Implants Prostheses Jan 2012

Implant SupportedImplant SupportedDental ProsthesesDental Prostheses

In 1948, two American Dentists, Gershoff & Goldberg, surgically placed a subperiosteal implant created by:Dr. Gustav Dahl of Sweden. The subperiosteal implant was prefabricated using a study model. This method of implantation met with limited success & proved over time to have a high failure rate due to infection.In1965, Swedish orthopedist PI. Brånemark placed the first titanium implant and coined the term “osseo-inintegration”.

Transosteal or Transmandibularimplant (TMI):

Are Reconstruction systems.

Indicated only for the severely resorbed mandible.

They are an invasive and technique-sensitive form of endosteal implants.

Blade or Plate-Form Implants:Considered as endosteal implants. Successfully used in a variety of bone widths and heights.Used in any site of in mandible or maxilla with sufficient bone.Can be placed when bone is inadequate for a cylindrical implant.Appropriate for most implant candidates. Have been used with success for the last 50 years.

Osseointegration:Incorporation of the implant with the bone is one of the greatest achievements in implant dentistry.

In 1967, Dr. Leonard Linkow of New York City placed the first blade implant.

By the 1970s, this was the most frequentlyemployed implant design.

Complete subperiosteal implant placement was first described as a treatment for the atrophic mandible in the 1940s. A mucoperiosteal flap was to be raised to allow an impression to be made of the surface of the mandible. CT scans were also used to allow CAD/CAM fabrication of the framework, avoiding the need for impressions. The framework usually rests on the mandible, with no penetration into the bone.

Intraoral Examination revealing a subperiosteal mandibular implant placed 20 years ago. The bar was firm and the patient reported experiencing no pain. There are multiple mucosal dehiscences anteriorly and posteriorly, with the exposure of necrotic bone. There appears to be some deposits of calculus associated with the abutments.

Radiographic examination showing a subperiosteal implant metal framework spanning the entire edentulous mandible. It sits approximately 2-2.5 mm above the alveolar ridge. Due to the smooth bony border and the even loss across the mandible, this is most likely to be due to continued resorption over time rather than pathological bone loss due to infection. The framework is secured to the bone by four retaining screws: 2 anteriorly & 2 posteriorly. The mandible itself is atrophic, with radiolucencies evident around the two anterior retaining screws.

Modern Dental implant: Modern Dental implant:

Definition:Definition:

An endosteal (within bone) alloplastic, An endosteal (within bone) alloplastic, biologically compatible material biologically compatible material surgically inserted into the edentulous surgically inserted into the edentulous bony ridge.bony ridge.

Used to:serve as a foundation for prosthodontic restoration.

Endosseous Implants require a small operation to be inserted. The gum is lifted & a small hole made in the bone using special drills made from titanium. The implant is placed and the gum is put back very much like the lid on a box.

Dental implant:Dental implant:

• History (endosseous)History (endosseous)

–dates to Egyptiansdates to Egyptians–Greenfield (1913) -Greenfield (1913) -

–patented two-stage system.patented two-stage system.

–Formiggini (1947) - Formiggini (1947) - –““father of modern implantology”father of modern implantology”–helical wire spiral implant.helical wire spiral implant.


History (endosseous):History (endosseous):

–single stagesingle stage–one-piece from bone through oral mucosa (crystal sapphire implants)one-piece from bone through oral mucosa (crystal sapphire implants)

–two-stagetwo-stage–bony implant separate from transmucosal portionbony implant separate from transmucosal portion–variable design & materialsvariable design & materials

Dental implant:Dental implant:Biomaterials:Biomaterials:

–most commonly used most commonly used –commercially pure (CP) titaniumcommercially pure (CP) titanium–titanium-aluminum-vanadium alloy titanium-aluminum-vanadium alloy

(Ti-6Al-4V) (Ti-6Al-4V) - stronger & used w/ smaller - stronger & used w/ smaller diameter implantsdiameter implants


• Titanium :Titanium :–Lightweight.Lightweight.–Biocompatible.Biocompatible.–corrosion resistant. corrosion resistant.

(dynamic inert oxide layer).(dynamic inert oxide layer).

–strong & low-priced.strong & low-priced.


• Fixture typesFixture types –HA coatedHA coated–Ti surface modifiedTi surface modified–tap or self-tappingtap or self-tapping–screw or press fitscrew or press fit

““Osseointegration” :Osseointegration” :

–Bränemark - late 1980’sBränemark - late 1980’s–direct structural & functional direct structural & functional

connection between ordered, living connection between ordered, living bone & surface of a load-carrying bone & surface of a load-carrying implantimplant


–similar soft-tissue relationship to similar soft-tissue relationship to natural dentition natural dentition (sulcular epithelium)(sulcular epithelium)

–hemi-desmosome like structures hemi-desmosome like structures connect epithelium to titanium connect epithelium to titanium surfacesurface


–circumferential and perpendicular circumferential and perpendicular connective tissueconnective tissue

–no connective tissue insertionno connective tissue insertion–no intervening Sharpey’s fiber no intervening Sharpey’s fiber

attachmentattachment

Osseointegration” :Osseointegration” :

–bone-implant bone-implant interfaceinterface–osteoblasts in close proximityosteoblasts in close proximity to interfaceto interface–separated from implant by thin separated from implant by thin

amorphous proteoglycan layeramorphous proteoglycan layer–osseointegration - highly predictable osseointegration - highly predictable


–bone-implant bone-implant interfaceinterface–oxide layer continues to grow-oxide layer continues to grow- (2000 A at 6 yrs) - mineral ion interaction (2000 A at 6 yrs) - mineral ion interaction – increase in trabecular patternincrease in trabecular pattern–bone deposition & remodeling in bone deposition & remodeling in

response to stressresponse to stress

Components & Terminology:Components & Terminology:

–coping or prosthesis screw coping or prosthesis screw (top)(top)–copingcoping–analoganalog

» implant bodyimplant body»abutment abutment

–transfer coping (indirect or direct)transfer coping (indirect or direct)

Components & Terminology:Components & Terminology:

–hygiene screw.hygiene screw.–Abutment.Abutment.

» for screw, cement or attachment.for screw, cement or attachment.–second stage permucosal abutment.second stage permucosal abutment.–first stage cover screw.first stage cover screw.–implant body or fixture implant body or fixture (bottom).(bottom).

Modern types:Modern types:

–implants are smallimplants are small: : –standard abutmentstandard abutment - usually 3.75mm - usually 3.75mm

or larger in diameteror larger in diameter

–wide-body or wide-platformwide-body or wide-platform - up to - up to 6.0mm6.0mm

Modern types:Modern types:

–lengthslengths - - typically range from abouttypically range from about 7 to 18mm7 to 18mm

– ““External hex” Mostly used:External hex” Mostly used: – good research literature.good research literature.– Easy to maintain.Easy to maintain.– (3i or Nobel Biocare systems).(3i or Nobel Biocare systems).

