PROCERA® IMPLANT BRIDGE

A new treatment concept for a fixed restoration of the edentulous jaw

presented by

Dr. Robert Noelken

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Dr. Robert Noelken

2002 “Specialist for Implantology” of theConsensus Conference for Implantology

2001 Appointed “Specialist for Periodontics”of the German Society for Periodontics

1995 Private practice limited to oral surgery,implantology, periodontics andmicroendodontics in Lindau / LakeConstance, Germany

1994 Thesis “Pathological changes in the anterior horn of the spinal cord in Alz-heimer’s disease”, Dr. med. dent.

1991-1994 Specialisation in oral surgery under Prof. Dr. Dr. Ralf Schmidseder, Frankfurt/Main, Germany

1986-1991 University of Frankfurt/Main, Germany, School of Medicine and Dentistry

Memberships:

- European Association for Osseointegration- German Association of Implantology- German Association for Restorative Dentistry- German Society of Implant Dentists - Workshop for Oral and Maxillofacial Surgery

within the Society of DGZMK- Society of German Oral Surgery- German Society for Periodontics- German Association for Esthetic Surgery

Publications and presentations in implant dentistry,periodontics and microendodontics

Implant dentistry is a predictable treatment modality – it’s hard to imagine modern dentistrywithout implants. Due to its high long-term success rate osseointegrated implants have become the treatment of choice for partially- andfully-edentulous patients.

The classic ”Brånemark“ concept of osseointegra-tion of dental implants is a two-stage procedure.This method is scientifically proven, very reliableand predictable. Today, attempts are being made tosimplify and accelerate the procedure from the in-stallation of the implants to the prosthetic recon-struction. For example, techniques have been deve-loped, which allow a one-stage procedure with earlyor immediate loading of provisional or definitiveprosthetic reconstructions.Nevertheless many dentists do not offer implanttreatments to their patients, because– of the confusing range of implant systems on offer,– money- and time-consuming continuing education

and– the high additional cost of equipment.For these reasons many colleagues judge implanto-logy to be difficult and expensive.

With Procera® Implant Bridge Nobel Biocare hascreated a new treatment concept, which makes itpossible to provide the patient with an edentulousarch with a fixed bridge in a short time. A teamapproach between prosthodontist, dental technicianund oral surgeon is vital.

With Procera® Implant Bridge a new method offramework production is presented. A computerisedindustrial milling technique makes it possible to pro-duce a bridge framework for implant restorationsfrom a homogeneous titanium block without welds,lunkers and tension. The material titanium ensuresthe highest possible biocompatibility. The excellentand precise fit saves money and time and the patient is more pleased with thelong-term result. The prosthodontist, fitting the Procera® ImplantBridge only requires a single screwdriver. And youwill feel the difference when tightening the prosthe-tic screws!

A clinical case illustrates in detail the Procera®

Implant Bridge concept.

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Indications

The Procera® Implant Bridge concept is es-pecially designed for edentulous patients,but is also indicated for smaller bridges. It ispossible to veneer the titanium frameworkwith denture teeth, resin composite or porce-lain veneer. It is also possible to create barreconstructions with this treatment concept.It is available for the Brånemark System®,Steri-Oss® und Replace® implants.

With this kind of technique it is possible totreat almost every edentulous jaw, which hasa minimum height of 12-13 mm and widthof 5-6 mm.

The patient has to be healthy enough to tole-rate surgery lasting two and a half hours andbe able to keep his mouth open adequately.The technique is useful for every shape andjaw relationship.

Advantages

The advantages of the Procera® Implant Brid-ge concept are:

- most precise and manufacturer guaranteedfit,

- fixed reconstruction in a short treatment time,- immediate loading possible,- framework out of one solid piece of

biocompatible titanium,- framework and implant pillar out of same

material,- absolutely tension-free bridge framework

without any solder joints,- the framework can be fabricated on implant

level and on all platforms and abutmenttypes,

- reduced costs as abutments are no longernecessary,

- reduced framework costs because oftitanium instead of gold alloy,

Fig. 4: Set-up in wax of new upper and lowerprostheses (ZTM Rainer Schmidt, Opfenbach,Germany)

Fig. 3: Favorable clinical situation with maintai-ned attached mucosa

Fig. 2: The preoperative panoramic x-ray shows the periodontally hopeless theeth in thelower jaw and a medium-grade resorption of the mandible

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- the framework, which will be produced du-ring the healing time after implant installa-tion, makes impression in the prostheticphase unnecessary,

- denture teeth, composite resin and por-celain can be added to the framework,

- high predictability.

