BASAL IMPLANTOLOGY gupta.pptx

An overview of basal implants

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2. PRESENTED BY, SWETHA M DAS FINAL YEAR MDS BASAL IMPLANTOLOGY 2

3. INTRODUCTION HISTORY CLASSIFICATION PARTS OF BASAL IMPLANTS BASAL IMPLANTS V/S CONVENTIONAL IMPLANTS INDICATIONS CONTRAINDICATIONS ADVANTAGES DISADVANTAGES CONTRAINDICATIONS PERIIMPLANT BONE HEALING METHODS TO CREATE PERMANENT BONE-TO-IMPLANTCONTACT 16 RECOGNIZED AND CLINICALLY PROVEN METHODS FOR PLACING BASAL IMPLANTS IMMEDIATE LOADING DENTAL IMPLANT SYSTEM PROSTHETIC PHASE COMPLICATIONS CONCLUSION REFERENCES CONTENTS 3

4. introduction Basal implantology also termed bi-cortical implantology , cortical implantology , and strategic implantology . Cortico -Basal Implantology ®  is a modern innovative implantology system which utilizes the basal cortical portion of the jaw bones for retention of the dental implants, which are less prone to resorption and are infection free. 4 GuptaAD , VermaA , Dubey T, Thakur S. Basal osseointegrated implants: Classification and review. Int J Contemp Med Res 2017;4:2329‑35.

5. 5 GuptaAD , VermaA , Dubey T, Thakur S. Basal osseointegrated implants: Classification and review. Int J Contemp Med Res 2017;4:2329‑35.

6. HISTORY Jean-Marc Julliet in 1972- developed and used the first single piece implant Dr. Gerard Scortecci , 1980- invented an improved basal implant system complete with matching cutting tools.- disk implants Germany (mid 1990)- lateral basal implants Dr. Stefan Ihde introduced bending areas in the vertical implant shaft. 2005 – lateral basal implants were modified to screwable designs 6 Babita Y, Choudhary N, Nazish B, Gaurav T, Pranit K. Basal Osseointegrated Implants. IJAHS. 2016;3:1

7. Classification Basal Implant Types Based on Morphology 7

8. Both of the types can be further categorized into SCREW FORM a. Compression Screw Design (KOS Implant) b. Bi-Cortical Screw Design (BCS Implant) c. Compression Screw + Bi-Cortical Screw Design (KOS Plus Implant) II. DISK FORM Basal Osseointegrated Implant (BOI) / Trans-Osseous Implant (TOI) / Lateral Implant b. ZSI Implant ( Zygoma Screw). 8

9. 1) According to abutment connection i . Single Piece Implant. ii. External Threaded Connection. iii. Internal Threaded Connection a) External Hexagon. b) External Octagon. 2) According to basal plate design i . Basal disks with angled edges. ii. Basal disks with flat edges also called as S-Type Implant. 9

10. 3 ) According to number of disks i. Single Disk. ii. Double Disk. iii. Triple Disk. III. PLATE FORM A. BOI-BAC implant. B. BOI-BAC2 implant . IV. OTHER FORMS a. TPG Implant ( Tuberopterygoid ). 10

11. PARTS OF BASAL IMPLANTS The basal implants are commonly single piece implants 11 a) Basal osseointegrated implant b) Bi cortical screw implant a) Kos with compression screws b) Kos implant with compression and bicortical screws

12. Boi (lateral basal implants) These implants are placed in the jaw bone from the lateral aspect. The masticatory load transmission is confined to the cortical bone structures and horizontal implant segments 12 Babita Y, Choudhary N, Nazish B, Gaurav T, Pranit K. Basal Osseointegrated Implants. IJAHS. 2016;3:1

13. Flapless implants that are inserted through the gingiva, without giving a single cut inserted like a conventional implant Bicortical screws (BCS) are also considered basal implants, as they transmit masticatory loads deep into the bone, usually onto the opposing cortical bone BCS (SCREW BASAL IMPLANT) 13 Babita Y, Choudhary N, Nazish B, Gaurav T, Pranit K. Basal Osseointegrated Implants. IJAHS. 2016;3:1