FixturesStandard.Mini implants.

Modern types Modern types ((Nobel Biocare):Nobel Biocare):

–AbutmentsAbutments–Standard.Standard.–CeraOne.CeraOne.–EsthetiCone.EsthetiCone.–MirusCone.MirusCone.–Angulated 17º (new) or 30ºAngulated 17º (new) or 30º

StandardNo anti-rotational properties.Can be used for multiple units.can be used for hybrid dentures.


–CeraOne:CeraOne:–single tooth esthetic replacement.single tooth esthetic replacement.–abutment attached to fixture w/ith abutment attached to fixture w/ith

restoration cemented to abutment.restoration cemented to abutment.–accommodation for fixture accommodation for fixture

misalignment.misalignment.–can be provisionalizedcan be provisionalized


–EsthetiCone:EsthetiCone:–esthetic FPD restorations.esthetic FPD restorations.–machined gold cylinder abutment allows machined gold cylinder abutment allows

crown margin to seat close to fixture crown margin to seat close to fixture (within 1mm).(within 1mm).


–MirusCone:MirusCone:–esthetic FPD restorations.esthetic FPD restorations.–use when decreased vertical height.use when decreased vertical height.–allows 4.5mm clearance.allows 4.5mm clearance.


–Angulated abutment 17º or 30ºAngulated abutment 17º or 30º–used to achieve better esthetic result used to achieve better esthetic result

where complicated anatomy exists.where complicated anatomy exists.–used if less than ideal fixture placement.used if less than ideal fixture placement.–used where esthetic cervical margin used where esthetic cervical margin

required.required.


–CeraOneCeraOne–EsthetiConeEsthetiCone–MirusConeMirusCone–Angulated abutmentsAngulated abutments

• All come with narrow, regular or wide All come with narrow, regular or wide platforms (NP, RP, WP)platforms (NP, RP, WP)

Modern types Modern types (3i):(3i):

–FixturesFixtures–MicroMiniplant.MicroMiniplant.–Miniplant.Miniplant.–StandardStandard–Wide Diameter. Wide Diameter.

(( surface area to use where surface area to use where vertical height) . vertical height) .


–FixturesFixtures–ICE (ICE (incremental cutting edge)incremental cutting edge)

» super self-tapping implantsuper self-tapping implant»uses tapered cutting flutesuses tapered cutting flutes»allows more placement controlallows more placement control» rapid bone engagement & implant rapid bone engagement & implant

stabilizationstabilization


–AbutmentsAbutments–EP (conical) - (esthetic profile)EP (conical) - (esthetic profile)–Gold UCLA-typeGold UCLA-type–Two-piece abutment postTwo-piece abutment post–STA (standard)STA (standard)–Pre-AngledPre-Angled–New Gold Standard ZR (zero rotation)New Gold Standard ZR (zero rotation)


–Gold UCLA-type abutment Gold UCLA-type abutment –screw-retained at fixture levelscrew-retained at fixture level–non-segmented abutmentnon-segmented abutment–screw-retained crown to implantscrew-retained crown to implant–uses larger screw because it runs all the uses larger screw because it runs all the

way to the fixtureway to the fixture

Modern types Modern types ( ( 3i 3i ):):

–Gold UCLA-type abutment Gold UCLA-type abutment – thin buccal-lingual tissues thin buccal-lingual tissues – limited inter-occlusal distance limited inter-occlusal distance (as little as 4.5mm)(as little as 4.5mm)–single or multiple unitssingle or multiple units


• Modern types Modern types ((3i 3i ))–EP (conical) EP (conical) - (esthetic profile) - (esthetic profile)

–screw-retained crown to the abutmentscrew-retained crown to the abutment–gold cylindergold cylinder–non-parallel implant placementnon-parallel implant placement–single or multiple unitssingle or multiple units–minimum 7mm inter-occlusal distance minimum 7mm inter-occlusal distance

requiredrequired

Modern types Modern types ((3i3i ): ):

–Two-piece abutment postTwo-piece abutment post–non-rotationalnon-rotational–cement-retained crown to the abutmentcement-retained crown to the abutment–simplicity of treatment - chairside simplicity of treatment - chairside

preparationpreparation–use when access to posterior region w/ use when access to posterior region w/

screw driver is limitedscrew driver is limited

What’s new?What’s new? ((3i3i ): ):

–Prep-Tite Posts Prep-Tite Posts »screw retained abutmentscrew retained abutment»standard impression procedurestandard impression procedure»cemented restorationcemented restoration»6º taper with 3 vertical grooves6º taper with 3 vertical grooves»multiple collar heightsmultiple collar heights

What’s new?What’s new? ((3i3i ) : ) :

–Osseotite Osseotite (“clot retentive surface”)(“clot retentive surface”)»specific micro-topographic acid-specific micro-topographic acid-

etched implant surface design Vs. etched implant surface design Vs. machined-surface implantmachined-surface implant

»single stage implantsingle stage implant» loaded after 2 months loaded after 2 months »claim 98.5% success after 3 yearsclaim 98.5% success after 3 years

Remember….Remember….

–For FPD’sFor FPD’s–plan for screw-retained restorations.plan for screw-retained restorations.–no anti-rotational properties.no anti-rotational properties.–always use at least 2 fixtures when always use at least 2 fixtures when

restoring posterior spaces not bound by restoring posterior spaces not bound by natural teeth! natural teeth!

Advantages:?Advantages:?

–no preparation of tooth / adjacent teeth.no preparation of tooth / adjacent teeth.–bone stabilization & maintenance.bone stabilization & maintenance.–Retrieveability.Retrieveability.– improvement of function.improvement of function.–psychological improvement.psychological improvement.

Advantage of Dental Implant

Prosthesis

Disadvantages:Disadvantages:

– risk of screw loosening.risk of screw loosening.– risk of fixture failure.risk of fixture failure.– length of treatment time.length of treatment time.–need for multiple surgeries.need for multiple surgeries.–challenging esthetics.challenging esthetics.

Treatment planning :Treatment planning :

““Diagnosis begins with complete Diagnosis begins with complete evaluation of the patient”evaluation of the patient”

–guidelines for “decision-making” guidelines for “decision-making” process.process.

– treat the “entire” patient.treat the “entire” patient.– restore form, function & esthetics.restore form, function & esthetics.

Treatment planning:Treatment planning:

–problem list & patient desires.problem list & patient desires.–initial evaluation.initial evaluation.

