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Fourth Year Class 2012/2013
IMPLANTSUPPORTED FIXED PROSTHESISBY DrMohamed H. GHAZYFebruary 10, 2013
Implant prosthodontics : The phase of prosthodontics
concerning replacement of missingteeth and/or associated
structures by restorations thatare attached to dental implants
A prosthetic device of alloplastic materialimplanted into the oral tissue beneath themucosal or/and periosteal tissue for fixedor removable prosthesis.
What is a dental implant ?
Indication & contraindicationIndications Single tooth loss
Inability to wear a removable P.D.
Free end distal extension
Need for long span FPD with
questionable prognosis Unfavorable number and location
of potential natural tooth abutment
Contraindications Lack of operator experience
Smoking
Pregnancy
Psychiatric disorders
Tumoricidal radiationto implant site
Antimetabolictreatment
Uncontrolled cardiovascular problems
Immunosuppression(chemotherapy,HIV, etc)
Bone diseases, such asHistiocytosis X,Paget's Diseaseand Fibrous Dysplasia
Uncontrolled hematologic disorderssuch as GeneralizedAnemias,Hemophilia
Endocrine disorders, such asuncontrolledDiabetes Mellitus,Pituitaryand Adrenal insufficiency andHypothyroidism
Treatment planning for implant patientIndication &contraindication
Clinical evaluationAdequate bone and anatomic structureVisual inspection & palpationFlabby excess tissuesBony ridgesSharp underlining osseous formations and undercutsRadiographic evaluation
Panoramic view with small radio opaque referenceCephalometric film to evaluate bone widthCT scan to locate inferior alveolar canal & maxillary sinuses
Diagnostic castsStudy the remaining dentitionEvaluate residual boneAnalyze maxillo-mandibular relationshipDiagnostic waxing and surgical templates
Bone soundingWith probe judging the soft tissue thickness and bone soundness
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SubperiostealTransosteal
Endosteal plate
form
Endosteal
root form
To the left you can
see a typical modern
Root form Implant
and to the right of
the implant is a
picture of a naturaltooth.
One can see how the
implant is designed
to replace the root of
a tooth by the
somewhat apparent
similarity.
Screw Retained
Transocclusal
Screw RetainedTransversal
CementedFixed Partial
Denture
Implant supportedprosthesis may be
OSSEOINTEGRATIONA direct structural and functional
connection between ordered living boneand the surface of a load carrying implant
Swedish professor of orthopedics namedPer-Ingvar Branemark
in 1965 he used the first titaniumdental implant into a humanvolunteer
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Implant most commonly used from
*Commercially pure (CP) titanium
*Titanium-aluminum-vanadium alloy
(Ti-6Al-4V)- stronger & used w/ smaller diameterimplants
Why Titanium lightweight biocompatible corrosion resistant (dynamic inert oxide
layer)
strong & low-priced
Principles of Implant locationAnatomic limitation
General guide lines
Ideal bone should be 10 mm vertical and 6mm horizontal
Two mm above the superior aspect ofinferior alveolar canal
Five mm anterior to mental foramen
one mm from the periodontal ligament ofadjacent tooth
Three mm between 2 implant to ensure bonevitality.
Anterior maxilla
1- Minimum of 1 mm between the
implant apex and nasal vestibule 2- Implant slightly off midline on either
sides of incisive foramen.
