Dr Ghazy 2013 Implant Lectures for 4th year students

8/23/2019 Dr Ghazy 2013 Implant Lectures for 4th year students

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Fourth Year Class 2012/2013

IMPLANTSUPPORTED FIXED PROSTHESISBY DrMohamed H. GHAZYFebruary 10, 2013

Implant prosthodontics : The phase of prosthodontics

concerning replacement of missingteeth and/or associated

structures by restorations thatare attached to dental implants

A prosthetic device of alloplastic materialimplanted into the oral tissue beneath themucosal or/and periosteal tissue for fixedor removable prosthesis.

What is a dental implant ?

Indication & contraindicationIndications Single tooth loss

Inability to wear a removable P.D.

Free end distal extension

Need for long span FPD with

questionable prognosis Unfavorable number and location

of potential natural tooth abutment

Contraindications Lack of operator experience

Smoking

Pregnancy

Psychiatric disorders

Tumoricidal radiationto implant site

Antimetabolictreatment

Uncontrolled cardiovascular problems

Immunosuppression(chemotherapy,HIV, etc)

Bone diseases, such asHistiocytosis X,Paget's Diseaseand Fibrous Dysplasia

Uncontrolled hematologic disorderssuch as GeneralizedAnemias,Hemophilia

Endocrine disorders, such asuncontrolledDiabetes Mellitus,Pituitaryand Adrenal insufficiency andHypothyroidism

Treatment planning for implant patientIndication &contraindication

Clinical evaluationAdequate bone and anatomic structureVisual inspection & palpationFlabby excess tissuesBony ridgesSharp underlining osseous formations and undercutsRadiographic evaluation

Panoramic view with small radio opaque referenceCephalometric film to evaluate bone widthCT scan to locate inferior alveolar canal & maxillary sinuses

Diagnostic castsStudy the remaining dentitionEvaluate residual boneAnalyze maxillo-mandibular relationshipDiagnostic waxing and surgical templates

Bone soundingWith probe judging the soft tissue thickness and bone soundness
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SubperiostealTransosteal

Endosteal plate

form

Endosteal

root form

To the left you can

see a typical modern

Root form Implant

and to the right of

the implant is a

picture of a naturaltooth.

One can see how the

implant is designed

to replace the root of

a tooth by the

somewhat apparent

similarity.

Screw Retained

Transocclusal

Screw RetainedTransversal

CementedFixed Partial

Denture

Implant supportedprosthesis may be

OSSEOINTEGRATIONA direct structural and functional

connection between ordered living boneand the surface of a load carrying implant

Swedish professor of orthopedics namedPer-Ingvar Branemark

in 1965 he used the first titaniumdental implant into a humanvolunteer


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Implant most commonly used from

*Commercially pure (CP) titanium

*Titanium-aluminum-vanadium alloy

(Ti-6Al-4V)- stronger & used w/ smaller diameterimplants

Why Titanium lightweight biocompatible corrosion resistant (dynamic inert oxide

layer)

strong & low-priced

Principles of Implant locationAnatomic limitation

General guide lines

Ideal bone should be 10 mm vertical and 6mm horizontal

Two mm above the superior aspect ofinferior alveolar canal

Five mm anterior to mental foramen

one mm from the periodontal ligament ofadjacent tooth

Three mm between 2 implant to ensure bonevitality.

Anterior maxilla

1- Minimum of 1 mm between the

implant apex and nasal vestibule 2- Implant slightly off midline on either

sides of incisive foramen.


Posterior maxilla

Bone ess dense, arger narrow spaces, and thin cortex

1- One implant for every tooth 2- One mm of bone between the floor of

sinus and implant



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Anterior mandible

1. One implant placed through theentire cancellous bone

2. Five mm anterior to the foramen


Posterior mandible

1.Two mm above the superior aspect

of inferior canal

2. More time required for integration

3. Attachment of mylohyoid muscle


Principles of Implant locationRestorative consideration

Implant placement1- Stay 1mm from the adjacent natural tooth but not so far

to for contouring restoration

Less ideal loc ation

2- Long axis of implant should be positioned in the central

fosse of the restoration

Principles of Implant location

Restorative consideration

Implant placement

Naturaltooth

Ideal

implant

placement


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Implant and restoration size1-Size should be considered during treatment planning 2- 4mm diameter for maxillary central

