Protetica Fixa Pe Implante
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Slide 1
Protetică fixă pe implante
Catedra de protetică dentară fixă şi ocluzologie 2005 – sef de lucrări Dr. Sergiu Drafta
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Slide 2
Obiectivele cursului
Implantologie –generalităţi Clasificarea implantelor
Elementele sistemului implantar
Indicatiile implantelor Limitele anatomice ale pozitionarii implantelor
Integrarea tisulara a implantelor
Etapele clinico-tehnice de realizare a RPF pe
implante
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Slide 3
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Slide 4
Definiţie :
Implantele endoosoase sunt materialealoplastice care se inseră chirurgical
într-o creastă osoasă reziduală cuscopul de a deveni o infrastructurăprotetică
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Slide 5
Materiale din care seconfecţionează implantele:
Titanul şi aliajele de titan
Hidroxiapatita Safirbioceramica
Zirconiu
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Slide 6
Clasificarea implantelor
După raportul cu osul :endoosoase, juxtaosoase (subperiostale, submucoase)
După momentul aplicării :imediate, imediat-tardive, tardive
După modalitatea aplicării : într -un timpchirurgical , în doi timpi chirurgicali
După formă
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Slide 7
Clasificarea implantelor după modalitateaaplicării
Într-un singur timpchirurgical
În doi timpi chirurgicali
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Slide 8
Clasificarea implantelor dupăformă
Implante rădăcină (root-form implants)
Implante lamă Implante ac
Implante disc
Implante combinate lamă-rădăcină Implante transmandibulare
Implante transfixante
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Slide 9
Implante rădăcină
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Slid 10
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Slide 10
Implante lamă
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Slid 12
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Slide 12
Implante cu alte forme
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Slid 13
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Slide 13
Implantul transmandibular
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Slide 14
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Slide 14
Implante transfixante
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Slide 15
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Slide 15
Elementele sistemului implantar
Corpul implantar
Şurub de acoperire
Extensie permucozală
Stâlpul implantar DTI,DTD
Capa
Implantul analog
Surubul de fixare
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Slide 16
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Slide 16
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Slide 17
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Slide 17
Alcătuirea stâlpilor implantari
Baza
Capul
Colereta
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Slide 18
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Slide 18
Baza stâlpilor implantari depindede dispozitivul anti-rotaţional al
implantului
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Slide 19
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Slide 19
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Slide 20
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Slide 20
Modalitatea de fixare la corpulimplantar
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Slide 21
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Slide 21
Capul stâlpului implantar
Drepţi Angulaţi
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Slide 22
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Slide 22
Colereta stâlpului implantar
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Slide 23
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Slide 23
Stâlpi implantari estetici
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Slide 24
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Slide 24
Criterii pentru alegerea stâlpilorimplantari
Angulaţia corpului implantar Adâncimea şanţului gingival Estetica (vizibilitatea coleretei metalice)
Nevoia de dispozitiv antirotaţional Accesul pentru igienă
Nevoia de a realiza restauraţii demontabile
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Slide 25
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Indicaţiile implantelor
Edentaţia totală
Edentaţie parţială terminală
Breşa edentată lungă
Edentaţia unidentară
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Slide 26
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Edentaţia totală
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Slide 27
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Edentaţia terminală
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Slide 28
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Agregarea mixtă
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Slide 29
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Breşa edentată lungă
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Slide 30
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edentatia unidentara
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Slide 31
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Slide 32
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Limitele anatomice ale poziţionării implantelor
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Slide 33
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Limitele anatomice ale poziţionăriiimplantelor
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Slide 34
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Slide 35
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Slide 36
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Integrarea tisulară a implantelor
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Slide 37
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Integrarea osoasă a implantelor
A fost descrisă deBranemark
Absenţa ţesutuluiconjunctiv de la nivelul
interfeţei os-implanteste cheia succesuluiclinic în implantologiaendoosoasă.
