Presentation detailing the benefits of using site specific implants in oral surgery

1. Simplified Implant Dentistry Through Innovative Implant Design Brian A. Mahler, D.D.S., P.L.C. 10550 Warwick Avenue Fairfax, Virginia USA

2. Placed March 1985, photo July 2004

5. Prosthetic heart valves Artificial back discs Six Southern Medical Groups

7. Tawse-Smith A., Payne A.G.T., Kumara R., Thomson W.M. One-stage operative procedure using two different implant systems: A prospective study on implant overdentures in the edentulous mandible. Clin Implant Dent Relat Res 2001; 3-4; 185-193. Watson G.K., Payne A.G.T., Purton D.G., Thomson W.M. Mandibular overdentures: Comparative evaluation of prosthodontic maintenance of three different implant systems during the first year of service. Int J Prosthodont 2002; 15: 259- 266. Tawse-Smith A., Payne A.G.T., Kumara R., Thomson W.M. Early loading of unsplinted implants supporting mandibular overdentures using a one-stage operative procedure with two different implant systems: A 2-year report. Clin Implant Dent Relat Res 2002; 4: 33-42. Daly P.F., Pitsillis A., Nicolopoulos S., Occlusal reconstruction of a collapsed bite by orthodontic treatment, pre-prosthetic surgery and implant supported prostheses. A case report. SADJ 2001; 56-6; 278 – 282. Dellow A.G., Driessen C.H., Nel H.J.C. Scanning Electron Microscopy evaluation of the interfacial fit of interchanged components of four dental implant systems. Int J of Prosthodont 1997 10; 216 – 221. Peer Reviewed Publications

8. Nikellis,I., Levi A., Niccolopoulos, C. “Immediate loading of 190 endosseous dental implants: A prospective observational study of 40 patient treatments with up to 2-year data” Int J Oral and Maxillofac Implants 2004; 19(1): 116-123. Boyes-Varley J.G., Lownie J.F., Howes D.G., Blackbeard G.A. Surgical modifications to the Branemark Zygomaticus Protocol in the treatment of the severely resorbed maxilla: a clinical report. Int J Oral Maxillo Facial Implants 2003. Boyes-Varley J.G., Lownie J.F., Howes D.G., Blackbeard G.A. Surgical modifications to the Branemark Zygomaticus protocol. COIR 2002; 13-4; xxxii Butz, S.J., Huys,LW. Long-term success of sinus augmentation using a synthetic alloplast: in 20 patients, a 7 year clinical report. Implant Dent. 2005 Mar; 14(1):36-42. Boyes-Varley J.G., Lownie J.F., Howes D.G. The Zygomatic Implant Protocol in the treatment of the severely resorbed maxilla. SADJ 2003; 58:3; 106-114. Peer Reviewed Publications

9. Esposito M., Grusovin, M.G., Coulthard, P., kThomsen, P., Worthington, H.V. A 5-year follow-up comparative analysis of the efficacy of various osseointegrated dental implant systems: a systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2005 Jul-Aug;20(4):557-68. Hall JA., Payne AG., Purton DG., Torr B., A randomized controlled clinical trial of conventional and immediately loaded tapered implants with screw-retained crowns. Int. Journal of Prosthodontics 2006 Jan-Feb;19(1):17-9. Hall JA., Payne AG., Purton DG., Torr B., Duncan WJ., DeSilva RK., Immediately restored, single-tapered implants in the anterior maxilla: prosthodontic and aesthetic outcomes after 1 year. Clin Implant Dent Relat Res. 2007 Mar;9(1):34-45. Vandeweghe S, Ackermann A, Bronner J, Hattingh A, Tschakaloff A, De Bruyn H. A Retrospective, Multicenter Study on a Novo Wide-Body Implant for Posterior Regions. Clin Implant Dent Relat Res. 2009 Dec 3. Peer Reviewed Publications

14. EXTERNAL HEX INTERNAL MORSE TAPER & OCTOGON INTERNAL TRI-LOBE Southern’s 3 Restorative Connectors

16. Tri-Nex Implant Internal Tri-Lobe Compatible with Nobel Biocare™ Select Connection

20. Minimize flowering fractures Weak point

21. Cross Section of 3.5 TriNex Implant Thicker wall to minimize fracture or distortion Platform switch Binon’s work showed less fit of components increases chances of screw loosening

22. Cross Section of 3.5 TriNex Implant Thicker wall to minimize fracture or distortion Platform switch Internal Hex for insertion

