Part 6- Clinical application of AQB implants
Chapter 1- Examples of the single to multiple implantation treatment– Lack of intermediary teeth
1. A case of implant prosthesis installed into a missing mandibular molar
Director of Ohmori Dental Clinic
Keiji Ohmori
The implant prosthesis treatment is not only considered effective for the recovery of the particular area towhich the implant is inserted, but also in protecting and in facilitating the neighboring teeth,
subsequently leading to improvements in the safety of the remaining natural teeth, and in motivating thepatient in looking after their oral health. Therefore implant treatment can be said to be an effectivemeans to reduce the future tooth loss than when treated with other prosthetic solutions such as bridge
prosthesis or partial denture.
Previously, implant treatment was only considered as the last resort having lost most or all of themasticatory ability, however, the current general consensus is to conduct implant treatment even on
relatively young patients and even in those with only one to two tooth losses. By replacing the missing
teeth in these patients, the probability of conducting pulpectomy or adjustments to the neighboring teeth
can be reduced. Furthermore, it is possible to recover the original occlusion with the natural teeth withsupport from bone. It is evident that the implant treatment has become an indispensible tool both interms of overall protection of natural denture as well as re-fabricating the missing teeth.
In this case study, we report of a successful implant prosthesis treatment in a 23 year-old female with a
missing tooth.
Patient:
year-old
femalePatient:
2323
year-old
femaleFirstadmission:
July
2001
First
admission:
July
2001
Chief
complaint:
Pain
right
side
of themandibletimeof chewing
Chiefcomplaint:
Pain
in in
thetheright
sideof themandibleat atthethetimeof chewing
Treatment
plan:
After
removalof No.
undergoprosthetics
treatment
with
one-piece
typeTreatment
plan:
After
thetheremovalof No.
20,20,
undergoprosthetics
treatment
with
one-piece
type
No. 20 was removed due to an advanced case of periodontal disease. Having waited two months for the
wound to heal, the state of the bone was examined under X-ray radiography. Patient consented to thetreatment after explaining what it entailed (Image-1 to 3).
The implant cavity was constructed with the usual drilling technique once gaining sufficient amount ofview from the alveolar crest incision and a longitudinal incision. The bone quantity was adequate interms of height and width, and the buccal exposure of the HA coating layer was able to be avoided by
implanting the 4 SM size, 2 mm deeper in by than what had been originally planned (Image-4 to 9).
Exertion of excess tension could be avoided by limiting the use of the circular knife to a crescentric motion
on the gingivae periosteal flap on the buccal side. The radiograph taken after the installation confirmedthat the implant body had been inserted with sufficient depth, and that it was inserted in a suitableorientation. The stitches were removed 7 days after the surgery, where the wound healing process of themucosa to have been satisfactory (Image-10 to12).

On the eighth week, the consolidation of the bone surrounding the implant was achieved. When tested
with the probe, it could not be inserted more than 1 mm in depth, therefore confirming the periodontal
tissues to have been recovered to a similar state to those surrounding the natural teeth (Image-13).
The abutment was fabricated on the tenth week, and the implant body fitted with a provisional resincrown for a period of roughly two weeks. It was then subsequently fitted with the hybrid crown as the
final superstructure (Image-14, 15).
A satisfactory progress with absence of any complications was confirmed on observation, even after eight
years since the attachment of the superstructure.
Had the patient requested bridge prosthesis eight years ago instead of the implant, I cannot, as a dental
practitioner, be confident that the bridge would have retained the stability of the neighboring teeth in asimilar manner. I believe it is because of the implant installation that the safety of occlusion, neighboring
teeth and the hygienic environment could be maintained. The factors such as the ease in its management,alongside retaining the patient‟s motivation have played a role in retaining the sufficient level of oral
hygiene. The lack of any abnormal symptoms arising for 8 years till this day, including whole of the oralcavity, can thus be said to be owing to the implant prosthesis. In addition, the regular check-ups by thedental hygienist was another important factor to the satisfactory outcome in the long run.

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Image 1: Dental radiograph at the first medical examination.
Advanced case of bone resorption was observed around No. 20, and was decided, this should not
be left untreated.
Image 2: Dental radiograph 2 months after the tooth extraction. The wound healing process had made asatisfactory outcome.
Image 3: Orthopantomogram featuring the state after 2 month of tooth extraction.
This showed sufficient bone quantity to be present for implant prosthesis. There were no tracesof past dental treatment, and as the dental bridges would have required the milling of adjacent
teeth, implant prosthesis was suggested to the patient instead. To which she gave consent.