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Slide 38
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Integrarea osoasă pe termen lung
Biocompatibilitateamaterialului
Designul implantului
Suprafaţa implantului Statusul patului osos
Tehnica chirurgicală
Condiţiile de încărcare
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Slide 39
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Biocompatibilitatea
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Slide 40
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Biocompatibilitatea
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Slide 41
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Designul implantului
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Slide 42
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Designul implantului
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Slide 43
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Designul implantului
Implante rădăcină conice
Implante cu hexagon intern
Implant şi stâlp implantar = o singură piesă(Direct – NobelBioCare)
Implante lamă închise
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Slide 44
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Suprafaţa implantului
Plasmă de titan
Gravaj acid
Sablare cu particule de siliciu sau cu oxid de
aluminiu Tratament cu laser
Combinaţii ale acestor metode
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Slide 45
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Suprafaţa implantului
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Slide 46
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Plasma de titan
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Slide 47
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Statusul patului osos
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Slide 48
f
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Diagnosticul ofertei osoase
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Slide 49
D i ă
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Densitatea osoasă
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Slide 50
T h i hi i lă
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Tehnica chirurgicală
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Slide 51
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Slide 53
C diţiil d î ă
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Condiţiile de încărcare
Încărcarea graduală tardivă are cea maimare rată de succes şi este recomandată
începătorilor
Încărcarea imediată este rezervată cazurilor în care stabilitatea iniţială primara aimplantelor este excelenta (mai mare de 20N:cm2)
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Slide 54
R bilit lă l ă i
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Reabilitarea orală cu lucrăriprotetice fixe pe implante
Examinare
Diagnostic Plan de tratament
Tratamentul propriu-zis
Dispensarizare
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Slide 55
E i
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Examinare
Stare generală de sănătate
Examen loco-regional (dinţi naturali restanţi,creste alveolare edentate, parodonţiu,
ocluzia, estetica) Examinare paraclinică (radiografia
panoramică, teleradiografia de profil,tomografia computerizată, modele de studiu,machete diagnostice)
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Slide 56
C t i di ţii
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Contraindicaţii
Generale : diabet zaharat decompensat,lupus, leucemii,hemofilie, TM regionale, bolimetastatice, abuz de alcool sau tutun,
tratament prelungit cu imunosupresoare,tulb. psihice severe,graviditate, pacienţinemotivaţi
Locale: factori anatomici, bruxism, raporturiocluzale nefavorabile
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Slide 57
R di fi i ă
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Radiografia panoramică
Examenul de bază ,indispensabil înimplantologie
Nu permite aprecierea precisă a calităţii
osului spongios Mărirea dimensiunilor în plan vertical de
aproximativ 1,3 ori
Se folosesc şabloane radiologice cu bilemetalice cu diametru cunoscut
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Slide 58
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Slide 59
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Slide 60
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Slide 61
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www.niznick.com
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Slide 62
Elaborarea planului de tratament
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Elaborarea planului de tratament
Alegerea tipului si numărului implantelor Lucrări demontabile vs.cimentate
Agregare pur implantară vs.agregare mixtă
Alegerea schemei ocluzale şi a materialelorocluzale
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Slide 63
Opţiuni terapeutice
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Opţiuni terapeutice
Proteze mobilizabile
Punţi colate
Punţi convenţionale
Restaurări pe implante
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Slide 65
Coroană solo pe implant fixată prin
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Coroană solo pe implant fixată princimentare
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Slide 66
Coroană solo pe implant fixată prin
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Coroană solo pe implant fixată prin înşurubare
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Slide 67
Punţi cu agregare mixtă ed
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Punţi cu agregare mixtă – edterminală
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Slide 68
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Slide 70
Punţi cu agregare pur implantara
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Punţi cu agregare pur implantara-ed terminală
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Slide 71
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Slide 72
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Slide 73
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Slide 74
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Slide 75
“Tomato on stick”
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Tomato on stick
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Slide 76
Fixare din lateral
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Fixare din lateral
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Slide 77
Punţi de întindere mărită cu
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Punţi de întindere mărită cuagregare mixtă-breşă ed lungă
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Slide 78
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Slide 79