–chief complaint.chief complaint.–medical/dental history review.medical/dental history review.– Intra / extraoral exam.Intra / extraoral exam.–evaluation of existing prosthesis.evaluation of existing prosthesis.


–initial evaluationinitial evaluation–diagnostic impressions/articulated castsdiagnostic impressions/articulated casts– radiographs - panoramic and periapical radiographs - panoramic and periapical

(CT scan or tomography - as indicated)(CT scan or tomography - as indicated)–photographsphotographs


–treatment options/informed consenttreatment options/informed consent–explanation of long-term commitmentexplanation of long-term commitment–restorative - surgical joint consultrestorative - surgical joint consult–two-stage surgery two-stage surgery

–stage I stage I –stage IIstage II


–Two-stage surgery Two-stage surgery – (use of clear acrylic surgical stent is (use of clear acrylic surgical stent is

mandatory!)mandatory!)

–stage I stage I -- implant fixture placement w/ implant fixture placement w/ cover screw (left submerged)cover screw (left submerged)


–stage I stage I

- - healing phasehealing phase–3 month minimum (mandible ) - usually 6 3 month minimum (mandible ) - usually 6

months for posterior regionsmonths for posterior regions– 6 month minimum (maxilla) - usually 6-9 6 month minimum (maxilla) - usually 6-9

months for all regionsmonths for all regions


–stage II stage II - - uncovering & placement of uncovering & placement of

transmucosal healing abutment transmucosal healing abutment

– healing phasehealing phase–4-6 weeks for soft tissue healing4-6 weeks for soft tissue healing


–restorative phaserestorative phase–maintenance and regular recallmaintenance and regular recall–fee & payment policyfee & payment policy–goal to restore form, function & goal to restore form, function &

estheticsesthetics

Treatment Planning:Treatment Planning:

Consider:Consider:–Advs / disadvs of proposed treatmentAdvs / disadvs of proposed treatment–Referrals / specialty consultsReferrals / specialty consults–appointment sequencingappointment sequencing–treatment alternativestreatment alternatives

Treatment Planning:Treatment Planning:

EVALUATION OF:EVALUATION OF:– OcclusionOcclusion– TeethTeeth– PeriodontiumPeriodontium– Radiographic analysisRadiographic analysis– Surgical analysisSurgical analysis– Esthetic analysisEsthetic analysis


Evaluation of Teeth:Evaluation of Teeth: - number & existing conditionnumber & existing condition

–prognosis of remaining teethprognosis of remaining teeth–size, shape & diameter of existing size, shape & diameter of existing

dentitiondentition– tooth & root angulations & proximitytooth & root angulations & proximity–mesiodistal width of edentulous spacemesiodistal width of edentulous space


Evaluation of Teeth;Evaluation of Teeth; - number & existing conditionnumber & existing condition

–minimum 6-7mm between teeth to minimum 6-7mm between teeth to facilitate implant placement facilitate implant placement

(based on 3mm fixture)(based on 3mm fixture)–> 1.5mm between implant & natural teeth> 1.5mm between implant & natural teeth–7mm from center of implant - to center 7mm from center of implant - to center

of implant for edentulous areaof implant for edentulous area


Evaluation of Teeth;Evaluation of Teeth;- number & existing conditionnumber & existing condition- more than 10mm mesiodistal space - single more than 10mm mesiodistal space - single

tooth implant tooth implant notnot recommended recommended- Multiple abutments should be splintedMultiple abutments should be splinted


Evaluation of Periodontium:Evaluation of Periodontium: Bone support Bone support

–Lekholm & Zarb classificationLekholm & Zarb classification–qualityquality - - best - thick compact cortical best - thick compact cortical

bone w/core of dense trabecular bone w/core of dense trabecular cancellous bonecancellous bone

–best region - mandibular symphysis; best region - mandibular symphysis; poorest in posterior regionspoorest in posterior regions


Evaluation of Periodontium;Evaluation of Periodontium;Bone support Bone support

–quantityquantity - - required for implant - required for implant - –6mm buccal-lingual width w/sufficient 6mm buccal-lingual width w/sufficient

tissue volumetissue volume–8mm interradicular bone width8mm interradicular bone width–10mm alveolar bone above IAN canal or 10mm alveolar bone above IAN canal or

below maxillary sinusbelow maxillary sinus


Evaluation of Periodontium:Evaluation of Periodontium:Bone support Bone support

–quantityquantity - - required for implant - required for implant - – if inadequate bone support may need if inadequate bone support may need

ridge or site augmentation ridge or site augmentation » ramus or chin graft (autograft)ramus or chin graft (autograft)»DFDBA (allograft)DFDBA (allograft)»Bio-Oss(xenograft)Bio-Oss(xenograft)


Evaluation of Periodontium:Evaluation of Periodontium: Bone supportBone support

–place implants minimum of 2mm from place implants minimum of 2mm from IAN canal or below maxillary sinusIAN canal or below maxillary sinus

–Crown / root ratioCrown / root ratio–mobilitymobility–furcationsfurcations–probing depthsprobing depths


Periodontium Periodontium Mucogingival problems: Mucogingival problems:

–need sufficient tissue volume to recreate need sufficient tissue volume to recreate gingival papillagingival papilla

–need some attached gingiva to maintain need some attached gingiva to maintain peri-implant sulcusperi-implant sulcus

–1st year post-op bone resorption ~ 1mm1st year post-op bone resorption ~ 1mm *crest of bone optimal 2- 3mm below CEJ*crest of bone optimal 2- 3mm below CEJ


PeriodontiumPeriodontiumMucogingival problems:Mucogingival problems:

–place implant 2-3mm apical to free place implant 2-3mm apical to free

gingival margin of adjacent tooth gingival margin of adjacent tooth – recreates biologic width of peri-implant recreates biologic width of peri-implant

sulcussulcus– *soft tissue height < 2mm or > 4mm may *soft tissue height < 2mm or > 4mm may

create challenge!create challenge!