23. Cross Section of 3.5 TriNex Implant Thicker wall to minimize fracture or distortion Platform switch Internal Hex for insertion Smaller polished collar 0.6mm vs. 1.5mm

25. Cross Section of 03.5 TriNex Implant Threads extending to apex of implant

27. Improvements of other Tri-Lobe Designs Thicker wall Platform switch Smaller polished collar 0.6mm vs. 1.5mm Threads extending to apex of implant Internal Hex for insertion Compatible w/ Nobel Biocare

29. Southern Implants

30. Southern Implants

32. Efficient is being effective without wasting time, effort, or expense It implies the least costly production means without sacrificing quality

34. Schropp L, Isidor F. Timing of implant placement relative to tooth extraction. J Oral Rehabil. 2008 Jan;35 Suppl 1:33-43. Review. Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate implants from 1988 to 2004 . Int J Oral Maxillofac Implants. 2006 Jan-Feb;21(1):71-80. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004;19 Suppl:12-25. Review. Immediate Implant Placement Immediate implant placement shortens treatment time, decreases the number of surgical procedures, and often eliminates need for grafting When certain parameters are met, long term results of immediate implant placement appears comparable to delayed placement Single rooted relatively easy, but multi-rooted teeth difficult

35. Molar sockets are too large and complex to allow for immediate placement of conventional implants

36. Delayed placement will result in longer treatment time and often a bone graft will be required Bone grafts are costly and time consuming

38. The Solution Develop an implant design and surgical protocol to facilitate immediate implant placement into molar sites This would optimize / preserve available bone and significantly reduce the time, complexity, and cost of treatment

39. The MAX Implant for Molar Replacement

40. Bucco-palatal = 10.7 mm range = 7.4 -14 mm M D B P 7.9 10.7 Cervical dimensions Maxillary first molar Mesio-distal = 7.9 mm Range = 6.4 -10.9 mm Woelfel 1990

41. Bucco-lingual = 9.0 mm Range = 7.3 -11.6 mm M D B P 7.9 10.7 Cervical dimensions Mandibular first molar Mesio-distal = 9.2 mm Range = 7.7-12.4 mm M D 9.2 L B 9.0 Woelfel 1990

44. Tri-Nex Connection OCT Connection Courtesy of Andrew Ackermann, BChD, MChD

45. Section root and remove carefully preserving buccal plate

49. Socket Preparation Instruments same as tapered implants until final Round bur to create pilot hole Twist drills to enlarge 4.0mm, 5.0mm, 6.0mm tapered final shaping drill Final dedicated MAX shaping drill

50. Dedicated drills

53. Place deep enough, even buccal plate

54. Place deep enough

55. Final Dedicated MAX Shaping Drill Six total: One for each length and diameter of implants 8mm diameter MAX 7mm length 9mm length 11mm length 9mm diameter MAX 7mm length 9mm length 11mm length

56. Careful sectional removal of molar to preserve buccal plate

57. Pilot Drills and Tapered Drills in Inter-Radicular Bone

58. Preserve thin buccal plate

60. Not cover with tissue

63. 23 months Buccal plate preserved

66. Final Dedicated MAX Osteotomes Six total: One for each length and diameter of implants 8mm diameter MAX 7mm length 9mm length 11mm length 9mm diameter MAX 7mm length 9mm length 11mm length

67. MAX Implant Dedicated Instruments Drills Taps Osteotomes Three dedicated instruments to facilitate MAX placement

72. Minimal Oral-Antral Bone Dimension Smoker / Immediate loading Immediate loading FAILURES

76. The Co-Axis Implant

77. Threaded implant with a 12° and 24° angle correction built into it

80. © 2009 Southern Implants, Inc. All rights reserved. Co-Axis with Industry Compatible Connections

81. Angled fixture mount allows symmetrical rotation when inserted How Do You Place This Implant? dimple on most coronal side of restorative platform 0.6mm thread pitch

82. Fixture and mount WHY?

84. Tilted Implants Literature Review 1 . Sütpideler M. Eckert SE, Zobitz M. An KN . Finite element analysis of effect of prosthesis height, angle of force application, and implant offset on supporting bone. Int J Oral Maxillofac Implants. 2004 Nov-Dec;19(6):819-25. 2. E, Griggs JA, Powers JM, Englemeier RL . Effect of abutment angulation on the strain on the bone around an implant in the anterior maxilla: a finite element study. J Prosthet Dent. 2007 Feb;97(2):85-. 3. Cehreli MC, Iplikcioğlu H, Bilir OG . The influence of the location of load transfer on strains around implants supporting four unit cement-retained fixed prostheses: in vitro evaluation of axial versus non-axial loading, J Oral Rehabil. 2002 Apr;29(4):394-400. 4. Brosh T, Pilo R, Sudai D . The influence of abutment angulation on strains and stresses along the implant/bone interface: Comparison between 2 experimental techniques. J Prosthet Dent 1998;79:328-334. 5. Clelland NL, Lee JK, Bimbenet OC, Brantley WA . A three-dimen­sional finite element stress analysis of angled abutments for an implant placed in the anterior maxilla. J Prosthodont 1995; 4:95-100 6. MC, Lplikçioğlu H . In vitro strain analysis and off-axial loading on implant supported fixed partial dentures. . Implant Dent. 2002;11(3):286-92. 7. O’Mahony A, Bowles Z, Woolsey G, Robinson SJ, Spencer P . Stress distribution in the single-unit osseointegrated dental implant: finite element analyses of axial and off-axial loading. Implant Dent. 2000;9(3):207-18. 8. Clelland NL, Gilat A, McGlumphy EA, Brantley WA . A photoelastic and strain gauge analysis of angled abutments for an implant system. Int J Oral Maxillofac Implants. 1993;8(5):541-8. 9. Celletti R, Pameijer Ch, Bracchetti G, Donath K, Persichetti G, Visani I . Histologic evaluation of osseointegrated implants restored in nonaxial functional occlusion with preangled abutments. Int J Periodontics Restorative Dent. 1995 Dec;15(6):562-73. 10. Barbier L, Schepers E . Adaptive bone remodeling around oral implants under axial and nonaxial loading conditions in the dog mandible. Int J Oral Maxillofac Implants. 1997 Mar-Apr;12(2):215-23.

85. Tilted Implants Literature Review 11. SF, Wolfinger GJ, Balshi TJ . Analysis of 356 pterygomaxillary implants in edentulous arches for fixed prosthesis anchorage. Int J Oral Maxillofac Implants. 1999 May-Jun;14(3):398-406. 12. Balshi SF, Wofinger GJ, Balshi TJ . Analysis of 164 titanium oxide-surface implants in completely edentulous arches for fixed prosthesis anchorage using the pterygomaxillary region. Int J Oral Maxillofac Implants. 2005 Nov-Dec;20(6):946-52. 13. Valerón JF, Valerón PF . Long-term results in placement of screw-type implants in the pterygomaxillary-pyramidal region. Int J Oral Maxillofac Implants. 2007 Mar-Apr;22(2):195-200. 14. Ahlgren F, Størksen K, Tomes K . A study of 25 zygomatic dental implants with 11 to 49 months' follow-up after loading Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):421-5. 15. Aparicio C, Ouazzani W, Garcia R, Arevalo X, Muela R, Fortes V . A prospective clinical study on titanium implants in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a follow-up of 6 months to 5 years. Clin Implant Dent Relat Res. 2006;8(3):114-22. 16. Becktor JP, Isaksson S, Abrahamsson P, Sennerby L . Evaluation of 31 zygomatic implants and 74 regular dental implants used in 16 patients for prosthetic reconstruction of the atrophic maxilla with cross-arch fixed bridges Clin Implant Dent Relat Res. 2005;7(3):159-65. 17. Farzad P, Andersson L, Gunnarsson S, Johansson B . Rehabilitation of severely resorbed maxillae with zygomatic implants: an evaluation of implant stability, tissue conditions, and patients' opinion before and after treatment. Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):399-404. 18. Eger DE, Gunsolley JC, Felmman S . Comparison of angled and standard abutments and their effect on clinical outcomes: a preliminary report. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):819-23. 19. Sethi A, Kaus T, Sochor P . The use of angulated abutments in implant dentistry: five-year clinical results of an ongoing prospective study. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):801-10. 20. Sethi A, Kaus T, Sochor P, Axmann-Krcmar D, Chanavaz M . Evolution of the concept of angulated abutments in implant dentistry: 14-year clinical data. Implant Dent. 2002;11(1):41-51.

86. Tilted Implants Literature Review 21. Krekmanov L, Kahn M, Rangert B, Lindström H . Tilting of posterior mandibular and maxillary implants for improved prosthesis support. Int J Oral Maxillofac Implants. 2000 May-Jun;15(3):405-14. 22. Maló P, Nobre Mde A, Petersson U, Wigren S . A pilot study of complete edentulous rehabilitation with immediate function using a new implant design: case series Clin Implant Dent Relat Res. 2006;8(4):223-32. 23. Rosén A, Gynther G . Implant treatment without bone grafting in edentulous severely resorbed maxillas: a long-term follow-up study. J Oral Maxillofac Surg. 2007 May;65(5):1010-6. 24. Calandriello R, Tomatis M . Simplified treatment of the atrophic posterior maxilla via immediate/early function and tilted implants: A prospective 1-year clinical study. Clin Implant Dent Relat Res. 2005;7 Suppl 1:S1-12. 25. Krennmair G, Fürhauser R, Krainhöfner M, Weinländer M, Plehslinger E . Clinical outcome and prosthodontic compensation of tilted interforaminal implants for mandibular overdentures. Int J Oral Maxillofac Implants. 2005 Nov-Dec;20(6):923-9. 26. Aparicio C, Perales P, Rangert B . Tilted implants as an alternative to maxillary sinus grafting: a clinical, radiologic, and periotest study. Clin Implant Dent Relat Res. 2001;3(1):39-49. 27 Msu ML, Chen FC, Kao HC, Cheng CK . Influence of off-axis loading of an anterior maxillary implant: a 3-dimensional finite element analysis. Int J Oral Maxillofac Implants. 2007 Mar-Apr;22(2):301-9. 28. Zampelis A, Rangert B, Heijl L . Tilting of splinted implants for improved prosthodontic support: a two-dimensional finite element analysis. J Prosthet Dent. 2007 Jun;97(6 Suppl):S35-43. 29. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Fabbro MD . Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res. 2008 Dec;10(4):255-63. 30. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL . Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32.

87. Tilted Implants Literature Review 31. Capelli M. Zuffettii F, Del Fabbro M, Testori T . Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: a multicenter clinical study. Int J Oral Maxillofac Implants. 2007 Jul-Aug;22(4):639-44. 32. Rosén A, Gynther G . Implant treatment without bone grafting in edentulous severely resorbed maxillas: a long-term follow-up study J Oral Maxillofac Surg. 2007 May;65(5):1010-6. 33. Bedrossian E, Rangert B, Stumpel L, Indresano T . Immediate function with the zygomatic implant: a graftless solution for the patient with mild to advanced atrophy of the maxilla. Int J Oral Maxillofac Implants. 2006 Nov-Dec;21(6):937-42. 34. Koutouzis T, Wennström JL . Bone level changes at axial- and non-axial-positioned implants supporting fixed partial dentures. A 5-year retrospective longitudinal study. Clin Oral Implants Res. 2007 Oct;18(5):585-90. Epub 2007 Jun 30 35. Cruz M, Wassall T, Toledo EM, da Silva Barra LP, Cruz S . Finite element stress analysis of dental prostheses supported by straight and angled implants. Int J Oral Maxillofac Implants. 2009 May-Jun;24(3):391-403. 36. Lin CL, Wang JC, Ramp LC, Liu PR . Biomechanical response of implant systems placed in the maxillary posterior region under various conditions of angulation, bone density, and loading Int J Oral Maxillofac Implants. 2008 Jan-Feb; 23(1):57-64. 37. Al-Ghafli SA, Michalakis KX, Hirayama H, Kang K . The in vitro effect of different implant angulations and cyclic dislodgement on the retentive properties of an overdenture attachment system. J Prosthet Dent. 2009 Sep;102(3):140-7. 38. Bellini CM, Romeo D, Galbusera F, Agliardi E, Pietrabissa R, Zampelis A, Francetti L . A finite element analysis of tilted versus nontilted implant configurations in the edentulous maxilla Int J Prosthodont. 2009 Mar-Apr;22(2):155-7. 39. Fortin T, Isidori M, Bouchet H . Placement of posterior maxillary implants in partially edentulous patients with severe bone deficiency using CAD/CAM guidance to avoid sinus grafting: a clinical report of procedure Int J Oral Maxillofac Implants. 2009 Jan-Feb;24(1):96-102. prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32. Epub 2008 Jan 3.