14. Used for single or multiple unit restoration in adequate bone tissue The formation of a direct interface between an implant and bone, without Intervening soft tissue Delayed loading 3-6 months Used for multiple unit restoration, mainly in extraction socket Cortical anchorage of thin screw Implants and excellent primary stability can be obtained along the vertical surfaces of these implants. Immediate loading 72 hours Basal implants v/s conventional implants 14 Ihde S. Comparison of basal and crestal implants and their modus of application. Smile Dental Journal 2009;4:36-46

15. A wide range of sizes and designs are available. Basal bone is more dense, mineralized, and less prone to bone resorption . The implant surgery kit is very simple, with very few instruments Limited range of size and design are available. Crestal alveolar bone, bone has less quality and is more prone resorption. A wide range of devices are required for the placement of two-piece implants 15 Ihde S. Comparison of basal and crestal implants and their modus of application. Smile Dental Journal 2009;4:36-46

16. Single sitting surgical procedure. Implant procedures are less time-consuming than those required for bridgework No need for bone augmentation. Simple procedure . More complex surgical procedures are often necessary, spread over 2 or 3 sittings in 3-6 months Most of the time additional surgery is required. Requires more complex procedures and chairside time . 16 Ihde S. Comparison of basal and crestal implants and their modus of application. Smile Dental Journal 2009;4:36-46

17. INDICATIONS Situations like several missing teeth or requiring extracted Failure of 2-stage implant placement or bone augmentation procedure All kinds of bone atrophies. i e, - Very thin ridge (high knife ridge, where crestal buccopalatal bone thickness is < 2 mm; pencil mandible). - Insufficient bone height 17 Pathania , N., Singh Gill, H., Nagpal, A., Vaidya, S. and Lalmalsawmi Sailo , J., 2021. Basal implants – A blessing for atrophied ridges.  IP Annals of Prosthodontics and Restorative Dentistry , 7(1), pp.16-21.

18. CONTRAINDICATIONS 1.Heavy bruxism, clenching, uncontrolled malocclusion, and/or a history of fractured teeth, especially when associated with psychological problems. 2. High-dose IV bisphosphonates used in the treatment of severe osteoporosis or cancer (risk of osteonecrosis of the jaw). 3. Facial and trigeminal neuropathies. 18 Pathania , N., Singh Gill, H., Nagpal, A., Vaidya, S. and Lalmalsawmi Sailo , J., 2021. Basal implants – A blessing for atrophied ridges.  IP Annals of Prosthodontics and Restorative Dentistry , 7(1), pp.16-21.

19. 19 4) Severe heart disease, recent stroke, or heart attack (risk of infective endocarditis), Uncontrolled diabetes , Untreated renal insufficiency. 5) Ongoing radiotherapy for cancer (risk of osteoradionecrosis of the jaw, especially after radiation of the head and neck region 6) Cases where bilateral equal mastication cannot be arranged Pathania , N., Singh Gill, H., Nagpal, A., Vaidya, S. and Lalmalsawmi Sailo , J., 2021. Basal implants – A blessing for atrophied ridges.  IP Annals of Prosthodontics and Restorative Dentistry , 7(1), pp.16-21.

20. 7. Allergies or hypersensitivities to chemical ingredients of material used: titanium alloy (Ti6Al4V6 ) 8. An unbalanced relationship between the upper and lower teeth and Poor hygiene of the mouth and teeth 9. Blood dyscrasias 10. Age less than 15 years 20 Pathania , N., Singh Gill, H., Nagpal, A., Vaidya, S. and Lalmalsawmi Sailo , J., 2021. Basal implants – A blessing for atrophied ridges.  IP Annals of Prosthodontics and Restorative Dentistry , 7(1), pp.16-21.

21. 21 11. Chronic or severe alcoholism 12. Heavy smoking habit (more than 20 cigarettes per day) 13.Severe hormone deficiency 14. Drug addiction Pathania, N., Singh Gill, H., Nagpal, A., Vaidya, S. and Lalmalsawmi Sailo, J., 2021. Basal implants – A blessing for atrophied ridges.  IP Annals of Prosthodontics and Restorative Dentistry , 7(1), pp.16-21.