Treatment sequenceThe treatment of an edentulous mandible withBrånemark System® implants and a Pro-cera® Implant Bridge is divided into the fol-lowing major treatment steps:- preoperative examination and

treatment planning (Set-up),- insertion of the Brånemark

System® implants,- intra-operative registration of the

implant position,- fabrication of the master cast,- fabrication of the resin framework, - scanning of the framework and the

master cast in Sweden,

- CNC-milling of the titanium framework,- finishing of the titanium framework,- second-stage procedure,- fitting the titanium framework,- determination of jaw relation,- fitting of wax try-in,- completion of the fixed bridge in the

laboratory,- delivery of the Procera® Implant Bridge, - maintenance and recall.Although the new treatment concept ”Pro-cera® Implant Bridge“ simplifies and shor-tens the procedure, the installation of the im-plants and intra-operative registration requiressurgical experience and implant know-how.

Preoperative Examination and Treatment Planning (Set-up)Prosthetic planning

For the prosthetic planning it is necessaryto fabricate study casts and to determinethe relationship between the jaws. The

Fig. 6: A panoramic x-ray with the radiographictemplate allows the vertical height of the man-dible to be determined

Fig. 5: Surgical guide created by duplication ofset-up with lingual reinforcing bar

Fig. 8: To start off, implant site preparation hasto be located in a suitable position; a minimumcentre-to-centre distance of 7 mm when using theguide drill must be ensured

Fig. 7: Crestal incision to the region of the firstmolars allows a good overview of the crest

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try-in of a tooth set-up is a prerequisite forcorrect insertion of the implants and theregistration of the implant positions andmakes it possible for the technician to fa-bricate a resin framework (fig. 4 and 5).

Radiographic examination

The vertical height of the jaw and the volu-me of the mandible are the two most im-portant criteria if the illustrated treatmentconcept is possible. A panoramic x-ray isnecessary to show potential pathologicalstructures and the anatomical structures,which limit the available bone (fig. 6). Profile radiographs illustrate the shape andwidth of the mandible in the middle of thejaw. For the treatment of an edentulousmandible with a fixed bridge, 5 to 6 im-plants in the interforaminal region are ne-cessary. The interforaminal space shouldbe wide enough to guarantee a minimuminter-implant space of 3 mm. Narrow platform implants and implants

below 10 mm in length are unsuitable forthis procedure. That is why the mandibleshould have a minimum height of 12-13mm and width of 5-6 mm to install the im-plants correctly.

Placement of the BrånemarkSystem® Implants

Incision

After local anesthesia, sedation or generalanesthesia and sterile coverage of the pati-ent a crestal incision is made to the regionof the first molar (fig. 7). Laterally orien-tated releasing incisions make it easier tomobilize the full-thickness flap.

Leveling of the alveolar crest

After visualization of the buccal and lingualsurfaces of the alveolar crest the foramina ofthe mental nerves are uncovered and thebody of the mandible examined for concavi-

Fig. 10: Surgical guide with direction indicatorsafter drilling with the 2 mm twist drill

Fig. 9: Direction indicators after drilling with the 2 mm twist drill show the correct angulation andspacing between the platforms of the implants

Fig. 12: For intra-operative registration of the im-plant positions the titanium registration copingsare installed

Fig. 11: Six Brånemark System® implants withoptimal spacing und angulation in place

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ties. To create an adaequate platform for theinsertion of the Brånemark System® im-plants, it is necessary to level the alveolarcrest moderately.

Implant site preparation

Maintaining the distance to the mental fora-mina implant site preparation starts by pre-paring initial marks with the guide drill. Aminimum centre-to-centre distance of 7 mmis important to ensure adaequate spacingbetween the implant platforms (fig. 8). Theplacement in vestibulo-oral direction has tobe verified with the surgical guide. Subse-quently with a 2 mm twist drill the first deepdrill process is carried out under continuouscooling with sterile sodium chloride soluti-on. Placement of the direction indicatorsmakes it possible to always check the rightrelationship with the surgical guide (fig. 9and 10). With the pilot drill the coronal partof the implant site is widened to 3 mm. Thetwist drills with 3 and 3.15 mm diameter are

used to open the complete implant site. Theuse of the countersink makes it possible toplace the implant head at bone level. If theinterforaminal bone structure is very dense,the use of a screw tap is advisable althoughthe Mk III implant design is self-tapping.