Evaluation of PeriodontiumEvaluation of Periodontium –oral hygiene - oral hygiene - important pre & post important pre & post

–systemic manifestations - systemic manifestations - ie. diabetics ie. diabetics are predisposed to delayed healingare predisposed to delayed healing

–destructive habits - destructive habits - smokingsmoking is is contraindicated - delayed or inadequate contraindicated - delayed or inadequate tissue healing & osseointegration noted tissue healing & osseointegration noted


RRadiographic analysisadiographic analysis– periapical pathologyperiapical pathology– Radiopaque / radiolucent regionsRadiopaque / radiolucent regions– adequate vertical bone heightadequate vertical bone height– adequate space above IAN or below adequate space above IAN or below

maxillary sinusmaxillary sinus


Radiographic analyses:Radiographic analyses:–adequate inter-radicular areaadequate inter-radicular area–bone quality & quantitybone quality & quantity–radiographs - radiographs - panoramic and peri-apical panoramic and peri-apical

(CT scan or tomography - as indicated) (CT scan or tomography - as indicated)

Treatment planning:Treatment planning:Radiographic Analysis:Radiographic Analysis:

– radiographsradiographs - - aid to determine amount aid to determine amount of “space”& bone availableof “space”& bone available

–CT (computed tomography) scan - gives CT (computed tomography) scan - gives more accurate & reliable assessment of more accurate & reliable assessment of bone (quality, quantity & width) & locale bone (quality, quantity & width) & locale of anatomic structuresof anatomic structures

Treatment planning:Treatment planning:Radiographic Analysis:Radiographic Analysis:

–radiographic stentradiographic stent - - (can double as (can double as surgical stent) surgical stent)

–acrylic stent with lead beads or ball -acrylic stent with lead beads or ball -bearings (5mm) placed in proposed fixture bearings (5mm) placed in proposed fixture locationslocations

– allows more accurate radiographic allows more accurate radiographic interpretation interpretation

Treatment planning:Treatment planning:Radiographic Analyses:Radiographic Analyses:

–distortion (distortion (common to all X-rays)common to all X-rays)–Panorex ~ 25% vertical; horizontal varies Panorex ~ 25% vertical; horizontal varies

with head position (1.20-1.25x)with head position (1.20-1.25x)–CT ~ 1:1; 1-2mm vertical error; CT ~ 1:1; 1-2mm vertical error; *most accurate (1.0-1.1x)*most accurate (1.0-1.1x)–Lateral Ceph ~ 8%Lateral Ceph ~ 8%–Peri-apical ~ 2.5-5%Peri-apical ~ 2.5-5%

Treatment planning:Treatment planning:Surgical Analyses:Surgical Analyses:

–surgical guide stentsurgical guide stent - - *one of the *one of the most critical factors for obtaining an ideal most critical factors for obtaining an ideal surgical & esthetic resultsurgical & esthetic result

–used during fixture installation as guide used during fixture installation as guide for optimal B/L and M/D positionfor optimal B/L and M/D position

–use of buccal channel drill guide allows use of buccal channel drill guide allows improved access & visibilityimproved access & visibility

Treatment planning:Treatment planning:Surgical analyses:Surgical analyses:

–implant length / diameterimplant length / diameter–determined by quantity of bone apical to determined by quantity of bone apical to

extraction site extraction site –use longest implant safely possibleuse longest implant safely possible–diameter dictated by corresponding root diameter dictated by corresponding root

anatomy at crest of boneanatomy at crest of bone


Surgical analysis:Surgical analysis:

TTreatment optionsreatment options–immediateimmediate - - place implant at time of place implant at time of

tooth extractiontooth extraction–delayed immediatedelayed immediate - - 8-10 week delay8-10 week delay–delayeddelayed - - 9-10 months or longer9-10 months or longer

• immediate will not allow bone resorption, but immediate will not allow bone resorption, but delayed allows bone fill for stabilizationdelayed allows bone fill for stabilization

Treatment planning:Treatment planning:Surgical analysis:Surgical analysis:

–proper surgical technique during proper surgical technique during implant placement is critical implant placement is critical

–minimal heat generation importantminimal heat generation important–< 47º Celsius for one minute or less < 47º Celsius for one minute or less

provides most predictable healing provides most predictable healing response response

Treatment planning:Treatment planning:Esthetic analysis:Esthetic analysis:

–smile line - smile line - high in maxilla; low in high in maxilla; low in mandiblemandible

–lip shape - lip shape - full Vs. thinfull Vs. thin

–existing ridge defect - existing ridge defect - if visible w/ if visible w/ high smile line will need augmentationhigh smile line will need augmentation

Treatment planning:Treatment planning:EEsthetic analysis:sthetic analysis:

–implant emergence profile implant emergence profile (360º)(360º)– restored implant should appear to restored implant should appear to

“grow” or emerge from the gingiva“grow” or emerge from the gingiva–very natural & desirable in appearancevery natural & desirable in appearance–avoid avoid “tomato on a stick” “tomato on a stick” crowns or crowns or

periodontal problems may developperiodontal problems may develop

Treatment planning:Treatment planning:Occlusal analysis:Occlusal analysis:

–Advs / disadvs of proposed treatmentAdvs / disadvs of proposed treatment–referrals/specialty consultsreferrals/specialty consults–appointment sequencingappointment sequencing–treatment alternativestreatment alternatives

Treatment planning:Treatment planning:OOcclusal analysis:cclusal analysis:

–improvement of function and/or improvement of function and/or esthetics (?)esthetics (?)

–parafunctional habits parafunctional habits –can be destructivecan be destructive– teeth lost to occlusal trauma or teeth lost to occlusal trauma or

parafunction - less success w/ implants parafunction - less success w/ implants

Treatment planning:Treatment planning:Occlusal analysis:Occlusal analysis:

–diagnostic casts diagnostic casts (mounted to determine opposing occlusion)(mounted to determine opposing occlusion)

–ridge width ridge width –existing inter-arch vertical space existing inter-arch vertical space 14-15mm minimum for complete denture; 14-15mm minimum for complete denture;

partially edentulous varies by implant type partially edentulous varies by implant type

Treatment planning:Treatment planning:Occlusal analyses:Occlusal analyses:

–maxillo-mandibular relationsmaxillo-mandibular relationsjaw classifications jaw classifications –Class II may have greatest benefitClass II may have greatest benefit–Class III requires surgical interventionClass III requires surgical intervention

Treatment planning:Treatment planning:Occlusal analyses:Occlusal analyses:

–Advs / disadvs of proposed treatmentAdvs / disadvs of proposed treatment–referrals/specialty consultsreferrals/specialty consults–appointment sequencingappointment sequencing–treatment alternativestreatment alternatives


Advantages & Disadvantages of Advantages & Disadvantages of Proposed Treatment:Proposed Treatment:

–are as individual as the case being are as individual as the case being treatment planned!treatment planned!

»costcost»patient desirespatient desires»clinician abilitiesclinician abilities»etc.etc.


Referrals/specialty consultsReferrals/specialty consultsCan prognosis be improved with (?):Can prognosis be improved with (?):

orthodonticsorthodonticsperiodontal therapyperiodontal therapyendodontic therapyendodontic therapy pre-prosthetic surgery: extractions. ridge contouring or exostosis removal. osteotomy. bone or soft tissue augmentation.


–appointment sequencing:appointment sequencing:–length of treatment timelength of treatment time–need for multiple surgeriesneed for multiple surgeries


Treatment alternatives:Treatment alternatives:FPDs.FPDs.RPDS.RPDS.RBBs.RBBs.Orthodontics.Orthodontics.Do nothing!Do nothing!