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Image 4: Photograph of the oral cavity pre-surgery.
Image 5: Alveolar crest incision was applied using the standard procedure. Sufficient view was able to beobtained.

Image 6: The pre-surgical examination indicated the suitability of 4SM size implant. The implant cavity
was drilled 2 mm deeper than the standard, totaling to 10 mm in depth.

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Image 7,8,9: The depth of the implant cavity was adequate, although some bone cleavage on the buccal
side could be observed. The implant body could be inserted fairly deep into the cavity, therefore
avoiding the exposure of the HA coating layer.

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Image 10: With the aim to fully restore the original state, suturing was conducted carefully to avoid
exerting excess tension to the mucosal flap.
Image11: Post-surgical dental radiograph confirmed the HA coating layer to have been fully inserted into
the bone, and that the orientation of the implant was favorable
Image 12: The view of the oral cavity at suture. Wound healing had shown good progress, but the mucosal
membrane around the implant resulted in gingival bleeding with a slight probing.

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Image 13: Photograph of the oral cavity after 8 weeks. Probing into the soft tissues surrounding theimplant showed the tissues to have hardened, with only allowing the probe to enter 1 to 2 mm in.
The periodontal susceptibility test result indicated -3.
Image 14: Abutment was fitted 8 weeks after implantation and provisional resin crown was then attachedto the implant body.
Image 15: Photograph of the oral cavity, 3 years after the superstructure attachment. Currently, into the
8th year after its installation, there have not been any reports of abnormal symptoms arising.

2. A case where the implant was chosen over bridge prosthesis
Director of Kashima Dental Clinic
Kenji Kashima
The decision as to whether a case should be treated with implants or with dental bridges can be difficult.
However since there are no difference in the cost between the two treatment options, the advantages of
the implant prosthesis to improve taste sensation and hygiene, implant option is perceived to be thesuperior of the two except in cases where surgical invasions should be avoided. The final determining
factor lies in the health conditions of the two neighboring teeth that may become the abutment teeth forthe bridges. Also practically, in terms of minimal intervention, the implant treatment is preferred where
the two neighboring teeth have not been modified.
I present here, a case where dental prosthesis was installed while leaving the neighboring teeth intact.
.

Patient: 60 year-old maleFirst admission: October 2008
Chief complaints: Missing teeth. Requested replacement treatment with bridge or implant
Treatment plan: Implant prosthesis was placed to the right side of the jaw, after the occlusion wasstabilized with the application of bridge prosthesis to the left side of the jaw. There wereintermediary deficiencies and previously treated teeth on both upper and lower jaw on the left

The mesiodistal diameter of the No. 21 tooth cervix was measured to be 6.6 mm in the study model(Image-1). The distance to the maxillary sinus was confirmed to be 10 mm from the radiograph (Image-2)
therefore the 4MS size AQB Implant was selected.
First an incision was applied to the alveolar ridge between the No. 20 and No. 22 teeth to form a flap. The
implant cavity was drilled carefully to avoid any damages to the roots of the neighboring teeth, for the
installation of one-piece 4 MS implant (Image-3). The implementation of CT scan as an examination toolin the recent diagnostic practices has furthered understanding of the conditions; however, the key to a
successful implant surgery still lies in the experienced skills of the surgeon. For example, thecontra-angle handpiece must be held stable, with certainty and to be operated with the utmost discretion.
If possible, it is preferable to apply a surgical guide constructed with simulation software.
The impression for this case example was taken once the buccal portion was prepared after a seven week
post-surgical monitoring period (Image-4). The neighboring teeth were able to be left intact (Image-5).
Platinum added gold alloy (PGA) based hybrid ceramics (Esthenia) was applied as the replacement of themolar teeth. In order to prevent it from fracturing, clearance space was established to accommodate
Esthenia of 2 mm thickness (Image-6). It was then treated with a primer (Image-7) and sand-blasted(Image-8) before its placement with super-bond adhesive.
The missing teeth on the right mandibular was also installed with implant prosthesis (Image-9,-10).

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Image-1: Taking study model measurements
Image-2: The panorama X-ray photograph at the primary examination
Image-3: The dental X-ray radiograph after implant body installation

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Image-4, -5: The neighboring teeth were left intact by using implant
Image-6: Esthenia with the cavity PGA lining.

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Image-7: Treated with primer, then adhered with super-bondImage-8: Sand blast treatment

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Image-9,-10: Implant prosthesis placed on the right mandible.