Principles of Implant locationAnatomic limitation
Posterior maxilla
Bone ess dense, arger narrow spaces, and thin cortex
1- One implant for every tooth 2- One mm of bone between the floor of
sinus and implant
Principles of Implant locationAnatomic limitation
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Anterior mandible
1. One implant placed through theentire cancellous bone
2. Five mm anterior to the foramen
Principles of Implant locationAnatomic limitation
Posterior mandible
1.Two mm above the superior aspect
of inferior canal
2. More time required for integration
3. Attachment of mylohyoid muscle
Principles of Implant locationAnatomic limitation
Principles of Implant locationRestorative consideration
Implant placement1- Stay 1mm from the adjacent natural tooth but not so far
to for contouring restoration
Less ideal loc ation
2- Long axis of implant should be positioned in the central
fosse of the restoration
Principles of Implant location
Restorative consideration
Implant placement
Naturaltooth
Ideal
implant
placement
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Implant and restoration size1-Size should be considered during treatment planning 2- 4mm diameter for maxillary central
3- 3mm for mandibular incisors
4- 5-6mm for molars
Surgical guideTemplate extremelyuseful for anterior
implantObjectives
1- Delineate the embrasures
2- Locate the implant withinthe restoration contour
3- Align the implant withinthe long axis of therestoration
4- Identify the level of CIJor tooth emergence fromthe soft tissue
Wax model of a tooth to be replaced in the surgical guide
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Surgical guide template
Stent used as guide for implant placement
Surgical guide for correct
implant placementImplant surgery
Surgical access
Implant placement
Postoperative evaluation
Implant uncover
Guide drill / 2mm twist drill / Pilot drill / 3mm twist drill / Countersink
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Implant restorationsSignificant factors for success1- Precise placement2- A traumatic surgery3- Unloaded healing4- Passive restoration
Fourth year Class 2012/2013IMPLANTSUPPORTED FIXED PROSTHESIS
BY DrMoHAMeD H. GHAZYFebruary 17, 2011
Implant fixture
Abutment
Retaining screw
Abutment screw
Components of an
implant restorationComposite resin
Screw- retained implant
restorations consist of
three components.
(a) Implant fixture
(b) Abutment
(c) Restoration
- The abutment screw secures
the abutment to the fixture
- The prosthetic retention
screw secures the prosthesis to
the abutment.
Gutta percha
Restoration
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Dental ImplantShould promote bone in-growth.
Structure and geometry differences arethe selling point for most companies.
Prosthetic CrownLook and feel of real tooth.
Easily replaced.
Implant Abutment
Secures the crown to the DentalImplant. Can be straight or angled
depending on implant location
Type I bonehomogenous, compact boneType II boneThick compact bone layer surrounding acore of dense trabecular boneType III bone
Thin cortical bone layer surrounding acore of dense trabecular bone of goodstrengthType IV boneThin cortical bone layer surrounding coreof low density .
Lekholm and Zarb bone type classification
Bone density is a key factor when predicting implant stability.
Impression post Closed tray
Impression
Imp post & analog
Imp post & analogrelocated on the
impressionPolyether soft tissue
injected around
analog beforepouring
Implant restorations
Imp post & analogconnected
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Poured cast
Impression copinglocates the analog in
the same position inthe cast as theimplant in the mouth
Contouring of thesoft tissue material
Zirconia abutmentseated on cast Zirconia abutment
seated in the mouth
Zirconia abutmentfor cement retained
restoration selected
Implant insertion into
the prepared socket
Unscrewing the abutment from the implantfixture, screw covering and suturing
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Removal of the cover screw inthe 2nd stage and abutmentattached to the fixture as a
coping ready for impression
The abutment removed from the implantfixture
Abutment and its implant analog andrepositioned in the impression
Abutment prepared to its final form in the
working cast
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Prepared abutment and final restoration
in the patient mouth
Dental ImplantShould promote bone in-growth.
Structure and geometry
differences are the selling pointfor most companies.
Prosthetic CrownLook and feel of real tooth.
Easily replaced.
Implant Abutment
Secures the crown to the DentalImplant. Can be straight or angled
depending on implant location
Titanium
screw
Clinical Implant system components
Hydroxylappetitecoatedscrew
HydroxylApatitecoatedcylinder
Titanium plasmasprayed cylinder
Implant body
Titanium screw
Is the component placed within the bone during1ststage surgery
Two images showing two different types of tapered,cylindrical implants. One looks like a Christmas treewith finsprojecting out to the sides; the other shows a special surface
treatment consisting of spherical titanium beads.