3- 3mm for mandibular incisors

4- 5-6mm for molars

Surgical guideTemplate extremelyuseful for anterior

implantObjectives

1- Delineate the embrasures

2- Locate the implant withinthe restoration contour

3- Align the implant withinthe long axis of therestoration

4- Identify the level of CIJor tooth emergence fromthe soft tissue

Wax model of a tooth to be replaced in the surgical guide


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Surgical guide template

Stent used as guide for implant placement

Surgical guide for correct

implant placementImplant surgery

Surgical access

Implant placement

Postoperative evaluation

Implant uncover

Guide drill / 2mm twist drill / Pilot drill / 3mm twist drill / Countersink


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Implant restorationsSignificant factors for success1- Precise placement2- A traumatic surgery3- Unloaded healing4- Passive restoration

Fourth year Class 2012/2013IMPLANTSUPPORTED FIXED PROSTHESIS

BY DrMoHAMeD H. GHAZYFebruary 17, 2011

Implant fixture

Abutment

Retaining screw

Abutment screw

Components of an

implant restorationComposite resin

Screw- retained implant

restorations consist of

three components.

(a) Implant fixture

(b) Abutment

(c) Restoration

- The abutment screw secures

the abutment to the fixture

- The prosthetic retention

screw secures the prosthesis to

the abutment.

Gutta percha

Restoration


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Dental ImplantShould promote bone in-growth.

Structure and geometry differences arethe selling point for most companies.

Prosthetic CrownLook and feel of real tooth.

Easily replaced.

Implant Abutment

Secures the crown to the DentalImplant. Can be straight or angled

depending on implant location

Type I bonehomogenous, compact boneType II boneThick compact bone layer surrounding acore of dense trabecular boneType III bone

Thin cortical bone layer surrounding acore of dense trabecular bone of goodstrengthType IV boneThin cortical bone layer surrounding coreof low density .

Lekholm and Zarb bone type classification

Bone density is a key factor when predicting implant stability.

Impression post Closed tray

Impression

Imp post & analog

Imp post & analogrelocated on the

impressionPolyether soft tissue

injected around

analog beforepouring

Implant restorations

Imp post & analogconnected


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Poured cast

Impression copinglocates the analog in

the same position inthe cast as theimplant in the mouth

Contouring of thesoft tissue material

Zirconia abutmentseated on cast Zirconia abutment

seated in the mouth

Zirconia abutmentfor cement retained

restoration selected

Implant insertion into

the prepared socket

Unscrewing the abutment from the implantfixture, screw covering and suturing


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Removal of the cover screw inthe 2nd stage and abutmentattached to the fixture as a

coping ready for impression

The abutment removed from the implantfixture

Abutment and its implant analog andrepositioned in the impression

Abutment prepared to its final form in the

working cast


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Prepared abutment and final restoration

in the patient mouth

Dental ImplantShould promote bone in-growth.

Structure and geometry

differences are the selling pointfor most companies.

Prosthetic CrownLook and feel of real tooth.

Easily replaced.

Implant Abutment

Secures the crown to the DentalImplant. Can be straight or angled

depending on implant location

Titanium

screw

Clinical Implant system components

Hydroxylappetitecoatedscrew

HydroxylApatitecoatedcylinder

Titanium plasmasprayed cylinder

Implant body

Titanium screw

Is the component placed within the bone during1ststage surgery

Two images showing two different types of tapered,cylindrical implants. One looks like a Christmas treewith finsprojecting out to the sides; the other shows a special surface

treatment consisting of spherical titanium beads.


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Cover screwIt is the component placed over the dental implant during theosseointegration phase to seal the occlusal surface of theimplant and prevent tissue from proliferating into the internalportion of the implant bodyIt should be of low profile to facilitate the suturing of softtissue tension _free.