3. Restoring occlusion by installing one-piece implants to the lower free-end multiple defects
Director of Kashima Dental Clinic
Kenji Kashima
Problems such as dental caries and looseness of the anchoring teeth are relatively frequent encounters in
the long-term use of partial dentures. The most distressful sensation for the patient, especially among
those who are highly sensitive, is where the sense of discomfort of the artificial denture attachment does
not disappear.
Here, we report of a case where a patient came complaining of discomfort from an unidirectionalremovable partial denture on the mandible that was installed 25 years ago (during which period it was
replaced several times), and requested for it to be replaced with implant prosthesis. This problem thatpersisted over the years was able to be solved by installing one-piece implant, which was able to achieve a
rapid occlusal recovery.
Patient: 75 year-old female
First admission: April 2008
Chief complaint: Continuous discomfort felt when wearing the partial denture.
Treatment plan: Three one-piece implants were installed to the No. 28 to 31 positions to recover theocclusion on the left side
A lower extension partial denture had been fitted onto the left mandible however, the sense of discomfort
was never relieved even though this was replaced five times within the 25 years. There were periods inwhich the denture was not worn by the patient, therefore the condition also presented with elongation of
the maxillary molars (Image-1).
In the implant surgery, the alveolar crest incision was applied to the left mandible, and the
mucoperiosteal flap was elevated (Image-2), followed by 4SM, 4SS, 4SS installation, in this order startingfrom the anterior region. Defects to the No.1 tooth were also evident but the installment at this position
was decided against to retain the sufficient level of oral hygiene (Image-3).
The occlusal plane was adjusted by grinding the elongated maxillary teeth in preparation for the dental
prosthesis. Even though the patient was in the seventies, the post-surgical progress was smooth and a
rapid osseointegration could be achieved rapidly, and the impression was able to be taken four weeks later.
This was followed by trials with metal connected crown, and the final superstructure was fitted six weeks
after the implantation (Image-4, -5).
Since the patient was freed from the sense of discomfort of partial denture that she had endured over theyears, she was very appreciative, and commented, “My life has changed. I should have changed to
implant much sooner”.

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Image-1: The presence of elongated maxillary teeth was evident from the pre-surgical panorama
radiograph.
Image-2: The constructed implant cavity
Image-3: Dental radiograph after implantation

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Image-4: The prosthesis was attached six weeks after the installation
Image-5: Panorama radiograph after attachment

4. A case of implant prosthesis to the missing intermediary maxillary molar
Director of Ohmori Dental Clinic
Keiji Ohmori
Due to the high success rate of the implant treatments in the recent years, it has become known as ahighly predictable treatment method. It had previously been used as a means to restore occlusion to thosethat had lost all or most of its masticatory ability. However, with its advantage of not necessitating themilling down of the remaining healthy teeth, it is considered to be one that is superior of the otherprosthetic treatments, such as attachment of the bridges or partial dentures. The current consensus
therefore is to conduct implantation even with the loss of one or two teeth. By the placement of implant
prosthesis to replace few teeth it can contribute to occlusal stability with respect to the disclosing or
adjacent teeth, and thus leading to prevention of further tooth losses.
Patient: 38 year-old female
First admission: March 2006
Chief complaint: Occlusal pain on the right maxillary molars.
Treatment plan: After overall periodontal disease treatment, a two-piece type to be installed toreplace the No. 13.
In 2003, the No. 14 tooth lost was replaced with a one-piece type implant and had been completed up to
the attachment of the prosthetics. The loosening of the No. 13 teeth was discovered by the dental
hygienist at the time of tooth cleaning (PMTC) during the patient‟s visit for a maintenance checkup. The
state was further examined using the X-ray radiography, when No. 13 was decided to be removed.
Informed consent was given to install AQB two-piece implant after conducting a socket-lift procedure(Image-1).
The best position for the application of the incision line usually is thought to be on the alveolar crest.
However, since the width of the alveolar crest was found to be relatively wide, indicating that a stabilized
surgical procedure was possible, the mucoperiosteal flap was formed carefully from the incision line that
extended in the buccal direction instead (Image-2, -3). The implant cavity was drilled using the standard
procedure to the point just below the maxillary sinus, and AQB osteotome was then used to perform
socket preservation technique (Image-4,-5,).
The elevated portion of the maxillary sinus was filled with simplex HA granules (Image-6).
At the time of insertion of size 4102 AQB two-piece type, the pressing force was restricted to a minimum
to avoid causing any damages to the mucous membrane of the maxillary sinus. The insertion procedure
was done carefully, relying solely on the rotational force of the ratchet movement (Image-6).
The surgery was completed with a three-stitch suture. The postsurgical X-ray radiography confirmed anelevation of 3 mm thickness in the sinus floor (Image-10, -11).
The healing abutment was placed, ten weeks after the initial installation, as a secondary procedure. The
periodontal susceptibility test was -3 (Image-12). The hybrid crown was fitted onto the straight abutment
after adjusting its orientation. Concurrently, the superstructure of the No. 14 was also replaced (Image-13
to -15).
The postsurgical progress was satisfactory, and there have not been any reports of abnormal symptoms

such as bone resorption, three years later (Image-16).