Indications:Indications:Good general health.Good general health.Adequate bone quality & volume.Adequate bone quality & volume.Appropriate occlusion & jaw relations.Appropriate occlusion & jaw relations.Inability to wear conventional prosthesis.Inability to wear conventional prosthesis.Unfavorable number/location of abutment.Unfavorable number/location of abutment.Single tooth loss.Single tooth loss.


Contraindications:Contraindications:Unrealistic patient expectations.Unrealistic patient expectations.Alcohol / drug dependence Alcohol / drug dependence (smoking).(smoking).Parafunctional habits.Parafunctional habits.Psychological factors.Psychological factors.Anatomical factors.Anatomical factors.Inadequate ridge / inter-arch dimensions.Inadequate ridge / inter-arch dimensions.Immunosuppression.Immunosuppression.


Contraindications Contraindications (relative):(relative):(need surgical intervention).(need surgical intervention).ramus graft.ramus graft.

inadequate bone at implant site.inadequate bone at implant site.excessive bony concavities.excessive bony concavities.

sinus lift or IAN transposition.sinus lift or IAN transposition.inadequate vertical space for implant.inadequate vertical space for implant.


• ““Osseointegrated implants can be placed in the Osseointegrated implants can be placed in the irradiated mandibles of selected patients without irradiated mandibles of selected patients without hyperbaric oxygen treatment”.hyperbaric oxygen treatment”.

Niini, Ueda, Keller, Worthington; Niini, Ueda, Keller, Worthington; Experience withExperience with Osseointegrated Osseointegrated Implants Placed in Irradiated Tissues in Japan and the United StatesImplants Placed in Irradiated Tissues in Japan and the United States , , Intl J Oral Maxillofac Implants 1998; 13:407-411Intl J Oral Maxillofac Implants 1998; 13:407-411

END OF PART 1END OF PART 1

AFTER-CARING AFTER-CARING AND MAINTAINING AND MAINTAINING

IMPLANT PROSTHESES.IMPLANT PROSTHESES.

Fazal GhaniFazal GhaniBSc, BDS (Pesh), MSc, CMP, PhD (London), FDSRCPSGlasg.BSc, BDS (Pesh), MSc, CMP, PhD (London), FDSRCPSGlasg.

Department of ProsthodonticsDepartment of ProsthodonticsKhyber College of Dentistry, University of Khyber College of Dentistry, University of

Peshawar (Pakistan)Peshawar (Pakistan)

HEALTH-CARE HEALTH-CARE

BEGINS BEGINS

WITH SELF-CAREWITH SELF-CARE

Maintenance:Maintenance:Maintenance visits shall consider:

- Peri-implant tissues evaluations.- Prosthetic evaluation.- Deposit removal.- Home-care reinforcement.- Modifications.- Radiographs to compare findings to baseline data to indicate impending problems with the Implant.- Patients’ self-care of implants prosthesis.

Intraoral view a subperiosteal mandibular implant placed 20 years ago. The bar appeared firm and the patient reported experiencing no pain. Multiple mucosal dehiscences anteriorly and posteriorly, with the exposure of necrotic bone can be seen. Calculus deposits on abutments are also evident.

Maintenance:Maintenance:


• Primary goal is to protectPrimary goal is to protect and and maintain “tissue-integration”; maintain “tissue-integration”;

Good Oral HygieneGood Oral Hygiene is a key is a key element!element!

Maintenance:Maintenance:Patient As Co-Therapist:Patient As Co-Therapist:

““Implant patients should be thoroughly Implant patients should be thoroughly instructed in maintenance therapy instructed in maintenance therapy with the understanding that the with the understanding that the patient serves as co-therapist”patient serves as co-therapist”

Grant et al, Grant et al, Periodontics, in the Tradition of Periodontics, in the Tradition of Gottlieb and OrbanGottlieb and Orban, ed 6. St. Louis, CV , ed 6. St. Louis, CV Mosby Co, 1988, pp1075-1094.Mosby Co, 1988, pp1075-1094.


““Practitioner wishing to practice Practitioner wishing to practice dental implantology must be dental implantology must be knowledgeable concerning post-knowledgeable concerning post-insertion maintenance of the insertion maintenance of the implant”implant”

NIH Consensus Development NIH Consensus Development

Conference, 1988Conference, 1988


Criteria for success:Criteria for success:(most important is good diagnosis!)(most important is good diagnosis!)

–no peri-implantitisno peri-implantitis–no associated radiographic no associated radiographic

radiolucencyradiolucency–marginal bone loss 1.0-1.5mm first marginal bone loss 1.0-1.5mm first

year; then < 0.1mm annually year; then < 0.1mm annually thereafter.thereafter.

Maintenance:

• Criteria for success:Criteria for success:–tissue integration: bone/soft tissue tissue integration: bone/soft tissue

“osseointegration”“osseointegration”–absence of mobilityabsence of mobility–no progressive soft tissue changes or no progressive soft tissue changes or

bone lossbone loss–stable clinical attachment levelstable clinical attachment level

Maintenance:

Criteria for success:Criteria for success:–absence of bleeding upon probing / absence of bleeding upon probing /

excessive probing depthsexcessive probing depths–absence of discomfortabsence of discomfort–success rate varies with bone quality, success rate varies with bone quality,

loading dynamics, etc.loading dynamics, etc.

Maintenance:

• Criteria for success:Criteria for success:–anticipated success rate of anticipated success rate of +97% anterior mandible; 90% maxilla; +97% anterior mandible; 90% maxilla; decreases in posterior quadrantsdecreases in posterior quadrants due to poorer bone quality due to poorer bone quality (10 yrs)(10 yrs)

–best bone: good cortical with some best bone: good cortical with some cancellous for vascular supplycancellous for vascular supply


Maintenance & Recall:Maintenance & Recall:–Four elements Four elements

–home-care regimenhome-care regimen–periodic recalls reinforcing regimenperiodic recalls reinforcing regimen–strict adherence to recall schedule & strict adherence to recall schedule &

verification of function, comfort, and verification of function, comfort, and esthetics esthetics

– lifetime maintenance commitmentlifetime maintenance commitment


Maintenance & Recall:Maintenance & Recall:–Frequency of recall Frequency of recall

– immediate post-deliveryimmediate post-delivery–24 hours24 hours–one weekone week– two weeks (re-torque if needed)two weeks (re-torque if needed)–6 months6 months–bi-annual or annual evaluation bi-annual or annual evaluation


