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Introduction
Oral implantology (implant dentistry) is the science and discipline concerned with the diagnosis, design, insertion, restoration, and/or management of alloplastic or autogenous oral structures to restore the loss of contour, comfort, function, esthetics, speech, and/or health of the partially or completely edentulous patient.
Implant prosthodontics is the branch of implant dentistry concerning the restorative phase following implant placement and the overall treatment plan component before the placement of dental implants.
Implant
Osseointegration Crestal bone loss Traumatic to supporting bone Stress Stress concentrated at crestal bone
fremitus, pain
or
prosthesis
fracture,
bone
loss,
mechanism)
TREATMENT PLANNING The ideal implant treatment plan is based on the patient's needs, desires, and financial commitment. Topdown planning Topdown planning refers to determining the restorative treatment plan and considering all treatment options before developing the necessary surgical treatments. In this way the treatment plan will be developed with the final goal in mind.
Type of restoration
Fixed
Anterior
8-10 mm
Posterior
7 mm.
Removable
12 mm
12 mm
The ideal position is directly under the incisal edge position of an anterior tooth and under the central fossa of posterior teeth out of the esthetic zone.
The maxillary premolars: the implant body should be positioned buccal to the central fossa to enhance cervical esthetics without hygienic compromise.
6. Existing occlusion:
The partially edentulous posterior ridge with facial resorption may require implant insertion more medial in relation to the original central fossa of the natural dentition. Enameloplasty of the stamp cusps of the opposing teeth often is indicated to redirect occlusal forces over the long axis of the implant body. The relationship of centric occlusion to centric relation is to be noted because of Potential need of occlusal adjustments to eliminate deflective tooth contacts, and Evaluation of their potential noxious effects on the existing dentition.
8. Location and number of Missing teeth: The number and location of missing teeth influences the prosthodontic treatment plan of the patient.
Location Implants are warranted whenever the following are missing: canine, lateral incisor, and first premolar; or canine, lateral, and central incisors; or canine, first premolar, and second premolar. When one of those three combinations of teeth is missing, an implant usually is placed in the canine region whenever possible.
is not replaced in posterior implant supported prosthesis. The mandibular first molar is designed to occlude with the mesial marginal ridge
of a natural second maxillary molar to prevent extrusion.
implant is mostly
NOT more than two posterior ponticse because greater span between abutments increases the flexibility in the prosthesis and porcelain fracture, cement breakage, or screw loosening in the restoration. To limit the effect of the law of beams, independent implant prostheses may reduce or eliminate the number of pontics while simultaneously increasing the number of abutments and distributing the forces more effectively.
When two pontics are considered, the thickness of the metal may be increased or Additional grooves on the facial and lingual aspects of the implant abutment. Nonprecious metals deform about 50% less than high noble alloys and therefore may be selected for long-span restorations supported by teeth. However, corrosion factors may be a concern with nonprecious alloys contacting titanium implants, especially with subgingival margins. The final restoration may be segmented (canine to canine and two posterior segments) when the number of implants permits.
As a consequence, complete cross-arch splinting of posterior molars with rigid, fixated implants is usually contraindicated in the mandible
Options Segment the restoration in 2 or more independent prostheses. Non rigid connectors Insert posterior implants only in one section.
12. Soft tissue support Evaluation of soft tissue support is primarily needed in planning for overdenture prostheses.
SURGERY
Prior to surgery, the implant site is carefully examined clinically,
radiographically and using mounted diagnostic casts. Diagnostic Casts Mounted study casts and a diagnostic wax-up are the foundation for determining implant location. Surgical Guide Templates This guide dictates to the surgeon the implant location that offers the best support for the prosthesis, as well as optimal esthetics and hygiene requirements.
IMPLANT IMPRESSIONS
Accurate recording of spatial implant position is required to obtain a proper support to definitive restoration with passive fitting. The purpose of Impression in implant dentistry is to record: 1. Position. 2. Depth. 3. Axis/Angulation. 4. Rotation-Hex position 5. Soft Tissue Contour (Emergence Profile)
ABUTMENT ANALOG ?