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Image-1: No. 6 position had been placed with one-piece type roughly three years ago. Two-piece type wasselected for No. 5 position.
Image-2: The incision line was applied in an arch-shape that extended to the buccal side. The woundhealing process is thought to be improved if the incision line is designed so that it does not lie on
top of the healing cap.
Image-3: Flap elevation

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Image-4: Drill with a drilling guide
Image-5: Performing socket-lift procedure using osteotome. The damages and fissures to the mucosal
membrane of the maxillary sinus can be avoided by a gradual elevation of the maxilla and fillingthe space with grafting agents.
Image-6: Boneject (Koken Co., Ltd.) as the HA granules, was injected, using the plastic syringe madespecifically for bone grafting.

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Image-7: The AQB two-piece type implant was removed from its case for it to be inserted.
Image-8: Where the socket lift procedure has been performed to facilitate implant installation, theimplant cavity depth should only be inserted further using the rotational force, and limiting thepressing force to a minimum. The risks of the implant body entering further in than planned
increases and could lead to perforating through to the maxillary sinus if too much pressure isapplied.
Image-9: Placement of the healing abutment

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Image-10: Oral cavity, post-suture
Image-11: Postsurgical dental radiograph, confirming 3 to 4 mm elevation.
Image-12: Healing abutment was fitted ten weeks later, and impression was taken two weeks after that.
Image-13: The state of the oral cavity, after the placement of the abutment.

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Image-14: Provisional crown attached
Image-15: Final placement of hybrid crown as the superstructure.
Image-16: There have been no reports of abnormal symptoms with either No. 13 or No. 14 implants since
their installation for roughly 3 and 5 years ago.

5. A case where one implant was used as an anchor tooth to stabilize an artificial denture
Director of Kashima Dental Clinic
Kenji Kashima
There are situations in which multiple implant installation in the elderly is not possible, for reasons of
their wellbeing and financial circumstances.
Here, we report a case where No.18 tooth was the only tooth remaining, acting as an anchor for a partial
denture, but due to a significant resorption of the alveolar ridge the partial denture had become unstable.
To which case, AQB one-piece implants was installed to act as the anchoring tooth achieving stability ofthe denture.
Patient: 77 year-old female
First admission: April 2006
Chief complaint: Instability of the partial denture on the mandible. The patient requested its
replacement.
Treatment plan: Install one-piece implant to the No. 27 and 28 positions to act as the anchor teeth
for stabilization of partial denture.
The patient came to the clinic complaining of difficulty to chew due to the instability of the partial
denture. The No. 18 tooth was the only tooth remaining, and was acting as an anchor with wiring, but theoverall resorption of the alveolar ridge (Image-1) had caused the partial denture to become unstable.
AQB one-piece implant, 4MS was installed into No. 27 and 28 positions (Image-2), and waited for thebone integration to be achieved with the application of a denture by drilling a hole at the positions that
corresponded to the implant abutment. The metal-base denture that had been worn on the mandible had
been constructed by another dentist a year earlier. The drilling into the metal denture was so hard thatthe time and effort that it took to drill though the metal, was more than the implant insertion.
Impression for fabrication of the superstructure prosthesis was taken six weeks after the implantation(Image-3), and concurrently, the hook wire was prepared for the anchoring tooth.
Having gained anchorage in the left mandible as well as the No.18 position (right mandible), the denture
was able to be finally stabilized, relieving the patient from the unease and dissatisfaction felt when eating(Image-4,-5).
Two years have passed since the installation of implant, yet there have not been any complaints of
discomfort (Image-6,-7). The cost effectiveness of this treatment was high since the patient has continued
using the denture that had been constructed previously.
This example differs from those cases whereby the installation of the multiple implants to result in theremovable prosthetics, but it is similar in terms of significant improvements made with insertion of
one-piece implants.
To overcome the drawbacks of implant treatment such as that the outcome can be influenced by thepatient‟s health or financial circumstances, these types of treatments could be the key, and should become
more common in the future.

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Image-1: A significant bone resorption of the mandible was evident.
Image-2,-3: Dental radiograph after the implant installation, and the placement of the superstructure.

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Image-4: Preoperative image of the oral cavity
Image-5: Image of the oral cavity after the placement of the superstructure.

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Image-6: The state two years after the implant installation.
Image-7: Dental radiograph two years after the implant installation.

6. A case where a denture was fitted using implant as an anchor
Chief Director of Niwa Dental Office
Ken Niwa
The implant treatment is usually complete with the placement of fixed bridge prosthetics however there
are instances where a removable prosthetics has to be used. The patient in this example arrived at theclinic complaining of dysfunctional occlusion.
Patient: 66 year-old female
First admission: October 2006
End of treatment: May 2008
Chief complaint: Could not chew due to the pain felt with the use of artificial denture.
Treatment plan: Socket-lift procedure and GBR, in conjunction with the installation of implants to
act as the anchor for the placement of Dolder-bar overdenture.
Patient‟s maxilla had been significantly resorbed (Image-2 to -6). The artificial denture had become
displaced with the majority of the jaw ridge disappearing. Fixed bridges can be applied even to thesecases by applying techniques such as sinus-lift procedures. However the danger lies in overlooking theimportance of improving the overall dental profile. Adverse reactions have been induced and encounteredin the past in neglecting this factor.
The C-ray radiography straight after the implantation is shown in Image-7. Two-piece type implant, 4082
and 4102 were implanted in conjunction with sinus-lift and GBR techniques.
The secondary surgery was conducted roughly 20 weeks later (Image-8 to 11), with the abutment
installed once gingivae had stabilized (Image-12) and then the impression was taken with the Dolder-bar.
The placement of artificial denture was completed with the standard procedure (Image-13,-14). The
dental profile was significantly improved from its preoperative state (Image-15), and the patient was
satisfied with the treatment outcome.

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Image-1: The preoperative profile. The cheeks are sunk in, with a low vertical occlusal height.
Image-2: Preoperative radiograph. The vertical distance of the bone is non-existent, at the No. 11
position.

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Image-3,-4,-5,-6: The oral cavity interior featuring an extremely destabilized denture, along with themaxilla that is significantly resorbed. Chewing is evidently difficult with this condition.

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Image-7: Postoperative radiograph. After GBR and the sinus-lift procedures, the two-piece type implant
was sufficiently installed.
Image-8: Image of the maxillary ridge before the secondary surgery.

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Image-9: The position check of the implant with probing.
Image-10: The No. 11 position at which GBR technique was conducted is filled with sufficient bonequantity.
Image-11: It is necessary to confirm the condition of the healing abutment with X-ray radiography.

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Image-12,-13: The abutment was placed two week after the secondary surgery. Even though there weretraces of gingival inflammation, the placement was still possible as the Dolder-bar margin wasset over the ridge.

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Image-14, -15: The completed Dolder-bar supported partial denture. The palate is left uncovered sincefirm support can be established (Collaborator: Mr Takahashi, Takahashi Dental Clinic, Oogaki,
Gifu-prefecture).
Image-16: Improved dental profile. A significant modification in the facial structures can be observed incomparison to the state before the surgery. It probably feels like the denture has been restored toits original state.

7. A case of safe insertion and prosthesis of 3 mm diameter AQB implant into regions other than theanterior teeth of lower mandible.
Director of Kinebuchi Dental Clinic
Takao Kinebuchi
Originally, the AQB implant with 3 mm diameter was developed with the intention of installing it to theanterior section of the mandibles, since this narrow body had the tendency to lead to traumatic bone
resorption or fracturing, when placed in the molar regions where it was subjected to strong masticatory
forces. For this reason, the AQB implant of this size had only been used in the anterior teeth in themandible up till now.
Initially, 4 mm diameter implant was planned to be used in this example, however, upon opening the flap,
it was discovered that the 4 mm size would be too wide and only the 3 mm size would be a suitable fit. It
was therefore decided that the connected crown would be placed with the installation of multiple
implants. The implant installation was initiated in 2003 to a region other than the anterior section of themandible (For details of the treatment plan, refer to Part 2, Chapter 4 of this book).
The patient had lost four of her anterior teeth where aestheticism is considered important. The treatment
plan for achieving an aesthetics finish that was devised by the author (refer to Part 6 Chapter 6 of thisbook) was followed, which enabled aesthetic finish to be retained till now.