Healing abutment

A- screw into implant

B- Screw into abutment(healing cap)

Dome shaped 2-10 mmscrew placed on the implantafter the 2 and stagesurgery & before insertionof the prosthesis

Healing Abutments

Transgingival Titanium piece whichwill form the soft tissue

Selected considering the

Emergence Profile needed for therestoration and the tissue height

Healing Abutments

Necessary Information:

Healing Abutment Height

Platform Diameter (normally same asimplant diameter )

Healing Abutment Diameter (EPProfile

Height

RestorativePlatform

EP (EmergenceProfile)

/ /


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Healing AbutmentsAbutmentComponent of the implant system thatscrew directly into the implant to supportand or retains a prosthesis or implant

superstructure

Abutment

Abutment

screw(green)

Abutment

can be either parallel

(standard) or conical

(estheticone) in shape.

are secured with an abutment

screw that is tightened to 20

Ncm.

(Screw retained restoration)

Abutment

(Cemented restoration)

Cera One abutment

Secured with a square head

screw tightened to 32 Ncm.

(red)

Straight

15 Pre-Angled

EngagesImplantHex

Click Zone

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Two impression techniques

Open tray impression Closed tray impression

Remove The Healing AbutmentPlace The Impression Coping

Closed Tray Impression


Syringe around the impressioncoping to capture the flat sides

Education

Remove the impression Remove the impression post from implant Mount impression post onto the analog (same color) Reposition and snap back into the impression


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Education

Open tray impression Concept

Intraoral situationImplant & impression post Analog & impression post58 Education

Impression procedure

Remove closure screw or healing abutment

Insert impression post and hand tighten screw withthe screwdriver

59 Education

Take impression with an open tray

Use an elastomeric impression material


60 Education

When impression material is set,unscrew and remove the impression


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A one piece coping

Screw into the abutment

used if the abutment does not

need to be changed on the

lab cast

Two piece coping

Screw into the implant

used if the abutment does

not need to be

changed on the lab

cast

Two piece coping

Screw into the abutment

used to orient the anti-

rotational feature or to

make impression of

very divergent implant

Types of impression posts

Two piece Impression coping

Impression coping attached to the implant analog

The impression posts attached to theimplants fixtures.

Impression with laboratory analog to make the master cast.

The master cast is that one used to fabricate thefinal prosthesis.

Laboratory analogsComponents made to represent the top ofthe implant fixture or the abutment in thelaboratory cast

Fixture analog{Duplicate implant top} Abutment analog{Duplicate abtument top}

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Attach Analog

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Push Analog/Impression Coping Assembly into ImpressionTwist and LockGrooves into Impression

Waxing sleeves

Plastic waxing sleeve tightenedto a laboratory analog Gold cylinder tightened to alaboratory analog

Combination

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Prosthesis retaining

screw

Screw used to secure theprosthesis to the implant

or the transmucosal

abutment

Prosthetic

retaining screw

Prosthetic retaining screw

Have a slot or hex head Access is usually covered by a combination of guttapercha and composite. used to retain the prosthesis to the abutment. Tightened to 10 Nc m.

Implant fixture

Abutment

Retaining screw

Abutment screw

Components of an implant

restorationComposite resin

Screw retained implantrestorations

consist of three components.

(a) Implant fixture

(b) Abutment

(c) Restoration

The abutment retaining screw

secures the abutment to the fixture

The prosthetic retaining screw

secures the prosthesis to the abutment.

Gutta percha

Screw retained implant crown

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Slot Screw Driver

- Used to remove or replace slotted prosthetic

retention screws.

- Tighten to 10 Ncm

Hex Screw Driver

- Used to remove or replace hex prosthetic

retention screws.

- Tighten to 10 Ncm.

Abutment Screw Driver

- Used to remove or re place abutment screws for

standard or conical (estheticone / mirus cone)

abutments.

- Tighten to 20 Ncm.

Square Screw Driver

- Used to remove or re place Cera One

abutment screw.

- Tighten to 32 Ncm

Impression tray without impression material:

Check the impression tray to see that it fits and fully covers the area of theimpression and that the hole in the tray is aligned with the guide pin.

Impression tray with impression material in the jaw:

The coping must be completely covered by impression material and the tray befully seated.It is very important that the guide pin protrudes through the impression trayin order to open it with the hex driver.