Maintenance & Recall:Maintenance & Recall:Clinical Parameters of Evaluation Clinical Parameters of Evaluation - oral hygiene including plaque index- oral hygiene including plaque index- implant stability (evaluate mobility)- implant stability (evaluate mobility)- retrievabilityretrievability- peri-implant tissue healthperi-implant tissue health- crevicular probing depthscrevicular probing depths


• Maintenance & Recall:Maintenance & Recall:–Clinical Parameters of Evaluation Clinical Parameters of Evaluation

–bleedingbleeding– radiographic assessment (serial) radiographic assessment (serial)

»crestal bone level & integrity of crestal bone level & integrity of attachment systemsattachment systems

–proper torque on screw jointsproper torque on screw joints–occlusionocclusion


Clinical Parameters of EvaluationClinical Parameters of Evaluation • oral hygiene (plaque index)oral hygiene (plaque index)

–plaque is 1º etiologic factor in tissue plaque is 1º etiologic factor in tissue destruction (peri-implant and natural tooth)destruction (peri-implant and natural tooth)

– review oral hygiene instructionreview oral hygiene instruction–monitor through plaque indicesmonitor through plaque indices–same requirements as for natural teethsame requirements as for natural teeth–use neutral sodium fluoridesuse neutral sodium fluorides

Clinical Parameters of Evaluation Clinical Parameters of Evaluation • implant stability (evaluate mobility)implant stability (evaluate mobility)

–may be the may be the key indicatorkey indicator of fixture health of fixture health–minimal mobility w/ osseointegrated minimal mobility w/ osseointegrated

fixtures: 17- 57um buccal;17- 66um lingual)fixtures: 17- 57um buccal;17- 66um lingual)–no significant difference in osseointegrated no significant difference in osseointegrated

fixture mobility relative to fixture length fixture mobility relative to fixture length (Sekine et al)(Sekine et al)

– implants may sustain extensive bone loss implants may sustain extensive bone loss without increased mobility if critical amount without increased mobility if critical amount bone still remaining.bone still remaining.


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • retrievabilityretrievability

– failing implant may be masked if connected failing implant may be masked if connected to same prosthesisto same prosthesis

– important to remove FPD to evaluate important to remove FPD to evaluate –annual removal recommended for multiple-annual removal recommended for multiple-

unit prosthesisunit prosthesis–early failure detection will minimize fibrous early failure detection will minimize fibrous

tissue zone size & may allow placement of tissue zone size & may allow placement of wider diameter fixturewider diameter fixture



Clinical Parameters of Evaluation Clinical Parameters of Evaluation • peri-implant tissue healthperi-implant tissue health

–visual inspection: signs of pathoses?visual inspection: signs of pathoses?– Alterations in color, contour & consistencyAlterations in color, contour & consistency

–alveolar mucosa may surround implant & alveolar mucosa may surround implant & appear more erythematous than gingivaappear more erythematous than gingiva

– tissue movement when adjacent tissues tissue movement when adjacent tissues retracted may affect soft-tissue-implant retracted may affect soft-tissue-implant attachment ~ (detrimental)attachment ~ (detrimental)

–perimucosal keratinized tissue is bestperimucosal keratinized tissue is best


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • crevicular probing depthscrevicular probing depths

–most accurate means of detecting peri-most accurate means of detecting peri-implant destruction implant destruction ((use plastic probes)use plastic probes)

–probing measurements closely probing measurements closely approximate actual bone levelsapproximate actual bone levels

–avoid during first 3 months after abutment avoid during first 3 months after abutment connection to avoid damaging weak connection to avoid damaging weak epithelial attachmentepithelial attachment

–may be difficult if threads supra-osseousmay be difficult if threads supra-osseous


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • bleedingbleeding

–controversy as to significance of BOP at controversy as to significance of BOP at peri-implant interfaceperi-implant interface

–BOP may precede clinical signs of BOP may precede clinical signs of inflammationinflammation

–BOP & radiographic changes are most valid BOP & radiographic changes are most valid indicators of peri-implant breakdownindicators of peri-implant breakdown

– recommend continued use of peri-implant recommend continued use of peri-implant sulcus probing to monitor implant successsulcus probing to monitor implant success


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment

–one of most valuable measures of implant one of most valuable measures of implant successsuccess

–of value when of value when – cannot probe area due to constricted implant cannot probe area due to constricted implant

neck, and neck, and – to assess future mobility without FPD removalto assess future mobility without FPD removal– to accurately determine amount of bone loss in to accurately determine amount of bone loss in

absence of increased crevicular depth absence of increased crevicular depth



–compare bony changes with stable compare bony changes with stable landmarks - implant threads -landmarks - implant threads -

– (one-half thread = 0.3mm)(one-half thread = 0.3mm)–compare horizontal/vertical implant compare horizontal/vertical implant

dimensions between serial radiographsdimensions between serial radiographs–periapical radiographs = 2.5 - 5% image periapical radiographs = 2.5 - 5% image

magnification Vs. direct clinical magnification Vs. direct clinical measurementsmeasurements



–bone level determination should be based bone level determination should be based only upon standardized periapical only upon standardized periapical radiographs radiographs

– threads of implant must appear sharp & threads of implant must appear sharp & well-delineated on X-ray to be accurate well-delineated on X-ray to be accurate

–X-ray beam: directed at 9º from line X-ray beam: directed at 9º from line perpendicular to long axis of implantperpendicular to long axis of implant

–keep film parallel & close to implantkeep film parallel & close to implant



– recommend kVp of not < 60 (best 65-70)recommend kVp of not < 60 (best 65-70)–exposure time determined so internal exposure time determined so internal

mechanical structure of fixture is clearly mechanical structure of fixture is clearly visiblevisible

–use long-cone paralleling technique w/ use long-cone paralleling technique w/ paralleling film holderparalleling film holder

–can use intra-oral landmarks and film holder can use intra-oral landmarks and film holder to standardize horizontal angulationto standardize horizontal angulation



–quality in film development is paramount!!!quality in film development is paramount!!!–post-op radiographic intervals:post-op radiographic intervals:

– not between fixture placement to abutment not between fixture placement to abutment connectionconnection

– one week after abutment insertionone week after abutment insertion– immediately following fixed prosthesis immediately following fixed prosthesis

insertion, then 6 months laterinsertion, then 6 months later– annually for first 3 years, then every 2 yearsannually for first 3 years, then every 2 years



–expect 1.0mm marginal bone loss during expect 1.0mm marginal bone loss during first year postinsertion.first year postinsertion.