Patient: 51 year-old female
First admission: September 2004 (Image-1,-2)
Chief complaint: Missing teeth, No.7 to 10 and No. 29 to 30, referral from another clinic for implant
to replace the missing teeth.
Primary treatment plan: Implant into the positions No. 29 and 31 for anchorage for bridge
placement for occlusion support of the left mandible.
Secondary treatment plan: Implant into positions No.7 to 10, and attachment of connected metal
bonded crown.
On October 22nd 2004 implants of sizes 4MM and 5SS were inserted into the No. 29 and 31 positions,
respectively, followed by the bridge placement on the January 29th 2005 to establish occlusion of the left
molars (Image-3,-4). On March 11th 2005, 3ML, 3MM, 3MM, 3ML, were inserted into the positions No. 7
to 10, respectively (Image-5-a,b, -6). Those that gave rise to a narrow occlusal clearing were milled downprior to the impression taking for the connected crown. On the next day, after the antiseptic wash
(Image-7), the connected temporal crown was provisionally attached with Neodyne (Zinc oxide-eugenol
cement), after the surface of the abutment was matted for finish (Image-8).
The suture was removed a week later, and after 2 to 3 days, tooth brushing was initiated with a soft brushspecifically designed for postoperative use, in a stoking manner. This then progressed to the level ofnormal tooth brushing in a period of three weeks. A through tooth brushing was conducted with a normal
type of tooth brush in the following month.
On May 27th of the same year, the temporary crown was removed (Image-9,-10) and the impression was
taken for the fabrication of connected crown. As mentioned in the chapter of a devised plan for aesthetic
finish, first, it was cast to the point below the gingival margin, in a similar manner to the impression

taking for natural teeth. It should be noted here that the abutment is positioned lower than that of thenatural tooth therefore there is no need for the formation of heavy chamfer or shoulders to form aboundary between the abutment and the gingival epithelium. On 10th June, the connected metal-bonded
crown was placed (Image-11-a,b,c). Due to the fragile nature of 3 mm AQB implant, as it carried a risk offracturing, the silicon mold was taken directly to the technical workshop for filling with epoxy-resin tofabricate a working model (Image- 12-1,b,c). A general cause for concern on the technical aspects is that in
the typical removable separated die-type working model, fixed with dowel pin, the prosthesis cannot
completely sink in due to a slight freedom in movement of the dowel-pin. For this reason, it was essential
to ask for a removable non-separable-dye-type working model.
At the time of checkup on the November 15th of the same year, the absence of any abnormal symptoms
was confirmed with the dental X-ray radiography and with gentle probing 8 months after the implantinstallation, and 5 months after the prosthesis placement. The subsequent follow up a year and a month
later, on April 19th 2006, since implantation (Image-16,-17), or two years on, on the March 26th 2007
(Image-18, 19) both confirmed its satisfactory progress.

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Image-1, -2: Panoramic radiograph at the time of first medical examination (09.18.2004)
A temporary crown that is close to a full bridge has been placed on the maxilla. A bridge that isanchoring only on natural teeth carries an extremely high risk, therefore, there was a request toplace implant prosthesis to the positions of No. 7 to 10 and No. 29 to 30.

34Image-3,-4: 4MM and 5SS were installed (10.22.2004) followed by bridge placement (01.29.2005). Imageof the oral cavity, and a radiograph shown at the time of gaining occlusal support on the left
mandible.

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Image-5-a,b: Dental radiograph taken right before excision of the pontic from the temporal bridge(03.11.2005).
Image-6: Dental radiograph right after the installation of the implants, 3ML, 3MM, 3MM, 3ML to the No.

7 to 10, having excised pontic of the temporal bridge.

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8Image-7: Image of the oral cavity at the time of antiseptic wash, the next day (03.12.2005). To securesufficient amount of occlusal clearance, some parts were milled down, for provisional attachmentof the connected temporal crown which had been matted with diamond point. Neodyne was usedas the adhesive.
Image-8: Image of the oral cavity at the time of attachment of connected temporal crown.

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Image-9,-10: Image of the oral cavity, before and after the removal of temporal crown. The connected
temporal crown was removed 2.5 months after the installation (05.27.2005). The impression was
taken for the connective crown.

11-a
11-b
11-c
Image-11-a,b,c: Image before the placement of chrome plated connective crown (06.10.2005). As theimplant of 3 mm diameter is very narrow, it does not have much lenience for various abutment
orientations. Therefore it is necessary to prioritize its parallelism at the time of installation.

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12-b

12-c

Image-12-a,b,c: The superstructure that was removable, non-separating die type was fabricated withepoxy resin. To achieve a good emergence profile, it is designed so that the crown emerges fromdirectly off the margin, and also taking into account of the need for the brush tips to reach theperi-implant pockets to maintain a sufficient level of hygiene.

