Screw versus cement for implant prosthesis installation part 2

Screw Versus Cement For Implant Prosthesis Installation. Part 2: The Game Changer that tips the

balance in Favour of Intra-oral Cementation.

Emil L.A. Svoboda PhD, DDS,Published to www.ReverseMargin.com

November 12, 2015

1

© Dr. Emil Svoboda PhD, DDS 2015

© Dr. Em

il Svoboda PhD, DDS 2015

2What if we could make intra-oral cementation

safer???Then we could, at least, achieve an optimal fit

of the implant-abutment junction at the deep tissue level!

Would that idea tip the scales in favour of Intra-oral Cementation for you and your patients???

© Dr. Em


3What do we understand about intra-oral cementation???

1. It is a hydraulic event2. Excess cement is difficult to control3. It can go deep into the subgingival environment4. It can be difficult to detect and remove 5. It can be a longstanding risk factor for periodontitis

and peri-implant diseaseThomas G Wilson Jr. The Positive Relationship Between Excess Cement and Peri-implant Disease: A Prospective Clinical Endoscopic Study. J. Periodont 2009;1388-1392The Influence of the cementation margin position on the amount of undetected cement. A pro-spective clinical study. Tomas Linkevicius et al. Clinical Oral Implants Research. Vol 24,Issue 1, 71-76, Jan 2013. Cementation in Dental Implantology. An Evidence Based Guide. Edited by Chandur P.K. Wadhwani. Published by Springer 2015.

© Dr. Em


4New Information about the Dynamics

of Intra-Oral Cementation 1. Effect of Margin Design2. Identifying the “Gingival Effects”3. Overcoming the Gingival Effects

by Design4. Reducing Cementation Pressure to

increase Cement Control

Controlling Excess Cement During The Process of Intra-oral Prosthesis Cementation: Overcoming the Gingival Effects. ELA Svoboda, OralHealth Oct 2015;52-66.

51) Effect of Margin Design


A

ChamferMargin

ReverseMargin

TaperedMargin

B

Figure 1 A—Shows 3 aluminum rods with different margin designs. B—Shows the rods with zirconia crowns cemented into place. The arrows indicate the direction of the margins and the cement flow. Note, the Tapered and Chamfer Margin designs direct the cement downwards while the Reverse Margin directs the cement upwards.

1) Effect of Margin Design


7

Enter Gingiva! Large amount of Subgingival Cement.

2) Gingival Effects Discovered!


8

Figure 8—A Shows 3 aluminum rods with 3 different margin designs that are 1 mm below the top of the clear Tygon tubes (gingiva) The black electrical tape was placed 1 mm below the margin and is 0.125 mm thick. It fills the space between the tube and the rod. The black arrows indicate the direction of the margins. B—Depicts the zirconia crowns cemented into place. Note the huge amount of sub-margin cement, regardless of margin design.

A

ChamferMargin

ReverseMargin

TaperedMargin

B

2) Gingival Effects


10

WHEN A CROWN IS LARGER THAN ITS RETAINER, AND WHEN IT MAKES A SEAL WITH THE PERI-IMPLANT GINGIVA PRIOR TO BEING SEATED ……

EXCESS CEMENT CAN GET TRAPPED BETWEEN THE GINGIVA AND THE CROWN UNDERSURFACE.

THE CROWN CAN THEN ACT LIKE A “PLUNGER” THAT PUSHES THE TRAPPED CEMENT FURTHER INTO THE PERI-IMPLANT SPACE.

2) “Gingival Effects” are comprised of at least 4 Effects


11

1. Deflection Effect2. Eddy Effect3. Plunger Effect4. Bellows Effect

These are described in greater detail in:Controlling Excess Cement During The Process of Intra-oral Prosthesis Cementation: Overcoming the Gingival Effects. ELA Svoboda, OralHealth Oct 2015;52-66 and are demonstrated in videos at www.ReverseMargin.com.

http://www.reversemargin.com/

© Dr. Em


This cemented implant crown was removed because of chronic “Food Impaction” 12

“X-ray is clear of visible cement. A hole was drilled into the crown to access the retaining screw for removal.”