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Slide 80
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Slide 81
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Slide 82
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Slide 83
Punţi de întindere mărită cu
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Punţi de întindere mărită cuagregare implantară-breşă ed lungă
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Slide 84
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Slide 85
Proteza fixă hibridă ( proteza high
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Proteza fixă hibridă ( proteza highwater, proteza Toronto) – ed totale
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Slide 86
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Slide 87
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Slide 88
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Slide 89
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Slide 90
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Slide 91
Fixare din lateral
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Fixare din lateral
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Slide 93
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Slide 94
Punte totală pe implante- ed totale
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p p
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Slide 96
Tratament preprotetic chirurgical
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p p g
Grefe osoase tip onlay sau sandwich ROG
Distracţie osoasă
Elevarea sinusului maxilar Repoziţ ionarea nervului alveolar inferior
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Slide 97
Grefe onlay
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y
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Slide 98
ROG
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Slide 99
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Slide 100
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Slide 101
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Slide 102
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Slide 103
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Slide 104
Distracţie osoasă
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ţ
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Slide 105
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Slide 106
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Slide 107
Elevarea sinusului maxilar
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Slide 108
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Slide 109
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Slide 110
Repoziţionarea NAI
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Slide 111
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Slide 112
Tratamentul preprotetic: realizareabl l i hi i l
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şablonului chirurgical
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Slide 114
Şablonul chirurgical
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Slide 115
Şablonul chirurgical
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Slide 116
Şablonul chirurgical
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Slide 117
Şablonul chirurgical
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Slide 118
Şablonul chirurgical
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Slide 119
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Slide 120
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Slide 121
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Slide 122
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Slide 123
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Slide 124
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Slide 125
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Slide 126
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Slide 127
Şablonul chirurgical
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Dictează plasarea implantelor în poziţia ceamai bună pentru suport, estetică,igienizare
Limitează chirurgul în timpul plasării
implantelor : M-D, V-O Trebuie să fie rigid şi transparent Trebuie să permită reflectarea lamboului
muco-periostal
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Slide 128
Faza I chirurgicală : inserareaimplantelor
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implantelor
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Slide 129
Inserarea implantelor
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Slide 130
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Slide 131
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Slide 132
Faza a doua chirurgicală
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Slide 133
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Slide 134
Cape de vindecare sau stâlpiimplantari definitivi?
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implantari definitivi?
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Slide 135
Alegerea stâlpilor implantari şimontarea lor
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montarea lor
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Slide 136
Amprenta
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La nivelul corpilor implantari sau la nivelulstâlpilor implantari
Cu DTI sau DTD
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Slide 137
La nivelul corpilor implantari sau lanivelul stâlpilor implantari ?
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nivelul stâlpilor implantari ?
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Slide 138
Amprenta la nivelul corpilorimplantari
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implantari
Dezavuată de şcoalaromânească deimplantologie
Se foloseşte când seutilizează stâlpi implantariUCLA
Se foloseşte când stâlpiiimplantari se selectează înlaborator
Este indicată în zonele încare exigenţele fizionomice
sunt maxime Pe model analogii
corpurilor implantare
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Slide 139
Amprenta la nivelul stâlpilorimplantari
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implantari
Este necesar control radiologic pentruevaluarea joncţiunii corp implantar - stâlpimplantar
Nu mai este necesară demontarea stâlpilor
implantari ceea ce ar putea produce o ruperea inelului conjunctiv periimplantar Este indicată atunci când stâlpii implantari au
fost aleşi şi fixaţi definitiv în timpul fazei a II-a
chirurgicale Pe model analogii stâlpilor implantari
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Slide 140
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Slide 141
Amprenta cu DTI sau DTD?