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Cover screwIt is the component placed over the dental implant during theosseointegration phase to seal the occlusal surface of theimplant and prevent tissue from proliferating into the internalportion of the implant bodyIt should be of low profile to facilitate the suturing of softtissue tension _free.
Healing abutment
A- screw into implant
B- Screw into abutment(healing cap)
Dome shaped 2-10 mmscrew placed on the implantafter the 2 and stagesurgery & before insertionof the prosthesis
Healing Abutments
Transgingival Titanium piece whichwill form the soft tissue
Selected considering the
Emergence Profile needed for therestoration and the tissue height
Healing Abutments
Necessary Information:
Healing Abutment Height
Platform Diameter (normally same asimplant diameter )
Healing Abutment Diameter (EPProfile
Height
RestorativePlatform
EP (EmergenceProfile)
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Healing AbutmentsAbutmentComponent of the implant system thatscrew directly into the implant to supportand or retains a prosthesis or implant
superstructure
Abutment
Abutment
screw(green)
Abutment
can be either parallel
(standard) or conical
(estheticone) in shape.
are secured with an abutment
screw that is tightened to 20
Ncm.
(Screw retained restoration)
Abutment
(Cemented restoration)
Cera One abutment
Secured with a square head
screw tightened to 32 Ncm.
(red)
Straight
15 Pre-Angled
EngagesImplantHex
Click Zone
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Two impression techniques
Open tray impression Closed tray impression
Remove The Healing AbutmentPlace The Impression Coping
Closed Tray Impression
Closed Tray Impression
Syringe around the impressioncoping to capture the flat sides
Education
Remove the impression Remove the impression post from implant Mount impression post onto the analog (same color) Reposition and snap back into the impression
Closed Tray Impression
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Education
Open tray impression Concept
Intraoral situationImplant & impression post Analog & impression post58 Education
Impression procedure
Remove closure screw or healing abutment
Insert impression post and hand tighten screw withthe screwdriver
59 Education
Take impression with an open tray
Use an elastomeric impression material
Impression procedure
60 Education
When impression material is set,unscrew and remove the impression
Impression procedure
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A one piece coping
Screw into the abutment
used if the abutment does not
need to be changed on the
lab cast
Two piece coping
Screw into the implant
used if the abutment does
not need to be
changed on the lab
cast
Two piece coping
Screw into the abutment
used to orient the anti-
rotational feature or to
make impression of
very divergent implant
Types of impression posts
Two piece Impression coping
Impression coping attached to the implant analog
The impression posts attached to theimplants fixtures.
Impression with laboratory analog to make the master cast.
The master cast is that one used to fabricate thefinal prosthesis.
Laboratory analogsComponents made to represent the top ofthe implant fixture or the abutment in thelaboratory cast
Fixture analog{Duplicate implant top} Abutment analog{Duplicate abtument top}
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Attach Analog
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Push Analog/Impression Coping Assembly into ImpressionTwist and LockGrooves into Impression
Waxing sleeves
Plastic waxing sleeve tightenedto a laboratory analog Gold cylinder tightened to alaboratory analog
Combination
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Prosthesis retaining
screw
Screw used to secure theprosthesis to the implant
or the transmucosal
abutment
Prosthetic
retaining screw
Prosthetic retaining screw
Have a slot or hex head Access is usually covered by a combination of guttapercha and composite. used to retain the prosthesis to the abutment. Tightened to 10 Nc m.
Implant fixture
Abutment
Retaining screw
Abutment screw
Components of an implant
restorationComposite resin
Screw retained implantrestorations
consist of three components.
(a) Implant fixture
(b) Abutment
(c) Restoration
The abutment retaining screw
secures the abutment to the fixture
The prosthetic retaining screw
secures the prosthesis to the abutment.
