2013 implant restorative overview

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Restorative OverviewReplace Select™

Nobel Replace Select™ Restorative Overview

Life changing experience !

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The NobelReplace Implant System - Goals

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The NobelReplace Implant System - Goals

HOW DO WE GET THERE?

Key to successful Implant restoration depends

1)Accurate Diagnosis and treatment planning.


• 2)Execution of required Technical procedures.

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• 3)Meeting or exceeding the patient’s realistic expectations

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4)Establishing good patient doctor communication resulting in patient confidence

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Nobel Replace Implant System

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Safety

Color Coding ensures safety by guaranteeing accurate device/material selection throughout the surgical and

restorative processes. Platform 3.5, 4.3, 5.0, 6.0mm

Predictability

Any NobelReplace™ implant in any patient can be very quickly identified by visual inspection eliminating need

for a radiographic analysis or platform measurement etc.

Organizational Benefits

Universal color coding ensures inventory organization and stocking efficiency. It is virtually impossible to open

the wrong package and inventory analysis is simple.

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Nobel Replace Implant System - Color Coding

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The Implant System – Tri-channel Internal Connection

Tactile and Easy to Use

Accurate prosthetic positioningInternal connection with three channels that provide accurate and repeatable indexing of abutment to implant. Positive lock is noticeable when seating an abutment and the abutment is situated correctly in the connection. Once locked, the internal connection resists rotation.

Secure abutment placementThree interlocking channels guide correct abutment placement also in sites with poor visibility and limited inter-occlusal space may compromise the clinician’s ability to manipulate the abutment.

Prosthetic versatilityTri-channel connections supports all forms of restorative solutions

nicolas weidmann, 01/04/2009

Picture Implant geschnitten mit bild blauer connection nebenan (S 10, NobelReplace Boschüre)

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The Implant System - Parts

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Abutment: Anything that Is attached to the implant and remains in the mouth between appointments.

Healing Abutments:

1) Come in various heights.

2) Placed by the periodontist.



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Abutments:

Standard a) “Off the rack” and is never modified b) Abutment placed before the impression – abutment level impressionc) Impression coping picks up Standard Abutment shape and position in the archd) Abutment Replica duplicates the abutment exactly

Custom a) Abutment prepped at the lab (sometimes in the mouth)

b) Abutment placed and torqued at the time crown is deliveredc) Can be one-piece abutment/crown (UCLA abutment)d) Impression at implant levele) Needed to mimic the contours of the soft tissue f) Must have soft tissue duplicated in model



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UCLA Abutments:

Angled Abutment Zirconium Abutment

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Screws:

Abutment a) One size for yellow, blue and green implants b) Different size for Narrow Platform (pink) implant c) Torque to 35 Ncm

Prosthetic a) One size only b) Torque to 15 Ncm only



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The Machine Screwdriver is inserted into the handle. There are two screwdrivers of different shaft lengths in the Restorative

Tool Kit.

Unigrip Screwdrivers Multi-unit Hex Driver Locator Abutment Driver

1) Machine Screwdrivers



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Tools:

1) Manual Screwdriver

2) Manual Torque Wrench

Push with finger or thumb here until the bar bends to desired

torque

Put index finger here to stabilize

wrench



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Manual Torque Wrench

The Torque Wrench directional pin can be removed by unscrewing the pin cap. Your staff will take the pin out when sterilizing the Torque Wrench between patients.

It is critical to ensure that the pin cap is tightened completely before use. If not, the ratchet will click, but

will not tighten the screw.



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Tissue Punch

The Tissue Punch is used to remove any tags of tissue that have grown over the Implant and prevents

complete seating of any abutment.

Put index finger here to stabilize wrench



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Impression Copings:

Closed Tray a) Plastic snap-on, abutment level b) Plastic snap-on, implant level (do not use)

c) Metal screw-retained, abutment level d) Metal screw-retained, implant level

Open Tray a) Metal only b) Screw retained



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Closed Tray Impressions:

Closed-Tray Impression Copings are indicated for:•single implant cases •multiple implant cases when the implants are parallel so that the impression can be removed from the mouth without tearing the impression

Some Closed-Tray Impression Copings stay in the mouth when the impression is removed. They must be loosened from the implants after the impression is taken and they must be reinserted into the impression before pouring the stone.