Insertion of the implants

Six Brånemark System® Mk III implants(diameter 3.75 mm, length18 mm, TiUniteTM

surface) are installed under control of the an-gulation and adequate cooling with sterilesodium chloride solution at 24 rpm (fig. 11).The StargripTM allows you to guide the im-plants exactly while having a close look atthe implant neck.

Intra-operative Registration of the Implant Position

Following the installation of the implantsthe titanium registration copings are moun-ted to the implant platforms (fig.12).

Fig. 14: After removal the rigid fixation of all im-plant registration copings has to be checked indetail

Fig. 13: Intra-operative registration of the im-plant positions with the surgical guide, implant registration copings and Pattern Resin

Fig. 16: Flap adaptation with matress- and singleinterrupted sutures

Fig. 15: Cover screws in place

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The surgical guide has, on occassions, to berelieved to fit without tension over the co-pings. It is also important to check that theocclusion between the surgical guide andthe upper denture is correct. Pattern Resin(GC, Tokyo, Japan) is now mixed viscousand filled into single-use syringes. After afinal check to ensure that the relationship tothe implant registration copings and theupper denture is correct, the surgical guide isfixed in the region of the first molars on bothsides with well-proportioned pressure. Pat-tern Resin is gradually filled between the co-pings and the surgical guide in small doses.It is necessary to ensure that the PatternResin is of such low viscosity that it does notcome into contact with bone and soft tissue,but also that it is smooth enough to comple-tely coat all copings and fixate the copingsto the surgical guide (fig. 13). Just one mo-ving or unstable implant registration copingis enough to make this treatment conceptimpossible. After hardening of the Pattern

Resin the slot screws of the registration co-pings are unscrewed and the surgical guideremoved from the oral cavity. After detailedcontrol of the rigid fixation of all copings itis possible to reinforce the registration withsome more Pattern Resin (fig. 14).

The wound area is now rinsed with sterilesodium chloride solution and cover screwsare placed on the implants (fig. 15). To get atension free flap adaptation a splitting of theperiosteum is, in most cases, necessary. Al-ternating single and matress sutures ensuretight wound adaptation (fig. 16). Postopera-tively the wound is compressed with sterileswabs and a panoramic x-ray is made forcontrol of the correct insertion of the im-plants (fig. 17). For perioperative medicati-on clindamycine (3 times a day 300 mg) andbromelaine (3 times a day 100 mg) are ad-ministered. Ibuprofen 400 mg is recommen-ded as needed. It is not allowed to wear thelower denture in the first two weeks. During

Fig. 18: Minor swelling one day postoperativelyFig. 17: The post-op panoramic x-ray shows opti-mal angulation and spacing of the implants

Fig. 20: Stone master cast with implant replicasand removable gingiva mask (ZTM RainerSchmidt, Opfenbach, Germany)

Fig. 19: Surgical guide with mounted implant replicas (ZTM Rainer Schmidt, Opfenbach, Germany)

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this time the patient should keep to a liquiddiet and rinse two to three times per day with0.2% chlorhexidine solution. Seven to tendays post-operatively the sutures should beremoved. Two weeks postoperatively thelower denture should be ground and a softtissue reline placed.

Fabrication of the Master CastThe dental technician again checks the rigidregistration of the copings to the surgicalguide. He then mounts the implant replicascarefully (fig. 19). Before the implant re-plicas can be installed into the cast, an im-

pression ofthe alveolarcrest shouldbe made.The techni-cian nowhas the dif-ficult job of

fitting the surgical guide back to the wor-king cast (on which the surgical guide wasfabricated) by grinding shafts for the im-plant replicas into the cast. When the surgi-cal guide fits without any tension on thecast, the implant replicas are fixed with pla-ster in the cast. To allow the scanning of theimplant replicas a removable gingiva maskmust be fabricated. Therefore the mastercast has to be reduced in the region of theimplants. After placing the impression of thealveolar crest on the cast, the resin gum ma-terial (Vesto Gum, Espe, Seefeld, Germany)is pressed through a shaft onto the mastercast to create the removable gingiva mask(fig. 20).