– 0.1mm per year anticipated thereafter 0.1mm per year anticipated thereafter

–greater bone loss observed in maxillagreater bone loss observed in maxilla



– rapid bone loss seen if:rapid bone loss seen if:– fractured fixturefractured fixture– initial osseous trauma at insertioninitial osseous trauma at insertion– fixture over-tighteningfixture over-tightening– occlusal traumaocclusal trauma– poor adaptation of prosthesis to abutmentpoor adaptation of prosthesis to abutment– ““normal” physiologic response normal” physiologic response – plaque-associated infection :plaque-associated infection :

- peri-- peri-implantitis.implantitis.



–REMEMBER ………REMEMBER ………

Endosseous implants may lose Endosseous implants may lose extensive amounts of bone support extensive amounts of bone support without showing rather obvious without showing rather obvious radiographic changes or increase in radiographic changes or increase in mobility detectable in periodontally mobility detectable in periodontally involved teeth !!!involved teeth !!!


Clinical Parameters of Evaluation Clinical Parameters of Evaluation Proper torque on screw jointsProper torque on screw joints

– loosened screws are the most common loosened screws are the most common problemproblem

–can result in localized inflammation, loose can result in localized inflammation, loose restorations, and discomfortrestorations, and discomfort

– if re-torquing a loose abutment - care not to if re-torquing a loose abutment - care not to strip or “round-off” the hexstrip or “round-off” the hex

–excessive force can fracture screw / excessive force can fracture screw / implant or create increased stresses in the implant or create increased stresses in the bonebone


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • occlusionocclusion

–excessive force concentrations - result in excessive force concentrations - result in extensive bone loss and implant fractureextensive bone loss and implant fracture

– MAJOR CAUSE: poor abutment prosthesis MAJOR CAUSE: poor abutment prosthesis adaptationadaptation

– poor force distribution & improperly planned poor force distribution & improperly planned occlusal schemes also factorsocclusal schemes also factors

– recommend anterior guidance ** BEST recommend anterior guidance ** BEST –group function / balanced occlusion also group function / balanced occlusion also


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • occlusionocclusion

–goal to prevent lateral forces on posterior goal to prevent lateral forces on posterior implants concentrated in cervical areaimplants concentrated in cervical area

– relationship between parafunctional activity relationship between parafunctional activity & increased marginal bone loss& increased marginal bone loss

– ideal is “light centric” occlusion only; ideal is “light centric” occlusion only; no contact in lateral excursionsno contact in lateral excursions

–no contact in MI, but with hard clench will no contact in MI, but with hard clench will hold shim stock (.0001”)hold shim stock (.0001”)


• Hygiene Aids:Hygiene Aids:–plastic scalersplastic scalers - ONLY! - - ONLY! - forfor abutment abutment

scaling to prevent easy abrasion of soft scaling to prevent easy abrasion of soft titanium; use in only one direction starting titanium; use in only one direction starting at the gingiva (best are from 3i)at the gingiva (best are from 3i)

–ultrasonic scalersultrasonic scalers - NO! - - NO! - do not use do not use Titan-S or ultrasonic scalers unless special Titan-S or ultrasonic scalers unless special non-metal tips usednon-metal tips used

Plastic Scaler

Graphite Scaler

Gold Tipped Scaler

Soft Bristle Brush

Yarn for CleaningTufted Floss

Plastic ProbeInter-Dental brush

Calculus build-up around Fixed Implant Prosthesis

Use of End Tuft Brush For Cleaning

Metal probe being used for Assessing the Keratinized Gingiva.

This probe should not be used for the Implant.


• Hygiene Aids:Hygiene Aids:–end-tufted & small interdental end-tufted & small interdental

brushesbrushes (ProxiBrushes) (ProxiBrushes) -- for cleaning for cleaning buccal & lingual abutment surfaces; all buccal & lingual abutment surfaces; all metal surfaces must be nylon coatedmetal surfaces must be nylon coated

–electric toothbrushes electric toothbrushes -- use if suggested use if suggested by dentist; by dentist;

may be useful if limited manual may be useful if limited manual dexteritydexterity


• Hygiene Aids:Hygiene Aids:–chlorhexidine chlorhexidine - use during peri-surgical - use during peri-surgical

periods or as needed if episodes of acute periods or as needed if episodes of acute soft tissue inflammation occur soft tissue inflammation occur

–fluoride rinses or gels fluoride rinses or gels -- use neutral use neutral sodium fluoride to avoid damage to sodium fluoride to avoid damage to titanium fixtures that may occur with titanium fixtures that may occur with acidulated typesacidulated types


Problems:Problems:Soft tissue reactionsSoft tissue reactionsFractured or loosened screwsFractured or loosened screwsFailing or failed fixtureFailing or failed fixtureBroken attachments / componentsBroken attachments / components


Problems:Problems:–soft tissue reactionssoft tissue reactions

– most common due to loose screwsmost common due to loose screws– poor oral hygiene can lead to poor oral hygiene can lead to “ “peri-implantitis” - may result in progressive peri-implantitis” - may result in progressive

bone lossbone loss

– lack of attached periabutment soft tissuelack of attached periabutment soft tissue– failed or failing implantsfailed or failing implants


Problems:Problems:–soft tissue reactionssoft tissue reactions

–treatmenttreatment::» remove offending screw, tighten remove offending screw, tighten

abutment & reinsert prosthesisabutment & reinsert prosthesis» reinforce oral hygienereinforce oral hygiene»soft-tissue autograftsoft-tissue autograft

» replacement of failed implantreplacement of failed implant


Problems:Problems:–fractured or loosened screwsfractured or loosened screws

–1st suspicion when complaint of “loose” 1st suspicion when complaint of “loose” implant or discomfortimplant or discomfort

–use correct screwdriver for screw head use correct screwdriver for screw head without excess force or can “round off” without excess force or can “round off” hexhex

– if retrieving (“teasing out”) fractured if retrieving (“teasing out”) fractured screw caution not to damage hexscrew caution not to damage hex


Problems:Problems:–failing or failed fixturefailing or failed fixture– FFailing implant Vs ailing implant Vs failedfailed implant. implant.– Implantitis” Vs Periodontal diseaseImplantitis” Vs Periodontal disease


Failing Implant:Failing Implant:


Problems: Problems: FFailing or Failed fixture:ailing or Failed fixture:FFailing implant: ailing implant: Clinical signsClinical signs: :

- Progressive crestal bone loss.- Progressive crestal bone loss.- Soft tissue pocketing.- Soft tissue pocketing.- BOP with possible purulence.- BOP with possible purulence.- Tenderness to percussion or torque- Tenderness to percussion or torque

Radiograph showing a “Ailing” Implant Showing bone loss without inflammation

Clinical picture of a Failing Implant with purulent exudate.

Radiograph of a “Treated Ailing Implant”.