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Slide 142
Amprenta cu DTI
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DTI Sunt confecţionate din
metal sau plastic Rămân pe câmpul
protetic la îndepărtareaamprentei din cavitateabucală
Au feţele laterele uşorconice şi uneori au
porţiuni plane pentru aajuta poziţionarea lor înamprentă
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Slide 143
Etapele amprentei cu DTI
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Se înşurubează DTI la corpii sau la stîlpii implantari Se alege şi se probează o lingură standard care săcorespundă înălţimii DTI
Se aplică adeziv pe lingură Se prepară materialul de amprentă, se încarcă
lingura si se introduce în cavitatea bucală apacientului După priză, se îndepărtează amprenta din c.b. Se dezinfectează amprenta Se deşurubează DTI şi se înşurubează în stâlpii
sau corpii implantari analogi Ansamblul DTI-analogi se repun în amprentă
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Slide 144
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Slide 145
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Slide 146
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Slide 147
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Slide 148
Amprenta cu DTI
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Avantaje Se poate verifica la
vedere repoziţionareaansamblului DTI-analogi
DTI rămân pe câmpulprotetic ca laamprentarea clasică
Dezavantaje Există dificultăţi la
repoziţionareaansamblului DTI-analogi
Există posibilitateaproducerii deformăriipermanente ladezinserţia amprentei
Nu se aplică în cazulexistenţei dedivergenţe implantare
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Slide 149
Amprenta cu DTD
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DTD Au o formă
paralelipipedicăretentivă
Au o gaură de accespentru şuruburile defixare (tije ghid)
Tijele ghid au lungimi
de 10, 15, 20 mm.
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Slide 150
Etapele amprentării cu DTD
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Confecţionarea unei linguri individuale deschise îndreptul DTD Se fixează DTD la implante sau la stâlpii implantari Se aplică adeziv pe lingură si pe DTD Se prepară materialul de amprentă, se încarcă
lingura si se introduce în cavitatea bucală apacientului După priză , se deşurubează tijele ghid ale DTD
care însă nu se scot din amprentă Se îndepărtează amprenta din gura
Se dezinfectează amprenta Se conectează la DTD analogii
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Slide 151
Confecţionarea lingurii individuale
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Slide 152
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Slide 153
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Slide 154
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Slide 155
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Slide 156
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Slide 157
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Slide 158
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Abutment
Analogues
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Slide 159
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Slide 160
Amprenta cu DTD
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Avantaje Risc scăzut de
deformare a amprenteila îndepărtarea din c.b.
Obţinerea unui modelfuncţional mai fidel Se poate aplica şi în
cazul divergenţelor
implantare
Dezavantaje Posibilitatea de
deformare a amprenteila montarea analogilor
Greu de realizat înregiunile posterioareale arcadelor mai ales
în cazul unei
amplitudini mici a DM cronofagă
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Slide 161
Confecţionarea modeluluifuncţional
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ţ
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Slide 162
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Slide 163
Confecţionarea şabloanelor deocluzie
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Se pot folosi : -DTD-cape sau cilindrii prefabricaţi
(metalici sau din plastic) Pentru susţinerea şablonului sunt necesare
minim 2-3 cape (DTD) Să fie vizibilă joncţiunea capă(DTD)-SI Bordura de ocluzie e întreruptă în dredtul
tijelor ghid
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Slide 164
Confecţionarea şabloanelor deocluzie
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Slide 165
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Slide 166
Înregistrarea de ocluzie
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Slide 167
Montarea modelelor în articulator
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Slide 168
Protezarea provizorie şi încărcareaprogresivă a osului
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Legea lui Wolff : osul se remodelează înfuncţie de forţele aplicate asupra lui Riscul maxim de eşec al implantelor este în
primul an
Timpul de tratament pentru încărcareaprogresivă a osului depinde de densitateaosoasă
Dacă există o creştere rezonabilă asolicitărilor , densitatea osoasăperiimplantară poate creşte
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Slide 169
Confecţionarea scheletului metalical suprastructurii
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Slide 170
Proba scheletului metalic alsuprastructurii în cavitatea bucală
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Testul Sheffield (verificarea pasivităţii) Dacă lucrarea nu e pasivă: -se secţionează scheletul metalic -se solidarizează intraoral cu Duralay -se face o cheie vestibulară de gips sau siliconi -se scoate scheletul metalic si cheia vestibulară din gura
pacientului-se plasează stâlpii analogi-se toarnă modelul -se îndepărtează răşina şi se repoziţionează scheletul metalic