Fabrication of the Resin frameworkFor the fabrication of a titanium frameworkthe production facility in Sweden needs aresin framework and a master cast with a re-

Fig. 22: A resin framework is fabricated by thetechnician as a model for the Procera® ImplantBridge titanium framework (ZTM RainerSchmidt, Opfenbach, Germany)

Fig. 21: Provisional cylinders on the master cast withthe matrix in place to fabricate a resin framework(ZTM Rainer Schmidt, Opfenbach, Germany)

Fig. 24: Laser-scanning of the master cast without the re-movable gingiva mask

Fig. 23: Factory in Sweden fabricatingthe Procera® Implant Bridge framework

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movable gingiva mask. Therefore provisio-nal cylinders are screwed to the implant re-plicas and the matrix which has been fabri-cated during the set-up, are fixed to themaster cast (fig. 21). Now the design of theframework can be waxed up with distal ex-tensions. When waxing up the framework itis important to anticipate the subsequentveneering technique. An impression is madefrom the wax-up of the framework in orderto transfer the material into resin (fig. 22).In this case the framework was prepared forveneering with denture teeth.

Scanning of the Resin Frameworkand the Master Cast in Sweden

The master cast and the resin framework aresent to the Nobel Biocare production facilityin Sweden (fig. 23). After removing the gin-giva mask the positions of the implant repli-cas are scanned by a laser (fig. 24). The resinframework is covered with a white varnish

to make the scanning process possible(fig. 25). The data from the scanning of theoutline of the framework and the position ofthe implant replicas in the cast are compiledin the computer. For this reason it is not ne-cessary to ensure a tension-free fit of theresin framework on the implant replicas.

CNC-Milling of the TitaniumFramework

On the basis of the calculated computer datathe rough titanium framework is milled out ofa round, massive and homogeneous titaniumblock using an industrial CNC-milling tech-nique (fig. 26 and 27). The abutmentconnections are milled very precisely and in-tegrated into the framework. The frameworkis separated from the titanium block (fig. 28).The tension-free and precisely fit is verifiedon the master cast. The framework and themaster cast are delivered to the dental labora-tory in 5 working days.

Fig. 26: The framework is fabricated by a CNCmilling machine out of a solid piece of titanium

Fig. 25: The resin framework is scanned by alaser

Fig. 28: The rough titanium framework prior toseparation from the titanium block

Fig. 27: A CNC-milling machine produces therough titanium framework

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Finishing of the Titanium Framework

Back in the laboratory the rough frameworkis finished coarsely with heatless-stones andtitanium mills to fit to the gingiva situationof the master cast. The finishing processshould not go too far at this stage, becausesmall changes in the jaw relationship, whichhas to be checked once again, can result inbig changes in the design of the framework(fig. 29). It is necessary to keep the frame-work strong enough to prevent fracturing ofthe distal extensions (fig. 30).

Second-stage Procedure

If all implants at the time of implant installa-tion have primary stability, resist a torque of35 Ncm and show good resonance frequen-cy values, an early loading of the implants ispossible. In this case the healing abutments

should be connected immediately and theprotocol should be changed to a one-stageprocedure. It is also possible to use specialone-stage implants, like the Replace SelectStraight with a 3 mm machined collar.

When following the classic protocol of P.-I.Brånemark the second stage procedure willtake place after 3 months of submerged hea-ling. After local anesthesia a crestal incisionon top of the cover screws is made to dividethe attached mucosa to the lingual and buccal.

A mucoperiostal flap is carefully elevatedfar enough to the lingual and buccal to seethe cover screws completely (fig. 32). Thecover screws are removed and the implantplatform and the inner aspect of the implantare cleaned with chlorhexidine. The healingabutments are selected by measuring theheight of the surrounding tissue and screwedand tightened to the implant head. It’s im-

Fig. 30: When finishing the titanium frameworkit is necessary to keep the dimension of the distalextension thick enough to prevent fracturing(ZTM Rainer Schmidt, Opfenbach, Germany)

Fig. 29: Finished titanium framework which hasbeen adapted to the gingival situation (ZTM Rai-ner Schmidt, Opfenbach, Germany)

Fig. 32: Elevated full-thickness flap with the ex-posed cover screws

Fig. 31: After three months of healing withoutirritations a cover screw in the right mandiblegets slightly exposed through the mucosa

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portant to ensure a gap-free fit of the healingabutment on the implant shoulder. The tightflap adaptation around the healing abut-ments is achieved by using single interrup-ted sutures (fig. 33). A postoperatively pan-oramic x-ray shows the gap-free tighteningof the healing abutments and the completeosseointegration (fig. 34). The denture hasto be grinded to fit over the healing abut-ments. A few days later a new provisonalsoft reline is possible. One week after the se-cond-stage procedure the sutures are remo-ved. Two week postoperatively the mucosashows excellent healing without irritations.

