Globally thousands of people suffer from missingteeth, Edentulous jaws will have definite effects not only on a persons oral cavity but also on hisoverall well being. A completelyedentulous condition will have anegative effect on the quality of life. Initially traditional removable dentures were the only treatment of choice to replace a complete set of missing teeth, these are usually unstable, which is more so with the lower denture when compared to the upper making it very difficult to speak or chew food.
Dental Implants introduced in the late seventies,has been a great reliever for people suffering with ill fitting removable dentures, but the happiness was shortlived as people had to undergo invasive and expensive procedures like sinus lifts, bone grafting and nerve repositioning and also wait for months together before they could finally get the fixed teeth of their choice.
The introduction of immediate loading Tilted implants has been a game changer for the Implantologists and the patients alike and has become a predictable treatment of choice and provide a safe and a reliable option for partial or complete replacement of teeth.
When it comes to full mouth rehabilitation,opting for Tilted or straight implants has always been a topic of debate.
Full mouth rehabilitation cases when presented with highly resorbed jaws, (when your dentist says resorbed jaws it is usually the posterior segment of the jaws as the bone condition in the anterior segment will be favorable to place implants in 90% of the cases and universally, if the quality of the bone is measured in a decling order, it is the anterior segment of the lower arch first followed by the anterior segment of the upper arch then comes the rear end of the lower and finally the most difficult portion to replace being the posterior segment of the upper arch due to its location, which will not have easy access to, the presence of sinus and the quality or quantity of bone being the major concern)the problem usually exists with the posterior segments due to retaining of infected teeth for long period as, many people actually wait for the teeth to fall off on their own instead of getting the infected teeth removed, in such a case the infection damages the bone surrounding the tooth root or also due to not replacing the extracted teeth immediately. The reason being, the Sinus present on either side above the upper jaw descends down due to gravity in the absence of the teeth making it difficult to accommodate even a implant of 10 mm length.
The problem in case of the lower jaw being, surfacing of the inferior alveolar nerve due to bone loss owing to infection. This is when additional procedures used to be suggested to lift the sinus to its original place and add bone underneath it in the upper arch and reposition the surfaced nerve in the lower arch to accomodate implants.
Therefore Sinus lift, bone grafting, nerve repositioning, placement of short implants or giving a posterior cantilever extension are some of the treatment options proposed to replace teeth in an attrided posterior arch but these techniques come with their own set of problems like,
- Patient will be subjected to additional surgical procedures like sinus lift, bone grafting and nerve repositioning,which can be otherwise avoided.
- The posterior grinding teeth that bear the maximum brunt of masticatory forces and the rear grinding teeth that require proper implant support will be devoid of any implant backing, if cantilevers are given. Sometimes the cantilever length on either side might have to be extended Upto 20mm in length so as to accommodate the grinding teeth in the posterior region there by increasing the risk of implant failure.
- Additional Procedures like sinus lift and bone grafts are not only inconvenient and expensive but
also delay the procedure by 6 to 8 months. - The least invasive among the alternative options to avoid additional surgical procedures being, the short Implants, but in few cases the available bone height will not be enough to accommodate the shortest available implant.
Tilted implants also known as angled Implants were introduced to avoid the above mentioned short comings associated with implantation in the attrided jaws.
These implants, as the name suggests are placed strategically at an angle of 30 to 45 degrees to the jaw bone based on the cbct analysis and depending on the requirement to avoid bone which is low on density,the deficiencies in the bone, steer clear of the important anatomical structures.
The prosthetic designing also plays an important role in determining the angulation of the Implants. The other benefits of tilting the implants being to engage maximum amount of available bone and increase the contact between the bone and the implants(Implant : Bone interface) by placing longer implants there by optimizing stability and
increment the load bearing capacity, to ensure proper stability and integration of implant.The idea behind tilting the
implants is also to provide better load distribution, reduce the cantilever length, proper cortical anchorage and to attain primary stability. This technique is specially indicated in patients with low bone cases seeking immediate rehabilitation of function and Aesthetics.