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Image-13-a,b: Image of oral cavity interior at the placement of connective crown.
Image-14: Dental radiograph at the placement of the connected crown. At the placement of the crown,occasionally, gingivae are known to become temporary ischemic due to exclusion with pressure
application, but in general, the peri-mucosal membranes adapt to the change in crown placement,
and can resume the blood circulation in 15 to 20 minutes.

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Image-15-a,b: Images of the oral cavity from the front and at an angle, eight months from the time of
implantation, and five months from prosthesis placement (11.15.2005).

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Image-16,-17: Dental radiographs of the oral cavity after a year and a month since implantation(04.19.2006).

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Image-18,-19: Dental radiograph of the oral cavity, two years after the implantation (03.26.2007), showedsatisfactory progress.

8. A case where a firm occlusal support was able to be achieved by “delayed-loading”
Director of Kinebuchi Dental Clinic
Takao Kinebuchi
There are instances where stabilization of dentures is made difficult for those with occlusal contact solely
at the anterior teeth, or those that reach B-4 in Eichner‟s classification, or worsened with other factors
such as attrition or periodontal diseases even if they are not crossbite occlusion. In such cases, gaining
occlusal support is of prime importance which is usually possible with implantation, but there are always
the exceptions.
Here, a case is reported where implantation was not possible since the bones surrounding the extraction
socket had not been set. Delayed loading method (refer to Page 68, Part 2 Chapter 4 „Treatment plan‟)
was chosen for this example instead, and rapid occlusal recovery could be achieved.
Patient: 61 year-old maleFirst admission: May 2005
Chief complaint: Displaced occlusion, requested to correct it.
Treatment plan: The implantation in the order, No. 28 to 30, followed by No. 10 to 13 is the mostdesirable to establish the occlusion on the molars first, however, as the No. 11 andNo. 28 tooth were only recently extracted, these sites had to be left to heal. First,
the implants were installed and prosthesis placed primarily to No. 29 and 30. The
prosthesis placement was delayed to the implant at No. 28. Meanwhile, a partial
plate denture was constructed for No. 10 to 15 in order to temporarily set theocclusion.

The No. 11 and No. 28 teeth had been extracted six months ago (Image-1,-2,-3,-4). First, the denture forthe placement at the positions No. 10 to 15 was fabricated, and was placed on June 10th with slightocclusal correction.
The 5MS implants were installed to the positions No. 29 and 30 (Image-5). Image-6 shows the state of theoral cavity after two months. On October 17th, gold-alloy crown was fitted onto the No. 29 and 30 implants(Image-7,-8), which aided in establishing the left molar occlusal support. The occlusion was corrected bymodifying its vertical distances, and the anterior teeth of the maxilla were corrected to the height thatwas elevated with composite resin fillings. Implants of sizes, 5SS, 4MM, 4MM were implanted into thepositions No. 11 to 13 (Image-9), the implant to the positions No. 12 and 13 were installed after thesocket-lift procedure. The denture was then cut into an arch shape.
On December 26th, a gold alloy crown was fitted onto No. 13, and connected metal bonded crown wasplaced onto No. 11 and 12 (Image-10,-11). The No.10 structure has been upheld by the artificial tooth ofthe plated denture. Implant, 5MM was planted into position No. 28 on March 3rd in the following year,with a delayed (Image-12). Image-13 shows the state of the oral cavity, two and a half months after the
implantation. On May 30th, mesio-pontic attached metal bonded crown was fitted onto the implant at No.
28 position (Image-14,-15). On July 19th, 4LM implant was implanted into the position No. 10, with thedelayed implantation procedure (Image-16,-17,-18). As an AQB metal bonded crown had already beenplaced on the No. 11, Y-shape incision was made instead of alveolar crest incision to prevent gingival

structures on both front and back of the alveolar crest from being affected. As a matter of fact, the author
has been applying this Y-shaped incision not only to the parts that are affected by the aesthetic prosthesis,but as a general incision making method for 6 to 7 years.
The metal bonded crown was placed to the No. 10, on October 16th (Image-19, 20, 21, 22). The unstable
occlusal contact just on the frontal teeth section, was corrected early on in the procedure by primarily
restoring the occlusal support at the No. 11 to 13 and No. 29 to 30. As the bone loss after the tooth
extraction of No. 10 and No. 28 was large, the implants were installed using the treatment method for thedelayed installation once the bone of the extracted socket had set sufficiently. This achieved a strongocclusal support in the molar sections of the jaw.

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Image-1, -2, -3, -4: Panoramic radiograph at the time of primary medical examination and images of in
the oral cavity. The No. 10 and No.28 teeth were extracted 6 months ago in the previous clinicthat the patient was referred from (04.19.2005).

