X by Dr.Suresh Implant Treatment Planning for the Edentulous Patient A Graftless Approach to Immediate Loading 1st Edition - April 15, 2010 Author : Edmond Bedrossian

33. The conversion technique PVS Material Applied To The Intaglio Surface Occlusion & Midline maintained Position of implants Recorded Holes were drilled Proper opening confirmed Titanium sleeves connected Implant Treatment Planning for the Edentulous Patient A Graftless Approach to Immediate Loading 1st Edition - April 15, 2010 Author : Edmond Bedrossian ALL ON X by Dr.Suresh

34. The conversion technique Sleeves secured Denture palate removed 2mm collar left exposed POST OP CARE instructed to maintain a soft-food diet Daily oral hygiene includes use of a soft brush to clean the provisional prosthesis A 0.12% chlorhexidine rinse before bedtime is prescribed for the first Month Elective removal of the provisional prosthesis should be avoided for 4 to 6 weeks Implant Treatment Planning for the Edentulous Patient A Graftless Approach to Immediate Loading 1st Edition - April 15, 2010 Author : Edmond Bedrossian ALL ON X by Dr.Suresh

35. THE RESTORATIVE PHASE ALL ON X by Dr.Suresh

36. MATERIAL OF CHOICE Durable Acrylic Prosthesis Acrylic Hybrid Monolithic Zirconia Component Hybrid ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

37. RECENT ADVANCES PEKKTON PEKK ( poly-ether-ketone-ketone ) 80% greater compressive strength High resistance to wear, high tensile, fatigue, and flexural strength can be milled And pressed Elastic modulus equal to teeth low translucency and a grey hue utilized as a framework that is veneered with composite or ceramic ALL ON X by Dr.Suresh

38. IMPRESSION MAKING CUSTOM TRAY FABRICATION IMPRESSION COPINGS PLACED NO BINDING OF TRAY ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

39. FLOSS ATTACHED IN CRISS-CROSS PATTERN RESIN APPLIED DISC THIN CUT MADE SECURE EACH SEMENT WITH GC PATTERN RESIN ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

40. TRAY ONCE AGAIN TRIED Light body PVS applied MEDIUM BODY PVS FINAL IMPRESSION ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

41. POURING THE MODEL ALL ON X by Dr.Suresh LUBRICANT APPLIED GINGIVAL MASKING AGENT APPLIED BOXING WAX FABRICATED MODEL ACQUIRED The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

42. WHAT HAPPENS IF THE IMPRESSION IS NOT PERFECT ? WHAT HAPPENS IF THE COPINGS MOVED SLIGHTLY ? MISFIT Branemark 1985 - stated that the misfit should not be more than 10um Klinberg and Murray 1985: Stated that a 30um gap would be acceptable Jemt 1991 stated that a misfit around 150 microns would be biologically acceptable a level of fit which will not produce or cause any longterm clinical problem ALL ON X by Dr.Suresh Complications The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

43. THE VERIFICATION JIG to confirm the accuracy of the mastercast Temporary abutments placed Floss connected and GC resin placed Cut The Pattern Resin GC resin luted with each piece ALL ON X by Dr.Suresh

44. If misfit is present make a trough around the analogue attach the analog to the corresponding location in the verification jig ? Seat it all back Tighten all the screws ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

45. runny consistency stone or GC pattern resin pour it into the troughed site in the master cast can loosen all of the screws and remove the verification jig from the stone model material slightly relieved to allow the seating of your gingival silicone ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

46. OCCLUSAL RECORDS & ANTERIOR TRY-IN WAX RIMS ATTACHED WAX RIMS CONTOURED 1-2mm incisal display at rest in older patients parallel to the interpupillary line ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

47. parallel to a line between the tragus and the infraorbital notch Adequate support of the lips The anterior edge of the maxillary rim should touch the wet-dry line of the lower lip when the patient makes "F" sounds ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

48. determine the patient’s vertical dimension of occlusion or VDO a facebow transfer For younger patients, 3mm of incisal display For older patients (60 yo +) 1mm of incisal display ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

49. Make z-shaped notches in the posterior region of the maxillary denture Take the centric relation record by expressing bite registration material ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

50. FULL WAX TRY IN Waxup placed on the model Putty mixed and applied to the facial aspect of the teeth After the putty is set the wax up removed and reseated to verify the position of implants to the planned teeth arrangement ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

51. FINAL PROSTHESIS ACRYLIC TITANIUM HYBRID ZIRCONIUM PROSTHESIS Titanium bar to be milled PMMA prosthesis to be milled Wax up try in done along with titanium bar PMMA try in done PROSTHESIS DELIVERY ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

52. ACRYLIC TITANIUM HYBRID BAR TRY IN Bar position in relation to teeth The Bar + Wax Up Try-in Centric relation ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

53. FINISHED ACRYLIC HYBRID PROSTHESIS Place the prosthesis on the implants and insert your prosthetic screws Initially only hand-tighten the screws torque each prosthetic screw to 15Ncm (if there is a multi-unit abutment ) or 35Ncm (if the prosthetic is being screwed directly onto the implant) ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

54. ZIRCONIUM PROSTHESIS GC pattern mock up PMMA milled try in ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

55. FINISHED ZIRCONIUM PROSTHESIS Place the prosthesis on the implants and insert your prosthetic screws Initially only hand-tighten the screws torque each prosthetic screw to 15Ncm (if there is a multi-unit abutment ) or 35Ncm (if the prosthetic is being screwed directly onto the implant) The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

56. COMPLICATIONS Post Operative Bruising Paresthesia Most commonly seen in the lower arches Usually return backs to normal after 1weeks Post Operative Pain Injectable IM Diclofenac sodium 1ml 75mg Oral 50mg IM Piroxicam 20mg 1ml ALL ON X by Dr.Suresh Extra oral application of HEPARIN cream The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

57. Complications Fracture Of Definitive Acrylic Restoration Chair side repair works Insufficient inter-arch space ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

58. Severe angulation Complications Defective prosthesis ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

59. Non passive fit REPAIR ALL ON X by Dr.Suresh Complications The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

60. Complications Stripped Multiunit Abutment Use a different prosthetic driver Try using a round carbide bur in reverse with slow speed handpiece Use a screw removal kit ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

61. Complications Implant failure Remove the failed implant Debride disinfect and graft the area Place the implant after 3 months of healing Select a neighboring location and place immediately If condition persists load immediately ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

62. ALL ON X HYGIENE TePe Implant care kit ALL ON X by Dr.Suresh The Implant Ninja All-On-X Handbook: A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017 

63. CONCLUSION Full-arch cases that are planned to be restored with an implant-supported fixed prosthesis need meticulous treatment planning for appropriate implant positioning and adequate number of implant insertion and provisionalization during the treatment phase The long-term proven success of osseointegrated implants is known to depend on bone type and volume , implant positioning in respect of the future prosthesis, force factors, and the design of the superstructures for distributing masticatory and functional loads to the implants

64. REFERENCES Misch's Contemporary Implant Dentistry , 4th Edition Author : By Randolph Resnik , DMD, MDS Clinical Implantology 1st Edition - January 23, 2013 Ajay Vikram Singh, English, ISBN : 97881312332459 7 The Implant Ninja All-On-X Handbook:  A Step by Step Clinical Guide, Ivan Chiccon Independently Published, 31 May 2017  Treatment planning for the edentulous patients - A Graftless approach to immediate loading, Edmond bedrossian Full arch implant rehabilitation – ARUN k Garg DMD, Quintessence Publishing.

65. THANK YOU