A replica of the superior portion of a dental implant. Usually used to provide an exact form of the dental implant abutment within the dental laboratory during fabrication of a prosthesis supported in part or whole by the dental implant
It is used in the casts as a replica of implant on which lab procedures are done.
dentistry:
Prepared Abutment An intra-oral impression is
Implant-level Impression An intra-oral impression is made transferring the emergence of the implant. The implants location and angle are recorded, with or without the orientation of the internal hex.
Abutment-level Impression An intra-oral impression is made of abutments that have been placed onto the implants. Abutment location and angle are recorded for screw-retained prosthesis
Implant-level and abutment-level impressions can be made by either of the following techniques: Closed Tray (Indirect) Transfer Technique or Open Tray (Direct) Pick-up Technique Prepared Abutment impressions are always made using the Closed Tray technique.
Note:
Uniform thickness of material throughout the tray yields good results. Custom trays present higher accuracy as compared to the impressions obtained with stock trays. If Implant is placed deep, to take transfer type: use small Diameter impression post. Always remove healing abutment and immediately place the impression post. Put them in order. It is important to take a periapical X-ray to verify the fit between the transfer coping and the implant. Verify the seating of components.
In case of improper interface, note small gap between impression post and implant analogue. Ensure that impression post and implant analog are securely screwed together and fully seated in impression. Inhibition of the polymerization of vinyl polysiloxane (VPS) impression materials has been reported to occur with the use of latex protective barriers such as gloves.
Advantages of Closed Tray Easier Suitable for short inter arch distance. Visual fastening of the analog to the coping is more accurate
Disadvantages of Closed Tray Inaccuracies with recovery and subsequent deformation of impression material may be encountered with nonparallel implants. Not Suitable for deeply placed implants.
Future Trends
Optical impressions CEREC Scannable abutments Scans can be prepared in two ways: without scan spray with scan spray
TRANSFER OF SOFT TISSUE DETAIL Several techniques for the accurate transfer of the intraoral peri-implant soft tissue developed by a provisional restoration may be summarized as follows: 1. fabrication of a customized impression coping that is adapted to the peri-implant soft tissue profile 2. use of provisional restoration as an impression coping 3. injection of impression material around a provisional restoration seated on a master cast.
Accurate Transfer of Peri-implant Soft Tissue Emergence Profile from the Provisional Crown to the Final Prosthesis Using an Emergence Profile Cast (J Esthet Restor Dent 19:306315, 2007)
The provisional crown connected to the laboratory analog inserted in the emergence profile impression prior to pouring.
A trayless impression technique for complete arch implant-supported immediately loaded provisional and definitive restorations (J Prosthet Dent 2005;94:202-3.)
TEMPORARY PROSTHESIS Temporary restorations are dependent on the treatment plan, the requirements of the patient and the final restoration planned. Temporization Prior to Second-stage Surgery Totally edentulous patient 1. The existing denture is relieved over the implant sites and relined with a soft material. 2. Transitional implants may be placed in between the permanent implants.
Partially edentulous patient 1. A removable prosthesis can be made which is relieved to protect the implant from function. 2. A Maryland bridge can be fabricated. 3. In non-esthetic zones a temporary may not be necessary.
Temporization After Second-stage Surgery Cement-retained crown & bridge A provisional crown or bridge restoration can be fabricated on a titanium or PEEK plastic temporary abutment. Techniques used for traditional temporaries on natural teeth are used. Screw-retained crown & bridge Screw-retained provisional restorations can be fabricated using PEEK plastic or titanium temporary abutments.
ABUTMENT SELECTION
Abutment selection criteria
Angulation
(degrees)
< 15 15-35 35+
Interocclusal
(mm)
2.8 3.5 4.5 5.0 6
Abutment
Cylindric
O * * * * * * # # #
Standard
O
O *
*
*
*
*
*
* #
#
#
#
#
#
#
Types of abutments: Prefabricated or Custom made abutments Manufactured abutments are available which vary in flare, diameter, marginal scallop, angulation and height. These abutments can be prepared or reshaped to a degree to accommodate crown design and location. The restorative clinician should first observe the clinical presentation of the healing abutment and the canal it creates through the soft tissue. Upon removal of the abutment this canal is assessed for width, depth and location.
Custom Abutments
A custom abutment is one in which the practitioner must make either a tissue or a bone-level impression of the implant with the help of a transfer impression coping. Custom abutments are the most universally used due to the variations in biologic width, occlusion, and aesthetic demands of patients. Custom abutments can be modified to allow for sufficient material placement to compensate for occlusal differences. the most efficient and the most costly. If the aesthetic demands of the patient are high, zirconia abutments can be used. If a custom abutment is used, the size of the platform of the implant is recorded and a transfer coping is selected based on an open or closed tray design.
Prefabricated abutments
A prefabricated abutment is machine made, seated and torqued atop the implant, prepared as needed, and treated as a conventional post-and-core restorative treatment procedure. The use of the prefabricated abutment reduces both the cost and number of visits.
Contraindications: 1) insufficient interocclusal space, where the abutment would not have sufficient height to retain a crown; 2) the implant requires an angle of correction greater than 15; 3) the collar height (the distance between the implant platform and the gingival margin) is more than 1 mm greater than the largest collar height offered by the manufacturer; and 4) the need for splinting three or more implants in a quadrant when parallelism is required.
Angulated abutment
The Angulated Prefabricated Abutment The implant systems use hexagonal, octagonal or triangular internal mechanism, therefore allowing a number of options for the correction of a malpositioned implant. Straumann synOcta allows 16 different positions of the angulated abutment. However, an angled abutment can only be used if the correction is within 15 to 20.
The abutment is now removed from the oral cavity and is ready for indirect preparation. The depth cuts are connected while establishing a chamfer finish line to the depth of the bur. Then polish using a rubber wheel or any polishing wheel. The abutment is now torqued into position The abutment is now treated as a conventional crown-and-bridge procedure. Retraction cord is placed and an impression is made. A provisional can also be fabricated at this time to protect the abutment.
CAD/CAM Abutments
The use of computer-aided design technology is available for fabrication of custom abutments e.g.Atlantis VAD (Virtual Abutment Design) is a patented process using 3D-optimized scanning software to generate an exact virtual image of the upper and lower implant-level model. Atlantis abutments are available in zirconia, titanium, or gold-shaded titanium. It is also available for all major implant systems. An alternative for the laboratory using a UCLA abutment (a goldplastic abutment used for waxing a custom abutment or screw-retained crown) in fabricating a custom abutment.
PROSTHETIC RESTORATION
indirect, at abutment level: small prosthetic screws hold the restoration to the standard abutment which is itself screwed down onto the fixture. direct, at fixture level: larger abutment screws fixates the restoration directly to the implant
Advantages Easier to retrieve prosthesis for servicing, revisions and hygiene maintenance Greater control of esthetics Minimal inter-arch space required
Indications
Multiple-unit restorations Abutment-level bar overdenture Fixed-detachable (hybrid type) restorations Extensive bone loss Thick tissue
Limitations
Limited inter-arch space to accommodate abutments, bar and overdenture
Advantages
Bar overdenture removable by patient for hygiene Fixed-detachable removable by dentist for hygiene
2. Cement-retained restorations cement-retained abutments are connected to implants with abutment screws, and the crowns are cemented to the abutments. Advantages
Easier correction of angulation problems. Improved esthetics When multiple implants are splinted, allows for easier, more accurate adaptation. more familiar
Disadvantages
Excess cement may be extruded into the tissues causing inflammation, soft tissue problems, and even severe bone loss. Retention may be unreliable.
Direct method A prefabricated abutment is connected to an implant and prepared intraorally with rotary instruments. Indirect method Implant abutments are fabricated in a laboratory on a cast obtained from an implant-level impression
RESTORATION SELECTION
In the aesthetic zone If screw-access is towards the buccal:
Cement retained crown or bridgework is almost unavoidable without using a secondary framework Favour flat-fronted CADCAM zirconium abutment if high smileline, thin gum type. Crown margin just below or at gingival level labially. Favour CADCAM titanium abutment if low smileline, or thick gum type. Crown margin just at or just below gingival level labially.
If screw-access is palatal: Screw retained crown or bridgework Favour screw-retained direct to fixture head, porcelain bonded to zirconium if high smileline. If low smileline or thick gum type, favour porcelain bonded to alloy bridgework, screwretained with intermediate titanium abutment.