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Open Tray Impressions:

Open-Tray Impression Copings should be used when the implant(s) are not parallel to each other or the natural teeth and it is unlikely that the impression can be removed from the mouth without tearing the impression material.

Open-Tray Impression Copings are attached to the implants by means of a long abutment screw.

Open-Tray Impression Copings will stay in the impression when it is removed. So they must be loosened from the implants after the impression material has set.



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To loosen the screw and free the impression coping from the implant, the screw of the impression coping must extend through the impression tray so that it can be loosened. The impression tray must be modified to allow access to the screw.



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Be sure to locate the screw before the impression material sets. Once set, loosen the screw, then remove the impression. Turn the screw counterclockwise to loosen it.



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Implant Replica: A replica of the Implant used to reproduce 1) the exact location of the Implant in the prosthetic model, and 2) the surface connection between the Implant and the restoration.

Abutment Replicas

Implant Replicas



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Temporaries:

Healing Cap a) Not tooth shaped b) Abutment level

Custom a) Cement or screw retained b) Abutment or implant level

Engaging: Prevents rotation of the restoration. For single units only.

Non-engaging: For multiple units that are splinted.



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Overdentures:

Locator

Clip/ERA



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Maintenance:

Implants can only be cleaned with implant-specific cleaning instruments that can clean plaque and tartar, but will not scratch the surface. Tartar does not penetrate the implant surface like it does on natural teeth, so it does not require the same planing action to clean the tartar.

Do not use metal instruments around implants to avoid scratching the surface. Scratched surfaces attract more bacteria that could lead to tissue inflammation around the implant.

Although a metal perio probe can be used to measure the tissue height, it should NEVER be used to probe the “sulcus.” The tissue does not attach to an implant as it does to a tooth, and probing will disrupt the tissue junction.



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The Implant System - Fit

FIT OF ANY PART TO THE IMPLANT IS CRITICAL !To verify FIT, a verification x-ray is taken every time any abutment, impression coping, or temporary abutment is

attached directly to the implant.



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FIT OF ANY PART TO THE IMPLANT IS CRITICAL !How to identify inadequate fit:



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Hot Clinical Tip !

DO NOT ANESTHETIZE WHEN SEATING ABUTMENTS

OR COPINGS ONTO THE IMPLANT. Patients should feel

no discomfort when placing and removing implant parts. If

there is discomfort, check for the cause – something is

wrong. Most often, discomfort from placing parts directly

onto the Implant is due to small areas where the soft tissue

has grown or collapsed over the Implant margins and that

tissue is being pinched between the parts. When this is the

case, anesthetize and then use a tissue punch to clear

away the offending soft tissue.

Exercise # 1Posterior Single Units – Snappy Abutment™

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What a difference X-ray angulation can make !



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FOR MULTIPLE UNITS CONNECTED BY A BAR OR SPLINTED, PASSIVE FIT IS CRITICAL !!



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FOR MULTIPLE UNITS CONNECTED BY A BAR OR SPLINTED, PASSIVE FIT IS CRITICAL !!

Implants will never accommodate to even a slight framework misfit !!For that reason ALMOST ALL multiple unit caseswill require indexing and soldering of the connectors, including bar connectors. It is best torequest all abutments/crowns be sent as individualpieces, rather than try to see if a one piece prostheticwill fit.

Index in the mouth using a product like Zap-It. Sendback to the lab for soldering. Try-in after soldering and verify with an X-ray. It is sometimes necessary to index and solder each connector one at a time. But there is no substitute for passive fit.



Soldering Technique

http://en.wikipedia.org/wiki/File:Post-solder_index.jpg

Hands on exercises

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Prosthetic Kit

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Exercise # 1 Posterior Single Units – Snappy Abutment™

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Snappy Abutment:

•Standard abutment

• Snap-fit connection

• Ideal for posterior single implant restorations

• Short profile - used without modification

•Cemented crowns only.


The Snappy Abutment comes in two different collar heights and two prepared abutment heights.

• 4.0mm (regular) 5.5mm (tall)


Collar0.5mm0.75mm, NP Only1.5mm

Collar0.5mm0.75mm, NP Only1.5mm

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Clinical measurements


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Hot Clinical Tip !!

DISINFECT THE IMPLANT AND THE IMPLANT PARTS.