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Image-5: Dental radiograph appearance at the time when placing 5MS implants to the No. 29 and 30
positions (05.25.2005). A partial denture was fitted onto the No. 10 to 15 implants after sufficientelevation of the bone.
Image-6: The state of the oral cavity, two weeks after the implantation to positions No. 29 and 30(07.27.2005).

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Image-7, -8: Dental and Panoramic radiograph appearances after the placement of gold-alloy crown to thepositions No. 29 and 30. The left molar occlusal support was able to be achieved. Simultaneously,
the elevation of occlusion was conducted by applying composite resin fillings to the frontal teethof the maxilla to adjust it to the height of occlusion (08.17.2005).
Image-9: Dental radiograph after implantation of types 5SS, 4MM, 4MM to positions No. 11, 12 and 13.

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Image-10, -11: Image of the oral cavity, after the placement of gold-alloy crown to the position No. 14, andconnected metal bonded crown to No. 12 and 13. The No.2 structure is secured with the artificial
tooth of the plated partial denture (12.26.2005).

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Image-12: Dental radiograph after the 5MM implant was installed with a delay, onto position No. 28.
Image-13: Image inside the oral cavity after two and a half months since installation at position No.28.

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Image-14, -15: Image of the oral cavity, and dental radiograph featuring the placement of metal-bonded
crown attached with pontic on the mesial side, to No.28 position (05.30.2005). The neighboring
tooth on the mesial side of the implant was slanted in the mesial direction. If the crown isinstalled that is in contact with the neighboring tooth, it would result in a crown that has anunnatural over contouring profile that is difficult to maintain a sufficient level of hygiene. Thisissue was solved by the placement of the crown with pontic. Advice to the patient to not only
brush the area, but also to thread the dental floss through the pontic, to clean the pocket that ispresent close to the tooth root, in the area around the implant.

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Image -16, -17,-18: Image and dental radiograph of the oral cavity at the time of delayed installation of
4LM implant to the position No.10. As AQB metal-bonded crown had been placed onto position
No.11, the mucosal membrane on the front and back of the alveolar crest (gingivae) were incisedin a Y-shape to preserve the gingival structure (07.19.2006).

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Image-19,-20,-21,-22: Dental radiograph and Image of the oral cavity at the time of metal bonded crownplacement to the No.10 position. Delayed implantation was conducted to allow the extraction
pocket for it to be set, and resulted in establishing strong occlusal support (10.16.2006).

9. A case study where the implant body has been installed into the tooth extracted pockets to retain
occlusal stability.
Director of Matsumoto Dental Clinic
Yasugi Matsumoto

Patient: 36 year-old female
First admission: February 2001
Chief complaint: Inability to chew
This patient was referred from another clinic having extracted No. 29 to 31 teeth in preparation for
implant treatment.
Occlusal stability was achieved after three AQB one-piece implants were installed and prosthesis placed.
The patient lost molars on the right of the maxilla, two years later.
Facilitated with the socket-lift technique, three implant bodies were installed and prosthesis placed,occlusal stability was able to be established.
Loss of No. 6 and No. 18 teeth followed 5 years later. Two implant bodies were installed into No. 18
extraction socket, and another implant to No. 6.
Patient‟s request to retain the occlusal stability of the whole jaw was able to be met by inserting theimplant bodies to replace the lost teeth. Thus led to patient satisfaction, and have been able to retain ahigh level of QOL.

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Image-1: Image of the oral cavity at the time of primary medical examination.
Image-2: Panoramic radiograph at the time of primary medical examination.

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Image-3: Panoramic radiograph after the implant body installation
Image-4: Image of the oral cavity after the placement of superstructure.

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Image-5: Panoramic radiograph after the placement of superstructure.
Image-6: Image of the oral cavity before implant to the right side of the jaw.
Image-7: Image of the right maxilla during surgery.

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Image-8: Panoramic radiograph after implantation.
Image-9: Image of the oral cavity after the placement of the superstructure.
Image-10: Image of the oral cavity after the placement of the superstructure.

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Image-11: Panoramic radiograph after the placement of the superstructure.
Image-12: Image of the oral cavity before implanting into No. 18 and No. 6 positions.
Image-13: Panoramic radiograph before implanting into No. 18 and No. 6 positions.

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Image-14: Panoramic radiograph after implanting into No. 18 and No. 6 positions.
Image-15: Image of the oral cavity after the placement of the superstructure.
Image-16: Panoramic radiograph after the placement of the superstructure.