Written by: Marieke Zaffron
Have you had a video conference recently with someone who clearly had no idea how to use the software? Maybe you wanted to check in on an elderly relative or have a virtual meeting with a colleague who communicates best face to face. It can be both amusing and frustrating to teach new technology to those who are resistant to it. After all, plenty of people got along just fine until now using only a phone, so why should they step outside their comfort zone? For those of us who constantly feel the need to upgrade to the latest model of smartphone, download the most innovative software, or order the new cutting-edge tablet, it may be difficult to understand why others in our lives don’t want to keep pace. How many of our parents or grandparents outright refused to purchase a smartphone 10 years ago but now rely on it like a lifeline? We can’t stop technology from moving forward, so what’s the point in resisting it?
This is how Dr Enrico Agliardi, MD, DDS, PhD, and Dr Davide Romeo, DDS, PhD, editors of Tilted Implants: Implant-Prosthetic Rehabilitation of the Atrophic Patient, feel about their preferred treatment protocol. The concept of tilting or angling implants, which is now a widely used option to treat partially and fully edentulous arches with techniques such as All-on-4, was initially rebuffed when it was first introduced by Dr Paulo Maló in the mid 2000s.
Even with a highly pneumatized sinus and an atrophic posterior bone crest, tilted implants allow anchorage into available bone with a reduced cantilever.
“Every clinician was taught to place implants axially for proper load distribution,” explains Dr Agliardi. After all, the Brånemark protocol for a full-arch fixed prosthesis had long-term studies and high success rates to back it up, so the protocol proposed by Dr Maló required a significant paradigm shift. Of course, herein lies the difference between the latest technology in our personal lives and the latest technology for patients—if you buy a new smartphone and it doesn’t work out, you wasted a few hundred dollars. If you place an implant in a way that doesn’t work out, you could cause harm to a patient.
Tilting implants, when done properly, results in the opposite of harm.
Yet, as the dental community slowly discovered over the last 15 years, tilting implants, when done properly, results in the opposite of harm. One of the initial concerns with tilted implants was that they might result in macromovements at the bone-to-implant interface and jeopardize the process of osseointegration; however, the evidence shows that tilted implants, especially those rigidly connected with axial implants, can reduce the amount of micromovements and result in successful osseointegration. So why haven’t tilted implants become part of every implant dentist’s armamentarium?
“Implant inclination can overcome anatomical limitations, allowing atrophic arches to be treated without resorting to bone grafting and with fewer biologic and economic costs.”
Perhaps, like those struggling with video conferencing software, clinicians just need more training on the proper methods. “We have to remember,” Dr Agliardi says, “that changing the way of doing implant dentistry all of a sudden—moving from established techniques such as sinus elevation and bone augmentation to new protocols—is always scary.” Yet, it may soon be necessary to face this fear. “In the near future, we are expecting an increasing number of patients—many of them systemically compromised, already edentulous, or with a periodontally failing dentition—who can benefit from immediate loading protocols that use residual native bone. Implant inclination,” Dr Agliardi explains, “can overcome anatomical limitations, allowing atrophic arches to be treated without resorting to bone grafting and with fewer biologic and economic costs.” Much like the current pandemic pushed people into using already available video conferencing software before they may otherwise have adopted it, the aging population will likely push clinicians to adopt these protocols for the sake of their patients’ overall health.
This patient’s mandible was very severely resorbed, but it was still possible to place enough implants for a full-arch prosthesis by tilting them and using the bone available.
Dr Romeo encourages anyone who doesn’t fully understand the benefits of these protocols to do a deep dive into the scientific literature and then “enroll in a hands-on course to practice the surgical phase and better understand the restorative protocols. Plan and execute your first cases together with a colleague who has performed the procedure before with success. Then, see if it works in your hands and get feedback from your patients.” If the surgical procedure is performed correctly, with an optimal distribution of the implant platforms, “this facilitates the restorative portion and allows for a functional and esthetically pleasing prosthesis that can be properly maintained by the patient.”
Of course, tilted implants shouldn’t replace the ability of the clinician to diagnose and treatment plan. There are still situations when straight implants or sinus augmentation is indicated as a preferred treatment option. Just like sometimes a video conference is necessary to get information across, while other times a phone call or email will suffice. But the best decision can’t be made unless all of the available options are explored. Tilted implants will be there when we need them, and thanks to Dr Agliardi and Dr Romeo’s continued research, clinicians now have an excellent resource for how to apply them when the time comes.
To preview the first chapter of Dr Agliardi and Dr Romeo’s new book, click here.
Enrico Agliardi, MD, DDS, PhD, graduated with honors from the University of Milan in 1994, specializing in medicine and surgery. At the same university, he attained a specialization in maxillofacial surgery in 2000 and a specialization in orthodontics in 2005. Since 2009, Dr Agliardi has been in charge of the Special Rehabilitation Surgery department at the Department of Dentistry of IRCCS San Raffaele of Milan, and he is also a professor in the Special Rehabilitation Surgery Department at Vita-Salute San Raffaele University. For over 15 years, he has been involved in the implant-prosthetic rehabilitation of compromised patients with tilted and zygomatic implants.
Davide Romeo, DDS, PhD, graduated with honors from the University of Milan in 2005, specializing in dentistry and dental prosthetics and with a thesis on the clinical efficacy of the All-on-4 protocol. He later obtained a doctorate from research in innovative techniques in oral implantology and implant-prosthetic rehabilitation, attending the dental clinic of the Galeazzi Institute of Milan before completing a year of study in periodontology at the Department of Periodontology and Implantology at New York University. He has been collaborating with Dr Enrico Agliardi for 14 years, carrying out clinical and research activities on immediate and partial and complete rehabilitations.
Tilted Implants: Implant-Prosthetic Rehabilitation of the Atrophic Patient
Edited by Enrico Agliardi and Davide Romeo
When presented with atrophic arches, clinicians often turn to invasive techniques such as bone grafting or maxillary sinus augmentation. However, using tilted implants instead can avoid these aggressive procedures, allowing the implant support to be moved posteriorly and for longer implants to be chosen. The implants can be loaded immediately to support a full-arch fixed prosthesis in multiple configurations, such as All-on-4, transsinus implants, zygomatic implants, or the authors’ signature V-II-V technique. This book first presents the science and clinical evidence behind the various protocols using tilted implants, then proceeds to discuss patient evaluation, diagnostics, and planning before diving into the methods themselves. Procedures are discussed separately for each arch, highlighted by dozens of clinical cases representing a diverse range of initial situations. In addition to the surgical protocols, methods for fabricating provisional and definitive prostheses are laid out with each step illustrated and explained. This comprehensive volume truly covers everything a clinician needs to know to use tilted implants with great success for their patients.
432 pp (hardcover); 2,091 illus; ©2020; ISBN 978-0-86715-818-2 (B8182); US $228
Contents
- The Biology of Osseointegration
- Osseointegration in Immediate Loading
- Immediate Loading with Tilted Implants
- Advantages of Tilting Dental Implants
- Evaluation of Edentulous Patients
- Diagnostics and Planning for Complex Rehabilitation
- Rehabilitation of the Compromised Patient
- Rehabilitation Protocols for the Maxilla
- Rehabilitation Protocols for the Mandible
- Provisional Prosthetic Solutions
- Definitive Prosthetic Solutions