Try-in of the Titanium FrameworkAfter disconnecting the healing abutmentsthe Procera® Implant Bridge frameworkcan be tried in the first time (fig. 35 and 36).For this the laboratory screws in the frame-work are loosened and removed with a slotscrewdriver.

After desinfection of the framework andthe implant platforms with chlorhexidinethe framework is tried in on the implantshoulders. You can now feel how preciselythe framework fits without any rocking,wobbling and feeling of tension on the im-plant heads. Six TorqTite® UnigripTM abut-ment screws are placed into the screw ac-cess holes and tightened by the wheel nutprinciple with a UnigripTM screwdriver.When tightening the screws you will feelthe difference of the guaranteed, gap andtension-free fit (fig. 37).

To ensure a gap-free fit a panoramic x-rayshould be made. This confirms the perfectfit between the titanium framework andthe implant heads (fig. 38).

The work of the oral surgeon is now com-pleted. The process is finished off by theprosthodontist and the dental technician.

An impression of every single implant isunnecessary because of the fitting frame-

Fig. 34: Panoramic x-ray for control of the osseointegration of the implants and the fit of the healing abutments

Fig. 33: After selection and connection of the hea-ling abutments the flap adaptation was obtainedwith single sutures

Fig. 36: Disconnecting the healing abutments fortry-in of the titanium framework

Fig. 35: Two weeks after second-stage surgery

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work. To make the finishing of the frame-work easier for the dental technician, im-pression material should be injected underthe basis of the framework. This shows theactual mucosal situation. Back in the labora-tory the original gingiva mask is removedfrom the master cast, the framework withthe impression material is connected to im-plant replicas and lined with plaster. Nowthe technician has a master cast whichshows the actual soft tissue situation.

Determination of Jaw Relationship

To mount the casts in relation to the skull intothe articulator, the use of a face bow is neces-sary. To determine the height of the bite youhave to fix the resting position and compare itwith the old denture. The height of the biteshould normally be fixed 2 mm below theheight of the resting position. For provisionaldetermination of the jaw relationship Pattern

Resin is placed at three points on the frame-work. The height of the bite and the symme-trical occlusion at the three Pattern Resinpoints have to be checked. In the laboratory the cast of the upper jaw ismounted in the articulator in relation to theskull. The cast of the lower jaw is fixed by theprovisional bite with Pattern Resin. To registerthe movements of the lower jaw, a registrationplate is fixed to the framework (fig. 39).

For the upper jaw a resin basis is preparedwith a pen. Because of the rigid fixation of theregistration plate on the framework, an exactregistration of the lower jaw is possible. Withthis it is possible to track the movement of themandible. The bite has to be fixed in centricrelation with the registration material. In thelaboratory the lower jaw cast is mountedagain to the new registration. The frameworkhas now to be finished based on the new jawrelationship, the actual soft tissue situation andthe matrix of the set-up for the new denture. Inthis case the framework is prepared for additi-

Fig. 38: A panoramic x-ray shows the absolutelygap and tension-free fit of the titanium framework

Fig. 37: First try-in of the Procera® ImplantBridge framework: Absolutely tension-free fit !

Fig. 40: Check bite after fitting the wax try-inFig. 39: On the basis of the titanium frameworkit is easy to fix a platform for registration of themandibular movements

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bite check with registration material shouldbe made (fig. 40). If, in the meantime, therehave been changes in the gingival situationimpression material may be injected underthe basis of the framework again. If the pa-tient and the prosthodontist are pleasedwith the outcome of the wax try-in, the Pro-cera® Implant Bridge is sent back for com-pletion for the last time to the dental tech-nician.

Completion of the Fixed Bridge in the Laboratory The dental technician can now start finishingProcera® Implant Bridge. First implant repli-cas are connected to the Procera® ImplantBridge and a special master cast is fabricated.The cast is invested for completion using hy-drocolloid material. After steam cleaning thewax the framework is sandblasted, preparedfor silanisation (Rocatec, Espe, Seefeld, Ger-many) and covered with tooth and pinkcoloured opaque veneering materials. Beforethe pink resin (Inkotherm 85, Hedent, Ger-many) is pressed into the mold, the gingiva at

Fig. 41 and 42: Completed Procera® Implant Bridge from occlusal and basal; the cleaning channelsfor the interproximal brush are clear to see (ZTM Rainer Schmidt, Opfenbach, Germany)

on of denture teeth. Alternatively it is also pos-sible to veneer the framework by adding por-celain or composite resin.

Fitting of the Wax Try-inWith the matrix in place the denture teethwere adapted so that each tooth is supportedby a metal pin of the framework. Because ofthe exact treatment planning and paralleland right angulated implant installation youcan now see that the screw access holes liecentrally underneath or lingual to the teeth.Canine guidance is established in the pre-sence of a well fitting upper denture. In caseof a fully but slightly moving denture in theupper jaw you should adjust the teeth in abalanced occlusion.

After fabricating the denture set-up in waxin the laboratory they are delivered to theprosthodontist for intraoral try-in. In additi-on to colour, design and position of thedentition the horizontal and vertical dimen-sions and the occlusion have to be checked.Following small adjustments once again a

Fig. 43 to 45: Completion of the Procera® Implant Bridge; interproximal brushes in the cleaning chan-nels in place (ZTM Rainer Schmidt, Opfenbach, Germany)

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the papillas and around the necks of the teethshould be individually characterised.

After polymerisation the prostheses shouldbe divested, finished as usual and placedback onto the master cast (fig. 41). The spa-ces around the implants can now be designedso that it is easy to clean the areas under thebridge and between the implants with an in-terproximal brush (fig. 42). Subsequently thecentric and the canine guidance have to beadjusted accurately. The finished and polished bridge is deliveredto the prosthodontist for final insertion(fig. 43-45).

Delivery of the Procera® Implant Bridge

After finishing in the laboratory the healingabutments are finally removed. The labora-tory screws, which retain the bridge to thecast are loosened and removed with a slotscrewdriver. The Procera® Implant Bridgeand the implant heads are desinfectedthoroughly with chlorhexidine. Final connec-

tion can now be made to the implants. TheTorqTite® UnigripTM abutment screws are pla-ced into the screw access holes and are tigh-tened by the wheel nut principle with the Uni-gripTM screwdriver (fig. 46).

At this stage the screw access holes are justclosed provisionally (for instance with Fer-mit, Vivadent, Liechtenstein), as the screwswill be retightened after a few days. The sym-metrical occlusion in the maximal intercuspalrelationship should be checked (fig. 47). Inthis case, because of the well fitting denture inthe upper jaw, it is possible to achieve an idealcanine guidance. A panoramic x-ray shouldbe made at this stage to be able to subse-quently compare the remodelling and themarginal bone structure after functional loa-ding.

On this day the patient is able to appre-ciate the benefits of a permanently fixedimplant bridge. The figures show theperfect integration of natural lookingdentition. Fixed teeth increase the pati-ent’s quality of life and self-confidence.

Fig. 46 and 47: Delivery of the finished Procera® Implant Bridge

Fig. 48 and 49: After final tightening of the abutment screws the screw heads are covered in warmguttapercha and the screw access holes are closed with resin composite

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Final closure of the screw access holes

One or two weeks later the provisonal fil-lings which close the screw access holes areremoved again. The UnigripTM abutment screws are tighte-ned with a torque of 35 Ncm. It is thereforepossible to use the manual torque wrench orthe machine screwdriver with the TorqueController. Subsequently the TorqTite® abut-ment screws are covered with warm gutta-percha. In case of the necessity of opening the screwaccess holes once again, the screw headswon’t be damaged (fig. 48). The final closure of the screw access holesshould be done with an opaque tooth-colou-red resin composite (fig. 49).

Maintenance and Recall

Instructions for oral hygiene

Immediately after delivery of the Procera®

Implant Bridge the patient is advised aboutthe special oral hygiene requirements of afixed cross-arch prosthetic restoration. Special attention should be given to the useof interproximal brushes with a triangularhead. These are pushed through the cleaningspaces at the basis of the bridge from thelabial to the lingual site and the oppositeway (fig. 44). The pressure of the interproximal brushshould be at the transition between the peri-implant mucosa and the titanium frame-work. An electric tooth brush with a rota-ting, small diameter head, to cleanespecially the deep lingual sites thoroughly,is also recommended.

Recall

Depending upon the oral hygiene situationthe patient should be recalled at regular in-tervals between one and six months, tocheck the oral hygiene as well as the clinicaland radiological situation. With panoramic and intraoral x-rays themarginal bone level and the osseointegrati-on of the implants should be checked everyyear (fig. 51).

Fig. 51: Panoramic x-ray at the follow-up one-year after delivering the fixed bridge shows mar-ginal bone remodelling to the first thread

Fig. 50: A satisfied smile

Fig. 52: The happy patient

THE FABRICATION OF THE

PROCERA® IMPLANT BRIDGE FRAMEWORK