pe model
-se aplică ceară la locul de lipire -se ambalează în vederea lipirii -se lipeste
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Slide 171
Testul Sheffield
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Slide 172
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Slide 173
Proba scheletului metalic alsuprastructurii în cavitatea bucală
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Slide 174
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Slide 175
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Slide 176
Aplicarea placajelor fizionomice
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Slide 177
Proba şi adaptarea lucrăriiprotetice definitive ; fixarea
t ă
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temporară
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Slide 178
Fixarea definitivă
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Slide 179
Igienizarea
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Regimul de întreţinere personală – permanent – întărit periodic prin dispensarizare
Procedurile de igienizare:
-de 3 ori pe zi-perii de dinţi medium şi soft -perii de dinţi interproximale
-şnururi dentare şi panglici dentare -periuţe dentare electrice
-aparatul WATER PIK
d ă d 2X i
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Slide 180
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Slide 181
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Slide 182
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Slide 183
Control clinic şi radiologic
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da
dada
da
La fiecare 3ani
1-2 sapt
6 sapt
6 luni12 luni
24 luni
36 luni
Anual
RXcontrol
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Slide 184
Criterii de succes Albrektsson 1991
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Absenţa mobilităţii Absenţa durerii Absenţa infecţiei periimplantare
Absenţa sângerării la palpare Pierdere osoasă 1.0-1.5mm în primul an;
apoi < 0.1mm anual
Rata de succes la 5 ani 95% iar la 10 ani de85%
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Slide 185
Complicaţii
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Complicaţii imediate
Complicaţii tardive
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Slide 186
Complicaţii imediate
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Accidente la montarea SI pe corpul implantarImposibilitatea montării SI dat.:
-alterării filetului intern al implantului -incongruenţei SI-corp implantar
-fracturării părţii filetate a SI -mobilităţii corpului implantar prin lipsa stabilităţii
primare
Accidente şi greşeli la montarea suprastructuriiprotetice
-fractura şurubului de fixare a lucrării protetice
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Slide 187
Complicaţii tardive
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Complicaţii ale ţesutului moale: Gingivita proliferativă Expunerea filetului corpului implantarIgienizare necorespunzătoare Complicaţii osoase
Pierderea progresivă a osului marginal Mobilizarea corpului implantar Complicaţii mecanice Fractura corpului implantarSlabirea SI sau a şuruburilor de fixare
Fractura şurubului SI Fractura suprastructurii protetice
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Slide 189
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Slide 190
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Slide 191
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Slide 193
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Slide 194
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Slide 195
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Slide 196
Ocluzia RPF pe implante
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După obţinerea integrării tisulare primare aimplantelor cauza principală a pierderiiiniţiale de os din jurul implantelor esteprezenţa unor forţe ocluzale excesive
Lipsa ligamentului parodontal determinăpierderea influenţei lui protectoare,
neexistând mecanisme specifice de apărare împotriva forţelor ocluzale
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Slide 197
Încărcarea axială a implantelor
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Slide 198
Ocluzia RPF pe implante
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Ocluzia lingualizată poziţionată medial
Legea componentei celei mai slabe
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Slide 199
Ocluzia lingualizată poziţionatămedial
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Implantele inserate,atât la mandibulă, câtşi la maxilar realizeazăo ocluzie mai medialădecât schema naturalăocluzală în carecuspidul vestibularmandibular estecuspidul dominant
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Slide 201
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Slide 202
Conceptul componentei celei maislabe
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Când un segment al unor arcade este supus
unor factori de forţă mai mari sau are un riscmai mare de complicaţii decât segmentulantagonist el reprezintă o componentă maislabă
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Slide 203
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Slide 204
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Realizarea unei inocluziiverticale de 30 de microni la
lucrările agregate pe implante
Zarb, Chapman
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Slide 205
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Slide 206
Cazul 1
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Slide 207
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Slide 208
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Slide 209
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