INDICATIONS OF TILTED IMPLANTS:
This concept is contemplated in those jaws where the quality and quantity of the jaw bone is not proper and want to avoid additional surgical procedures, do not want to wait for months together for the fixed teeth and where the anatomic constraints are making the placement of regular Implants difficult as these implants help avoid the key structures and increase support in compromised situations.
The implants thus placed at an angle are straightened at the gum level with the help of specialised abutments,which are available in different sizes and angulations.
Other functions of the multiunitabutments being:
- Connect implants to the prosthesis.
- Aligns the components of the prosthesis effectively for improved function and better aesthetics.
- Connects the multiple implants used, at a single level.
- Brings the restorative platform above the gingiva or gum making it easy to change the prosthesis when ever required without any surgical intervention.
- Helps in preserving tissue when placed at the time of Implantation.
- manages jaw bone height disparities and misalignments.
Multiunit abutments are crucial for the success of multiple implant supported restorations. These are mandatory in a full arch or a full mouth rehabilitation cases.
Full mouth rehabilitation using tilted implants can be accomplished using “ALL ON 4” or the “ALL ON 6” concept.
ALL ON 4
General procedure- Badly damaged teeth if any, are removed under Local anesthesia and the area clearly debrided.
Four regular implants are strategically placed at an angulation, in the anterior and the mid section of the upper and
lower jaws and in case of absence of bone, due to some anamoly, trauma, previous failed implants or conditions like Mucor mycosis commonly called as Black fungus, two Zygoma or cheek Implants will be utilized to engage the Zygoma bone and in cases where there is absolutely no bone left due to some reason, two Zygoma implants will be placed on either side in the upper jaw(quad zygoma)Therefore there is no such case where fixed teeth on Implants are not possible. The Implants thus placed require small fixtures called Multi unit abutment that straighten the
implants at the gum level and now the implants are scanned to prepare, Acrylic teeth on a cobalt chromium frame work, this will be fastened on the implants with the help of screws.
ALL ON 6
This is a variation of the All on 4 technique, where along with the 4 Implants as in ALL ON 4 technique an extra Implant will be added in distal end of each of the upper jaw called the Tubero Pterygoid implant. In highly resorbed lower jaws, nerve bypass technique instead of nerve repositioning to place an implant in the distal end of the lower jaw to spread out implants uniformly and to avoid cantilevers. As mentioned above, in cases where there is too much
of bone loss and placement of regular implants is not feasable, Zygoma Implants will come to the rescue, followed by placement of the Multiunit abutments and then scanned to prepare a PFM or a DMLS bridge, the bridge will be then fastened on the implants with the help of screws in less than a week.
The entire procedure will be performed under local anesthesia and for apprehensive patients, Nitrous oxide sedation also called as Sleep dentistry can be provided.
Benefits of the titled implants:
- No more waiting for months, immediate loading of teeth. Teeth can be now loaded in less than a week days( permanent teeth in 3 days)
- No additional surgical procedures required.( no Sinus lifts or Nerve repositioning)
- Improved stability due to increased implant, bone interface.
- Improved aesthetics.
- Patient satisfaction.
- No bone grafting.
- Simple hassle free procedure.
- cost effective as number of implants are reduced( All on 4 or All on 6 technique)and also due to reduced surgical procedures and number of sittings too.
Tilted Implants technique is a conservative solution and also helps in improved risk management as it is minimally invasive with accuracy in implant placement, predictability, reduced surgical discomfort and immediate restoration of fixed teeth. This helps the person to have food of his choice.
Immediate loading of teeth using Tilted Implants ( Conventional Two piece implants) or Basal Implants is made possible due to engagement of the Basal bone which is present in all, irrespective of the amount of
bone loss. People suffering from Diabetis or any other systemic problems are also suitable for immediate rehabilitation of teeth.