In many cases, when you remove implant parts from the

mouth, there will be a bad odor from bacteria that get into

and around the connections. Always keep chlorhexadine

gluconate 4.0% (Peridex) on hand and use a syringe to

flush the implant, screw openings and soft tissues. It is a

good idea to place all parts in a small cup of chlorhexadine

as they are taken from the mouth.


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1) Seat the Snappy Abutment onto tooth # 13 of the model.

2) Ensure that it is seated all the way down.

3) Clinically, an X-ray would be taken AND SAVED to verify fit.

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4) Clinically, the abutment would be torqued to 35 Ncm. Torque to 15 Ncm on the model.

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Snappy™ Abutment: Quick Placement Review

Remove Healing Abutment Place Snappy Abutment

Torque 35 Ncm

VERIFY FIT WITH AN X-RAY

Looking Good !

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Orientation


When the implant is placed one of the Internal Trichannel Connector receptors should be oriented to the buccal.

As a result, one of the grooves should also be oriented to the buccal. The Snappy Impression Coping has an arrow to show the location of the corresponding buccal groove.

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Place the Snappy Impression Coping.Listen/feel for the SNAP.


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Take the impression with a stock tray (no modification) and PVS or a similar impression material. The Snappy Impression Coping will come out

in the impression.


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Place Snappy Implant Replica into the Snappy Impression Coping.

Clinically, after disinfection of the impression, the case would next be sent to the lab

for pouring of the soft-tissue model and fabrication of the crown.


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Temporizing the Snappy Abutment can

be done simply by using Snappy Healing

Cap to prevent soft tissue collapse.

Or a temporary crown can be made

using the Snappy Plastic/Temp Coping

(engaging or non-engaging). Acrylic is

added to the Plastic/Temp Coping and it

is shaped and polished like any other

custom acrylic temporary.


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Hot Clinical Tip !!!

COVER AND PROTECT THE ABUTMENT or

PROSTHETIC SCREW. Before cementing a temporary or

a final crown, place a small piece of cotton and an easy-to-

remove sealing material over the screw that connects the

abutment to the implant. Good materials to use internally: a

small dab of light-body impression material or gutta percha.

For the openings in screw-retained crowns, place cotton

and cover with composite.

Exercise # 1 Posterior Single Units – Snappy Abutment™

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Exercise # 2Anterior Single Units – Closed-Tray Impression

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1) Place Closed-Tray Impression Coping

on tooth # 8 in the model.

2) Clinically, an X-ray would be taken

AND SAVED to verify fit.

3) Hand tighten with Unigrip

Screwdriver.

4) Fill the Unigrip Screwdriver hole in the

top of the Impression Coping screw with

some wax. If you don‘t, it may be

difficult to seat the impression coping

back into the impression with the

necessary precision.


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5) Take impression using PVS or similar material in a stock tray.

6) Remove impression when set. Closed-Tray Impression Coping will stay ON THE

IMPLANT. The impression will have a negative mold of the impression coping.


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7) Remove Closed-Tray Impression Coping with hand screwdriver (turn

counterclockwise).

8) Attach Implant Replica to Closed-Tray Impression Coping using hand

screwdriver.


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9) Seat Closed-Tray Impression Coping back into impression making sure that the

coping is fully seated with all indexing lined up correctly.

10) Clinically, after disinfection of the impression, the case would next be sent to the

lab for pouring of the soft-tissue model and fabrication of the abutment and crown.


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11a) Place an Implant-level Temporary Abutment (cementable). Hand tighten only.

As with all parts that connect to the Implant, a verification of fit X-ray is necessary.

Clinically, you may simply replace the Healing Abutment. Remember to take an X-ray to verify that the Healing Abutment if fully seated.

Exercise # 2Anterior Single Units – Provisionals

The Cementable Temporary Abutment is seated on the implant and hand tightened. Acrylic is added to the

“sleeve” to create a custom temporary. The temporary is cemented to the

Temporary Abutment with just a tiny amount of temporary cement (it might

be a good idea to add some vaseline to the temporary cement).

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11c) Essix Appliance temporary.

An Essix Appliance temporary can be used over the healing abutment for short term temporization. The trays are easily made using the same equipment used for suck-down bleaching trays, only the tray material is a firm plastic, not rubbery like the bleaching trays. A denture tooth is placed on the model to replace the missing tooth and acrylic or the denture tooth can be used to build a replacement inside the appliance.

