Angulated implants: How would you restore this case?

This is a great opportunity to use your full arch scanner and create a full arch cemented zirconia restoration. Of course you have to meticulously clean up the cement around your C & B abutments. So, no screws to come loose. Good luck.

The way the implants are planned with poor AP spread. you can use the same umber of implants to place 4-5 dental implants with good AP spread and it won't cost you more and it will be a better service to the patient. there is not point is keeping the molars. when you place the implants in the correct position, you can use different Restorative Options to finish the case. Restorative Options are from Overdenture to Fixed Zr bridge, etc. I shall disagree with Dr. Hacker, in regard to cementation. Always do all the effort to make a screw retained prosthesis. You must leave yourself and the patient a way out if a complication happens. it is a rather expensive proposition to have a chipped bridge removed and remade, because it is not retrievable. these things needs to be maintained and if you cement them permanently, you will loose the chance to do so. I hope i could help. and good luck. it is a good case and you should be able to do it well.

I would treatment plan 5 or 6 implants and keep the A-P spread large and the distal cantilever small. The best way to create and correct path of placement in these cases requires custom abutments. You finish the case with a nice cementable fixed partial denture. You can design the case with clensable embrasures and no concavities in the intaglio. I have seen screw retained cases that are practically impossible to clean on a daily basis.

You might consider a Telescopic Trinia bridge over Bicon Short Implants. Retentive Morse Tapered copings hold it in place without any cement (the copings themselves are cemented into the bridge after a unique “self aligning” abutment procedure is used to correct for non-parallel implant bodies. It is easily removed in that you can select retentive and non-retentive copings in a mix. Neither the implants nor abutments need to be symmetrical nor parallel, so you could place an abutment in the lower 2nd bicuspid and the lower molar along with 2 in the anterior segment.

From a restorative parts perspective only - angled screw channel ti bases for zirconia , peek, pmma, trinia, trilor, juvora. Angle correction also through angled multunit's and ontop could be locators, AngleBase (if you need further angle correction). Please contact us at www.dess-usa.com and we can discuss your options for you and your lab.

Hi, Keith is absolutely right. Angle correction abutments and that is it. I see from the image that you are most likely using internal hex, I do too and use Paltop ACS abutments ( they are sold also in the US and are much more convenient than custom abutments. Just keep the cantilever as short as possible and have a good try out before getting things cemented to the abutments, prior to insertion

All the above comments should be taken into consideration. More implants could be better and of course the more distal the better. However to address you question specifically. I never cement bridges and I have never regretted that decision. Retrieveability is one major advantage of implant borne prostheses. The more I do; the more repairs, additions or modifications I have to do. As all of us know, things can go wrong with any restoration and being able to easily remove the bridge and do the necessary is a blessing. However, also being able to remove and clean the bridge and do any required maintenance on the implants is also easy. In regards to the angulation issue, you can place intermediary gingival level abutments on the implants then screw retain the bridge to those abutments. I am not sure what implant system you intend to use but you should discuss this with your laboratory or implant sales rep. When implants are divergent, I used to screw bridges directly to the fixtures but in many cases the different angles made impression taking hard and insertion difficult. Another factor to consider is where the fixture height is. If they are buried deeply, then it can be difficult and very painful for the patient to have the bridge placed and removed (due to gingival collapse). So nowadays (if implants are divergent or buried very deeply), I place individual flat or conical abutments separately on each implant, and then screw the bridge onto those abutments. This way, not only does it make it easy to position the bridge initially, but removal and repositioning is simple and easy - and usually you do not have to touch the individual abutments. It might cost a little more, but it is worth it.

This is a perfect case for all on four o five implants . Trying to graft the alveolus and the AP ratio, don´t seems to me could be better than the All on four technic. You can correct any angulation with multiunits. In addition to that immediate loading

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These type of angulations can be easily corrected by screw retained prostheses utilising Dynamic abutment solutions from Spain. They have Dynamic Ti bases for CADCAM based prostheses and castable abutments for conventional casting also. They give a beautiful passive precision fit prostheses. I have been using since last 4 years

Not to be taking sides, but after having placed and restored thousands of implants , I couldn't agree more with those who are touting the benefits of screw retention. Even if you can confidently remove every last bit of cement (which you can never do), the fit your cementable prosthesis, as with all those "roundhouse" bridges of the 1980"s, would be questionable at best. So, since you have two existing implants in #19 and #20 sites, you can either place an implant in #30 site (you may have to graft) or extract, graft and place an implant in the #31 site or angulate your most distal implant on the right to attain your AP spread. Finally, the anterior implants can be downsized and straightened up enough for a screw retained prosthesis. You may have to perform some alveoloplasty on that anterior ridge to accomplish this...but if you do, it will insure you a better long term prognosis because although you were able to preserve the vertical dimension of the ridge, you don't have enough thickness of bone to maintain the 2mm of bone (and 2mm of tissue thickness!) buccal to the implants for long term stability. Did anyone discuss lipline?!?...Oh so much to consider...Have Fun!!