© Dr. Em


Residual Cement is not a MythIt is a Problem! 13

Loose piece of cement placed

back onto crown

Undersurface of abutment with

biological debris

© Dr. Em


Residual cement can be hard and smooth and difficult to detect 14

red arrow shows residual acrylic cement

© Dr. Em


Beware of the “Gingival Effects”

Excess cement is difficult to locate, access, and remove ……. because the prosthesis may block access to effective

instrumentation.

“Better to schedule surgery to locate and remove excess

cement!

15

© Dr. Em


Poor Cement Control

Many implants today still have almost straight walled standard abutments that are designed for

intra-oral preparation and cementation

“It would be difficult to avoid subgingival cement injection”

16

Figure from “Dental Implant Prosthetics, Carl E. Misch, Elseier Mosby, 2005 Pg 445

3) Overcoming the Gingival Effects by Design


17

NarrowCrown

HybridCrown

WideCrown

A B

Figure 9—A Shows 3 aluminum rods with Reverse Margins that terminate 1 mm below the top of the clear Tygon tubes (gingiva). The black electrical tape was placed at the margin and is 0.125 mm thick. It fills the space between the tube and the rod. There are 3 crown designs, wide, narrow and hybrid. The narrow is smaller in diameter than the tube, and the hybrid has a narrow part sub-gingival tapering to a wider profile 1/2 mm above the tube. B—Depicts the crowns cemented into place. Note the huge amount of sub-margin cement under the wide crown, while the narrow and hybrid crowns did not have any cement that breached the black tape border.

3) Overcoming the Gingival Effects by Design

A “Well Designed” Custom Abutment Controls: 1. Emergence profile – to support shape of the base of the prosthesis 2. Margin height – to specifically control the margin position (Supra-, Equi-, up to 1 mm Subgingival)3. Margin design – use Reverse Margin™ Design and avoid tissue facing margins4. Margin width – use a horizontal rim to push gingiva away to form a barrier to cement, and allow it

to flow out of the tissues5. Material – Titanium, hybrid Titanium/Zirconia - for biocompatibility and aesthetics

A “Well Designed” Custom Prosthesis Controls:6. Emergence profile – that works with the custom abutment to allow excess cement to move out of

the tissue spaces during the process of intra-oral cementation7. Margin Design – to compliment abutment margin and to direct excess cement out of the tissue

space8. Material Composition – to meet aesthetic needs of the pateint


19

Custom Abutments shouldStretch the surrounding gingiva

Stretching adjacent gingiva creates a barrier against excess cement intrusion

© Dr. Em


20

StretchedGingiva

X-section ofStandard abutment

X-section of Custom abutment

Loose gingiva

The Well Designed Custom Abutment

Stretches the Gingiva Stretching the peri-implant gingiva creates a tighter seal that can further resist excess cement injection

The Reverse Margin Design makes the custom abutment even better, by changing the direction of the excess cement ejection away from the soft tissue


21

Note the blanching of the tissues – yellow arrows

Look at Custom Abutments from a premium abutment company

These are designed with limited control from dentists

Margins are positioned subgingival, even where this is not necessary for aesthetics

They have tissue facing margins They are much narrower than the

emergence profile crowns that will be cemented onto them (cause Gingival Effects)


22

These Abutments have Poor Cement Control Features!

© Dr. Em


These custom abutments are Poor Choice for Cement Control!

Not much better than a Stock Abutment below, available at “no cost” from another implant company.

During cementation, neither system will control projection of cement into the peri-implant space, or prevent the “Gingival Effects”

Where is the value in these custom

abutments ????