Gutta percha
Screw retained implant crown
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Slot Screw Driver
- Used to remove or replace slotted prosthetic
retention screws.
- Tighten to 10 Ncm
Hex Screw Driver
- Used to remove or replace hex prosthetic
retention screws.
- Tighten to 10 Ncm.
Abutment Screw Driver
- Used to remove or re place abutment screws for
standard or conical (estheticone / mirus cone)
abutments.
- Tighten to 20 Ncm.
Square Screw Driver
- Used to remove or re place Cera One
abutment screw.
- Tighten to 32 Ncm
Impression tray without impression material:
Check the impression tray to see that it fits and fully covers the area of theimpression and that the hole in the tray is aligned with the guide pin.
Impression tray with impression material in the jaw:
The coping must be completely covered by impression material and the tray befully seated.It is very important that the guide pin protrudes through the impression trayin order to open it with the hex driver.
Inverted impression tray withemphasized hex:The hexagon of the impression copingcan be seen. It is very important tocheck that the position of theimpression coping has been accuratelyrecorded and that the hex is clear ofany impression material.
Inverted impression showing gingiva beingsyringed around analogThe analogue can now be attached to theimpression coping by screwing in the guide
pin. It should be confirmed that thecoping is attached to the analoguewith no misalignment of gaps. At thisstage, injecting impression materialaround the neck of the analog cansimulate the gingiva.
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Stone model prepared with simulatedgingiva and implant analog
In the final stage in impression taking, astone model of the gingiva and teethshould be cast, and the simulated gingivashould remain on the model.
After the stone is hardened, theimpression coping can be released fromthe model by removing the guide pin.
The impression tray can now beseparated from the model
Silicone index and wax modelof tooth
When the wax model of the tooth isappropriately positioned a silicon keycan be prepared that will serve as agood replica of the missing tooth.
Option 1: Placing the gold plastic cylinder abutment on the stone modelFollowing the construction of the silicone index a gold plastic cylinderabutment with hexagon can be selected.
Option 1: Wax CarvingThe plastic part of the gold plastic cylinder abutment can now be grind to theappropriate height on the stone model, taking into account the height of the adjacentteeth. After the gold abutment and the plastic cylinder have been prepared, it is
possible to carve the wax to the desired shape.
Following the carving of the wax on the gold abutment and the plasticcylinder they will be cast.
Option 1: Silicon indexwith wax upThe silicon index will beused to check that thedimensions of the wax-upare appropriate to itssurroundings.
Option 1: Metal casting
When fabricating P.F.M crown,using the direct wax-up techniqueon the cap to get a metal frameonto which the porcelain firingtakes place.
Checking the metal on the stonemodel and the seating of theexternal hex of the gold abutmentin the internal hex of the implantanalog.
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Option 1:Porcelain in mouthAfter placing the crown, the screw of the
gold abutment should be tightened to 20Ncm utilizing the TORKIT wrench.
This will minimize the chances of thescrew opening. After the screw has beentightened, the screw hole should beclosed.
Option 2: Placing the plasticcylinder on the stone model
Following the construction of thesilicon index a plastic cylinderwith hexagon can be selected
Option 2: Wax CarvingThe plastic cylinder can now be grindto the appropriate height on the stonemodel, taking in the account theheight of the adjacent teeth.
After the plastic cylinder have beenprepared, it is possible to carve thewax to the desired shape.Following the carving of the wax onthe plastic cylinder they will be cast.
Option 2: Silicon index withwax upThe silicon index will be usedto check that the dimensionsof the wax-up are appropriateto itssurroundings.MT-HHR13
Option 2: Metal castingWhen fabricating P.F.M crown, usingthe direct wax-up technique on the
plastic cylinder a metalframe onto which the porcelainfiring takes place.Checking the metal on the stonemodel and the seating of theexternal hex of the casting (whatwas previously the external hex. ofthe plastic cylinder MD-CPH13), inthe internal hex of the implantanalog.