Exercise # 2Anterior Single Units – Provisionals

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12) Seat the Custom Abutment and finger tighten.

13) Clinically, an X-ray would be taken AND

SAVED to verify fit.

14) Clinically, the abutment would be torqued to

35 Ncm. Torque to 15 Ncm on the model.

15) Clinically, the crown would be tried-in,

adjusted and delivered (with temporary cement

only – so the crown can be retrieved at a later

time, if necessary). Remember to seal the

opening for the abutment screw with cotton and

gutta percha or impression material.

Exercise # 2Anterior Single Units – Deliver Custom Abutment

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Exercise # 2Anterior Single Units – Deliver Crown

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TempBond Original Kerr MfgTempBond NE Kerr MfgFleck’s Mizzy, IncDycal Dentsply IntlRelyX Luting 3M ESPERelyX Unicem 3M ESPEImprov AlvelogroPremier Implant Cement Premier Products Co


Most radiopacity

Least radiopacity

from Wadhwani C, Hess T, Faber T, Piñeyro A, Chen CS.

CONCLUSIONS: CONCLUSIONS: Some types of cement commonly used for the Some types of cement commonly used for the cementation of implant-supported prostheses have poor radiodensity cementation of implant-supported prostheses have poor radiodensity and may not be detectable following radiographic examination. and may not be detectable following radiographic examination.

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One piece screw-retained crown advantages• no concern with cement removal• cost-effective without use of gold• if tissue recession over time, no visible margin• easily retrievable to modify without destroying crown

(Modified Plaque Index, Sulcus Bleeding Index)(Modified Plaque Index, Sulcus Bleeding Index)

Cement-retained crowns:Cement-retained crowns:MPI & SBI scores: worse over timeMPI & SBI scores: worse over time

Screw-retained restorations:Screw-retained restorations:MPI & SBI scores improved over timeMPI & SBI scores improved over time

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Exercise # 3Posterior Multiple Units – Open-Tray Impression

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Hot Clinical Tip !!!

KEEP THE IMPLANT COVERED. In many cases,

when you remove the healing abutments from the

mouth, the tissue can collapse into the space that

was vacated. To prevent this, it is best to remove

one healing abutment at a time and place the Multi-

unit Abutment as quickly as possible. Remember to

always rinse with chlorhexadine gluconate 4.0%, and,

after placing the abutment, take a verification-of-fit X-

ray.

Posterior Multiple Units

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1) Using the yellow plastic carrier, place

the Multi-unit Abutment with the Multi-

unit Abutment Screw on tooth # 4. Hand

tighten with the Multi-unit hex driver.

2) Clinically, an X-ray would be taken

AND SAVED to verify fit.

3) Clinically, the abutment would be

torqued to 35 Ncm. Torque to 15 Ncm

on the model.

Posterior Multiple Units – Open-Tray Impression

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4) Place the Multi-unit Open-tray

Impression Coping on the Multi-unit

Abutment. Place the Multi-unit

Impression Coping Guide Pin.

5) Hand tighten only.

6) No X-ray is necessary - the

impression coping is not attached to the

implant.


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7) Prepare impression tray by cutting

away an area to allow the Impression

Coping Guide Pin to exit the impression

tray when it is fully seated in the mouth.

8) Take impression with PVS or similar

impression material.

9) Unscrew the Guide Pin completely to

allow the Impression Coping to come

apart from the Implant. Remove the

impression (the Impression Coping will

remain in the impression).


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Exercise # 4Overdenture – Two Locator Attachments

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Resilient tissue-supported overdenture•Mandible: 2 or more implants•Multiple collar heights for variable tissue levels:0 to 6 mm depending on platform•Available in NP, RP, WP

Locator Attachment


Torque to 35 Ncm clinically (15 Ncm on the model)

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Well-fitting denture• Chairside abutment selection by tissue height• Chairside curing of attachments

Denture needing reline• Chairside abutment selection by tissue height• Reline impression over Locator metal housing/black processing male• Laboratory or chairside processing of attachments

Needing new denture• Chairside abutment selection by tissue height• Abutment level impression with impression coping• Laboratory or chairside processing of attachments

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Tissue Depth


The Locator Abutment is selected to be 1.5mm above the tissue height.

Once the abutment is seated, an x-ray must be taken to verify fit.

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• Place a white block-out spacer ring on each abutment.

• The spacer ring is used to block out the area surrounding the abutment.

• Place the metal housings with the black processing males onto the Locator Abutments.


• Use an appropriate method to mark the locations of the Locator Abutments on the existing denture.

• Hollow out the existing denture base in the areas of the Locator Denture Caps.

• Most dentists place a hole in the lingual area to allow excess acrylic to escape and the denture to seat fully.

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• Fill the receptor sites with prosthetic resin (light cure or self-curing resin).

• Apply suitable bonding agent onto Locator metal housings. Lingual connecting holes may be used to anchor the metal housings in the denture.

• Seat denture and confirm proper occlusion (tap, tap, bite lightly).

• Cure resin in light occlusion without compression of the soft tissue.

• Once the resin has cured, remove the denture from the mouth and discard the white block-out spacers.

• Fill in any acrylic voids, remove any excess acrylic and polish the denture.

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• Select replacement males by considering preferred retention and angle of implant divergence.

• Remove the black processing males from the metal housing using the Locator Core Tool.

• 6 lbs. of retention per arch total is recommended (two 3.0 lb males, four 1.5 lb males, etc). But always best to start at the lowest level of retention.

10–20° divergence

8515 8524 8527 8529 8547 8548 8915Processing 5 lbs 3 lbs 1.5 lbs 3–4 lbs .5 lbs 2 lbs


Male Seating Tool•Separate the Male Removal Tool section from the Locator Core Tool and use the Male Seating Tool end to place a new male into the empty titanium metal housing.•The male is fixed firmly in the cap when a click is heard.

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Male Removal Tool Male Seating Tool Abutment Driver

Abutment Driver•The gold-colored end of the Locator Core Tool is used for screwing and unscrewing the Locator Abutments to and from implants and replicas.


To remove the male from the instrument:• Screw the tip clockwise completely onto the middle section. This activates the loosening pin inside the tip, which releases the male.

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Male Removal ToolTo remove a Locator male from the titanium metal housing: • Insert the tip into the cap/male assembly and push straight into the

bottom of the male. • Then tilt the tool so that the sharp edge of the tip will grab hold of

the male and pull it out of the metal housing.

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Locator Male Processing Package

(REF08519-2)


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Locator® Extended Range Male Processing Package

(8540-2)



Clinical case• Seat two Locator abutments

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Clinical case courtesy of J. Bain, DDS


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Hand tighten with the Abutment Driver andTake a verification x-ray.


Torque to 35 Ncm clinically (15 Ncm on the model)

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Photo courtesy of J. Bain, DDSPhoto courtesy of Per-Olof Karlsson, Sweden

Create space in the denture base for the metal housing


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Place white block-out spacer ring over abutment (may need more than one per abutment)


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Photos courtesy of J. Bain, DDS

Inspect for show-through – Ensure clearance!


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Clean receptor sites with alcohol Seat metal housing

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Paint bonding agent on clean roughened acrylic and add acrylic into receptor sites and on metal housing



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Seat denture and confirm proper occlusion (tap, tap, bite lightly)


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Photo courtesy of J. Bain, DDS

Remove denture, fill any voids in acrylic, adjust any excess acrylic and polish denture. Remove the black processing male and insert the selected retentive male into the metal housing.*** It is often best to start with the lightest force retentive male !


Check— • Occlusion• Patient’s manual dexterity

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Photo courtesy of J. Bain, DDS





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• Place a white block-out spacer ring on each abutment to block out the area surrounding the abutment.

• Place the metal housings with the black processing males onto the Locator Abutments.

• Take an impression to pick up the black processing males and the metal housing for laboratory placement of the housing.

• Better yet, complete the reline and add the housings as shown in the last section.






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Locator Impression Coping


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Clinical case courtesy of Allen L. Schneider, DDS

Place white block-out spacer rings, and then place Locator impression copings.


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Photos courtesy of Allen L. Schneider, DDS

Final impression with full extensions and border

molding!

Abutment replicas in place – ready to pour model. Follow

standard denture steps.


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Clinical case courtesy of Allen L. Schneider, DDS

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Exercise # 5Overdenture – Making a Stent

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Before implant placement in the fully edentulous patient,it is required to have defined the proper tooth position.

This can be accomplished by:1. An existing denture 2. A new denture3. A wax try-in that goes unprocessed

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Please put everything back

2013 implant restorative overview

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Transcript of 2013 implant restorative overview