Inverted impression tray withemphasized hex:The hexagon of the impression copingcan be seen. It is very important tocheck that the position of theimpression coping has been accuratelyrecorded and that the hex is clear ofany impression material.

Inverted impression showing gingiva beingsyringed around analogThe analogue can now be attached to theimpression coping by screwing in the guide

pin. It should be confirmed that thecoping is attached to the analoguewith no misalignment of gaps. At thisstage, injecting impression materialaround the neck of the analog cansimulate the gingiva.

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Stone model prepared with simulatedgingiva and implant analog

In the final stage in impression taking, astone model of the gingiva and teethshould be cast, and the simulated gingivashould remain on the model.

After the stone is hardened, theimpression coping can be released fromthe model by removing the guide pin.

The impression tray can now beseparated from the model

Silicone index and wax modelof tooth

When the wax model of the tooth isappropriately positioned a silicon keycan be prepared that will serve as agood replica of the missing tooth.

Option 1: Placing the gold plastic cylinder abutment on the stone modelFollowing the construction of the silicone index a gold plastic cylinderabutment with hexagon can be selected.

Option 1: Wax CarvingThe plastic part of the gold plastic cylinder abutment can now be grind to theappropriate height on the stone model, taking into account the height of the adjacentteeth. After the gold abutment and the plastic cylinder have been prepared, it is

possible to carve the wax to the desired shape.

Following the carving of the wax on the gold abutment and the plasticcylinder they will be cast.

Option 1: Silicon indexwith wax upThe silicon index will beused to check that thedimensions of the wax-upare appropriate to itssurroundings.

Option 1: Metal casting

When fabricating P.F.M crown,using the direct wax-up techniqueon the cap to get a metal frameonto which the porcelain firingtakes place.

Checking the metal on the stonemodel and the seating of theexternal hex of the gold abutmentin the internal hex of the implantanalog.

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Option 1:Porcelain in mouthAfter placing the crown, the screw of the

gold abutment should be tightened to 20Ncm utilizing the TORKIT wrench.

This will minimize the chances of thescrew opening. After the screw has beentightened, the screw hole should beclosed.

Option 2: Placing the plasticcylinder on the stone model

Following the construction of thesilicon index a plastic cylinderwith hexagon can be selected

Option 2: Wax CarvingThe plastic cylinder can now be grindto the appropriate height on the stonemodel, taking in the account theheight of the adjacent teeth.

After the plastic cylinder have beenprepared, it is possible to carve thewax to the desired shape.Following the carving of the wax onthe plastic cylinder they will be cast.

Option 2: Silicon index withwax upThe silicon index will be usedto check that the dimensionsof the wax-up are appropriateto itssurroundings.MT-HHR13

Option 2: Metal castingWhen fabricating P.F.M crown, usingthe direct wax-up technique on the

plastic cylinder a metalframe onto which the porcelainfiring takes place.Checking the metal on the stonemodel and the seating of theexternal hex of the casting (whatwas previously the external hex. ofthe plastic cylinder MD-CPH13), inthe internal hex of the implantanalog.

Option 2: Check the casting in themouthAfter completion of the casting, acheck must be made in the

paients mouth using the screwMD-SO220 to connect it.

Option 2: Porcelain on plastermodelFollowing the selection of theappropriate color, the porcelain isfired on the metal casting.

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Option 2: Porcelain in mouthAfter placing the crown,the screwof the plastic cylinder shouldbe tightened to 20 Ncm utilizing theTORKIT wrench.

This will minimize the chances of thescrew opening. After the screw has

been tightened the screw hole shouldbe closed.

IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.There are two distal-extension restorative options.

1. Tooth-implant supported restorationPlace an implant distal to the most

posterior natural abutment andfabricate a fixed prosthesis

connecting the implant with thenatural tooth. However, there areproblemsassociated with implants connected to natural teeth.

2. Implant supported restorationPlace two or more implants posterior tothe most distal natural tooth andfabricate a completely implant-supportedrestoration ).