22. 22 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

23. 23 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

24. 24 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

25. 25 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

26. 26 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

27. 27 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

28. 28 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

29. 29 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

30. 30 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

31. 31 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

32. 32 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

33. 33 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

34. 34 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

35. 35 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

36. 36 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

37. 37 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

38. 38 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

39. DISADVANTAGES OF BASAL IMPLANTS 1. Compromised aesthetics with single tooth replacement . Narrow emergence profile. 2. Skilled surgeon with sound anatomic knowledge is required to carry out successful surgery. 3. Overload osteolysis can be seen, if load distribution is not done properly. 39 Tosic brochure 2022 ; INTERNATIONAL IMPLANT FOUNDATION;(IF )

40. Description of Methods to Create Permanent Bone-to- ImplantContact . Clinical Indications and Modalities for these Methods . 4 th IF ® Consensus Document for Oral Implantology: Description of Methods to Create Permanent Bone-to-Implant Contact. Clinical Indications and Modalities for these Methods © 2022, International Implant Foundation, Munich/Germany 40

41. Image above illustrates an implant inserted to achieve “osseointegration”. The crestal cortical bone and the spongious bone will (must) develop now more bone on the implant’s surface. A procedure that takes 3-6 or more months. To ensure that all the necessary processes will happen, enough spongious bone must be available between the endosseous surface of the implant and the outer cortical to secure the constant supply of nutrients to the repair site. 41 4 th IF ® Consensus Document for Oral Implantology: Description of Methods to Create Permanent Bone-to-Implant Contact. Clinical Indications and Modalities for these Methods © 2022, International Implant Foundation, Munich/Germany

42. Image above illustrates the bone-implant contact re­gion after a vertical cortical bone contact has been established along the implant body. The crestal and vertical cortical bones form one functional unit. Osseointegration is considered complete, and the (2-stage) implant can be effectively used/loaded. 42 4 th IF ® Consensus Document for Oral Implantology: Description of Methods to Create Permanent Bone-to-Implant Contact. Clinical Indications and Modalities for these Methods © 2022, International Implant Foundation, Munich/Germany

43. II. The “Compression of Spongious Bone” Approach All endosseous implants with a conical shape design must be considered as “compression screws” implants. The drill hole into which the implant is inserted is under-dimensioned, at least in width, compared to the implants inserted later. 43 4 th IF ® Consensus Document for Oral Implantology: Description of Methods to Create Permanent Bone-to-Implant Contact. Clinical Indications and Modalities for these Methods © 2022, International Implant Foundation, Munich/Germany

44. An under-dimensioned conical drill removes a minimal amount of bone, just enough to allow placement of the implant with compression force up to approximately 80 Ncm . Subsequent to implant in­sertion, the spongious bone is displaced laterally and com­pressed both laterally and at the apex of the implant, forming a higher mineralization zone. This process has been named “ corticalisation of spongious bone”. 44 4 th IF ® Consensus Document for Oral Implantology: Description of Methods to Create Permanent Bone-to-Implant Contact. Clinical Indications and Modalities for these Methods © 2022, International Implant Foundation, Munich/Germany

45. 3 . The approach of “lateral basal implants” and “blade implants” Both the “lateral basal implants” and “blade implants” are hammered into thin slots in the bone. Implants in this approach gain their primary stability by getting their plates stuck between the corticals . After this, the bone slot is filled with woven bone. Both im­plant designs (lateral basal implants and blade implants) tend to fail, if the implants are not in contact with cortical bone in the final position. 45 4 th IF ® Consensus Document for Oral Implantology: Description of Methods to Create Permanent Bone-to-Implant Contact. Clinical Indications and Modalities for these Methods © 2022, International Implant Foundation, Munich/Germany

46. PERI-IMPLANT HEALING (BOI AND BCS IMPLANT) Implants have a unique design their peri -implant healing is also unique. According to philosophy of basal implantology the process of Osseoadaptation is carried out by a “Bone Multicellular Unit” (BMU ). Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21. 46

47. The formation of this BMU takes place when the BOI and BCS implant are subject to immediate loading which leads to remodeling of bone under functional stresses leading to development of this unit, and thus initiates the healing phase and leads to formation of a dense peri -implant bone. 47 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

48. 48 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

49. CASCADE OF PROCESS 49 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

50. Activation phase In this phase, lasting for three days, the precursor Cells/human mesenchymal stem cells develop into o steoblasts and osteoclasts. Resorption phase In this phase, osteoclastic activity begins and shows soft and porous bone. Reversal phase In this phase, the osteoblastic activity occurs, where the Osteoblasts lay down new bone in the haversian canals at a rate of 1-2micro metres /day. 50 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

51. PROGRESSIVE PHASE In this phase, the osteoblasts forms concentric lamella in haversian canals, which leads to reduction in diameter of the canal and increase in bone density. At this stage the diameter of the haversian canal is 40-50 micro metres . Non-Mineralized Matrix Osteoid is the newly formed bone and this phase lasts for 3 months. MINERALIZATION PHASE This phase begins after ten days of osteoid formation. 51 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

52. It should be noted that throughout these phases the implants are under functional loads and because of which there is a continuous stimulation of the BMU throughout the life of the implant, which causes the peri -implant bone to become dense (which increases throughout the implants life) and to adapt over the surface of the implant, thus the term “ Osseoadaptation ”, and this is how remodeling plays a key role and is called as the “ 4th Dimension ” 52 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

53. DORMANT PHASE During this phase, osteocytes develop from osteoblasts and line the haversian canals and perform the mechanical, metabolic and homeostatic functions. 53 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

54. 16 RECOGNIZED AND CLINICALLY PROVEN METHODS FOR PLACING BASAL IMPLANTS 54

55. Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62. 55 (a) Corticobasal ® implant with an apical cutting thread and a polished shaft. This abutment head features a multiunit design, and it is designed for a screw connection to prosthetics. (b) Corticobasal ® implant with an apical cutting thread and a polished shaft. This abutment head is designed for cementing. METHOD 1

56. 56 Converging placement of four Corticobasal ® implants in the interforaminal region of the mandible. This way of placement ensures safety for the mental nerve, optimum utilization of the corticalized bone . METHOD 2

57. 57 METHOD 3 Placement of implant(s) in the gap between the root of the canine and the mental nerve, with the implants reaching far deeper (caudal) than the root of the canine. Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

58. 58 METHOD 4 Nerve bypass, on the lingual or vestibular side of the nerve. With or without anchorage in the basal (2nd) cortical Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

59. 59 METHOD 5 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

60. Method 6: 60 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62. ( a) The implant is engaged into the vestibular and lingual cortical of the maxilla, without reaching the cortical of the floor of the maxillary sinus (as a 2 nd cortical). The method is used often if earlier implants fail and the 2 nd cortical in the axial direction is not available. (b) T his is often used in the anterior mandible and skeletal Class 2 cases. These cases provide often a sand clock‑shaped (anterior) mandible and the isthmus provides additional possibility as well as vertical support

61. METHOD 7 61 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

62. 62 a) The implant in the area of the 1 st upper molar engages into the floor of the sinus as the 2 nd cortical. (b) The implant in the area of the 1 st upper molar engages into an intrasinusal buttress as the 2 nd cortical. METHOD 8 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

63. In this two/three walls of the sinus are sectioned to facilitate placement of the basal disk in the sinus The sole purpose of this technique is to gain bi-cortical support; also only one implant can be placed this way in each sinus . Sinus Section Technique Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62. 63

64. METHOD 9 64 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62. Canine bypass. The implant is inserted in an oblique direction of the sphenoid bone from the area of the 1st upper premolar, it is bypassing the root of the canine on the palatal side of the root, and it reaches the floor of the nose where it is anchored cortically.