Problems:Problems:FFailing or failed fixture / fixture loss:ailing or failed fixture / fixture loss:Failing implant:Failing implant:CCausesauses: surgical compromises (bone : surgical compromises (bone

overheating, lack of initial stability); nonpassive overheating, lack of initial stability); nonpassive superstructures; too rapid initial loading; superstructures; too rapid initial loading; functional overload; inadequate screw joint functional overload; inadequate screw joint closure; infection closure; infection


Problems:Problems:Failing or failed fixture fixture lossFailing or failed fixture fixture lossFailing implant: Failing implant: TreatmentTreatment::

Remove and replace with larger diameter fixture; or Remove and replace with larger diameter fixture; or treat infection & re- evaluate.treat infection & re- evaluate.

Interim - remove prosthesis & abutments & irrigate Interim - remove prosthesis & abutments & irrigate area with CHX.area with CHX.

Disinfect components & reinsert.Disinfect components & reinsert.


Problems:Problems:Failing or failed fixture fixture loss:Failing or failed fixture fixture loss:FailedFailed implant: implant:Clinical signsClinical signs: mobility; “dull” percussion : mobility; “dull” percussion

sound.sound.Peri-implant radiolucency (connective tissue Peri-implant radiolucency (connective tissue

implant encapsulation may not be visible on implant encapsulation may not be visible on radiograph).radiograph).


Problems:Problems:Failing or failed fixture fixture loss:Failing or failed fixture fixture loss:Failed Failed implant implant (most noted at Stage II)(most noted at Stage II)

CausesCauses: surgical compromises (bone overheating, : surgical compromises (bone overheating, lack of initial stability); nonpassive superstructures; lack of initial stability); nonpassive superstructures; too rapid initial loading; functional overload; too rapid initial loading; functional overload; inadequate screw joint closure; infection.inadequate screw joint closure; infection.

Treatment: Removal of implant.Treatment: Removal of implant.


Problems:Problems:Failing or failed fixture fixture loss:Failing or failed fixture fixture loss:““Implantitis” Vs Periodontitis:Implantitis” Vs Periodontitis:Clinical signsClinical signs::

similar clinical presentation w/ same pathogenic similar clinical presentation w/ same pathogenic microorganisms.microorganisms.

CausesCauses:poor oral hygiene; bacteria; cause may :poor oral hygiene; bacteria; cause may be unknown (?)be unknown (?)


Problems:Problems:Failing or failed fixture fixture loss:Failing or failed fixture fixture loss:““IImplantitis” Vs periodontitismplantitis” Vs periodontitisTreatmentTreatment::

Consults to provider - consider remake or guided Consults to provider - consider remake or guided tissue regeneration, etc.tissue regeneration, etc.

Interim - remove prosthesis & abutments & irrigate Interim - remove prosthesis & abutments & irrigate area with CHX.area with CHX.

Disinfect components & reinsert.Disinfect components & reinsert.


Problems:Problems:Broken attachments/ componentsBroken attachments/ components

– remove offending attachment remove offending attachment (if possible) and replace or (if possible) and replace or

provisionalizeprovisionalize

–be careful not to damage external hex or be careful not to damage external hex or scratch titanium fixture or abutmentscratch titanium fixture or abutment

Implant GuidelinesImplant Guidelines

Case Selection:Case Selection:Implant recommended for Implant recommended for

replacement of teeth #27,19 & 30replacement of teeth #27,19 & 30. .

Implant Implant not not recommended forrecommended for replacement of tooth #28.replacement of tooth #28.

Case #1Case #1


Implant recommendedImplant recommended• 46 y/o male presented with failing 46 y/o male presented with failing

NSRCT #27 and severe localized NSRCT #27 and severe localized periodontitis periodontitis

• tooth deemed hopeless and tooth deemed hopeless and extractedextracted


Implant recommendedImplant recommended• 4.0 x 18mm Nobelpharma fixture 4.0 x 18mm Nobelpharma fixture

placedplaced


Implant recommendedImplant recommended• Cera-One abutment restored with Cera-One abutment restored with

cemented (Ketac Cem) PFM crowncemented (Ketac Cem) PFM crown

Case # 2Case # 2


Implant recommendedImplant recommended• 31 y/o female presented with 31 y/o female presented with

missing #19 & 30, and retained missing #19 & 30, and retained #17 & 32 (third molars)#17 & 32 (third molars)


Implant recommendedImplant recommended• mesial-angulated #18 & 31 with mesial-angulated #18 & 31 with

inadequate mesial-distal and inter-inadequate mesial-distal and inter-arch spacing due to super-erupted arch spacing due to super-erupted opposing # 3 & 14opposing # 3 & 14


Implant recommendedImplant recommended• buccal-lingual ridge widths in areas buccal-lingual ridge widths in areas

of missing #19 and #30 also of missing #19 and #30 also deficientdeficient


Implant recommendedImplant recommended• teeth # 17 & 32 extracted and teeth # 17 & 32 extracted and

bilateral ramus grafts placed at bilateral ramus grafts placed at edentulous sites (#19 & 30)edentulous sites (#19 & 30)


Implant recommendedImplant recommended• molar uprighting of teeth #18 & 31 molar uprighting of teeth #18 & 31

completed to create adequate completed to create adequate space for implantsspace for implants


Implant recommendedImplant recommended• 5.0 x 11.5mm 3i fixtures placed 5.0 x 11.5mm 3i fixtures placed

bilaterallybilaterally


Implant recommendedImplant recommended• restoration of fixtures with screw-restoration of fixtures with screw-

retained non-segmented UCLA retained non-segmented UCLA abutments w/ PFM crownsabutments w/ PFM crowns


Implant recommendedImplant recommended• restoration of teeth # 3 & 14 with restoration of teeth # 3 & 14 with

PFM crowns to re-establish proper PFM crowns to re-establish proper occlusal planeocclusal plane

Case # 3Case # 3


Implant Implant notnot recommended recommended• 34 y/o male presented with past 34 y/o male presented with past

history of supernumerary #28history of supernumerary #28• Note: dilacerated root to mesial on Note: dilacerated root to mesial on

#28#28


Implant Implant notnot recommended recommended• edentulous site presented with edentulous site presented with

inadequate facial bone, and inadequate facial bone, and inadequate spacing existed inadequate spacing existed between #27 & 28 root apices to between #27 & 28 root apices to allow implant placementallow implant placement


Implant Implant notnot recommended recommended• after two years of orthodontic after two years of orthodontic

therapy, #28 failed to move to therapy, #28 failed to move to facilitate implant placementfacilitate implant placement


Implant Implant notnot recommended recommended• edentulous area restored with a edentulous area restored with a

resin-bonded fixed partial denture resin-bonded fixed partial denture (RBFPD #27-28)(RBFPD #27-28)

QUESTIONS ???QUESTIONS ???

Implants Prostheses Jan 2012

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