If the crown-to-implant ratio is favorable, two implants to support a three-unitfixed prosthesis.If implants are short and crowns are long, one implant to replace each missing tooth.If doubt remains, more implants are used when heavier forces are expected (e.g.,posterior part of the mouth in patients with evidence of parafunctional activity).Fewer implants are used when lighter forces are expected (e.g., those opposing acomplete denture or those supporting a prosthesis in the anterior part of the mouth).

IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.

Long Edentulous Span Restoration.1. Multiple implants placed between the

remaining natural teeth to fabricate afully implant-supported restoration.

2. One or two implants can be placed in thelong edentulous span and the finalrestoration connected to natural teeth.

When it is necessary to connect implants and thenatural teeth, protecting the teeth withtelescopic copings is recommended .

In this manner, prosthesis retrievability can bemaintained.

Some long edentulous spans require the reconstructionof soft and hard tissue and teeth. using resinteeth processed to a metal substructure ratherthan a conventional metal-ceramic restoration isrecommended.

Soft tissue esthetics can be more easily andaccurately mimicked with heat-processed resin .

This type of restoration has been called ahybridbecause it combines the principles of conventionalfixed and removable prosthodontics.

IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.Long Edentulous Span Restoration.

Single-tooth Implant Restoration.

Indicated in the following situations:1. An otherwise intact dentition2. spaces difficult to treat with conventional fixedprosthodontics3. Distally missing teeth.

4. A prosthesis that needs to closely mimic the missingnatural tooth

The requirements for single-tooth implant crowns are:1. Esthetics2. Ant rotation to avoid prosthetic componentloosening3. Simplicity-to minimize the amount ofcomponents used4. Accessibility-to maintain optimum oral health5. Variability-to allow the clinician to control theheight, diameter, and angulations of the implantrestoration

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IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.Long Edentulous Span Restoration.Single-tooth Implant Restoration.

Fixed Restoration in the CompletelyEdentulous Arch.1.The hybrid prosthesis is a cast alloyframework with processed denture resin

and teeth.Five implants in the mandible and six in themaxilla.Suitable for patients who have hadmoderate bone loss, the prosthesisrestores both bone and soft tissuecontours.

2. The metal-ceramic rehabilitation alsorequires five implants in the mandible andsix in the maxilla. Only if minimal bone losshas occurred and is best suited for

patients who have recently lost theirnatural teeth (within 5 years).

3. For patients with severe bone loss,there is probably only one option: aremovable restoration .

Minimal resorptionMetal ceramicrestorations

Moderateresorptionresin tometal restorations

sever resorptionOver denture

CEMENT-RETAINED VERSUSSCREW-RETAINED IMPLANTCROWNS

Zinc phosphate, glass ionomer, and compositeresin cements have all been suggested for thispurpose.Advantages of cement-retained restorations.

1. Simplicity2. Less expensive.3. Allow minor angle correction.4. More esthetically pleasant

Disadvantages of cement-retained

restorations.

1. Require more chair time2. Have the same propensity to loosen as

the screw retained.

Advantages of screw-retained restorations.

1. Retrievability

Disadvantage of a screw-retained implantrestoration

1. The screw may loosen during function.2. Cost

CEMENT-RETAINED VERSUSSCREW-RETAINED IMPLANTCROWNSIf the screw is sufficiently tightened into theimplant crown to seat it, a clamping load orpreload is developed between the implant and thecrown.

If this clamping force is greater than theforces trying to separate the joint betweenimplant and crown, the screw will not loosen.

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http://www.google.com/url?sa=i&source=images&cd=&cad=rja&docid=B82ZAIZs0HnJ2M&tbnid=jD8oEdcZfbcPgM:&ved=0CAgQjRwwAA&url=http%3A%2F%2Fwww.deardoctor.com%2Finside-the-magazine%2Fissue-17%2Fhow-crowns-attach-to-dental-Implants%2F&ei=mYwgUdbqA8eLtAbxk4CQCg&psig=AFQjCNE6BmFXsaiEsg6Qnoe40n7wAr7boA&ust=1361174041133195


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Screw-Retained CrownsScrew Retained Transversal

Screw RetainedTransocclusal

Cemented Crowns

Dr Ghazy 2013 Implant Lectures for 4th year students

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