If screw-access is occlusal/palatal:
Screw-retained crown or bridgework Porcelain bonded to alloy bridgework intermediate titanium abutment. Porcelain bonded to zirconium for crown or bridgework screw retained directly to fixture head.
Final prosthesis after 3-6 months of initial healing 1stage Loading 3 months after 2stage implant placement
Provisional prosthesis brought progressively into occlusion Between 2 wks 3 months Within 2 weeks of implant placement loading is done
Acrylic
contact
only
on
implant;
no
contact
on
cantilevers/pontics; occlusal table same as final prosthesis or Occlusion follow implant-protective occlusion
Adjust occlusion
5 Final prosthesis Final cementation
or Same as above
Additional clinical procedures in partially and completely edentulous residual ridges for implantsupported prostheses
Maxillomandibular relations
Mandibular occlusal rim stabilized with gold copings Centric relation record Protrusive record Facebow registration Tooth shade, denture tooth mold & occlusal scheme
Casts mounted on semiadjustable articulator Anterior & full tooth trial fitting used to established esthetics, phonetics, lip support, VD. CR verified with interocclusal records. Max distal extension cantilever 15mm distal to the distal most, fixture abutment interface bilaterally.
Maximum distal extension cantilever -15mm Modified by factors (10 mm) Arch form of abutment: fixture placement in a straight line places more load on the fixtures, abutment screws, and all components than does placement with an arch form. Implant length & prognosis: distal fixtures shorter than 10mm (or those placed in less than ideal bone) limit load potential. Natural opposing dentition Parafunctional habits
Vertical hole drilled through selective teeth to gain access to underlying fixture. Alignment of implant fixture is determined by guide pin. Jaw relation & occlusal contact reconfirmed
The distance from the midline is measured to the most posterior left and right fixtures and is then recorded. The shortest measurement is used and added to the maximum allowable extension. This calculation is the maximum limit of the cantilever section of the implant prosthesis.
Implant Protective Occlusion: Implant-protective occlusion (IPO) was presented previously as medial positioned-lingualized occlusion and developed by Carl E. Misch. This occlusal scheme is a combination of various principles which need to be addressed when fabricating implant supported prosthesis.
whether a rigidly fixated implant may remain successful when splinted to natural teeth!!!!!!! The implant prosthesis should barely contact, and the surrounding teeth in the arch should exhibit greater initial contacts. Only light axial occlusal contacts should be present on the implant crown. Contacts should be of similar intensity on the implant crown and the adjacent teeth when under greater bite force because all the elements react similar to the heavy occlusal load.
Mutually protected articulation The posterior teeth are protected by the anterior guidance during excursion, whereas the anterior teeth have only light contacts and are protected by the posterior teeth in centric occlusion. This concept is called the mutually protected articulation. The anterior guidance of implant prosthesis with anterior implants should be as shallow as practical
Implant body orientation and influence of load direction: Implants are designed for long-axis loads. An axial load over the long axis of an implant body generates a greater proportion of compressive stress than tension or shear forces. IPO attempts to eliminate or reduce all shear loads to the implant-to-bone interface. The greater the angle of the force, the greater is the shear component. Because shear forces are increased with an angled load to the implant body, an attempt is made to reduce the negative effect of angled loads.
Permissible cantilever extension for implant supported prosthesis according to various authors: Branemark 2-3 premolars Zarb and Schmitt- 20mm Taylor and Bergmann- 20mm(5-6 abutments) and 15mm(4 abutments) Rangert et al- 15-20mm in mandible and 10mm in maxilla English- 1.5xA-P spread
The noxious effects of a poorly selected cusp angle, an angled implant body, or an angled load to the crown will be magnified by the crown height measurement.
Occlusal materials
The occlusal surface materials selected affect the transmission of forces and the maintenance of occlusal contacts. In addition, occlusal material fracture is one of the most common complications for restorations on natural teeth or implants.
Occlusal materials may be evaluated by esthetics, impact force, a static load, chewing efficiency, fracture, wear, inter arch space requirements, and groups of castings. The three most common groups of occlusal materials are prostheses on implants are porcelain, gold and resin.
Conclusion
Implantology is a prosthetically driven entity. Information Before Treatment is Diagnosis Information after Treatment is an excuse A good impression is the key to success of the implant prosthesis.
Thank you