Option 2: Check the casting in themouthAfter completion of the casting, acheck must be made in the
paients mouth using the screwMD-SO220 to connect it.
Option 2: Porcelain on plastermodelFollowing the selection of theappropriate color, the porcelain isfired on the metal casting.
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Option 2: Porcelain in mouthAfter placing the crown,the screwof the plastic cylinder shouldbe tightened to 20 Ncm utilizing theTORKIT wrench.
This will minimize the chances of thescrew opening. After the screw has
been tightened the screw hole shouldbe closed.
IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.There are two distal-extension restorative options.
1. Tooth-implant supported restorationPlace an implant distal to the most
posterior natural abutment andfabricate a fixed prosthesis
connecting the implant with thenatural tooth. However, there areproblemsassociated with implants connected to natural teeth.
2. Implant supported restorationPlace two or more implants posterior tothe most distal natural tooth andfabricate a completely implant-supportedrestoration ).
If the crown-to-implant ratio is favorable, two implants to support a three-unitfixed prosthesis.If implants are short and crowns are long, one implant to replace each missing tooth.If doubt remains, more implants are used when heavier forces are expected (e.g.,posterior part of the mouth in patients with evidence of parafunctional activity).Fewer implants are used when lighter forces are expected (e.g., those opposing acomplete denture or those supporting a prosthesis in the anterior part of the mouth).
IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.
Long Edentulous Span Restoration.1. Multiple implants placed between the
remaining natural teeth to fabricate afully implant-supported restoration.
2. One or two implants can be placed in thelong edentulous span and the finalrestoration connected to natural teeth.
When it is necessary to connect implants and thenatural teeth, protecting the teeth withtelescopic copings is recommended .
In this manner, prosthesis retrievability can bemaintained.
Some long edentulous spans require the reconstructionof soft and hard tissue and teeth. using resinteeth processed to a metal substructure ratherthan a conventional metal-ceramic restoration isrecommended.
Soft tissue esthetics can be more easily andaccurately mimicked with heat-processed resin .
This type of restoration has been called ahybridbecause it combines the principles of conventionalfixed and removable prosthodontics.
IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.Long Edentulous Span Restoration.
Single-tooth Implant Restoration.
Indicated in the following situations:1. An otherwise intact dentition2. spaces difficult to treat with conventional fixedprosthodontics3. Distally missing teeth.
4. A prosthesis that needs to closely mimic the missingnatural tooth
The requirements for single-tooth implant crowns are:1. Esthetics2. Ant rotation to avoid prosthetic componentloosening3. Simplicity-to minimize the amount ofcomponents used4. Accessibility-to maintain optimum oral health5. Variability-to allow the clinician to control theheight, diameter, and angulations of the implantrestoration
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IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.Long Edentulous Span Restoration.Single-tooth Implant Restoration.
Fixed Restoration in the CompletelyEdentulous Arch.1.The hybrid prosthesis is a cast alloyframework with processed denture resin
and teeth.Five implants in the mandible and six in themaxilla.Suitable for patients who have hadmoderate bone loss, the prosthesisrestores both bone and soft tissuecontours.
2. The metal-ceramic rehabilitation alsorequires five implants in the mandible andsix in the maxilla. Only if minimal bone losshas occurred and is best suited for
patients who have recently lost theirnatural teeth (within 5 years).
3. For patients with severe bone loss,there is probably only one option: aremovable restoration .
Minimal resorptionMetal ceramicrestorations
Moderateresorptionresin tometal restorations
sever resorptionOver denture
CEMENT-RETAINED VERSUSSCREW-RETAINED IMPLANTCROWNS
Zinc phosphate, glass ionomer, and compositeresin cements have all been suggested for thispurpose.Advantages of cement-retained restorations.
1. Simplicity2. Less expensive.3. Allow minor angle correction.4. More esthetically pleasant
Disadvantages of cement-retained
restorations.
1. