CE—CLINICAL APPLICATION

Prosthetic Rehabilitation of a
Patient with Failing Dentition
with an Immediate Load Implant
Alessandro Agnini, DDS
Roberto Apponi, DDS
Andrea Agnini, DDS

CE
CREDIT
Abstract
Dental diagnostic and therapeutic processes have
become far more complex in recent years. Treatment, Learning Objectives
especially in complex rehabilitation cases, can no longer
After reading this article, the participant should be able to:
be completed by a single practitioner, no matter how well
prepared and up to date. Rather, more specialists must
be involved to formulate a correct diagnosis and carry 1. Understand the importance of working with specialist(s)
out a multidisciplinary treatment plan. Understanding in a multidisciplinary complex restorative case.
the timing and the means by which it is possible to
solve a complex, multidisciplinary case such as the one 2. Understand and be able to apply a diagnostic approach
described in this article requires a diagnostic approach and a prosthetic surgical protocol that allows for a
and a prosthetic surgical protocol that allows a strategic strategic sequencing of complex implant treatment.
sequencing of corrective therapies. The patient must be
considered holistically; therefore, improved quality of 3. Apply a philosophy of treatment that improves patient
life not only after treatment but also during it must be comfort by simplifying treatment protocols and
at the forefront. This article presents an approach that decreasing the number of surgical sessions.
improves patient comfort by simplifying protocols and
decreasing the number of surgical sessions.

Key Words: failing dentition, immediate loading, Disclosure: The authors are employed by BioHorizons.
full arch rehabilitation, one-model technique

70 Winter 2018 • Volume 33 • Number 4

 Agnini/Apponi/Agnini

"Over the past few decades there

has been a profound transformation
in the philosophy and formulation of
treatment plans..."

Journal of Cosmetic Dentistry 71

CE—CLINICAL APPLICATION

Introduction
Over the past few decades there has been a profound trans- tal implants or using short implants, depending on the anatomi-
formation in the philosophy and formulation of treatment cal situation. The following clinical case was treated utilizing the
plans, especially those for complex clinical cases. One of TeethXpress protocol, with the placement of five implants (Laser-
the major changes is the importance and attention given Lok Tapered Internal, BioHorizons), four straight and one tilted.
to patients’ needs from the early corrective stages.1 It is
essential to simplify operative protocols, thereby improv- Patient Complaint and Risk Profile
ing the quality of treatment plans and patient comfort.2 A A 66-year-old male patient presented with an upper fixed prosthesis
comprehensive diagnostic evaluation, which begins with and a partial fixed prosthesis in the lower right posterior quadrant.
a complete anamnestic medical examination; considers He complained of a recurring abscess in the upper left posterior
the patient's expectations and requests; and considers the quadrant due to an old implant, and of upper prosthesis mobility.
biological context, adequate infection control, and ability The first appointment, which comprised the interview and clini-
to manage occlusal risk factors, is essential. The clinical cal examination, allowed us to determine his risk profile. The pa-
case described here addresses the variables controlled by tient, who was dental phobic, had a high gag reflex and was fearful
the dental team and how the introduction of new digital of wearing a removable prosthesis during therapy. His expectations
technology, including the latest generation of scanners, and demands were focused only on the maxillary arch. He had low
materials, and tools, has improved treatment efficiency and systemic, esthetic, and functional risk profiles and an average peri-
effectiveness.3-5 odontal risk profile. Due to the various issues a diagnostic study
In rehabilitating such cases, it is necessary to utilize a was necessary (Figs 1 & 2).
multidisciplinary approach in which the treatment plan
provides an ordered sequence of individual corrective steps Treatment Plan
aimed at achieving the therapeutic treatment objectives, in- A preliminary treatment plan that included emergency manage-
cluding a vision of future hygiene maintenance.6 ment with antibiotic therapy, photographs and videos, the nec-
In a full arch implant rehabilitation, the clinician often is essary radiographs, causal therapy, the cast mounting in centric
faced with reduced bone volume, especially in the posterior relation (CR), and a reevaluation visit was agreed upon with the
region. To deal with this, the dentist can use a prosthetic dis- patient (Fig 3). This enabled identification of a high endo-conser-
tal cantilever,7 place short implants,8,9 perform guided bone vative and anatomical risk profile, thereby completing the overall
regeneration,10 carry out a maxillary sinus lift,11 or place den- risk profile and allowing us to consider different therapeutic plans.
tal implants in specific areas such as the pterygoid or zygo- The prosthetic therapeutic needs were not related solely to the up-
matic region.12 However, these procedures require advanced per arch, but also to the lower posterior quadrants to achieve the
surgical skills, have a higher risk of complications, and re- functional therapeutic goals.
quire treatment lengths that may limit patient acceptance. In the upper arch (with prognostically terminal dentition in re-
The advantage of a screw-retained prosthesis on im- lation to the low esthetic risk profile), the treatment plan included
plants a few hours after surgery is that it allows patients to an implant-prosthetic rehabilitation with a pink artificial gingival
avoid the psychological trauma and discomfort caused by component directly screwed to the implant abutments.
a removable provisional prosthesis.2 The implants’ primary The plan for the lower arch was to replace the old fixed par-
stability is influenced by the implant macrogeometry, the tial denture in the lower right posterior area; and, in the lower left
quality and amount of bone tissue, and the surgical tech- posterior area (after the patient declined an orthodontic upright-
nique. Splinting of the implants in the edentulous arch ing treatment), to extract #18 and #17, and place an implant and
promotes a better distribution of occlusal loads and limits crown on #19 and a crown on #20. The corrective therapies were
the implants’ macromovements.13 The osteoconductive sur- planned strategically to improve the patient’s quality of life, not
faces available today allow faster osteointegration.14 only after treatment was completed, but also during it.
A number of clinical studies have shown the prosthetic
and surgical advantages of using tilted implants in the pos- Treatment
terior regions. Cases of full arch rehabilitation with the use The following were accomplished in a single session:
of tilted implants have reported survival rates comparable
to those supported by straight implants.15-19 However, the • The pre-existing prosthesis was removed.
ideal number of implants for a full arch rehabilitation has
not been defined in the literature. • Teeth #4, #10, and #11 were extracted, as was the existing
The goal of the TeethXpress approach (BioHorizons; implant at #15.
Birmingham, AL) is to simplify protocols and decrease the
number of surgical sessions to improve patients’ comfort. • The reinforced provisional restorations of the upper arch
This prosthetic-surgical technique allows immediate load and the lower right posterior quadrant teeth were relined,
full arch rehabilitation with the use of four to six fixtures polished, and cemented (Fig 4).
by taking advantage of the inclination of one or both dis-

72 Winter 2018 • Volume 33 • Number 4

 Agnini/Apponi/Agnini

Figure 1: The dentolabial analysis highlighted a low smile Figure 2: Intraoral analysis; note the periodontal disease, dental disproportions,
line, thin upper lip, inappropriate occlusal planes, and and mesial inclination of #17 and #18.
signs of chemical erosion in the lower incisors.

Figure 3: The periapical x rays show, in the upper arch, the presence of destructive decay, periapical lesions, an unfavorable crown/root ratio,
a fracture, and an abscess. The lower arch shows a moderate generalized periodontitis as well as the mesial inclination of #17 and #18.

"The corrective therapies

were planned strategically
to improve the patient’s
quality of life, not only after
treatment was completed,
but also during it."
Figure 4: First set of the reinforced provisional restorations cemented on
natural teeth, relined, polished, and cemented. The extraction of #17 and #18
had been planned during the upper implant placement to decrease the number
of surgical steps and enhance patient comfort.

Journal of Cosmetic Dentistry 73

CE—CLINICAL APPLICATION

The primary objective was to deliver a fixed prosthesis on

natural dentition that considered the patient’s needs and com-
fort, and improved function and overall esthetics compared to
the initial situation. This therapeutic phase allowed us to re-
move the most compromised teeth and to reduce the overall
hard and soft tissues inflammation (Fig 5).
After two months without any complications, the remain-
ing teeth in the maxillary arch were replaced with five im-
plants. The one-model technique protocol allows the techni-
cian to transfer the wax-up information for realization of the Figure 5: Note the health of gingival tissues at the one-month
immediate loaded provisional, maintaining all esthetic, func- follow-up appointment. The primary retention of the abutments
tional, and structural requirements.20 and the patient’s low biomechanical risk aided in avoiding
complications during this first phase of treatment.
The One-Model Technique
The one-model technique is characterized by three phases:
The transfer template has several functions:
Presurgical prosthetic phase: The objective was to create the
prosthesis and build the transfer plate. The following steps • During cone beam computed tomography the tem-
were accomplished in a single session: plate helps to evaluate bone quality and quantity in
the areas implants are planned to be placed by deter-
• The impression of the upper provisional restoration was mining the best sites for maximum stability for the
taken and relined and vertical dimension was recorded. implants to support the final prosthesis.

• The provisional restoration was removed, and a full arch • To transfer the exact position of the conical multi-unit
impression of the partially edentulous upper jaw and an abutments (MUAs) to the mounted master cast.
impression of the antagonist jaw were taken.
Surgical and prosthetic phase: The goal of this phase was
• A facebow transfer was done to establish reference points. to record the positions of the implants using the transfer
template. The following steps were accomplished in a sin-
• The interjaw relationship in CR had been recorded at the gle session utilizing conscious sedation:
previously measured vertical dimension using extra-hard
wax with intraoral fixed landmarks (Fig 6). With this • The provisional restoration was removed and the exact
information, the casts were mounted on the semi adjust- position of the transfer template and its occlusal gear
able articulator in the correct spatial position of CR. The were checked with the antagonist.
technician, using reference points from the provisional
shell and from the information derived from the video and • Four axial implants were placed at #3, #5, #8, and #12,
photographs, planned a new prosthesis. and a tilted one at #13, according to the residual bone
anatomy (Fig 10).
• The correct occlusal plane was designed starting from
the central incisor position while a prosthetic gingival • Four conical MUAs and one pre-angled 30-degree
component was created and the spaces for hygiene were abutment on the tilted dental implant were screwed in
carefully evaluated to obtain optimal structural character- and tightened up to 30 Ncm (Fig 11).
istics (Fig 7).
• Temporary titanium cylinders were screwed onto the
• The prosthesis without the flange was tested in the pa- conical MUAs and were blocked with dual composite
tient’s mouth and the esthetic and functional parameters (Fig 12) (Protemp, 3M ESPE; St. Paul, MN) after check-
were evaluated. Additional changes, based on the facial ing the passive fit and occlusal position of the transfer
reference lines and on the patient's esthetic requirements, plate.
were made (Fig 8).
• The template and titanium cylinders were unscrewed
Based on the completed prosthesis a silicone index was tak- and sent to the dental laboratory without any intrasur-
en against the opposing cast. Next, the prosthesis was dupli- gical impression and intermaxillary registration.
cated using a tissue-supported transfer template with occlusal
stability (Fig 9). • Teeth #17 and #18 were extracted and an axial implant
was placed in the area of #19.

74 Winter 2018 • Volume 33 • Number 4

 Agnini/Apponi/Agnini

Figure 6: CR is recorded using two points at the provisional Figure 7: Dental technician’s prosthesis (indirect mock-up) based
restoration’s new vertical dimension. on the information derived from the first provisional’s esthetic and
functional analysis.

Figure 8: Mock-up without flanges in position. Observe the Figure 9: Mucosa-and-teeth-supported template with occlusal gear,
improvement in comparison to the first provisional using an verified in CR at the correct vertical dimension using the pattern
artificial gingival component. Any modifications can be evaluated, resin.
discussed, and performed by the laboratory.

Postsurgical prosthetic phase: The objective was to, in the • Accuracy—due to the use of the original manufacturer’s
laboratory, transform the initial model of the prosthesis in prosthetic implant components.
the master model and build the final prosthesis. The conical
MUA analogs were screwed to the cylinders and attached to • Strength—guaranteed by the presence of the metal alloy
the transfer template. After the holes in the plaster of the ini- reinforcement and by the interocclusal spaces present.
tial cast were created, the template, cylinders, and analogs were
repositioned passively on the same model (Fig 13). A Class IV • Passive fit—obtained thanks to the adhesive cementation
plaster was used to incorporate the analogs inside the model. of the metal reinforcement on the provisional titanium
The initial model was thus transformed into the master model, cylinders. The provisional was delivered to the patient
already mounted in the articulator. the day after surgery with minimal occlusal adjustments,
During the presurgical phase the dental technician, using respecting the case's esthetic, functional, and structural
the silicone index of the tested mock-up on the patient, had goals; and not interfering with the implants’ osseointegra-
designed the metal reinforcement (Fig 14), cemented with tion, soft tissue healing, and patient satisfaction. After a
resin cement, on the temporary cylinders. four-month healing period (Figs 17 & 18) with successful
The presurgical prosthesis was then transformed into a pro- osseointegration and without any prosthetic complica-
visional restoration directly screwed to the conical MUAs with tions, the case was finalized.
three mandatory characteristics (Figs 15-16b):

Journal of Cosmetic Dentistry 75

CE—CLINICAL APPLICATION

Figure 10: Placement of the axial implant in the Figure 11: Positioning of the four straight MUAs and one tilted 30 degrees, then
fresh extraction socket site #8, following esthetic tightened to 30 Ncm.
and structural evaluation of the prosthesis,
obtaining a primary stability of 50 Ncm.

Figure 12: The template is used at this stage as a custom tray to transfer, through the dual Figure 13: The transfer plate complex is
composite, the exact position of the MUAs on the master model mounted on an articulator. passively positioned on the same model
on which it was built, transforming it into
the master model.

Figure 14: The silicone index is repositioned on the master model to design and produce the metal reinforcement of the immediate
provisional restoration on implants.

76 Winter 2018 • Volume 33 • Number 4

 Agnini/Apponi/Agnini

"Potentially edentulous
patients or patients with a
failing dentition require a
thorough multidisciplinary
approach due to the
complexity of clinical and
psychological issues present."
Figure 15: Intraoral view of the screw-retained reinforced provisional restoration
the day after surgery.

a b

Figures 16a & 16b: Immediate load provisional implant restoration details in intraoral and dentolabial views. Esthetic, functional, and
structural goals have been achieved.

Figure 17: After four months, osseointegration is complete and Figure 18: Detail of the quantity and quality of peri-implant
hard and soft tissues are stable. Note that the upper arch’s shape is keratinized tissue around the straight MUA with 2 mm of height.
different from the initial situation.

Journal of Cosmetic Dentistry 77

CE—CLINICAL APPLICATION

a b

Figures 19a & 19b: The zirconia framework design is fabricated to support the veneering ceramic in critical functional areas. Note how the
weakest area—the screw hole channel—has been designed completely in zirconia to increase the strength.

The following steps were accomplished in a single appoint- During the CAD phase the technician worked on a digital
ment: prosthesis, resulting from the merging of all the different scans.
He customized the zirconia framework following the zirconia
• The final impression of the lower arch was taken and inside laminate (ZIL) concept,21 occupying the anatomy of the
the position of CR at the correct vertical dimension was tooth as much as possible with the zirconia, minimizing the
registered using the immediate load provisional as the portion of the ceramic layering, and trying to minimize any
antagonist. future chipping.21-23
After CAM production, the zirconia frameworks were
• The new position of the upper arch’s soft tissue was re- tried in to evaluate the passive fit and the occlusal situation
corded, using the provisional restoration as a support for (Figs 19a & 19b).
the impression material. The dental technician finalized the case after the bisque
bake try-in and it was checked for esthetics, function, and
• The provisional was screwed onto the cast and the space spaces for ease of maintaining hygiene. The prosthetic work
between the impression and the plaster material was filled was finalized according to the dental technician’s artistic abil-
with pink silicone. ity while the static and dynamic occlusal accuracy was checked
on the articulator (Figs 20-22). Lastly, the titanium bases were
• The provisional screw-retained restoration was related to cemented on the model with a resin cement (Panavia, Kuraray;
the opposing master model using the CR bite registration Tokyo, Japan).
on the same articulator. The final prosthesis was delivered nine months after the
first consultation, respecting the case’s esthetic, functional, and
• Based on previous provisional information and with the structural goals. Thanks to good planning and a strategic work-
use of updated videos and photographs, the dental techni- flow, the patient’s needs and expectations were fulfilled, opti-
cian fabricated the final prosthesis: a ceramic-layered, mizing costs and overall treatment time (Figs 23-25).
screw-retained zirconia framework on titanium bases in
the upper arch; and in the lower arch, a fixed three-unit
bridge prosthesis and two single zirconia ceramic crowns
were created in the lower left posterior and lower right "A number of clinical studies have
posterior quadrants.
shown the prosthetic and surgical
The case was created and fabricated using CAD/CAM tech-
nology. The accuracy of the laboratory scanner, the dedicated
advantages of using tilted
software, and the accuracy of each step of the digital workflow implants in the posterior regions."
were key to final success.

78 Winter 2018 • Volume 33 • Number 4

 Agnini/Apponi/Agnini

Figure 20: Finalizing the work with two final bakes in which the esthetic characterizations were created before the polishing stage.

Figure 21: Esthetic details of the final restorations. The presence of the Figure 22: Occlusal view of the accuracy obtained in
pink artificial ceramic component made it possible to restore the correct the articulator. Note the framework’s palatal design and
dental proportions and, consequently, the white and pink esthetic thickness, critical to achieving the prosthetic's structural goal.
balance.

Figure 23: Thanks to a coordinated and accurate workflow, the Figure 24: Final zirconia-ceramic layered restoration. The correct
patient’s needs and wants were fulfilled, realizing a prosthesis well- occlusal compensation curves have been restored.
integrated into his smile.

Journal of Cosmetic Dentistry 79

CE—CLINICAL APPLICATION

• The clinician does not need to take conventional impres-

sions, intermaxillary relation, and vertical dimension
during the surgery.

• Because the technician can use the diagnostic wax-up

(which was evaluated at the presurgical esthetic try-in
appointment, utilizing the information provided by the
remaining teeth) directly on the master model, the overall
laboratory time is reduced.

• The dentist and the technician have at their disposal a

unique codified protocol, applicable in all clinical situa-
tions, to build a provisional or a final restoration.2

Figure 25: The three-year follow-up panoramic radiograph confirms Summary

the precision of the protective structure and the correct peri- In a complex multidisciplinary case, the path to the final res-
implant bone levels. Observe the inclination of the implant area,
toration is as important as the restoration itself. Therefore, in
compensated by the 30-degree tilted abutment.
modern treatment plan philosophy, in addition to the tradi-
tional clinical goals of surgical, prosthetic, and functional suc-
cess, the most important objectives are related to improving
the patient’s quality of life not only at the end of treatment but
Discussion also during the entire treatment process.3,18 What guarantees
Potentially edentulous patients or patients with a failing denti- the successful outcome of the final prosthetic rehabilitation is
tion require a thorough multidisciplinary approach due to the its long-term prognosis and stability over time. New technolo-
complexity of clinical and psychological issues present. Patient gies and materials provide excellent tools to simplify workflows
communication plays a primary role in understanding not and facilitate an effective and efficient restoration for complex
only their need for care, but also how to carefully assess the cases. In the case described here, we were able to achieve the
relevant emotional and economic issues.2 esthetic, structural, and functional goals of the prosthetic reha-
Patients with terminal dentition can be divided into two bilitation, and optimize time and costs to the satisfaction of
groups: those with prognostically failing dentition (when the the patient and the entire dental team.
remaining teeth are affected by untreatable diseases and the
prognosis is not adequate for their use as prosthetic supports);
and those with strategically failing dentition (when there are Acknowledgments
remaining teeth with good prognosis whose maintenance is
The authors thank Laura Morselli, DT, Luca Dondi, DT, and Matteo
strategically disadvantageous in the context of the planned
Dondi, DT (Bologna, Italy) for their beautiful technical work.
prosthetic rehabilitation).
These patients often exhibit a fear of dentists/dentistry,
which requires the clinician to present a reassuring manner.
They also often wish to avoid removable dentures, even for References
short periods of time during treatment.
Today, thanks to the reliability of implant therapy and the 1. Merli M. Terapia implantare [Implant therapy]. Milan: Quintessenza Ed-
ability to decrease the number of surgeries as well as the over- izioni; 2013. p. 89-90.
all treatment time, it is possible to meet these patients’ needs.
However, clinicians must be careful not to oversimplify this 2. Biscaro L. La dentatura terminale [The terminal dentition]. Villa Carcina
approach, which requires multidisciplinary skills. (Italy): Teamwork Media; 2016. p.18-20. Italian.
The protocol presented here focuses not only on the surgi-
cal step (which remains an unquestionably important thera- 3. Agnini A, Coachman C, Agnini A. Digital dental revolution: the learning
peutic support), but also on a detailed prosthetic evaluation, curve. Milan: Quintessenza Edizioni, 2014: p. 213-6.
done before the day of surgery. The concept is, in fact, based on
so-called prosthetically driven surgery. The prosthesis was de- 4. Agnini A, Dondi L, Dondi M, Agnini AM. Complex case rehabilitation in
veloped following the protocol of the one-model technique.20 light of the new technologies: CAD/CAM-milled full-arch restoration. J Cos-
This approach offers three benefits: metic Dent. Winter 2014;29(4):18-30.

80 Winter 2018 • Volume 33 • Number 4

 Agnini/Apponi/Agnini

5. Agnini A, Dondi L, Dondi M, Agnini AM. Riabilitazione implanto-protesica 18. Agnini A, Agnini AM, Romeo D, Chiesi M, Pariente L, Stappert CF. Clinical
di un caso complesso alla luce delle nuove tecnologie: un caso clinico [Im- investigation on axial versus tilted implants for immediate fixed rehabilita-
plant-prosthetic rehabilitation of a complex case in the light of new tech- tion of edentulous arches: preliminary results of a single cohort study. Clin
nologies: a clinical case]. CAD/CAM J. 2015 Apr;4(1):2-8.]. Italian. Implant Dent Relat Res. 2014 Aug;16(4):527-39.

6. Poggio CE. Quali materiali in protesi fissa oggi [Which materials in fixed 19. Agnini A, Salama MA, Agnini AM, Salama H, Stappert FCJ, Romeo D. Revi-
prosthesis today?]. Il Dentista Moderno. 2012 Dec 5:40-56. Italian. talize patient solutions: preliminary results from a single cohort prospective
study using Screw-Vent TSVT implants. Quintessence Int. 2014;30(1)5-12.
7. Shackleton JL, Carr L, Slabbert JC, Becker PJ. Survival of fixed implant-
supported prostheses related to cantilever lengths. J Prosthet Dent. 1994 20. Biscaro L, Becattelli A, Poggio PM, Soattin M, Rossini F. The one-model tech-
Jan;71(1):23-6. nique: a new method for immediate loading with fixed prostheses in eden-
tulous or potentially edentulous jaws. Int J Periodontics Restorative Dent.
8. Kotsovilis S, Fourmousis I, Karoussis IK, Bamia C. A systematic review and 2009 Jun;29(3):307-13.
meta-analysis on the effect of implant length on the survival of rough-sur-
face dental implants. J Periodontol. 2009 Nov;80(11):1700-18. 21. Dondi L, Dondi M, Agnini A, Agnini A. Concept Z I L: nouvelle architec-
ture des armatures en zircone [Z I L concept: a new architecture of zirconia
9. Raviv E, Turcotte A, Harel-Raviv M. Short dental implants in reduced alveo- frames]. Réalités Cliniques. 2015;26(3);231-40. French.
lar bone height. Quintessence Int. 2010 Jul-Aug;41(7):575-9.
22. Silva NR, Bonfante EA, Rafferty BT, Zavanelli RA, Rekow ED, Thompson VP,
10. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coelho PG. Modified Y-TZP core design improves all-ceramic crown reli-
Coulthard P. The efficacy of horizontal and vertical bone augmentation ability. J Dent Res. 2011 Jan;90(1):104-8.
procedures for dental implants - a Cochrane systematic review. Eur J Oral
Implantol. 2009 Autumn;2(3):167-84. 23. Koenig V, Vanheusden AJ, LeGoff SO, Mainjot AK. Clinical risk factors relat-
ed to failures with zirconia-based restorations: an up to 9-year retrospective
11. Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, Worthing- study. J Dent. 2013 Dec;41(12):1164-74. jCD
ton H, Coulthard P. Effectiveness of sinus lift procedures for dental implant
rehabilitation: a Cochrane systematic review. Eur J Oral Implantol. 2010
Spring;3(1):7-26.

12. Balshi TJ, Wolfinger GJ, Balshi SF 2nd. Analysis of 356 pterygomaxillary im- Dr. Alessandro Agnini is an adjunct professor, Department
plants in edentulous arches for fixed prosthesis anchorage. Int J Oral Maxil- of Prosthodontics, University of Modena and Reggio Emilia,
Modena, Italy. He maintains a private practice in Modena and
lofac Implants. 1999 May-Jun;14(3):398-406.
Sassuolo, Italy. He can be contacted at [email protected].

13. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP. Implant loading proto-
cols for edentulous patients with fixed prostheses: a systematic review and
meta-analysis. Int J Oral Maxillofac Implants. 2014;29 Suppl:256-70.
Dr. Apponi practices in Modena and Sassuolo, Italy. He can be
contacted at [email protected].
14. Wennerberg A, Albrektsson T. Effects of titanium surface topography on
bone integration: a systematic review. Clin Oral Implants Res. 2009 Sep;20
Suppl 4:172-84.

15. Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma

concept: a 7-year prospective study. Int J Oral Maxillofac Implants. 2010
Dr. Andrea Agnini maintains a private practice in Modena and Sas-
Nov-Dec;25(6):1213-21. suolo, Italy. He can be contacted at [email protected].

16. Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior man-

dibular and maxillary implants for improved prosthesis support. Int J Oral
Maxillofac Implants. 2000 May-Jun;15(3):405-14.

17. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxil-

lary sinus grafting: a clinical, radiologic, and periotest study. Clin Implant
Dent Relat Res. 2001;3(1):39-49.

Journal of Cosmetic Dentistry 81

 AACD Self-Instruction
(CE) Exercise No. jCD32
Implants AGD Subject Code: 690

This Continuing Education (CE) self-instruction exam is based on the article Prosthetic Rehabilitation of a Patient with
Failing Dentition with an Immediate Load Implant by Dr. Alessandro Agnini, Dr. Roberto Apponi, and Dr. Andrea Agnini
CE (pages 70-81).
CREDIT The examination is free of charge and available to AACD members only. AACD members must log onto www.aacd.com
to take the exam. Note that only Questions 1 through 5 appear in the printed and digital versions of the jCD; they are for
3 Hours Credit readers’ information only.

1. The success of a prosthetic rehabilitation 4. The splinting of dental implants in the edentulous arch

a. is measured by its long-term prognosis and stability over time. a. is not necessary as the prosthesis naturally provides stability.
b. improves when a multidisciplinary treatment plan is implemented. b. promotes a better distribution of the occlusal load.
c. varies from case to case due to the unique biological condition of each c. provides a way to limit implant macromovement and promotes faster
patient. healing.
d. is entirely dependent on patient compliance. d. improves the survival rate of both tilted and straight implants.

2. The clinical goals of a modern treatment-planning philosophy 5. The ideal number of implants needed for a full arch rehabilitation

a. should focus solely on improving the patient’s quality of life. a. has not been defined in the literature.
b. are best accomplished utilizing modern diagnostic technology with a b. is fluid, being totally dependent on each individual case.
strict surgical protocol. c. is decreased by combining straight with tilted implants.
c. should be related to its surgical, prosthetic, and functional success. d. is universally considered to be four.
d. vary depending on the patient and his or her clinical presentation.
To take the complete exam, log onto www.aacd.com/jcdce
3. Understanding of a patient’s need for care is

a. best assessed by a multidisciplinary diagnosis.

b. incorporated with both macro and micro diagnostic capabilities.
c. evaluated through good communication with the patient.
d. required for a complete anamnestic medical evaluation.

AACD Self-Instruction Continuing Education Information

Exams will be available for 3 years from publication date for dentists, and 1 year from publication date for laboratory technicians.
To receive course credit, AACD members must answer at least 70% of the questions correctly.
Participants will receive test results immediately and can only take each exam once. A current web browser is necessary to complete the exam.
Verification of participation will be sent to AACD members via their MyAACD account. All participants are responsible for sending proof of earned CE credits to their state dental board or agency for licensure purposes.
For more information log onto www.aacd.com/jcdce.
Contact the AACD at email: [email protected] or phone: 800.543.9220 or 608.222.8583.

The American Academy of Cosmetic Dentistry® is designated as an ADA CERP is a service of the American Dental Association to assist
Approved PACE Program Provider by the Academy of General Dentistry. dental professionals in identifying quality providers of continuing
The formal continuing education programs of this program provider dental education. ADA CERP does not approve or endorse individual
are accepted by the AGD for Fellowship/Mastership and membership courses or instructors, nor does it imply acceptance of credit hours
maintenance credit. Approval does not imply acceptance by a state or by boards of dentistry. AACD designates this activity for 3 continuing
provincial board of dentistry or AGD endorsement. The current term education credits. Concerns or complaints about a CE provider may be
of approval extends from (1/1/2016) to (12/31/2019). Provider ID# 216647 directed to the provider or to ADA CERP at www.ada.org/goto/cerp.

82 Winter 2018 • Volume 33 • Number 4