23

Abutment TypesSimpleStock

Pre-shapedStock

UCLA Base-Cast

Custom Milled

Milled Base Yes Yes Yes Yes

Distorted by CastingProcesses

No No *Yes No

Margin type Downwards Downwards/Sideways

**Controlled **Controlled

Prevents Gingival Effects by Design

No No **Yes **Yes

Optimized Implant-Abutment Connection

Yes Yes *No **Yes


24

*The UCLA base is distorted by high temperatures during the casting and removal of investment material**The Reverse Margin Design and Cement Control Design are Patent Pending … available through licensed Labs . Core3D Centres are licensed in Canada and the USA. Info at www.ReverseMargin.com


4) Reducing Cementation PressureDentists use Huge Insertion Pressure to cement crowns and bridges into the

mouth. This behavior is evolved from use of older cements with poor compression, retentive, solubility and handling properties.

Hard Biting 600 N Finger Pressure 40 N *Low Pressure 2.5 N **Super Low Pressure 0.125 N ***


25

* Effects of finger pressure applied by dentists during cementation of all-ceramic crowns. M.Zortuk M. et al, Eur J Dent 2010, Oct; 4(4):383-388.

**Low force cementation. Wilson PR. J Dent. 1996 Jul;24 (4):269-73.*** Super Low Cementation Forces. Emil L.A. Svoboda PhD, DDS, Video Published to www.ReverseMargin.com,

July 13, 2015.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Wilson%20PR%5BAuthor%5D&cauthor=true&cauthor_uid=8783532

http://www.ncbi.nlm.nih.gov/pubmed/?term=Wilson%20PR%5BAuthor%5D&cauthor=true&cauthor_uid=8783532

http://www.ncbi.nlm.nih.gov/pubmed/8783532

How is it Possible … To Reduce Cementation Pressure so Much??

With the Cement Control System™ and a modern dual cure, fluid acrylic based cements, it is not necessary to overcome tight contacts and resistance from gingiva … and do all of this under the added pressure of time, to avoid premature setting of cement.Everything has already been tried in and confirmed .. Fit good, Contacts good, Occlusion good …. Clean and dry, gently tap the prosthesis into place … light cure for 4 seconds per side and start cleaning away excess cement .. Its so easy.

Much better control over the whole cementation process!


26

1. Super Low Cementation Forces. Emil L.A. Svoboda PhD, DDS, Video Published to www.ReverseMargin.com, July 13, 2015.

2. Prosthesis Installation Technique using the Reverse MarginTM Design and Technique. Emil L.A. Svoboda, Published to www.ReverseMargin.com. June 16, 2015.


The Cement Control System™ includes

Super Low Installation Pressure Installation


27

Intra-oral Cementation


28

Install Custom Abutment, Fit OK?, Torque, Teflon, Lubricate, Cement, Remove Excess,

Maintain … Great Control of Excess Cement!


32

Screw or Cement??


The Cement Control System™ Makes

Intra-oral Cementation BETTER

Because it 1) Controls Excess Cement

2) Optimizes the Implant-Abutment Connection

3) Avoids Cantilevers Created for Screw Access

33

© Dr. Em


USE THE REVERSE MARGIN™ AS PART OF YOUR CEMENT CONTROL SYSTEM™

TO PROTECT THE FOUNDATIONSOF YOUR PROSTHETIC TREATMENT

Go to www.ReverseMargin.com to view videos and other supporting information

34


We Partnered with a Large Precision Milling Group to Create Custom

Components for the“Cement Control System™”


35

Workflow – Your Lab or Diamond Dental Studio receives your models and/or digital impressions and sends files to Core 3 D Centres for Design and Precision Milling. Your Lab or Diamond Dental Studio then assembles and further customizes work for delivery to Your Office and your Patients. Contact us at www.ReverseMargin.com

North America

Making It Available

Screw versus cement for implant prosthesis installation part 2

Health & Medicine

Transcript of Screw versus cement for implant prosthesis installation part 2