65. 65 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62. One or two implants are inserted through the distal maxilla into the fusion zone between the distal maxilla and the pterygoid process of the sphenoid bone METHOD 10

66. These implants are placed in the pterygoid bone and aid in providing additional support to the prosthesis. These are used in conjunct with Sinus Section technique and are placed at 20º-45º in the bone and the angulation between BOI implant and TPG screw should not exceed 90º otherwise prosthesis placement becomes difficult Tuberopterygoid (TPG) Screws 66 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

67. 67 Anchorage in the bone on the palatal side of the maxillary sinus, without anchorage in the nasal floor or in the median raphe of the maxilla . METHOD 11 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

68. METHOD 12 68 Anchorage of the implant in the body of the zygomatic bone: Using a trans‑ sinusal procedure or inserting from caudal, directly into the body of the zygomatic bone Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

69. These are zygomatic implants that are placed in the zygomatic bone and like the BCS implant these also have sharp edged cortical screws that gain bicortical support . Zygomatic Screw Implant (ZSI) 69 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

70. 70 METHOD 13 Anchorage of the load‑transmitting threads of the implants into the cortical base of the mandible if knife‑edge ridges are present, which are larger than the implant. The vertical implant parts run vertically and subperiosteally. Implant length and abutments are placed with respect to a good possibility to provide prosthetic equipment . Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

71. 71 Anchoring an implant in the fresh extraction socket of the first or second premolar with at least mesial and distal cortical anchorage in the bone of the extraction socket. Utilizing the medial cortical of the mandible increases the anchorage. METHOD 14 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

72. 72 METHOD 15 Anchoring a larger diameter implant into the fresh extraction socket of the palatal root of the upper first or second molar Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

73. 73 (a) Two implants are placed into the extraction socket of a two‑rooted 1 st upper premolar. The implant on the palatal side is placed according to Method 9; the vestibular implant is placed in the vestibular socket of the root. (b) Two implants are replacing the 1st upper molar: the smaller implant inserts into the extraction socket of the palatal extraction root (4.6 mm in diameter), whereas the vestibular socket is equipped with a longer implant (3.6 mm in diameter) METHOD 16 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

74. Cortically Fixed @ Once. I ntroduced by Dr. Henri Diederich in 2013 This is basically a plate form implant, which looks like mini plates (used for fracture reduction) with an abutment platform, this unique design allows them to be bent and adapt to any surface and is anchored to bone using bone expanding mini screws . 74 Antonina I, Lazarov A, Gaur V, Lysenko V, Konstantinovic V, Grombkötö G, et al . Consensus regarding 16 recognized and clinically proven methods and sub-methods for placing corticobasal ® oral implants. Ann Maxillofac Surg 2020;10:457-62.

75. IMMEDIATE LOADING DENTAL IMPLANT SYSTEM 1.Use a DOS 1 or BCD 1 (yellow) drill for pre-drilling. 2.Use the shaping drill to the implant bed to full length. Use an intermittent drilling technique and copious saline irrigation. 3. The laboratory might insert guide sleeves (BFH) into the drill holes to ensure that the drilling angle is exactly correct. Simpladent single piece Sap brochure 75

76. In hard bone, if the full drilling depth is difficult to attain with DOS 1 , use the DS 2 cylinder drill (2 mm) to achieve the correct depth 76 Simpladent single piece Sap brochure

77. DRILLING /PREPARING DOS 2 / BCD 2 Determine the correct direction and depth; alternatively, use BCD 1 “pathfinder” drill. DS 2 pilot drill Use for hard bone, but only in the cortical area. 77 Simpladent single piece Sap brochure

78. IMPLANT PACKAGING All KOC® implants are used as compression screws. In order to acchieve a good bone condensation and implant stability, the drilling should be carried out thinner than the core diameter of the implant. The minimal diameter of the drill depends on the bone density. 78 Simpladent single piece Sap brochure

79. It is therefore not possible to advise drill-sequences which fit all bone-qualities. Typically in the soft maxillary bone only small drill-diameters are used (e.g. the usage of DOS1 only, for implants with 3.0 - 5.0 mm diameter), whereas in the highly mineralized lower jaw a specific drill sequence with respect to the mineralisation of the bone is necessary . 79 Simpladent single piece Sap brochure

80. REMOVE THE IMPLANT FROM ITS PACKAGING 1 .Open the lid. 2.The implant is fixed to the lid by a break joint. 3.Remove the implant without touching the inner wall of the tube. 80 Simpladent single piece Sap brochure