88. Tilted Implants Literature Review 40. Bevilacqua M, Tealdo T, Pera F, Menini M, Mossolov A, Drago C, Pera P . Three-dimensional finite element analysis of load transmission using different implant inclinations and cantilever lengths . Int J Prosthodont. 2008 Nov-Dec;21(6):539-42. 41. Agliardi EL, Francetti L, Romeo D, Taschieri S, Del Fabbro M . Immediate loading in the fully edentulous maxilla without bone grafting: the V-II-V technique. Minerva Stomatol. 2008 May;57(5):251-9, 259-63. 42. Zampelis A, Rangert B, Heijl L .Tilting of splinted implants for improved prosthodontic support: a two-dimensional finite element analysis. J Prosthet Dent. 2007 Jun;97(6 Suppl):S35-43. Erratum in: J Prosthet Dent. 2008 Mar;99(3):167. 43. Francetti L, Agliardi E, Testori T, Romeo D, Taschieri S, Fabbro MD . Immediate rehabilitation of the mandible with fixed full prosthesis supported by axial and tilted implants: interim results of a single cohort prospective study. Clin Implant Dent Relat Res. 2008 Dec;10(4):255-63. Epub 2008 Apr 1. 44. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL . Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008 Mar;19(3):227-32. Epub 2008 Jan 3. 45. Cruz M, Wassall T, Toledo EM, da Silva Barra LP, Cruz S . Finite element stress analysis of dental prostheses supported by straight and angled implants Int J Oral Maxillofac Implants. 2009 May-Jun;24(3):391-403. 46. Kao HC, Gung YW, Chung TF, Hsu ML . The influence of abutment angulation on micromotion level for immediately loaded dental implants: a 3-D finite element analysis. Int J Oral Maxillofac Implants. 2008 Jul-Aug;23(4):623-30 47. Las Casas EB, Ferreira PC, Cimini CA Jr, Toledo EM, Barra LP, Cruz M . Comparative 3D finite element stress analysis of straight and angled wedge-shaped implant designs. Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):215-25. 48. Markarian RA, Ueda C, Sendyk CL, Laganá DC, Souza RM . Stress distribution after installation of fixed frameworks with marginal gaps over angled and parallel implants: a photoelastic analysis. J Prosthodont. 2007 Mar-Apr;16(2):117-22.

89. Tilted Implants Literature Review Tilted implants are a safe and effective treatment that has many benefits for the patient

91. Added components Smaller screws Added modes of failure Increased cost Increased time Large Screw Retained Restorations

92. 2 mm minimum distance To correct angle More time and cost than going direct to implant Potential aesthetic problems Angle corrected abutments often require tabling of bone Templates for lab to mouth

95. Anatomy and/or bone loss often lead to less than ideal implant location in the maxillary anterior making their restoration difficult Problem:

98. Co-Axis Implant Development It was determined by digital photographic analysis and cephalometric evaluation that an angle correction of 12 degrees would allow for vast majority of maxillary anterior implant restorations to be screw retained Edentulous areas

99. C. Nikolopoulos, Oral Surgeon P. Youvanoglou, Pros. G. Ioannou, Technican Co-Axis Implant No intermediate abutments No tabling bone

100. Co-Axis 24 º External hex with slightly shorter screws and healing components

101. Restoring implants that intersect

103. The Co-Axis Implant Co-Axis implant may be placed into available bone while leaving the restorative platform in an optimal position Use Co-Axis implants in locations where conventional implants would require a bone graft or result in the inability to easily or adequately restore the implant Correct angle in implant, not the restoration

104. Co-Axis Implant Instrumentation 12 degree direction indicator (after twist) 12 degree direction indicator (after final shaping) in 10, 13 and 15mm

107. Options

109. Is It Strong Enough With That Thin Wall? Straight Implant Co-axis Implant Same amount of titanium just more on one side than other

110. Finite element analysis 3.75 mm Implant Ext. Hex 350N load at 22° to long axis 350N load at 22° to long axis Finite element analysis Co-Axis 12 degree Finite Element Analysis

113. Serendipity Making a fortunate discovery while searching for other things

116. Mid-Facial Soft Tissue Recession in Single Tooth Restorations Interproximal soft tissue levels determined by bone on adjacent teeth

117. 26° 17° Angle of Implant

118. 10 degrees More vertical placement of implants Under contouring of restoration Narrower healing caps Platform switching Immediate restoration Increase amount of tissue

119. Vertical Placement of Implants In Anterior Maxilla Anatomy of the anterior maxilla often results in facially inclined implants that leads to long teeth

120. In same osteotomy site a Co-Axis implant will result in more mid-facial soft tissue than a straight implant

121. “ Need my crown recemented” Emergency immediate restoration

123. Immediate implant placement & restoration Final 13 months post insertion Pre-op model

124. Atraumatic extraction

125. Out of occlusion Post op instructions

131. The Co-Axis implant has two distinct axes to allow easier replication of the two planes nature gave maxillary anterior teeth

137. Thank You Brian A. Mahler, D.D.S., P.L.C. 10550 Warwick Avenue Fairfax, Virginia [email_address]