81. HANDLING Hold implant at the carrier, and place the placement aid on the implant head. Do not touch the endosseous implant surface.Remove the implant complete with the plug and then remove the plug at the break line. 81 Simpladent single piece Sap brochure

82. 82 Simpladent single piece Sap brochure

83. DEFINITIVE IMPLANT INSERTION Use the ratchet, torque wrench or angled handpiece to screw the implant clockwise into the implant bed. The roughened endossous aspect of the implant must be completely submerged in the bone. The polished implant head must be at the level of the mucosa. For KOC, KOC Micro and BECES ex, TPG Uno and BECES N It is recommended to screw the implant so deep into the bone that 1 mm of the thin & polished implant shaft (above the thicker, endosseous area) is below the level of the 1st cortical. 83 Simpladent single piece Sap brochure

84. recommended Torque limitation provided for the basal implants 1. Basal implant from diameter 3 .0 mm, via direct insertion - Never exceed 117 Ncm 2. Basal implant from diameter 4.5 mm - 5.0 mm, via direct insertion - Never exceed 238 Ncm 3. Basal implant from diameter 5.5 mm, via direct insertion - Never exceed 298 Ncm 84 Pathania N, Gill HS, Nagpal A, Vaidya S, Sailo JL. Basal implants – A blessing for atrophied ridges. IP Ann Prosthodont Restor Dent 2021;7(1):16-21.

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86. PROSTHETIC PHASE 86

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88. 88

89. Intraoperatively, rupture of palatine vessels while placing pterygoid implants N asal bleeding and breakage of drill while placing implants anchoring floor of the nose B reakage of drill while drilling for pterygoid implants, however, it could be easily retrieved. COMPLICATIONS 89 Patel K, Madan S, Mehta D, Shah SP, Trivedi V, Seta H. Basal implants: An asset for rehabilitation of atrophied resorbed maxillary and mandibular jaw – A prospective study. Ann Maxillofac Surg 2021;11:64-9.

90. Immediately postoperatively, ecchymosis intraorally as well as extraorally could be seen which disappears in 1-2 weeks Sometimes reduced mouth opening after pterygoid implant placement due to injury to muscle fibers which gradually returns to normal. Postoperatively, ceramic chipping off from metal framework and prosthesis loosening due to de-cementation can happen 90 Patel K, Madan S, Mehta D, Shah SP, Trivedi V, Seta H. Basal implants: An asset for rehabilitation of atrophied resorbed maxillary and mandibular jaw – A prospective study. Ann Maxillofac Surg 2021;11:64-9.

91. Overload osteolysis around a single implant due to high cuspal contact. The key for the long-term survival is proper case selection, atraumatic extraction, achieving primary stability and anchorage from second or third cortical, rigid prosthesis fabrication with occlusion concept outlined by Dr Ihde , achieving equal bilateral mastication and lingualized occlusion, maintaining good oral hygiene, and routine follow-up at regular intervals. 91 Patel K, Madan S, Mehta D, Shah SP, Trivedi V, Seta H. Basal implants: An asset for rehabilitation of atrophied resorbed maxillary and mandibular jaw – A prospective study. Ann Maxillofac Surg 2021;11:64-9.

92. Shahed et al. stated that basal implants may lead to submucosal infection. This may result in infected vertical parts if the implants are submerged below the mucosal level over time, eliminating the necessary gateway for suppuration as the area of penetration is closed with scar tissue. Any inflammation of this type will spread just like a submucosal abscess and is treated in the same way. 92 Patel K, Madan S, Mehta D, Shah SP, Trivedi V, Seta H. Basal implants: An asset for rehabilitation of atrophied resorbed maxillary and mandibular jaw – A prospective study. Ann Maxillofac Surg 2021;11:64-9.

93. 93 Evolution of basal implants have given positive hope for the patients with atrophied ridges which can be rehabilitated not only by avoiding augmentation procedures,time,cost but also by immediately loading of prosthesis making them more confident and socialize normally. Sometimes the best solutions are found in unconventional Also with respect to the accepted principle “primum nihil nocere ” , i.e. limiting treatment, basal implants are the devices of first choice, whenever (unpredictable) augmentations are part of an alternative treatment plan. CONCLUSION

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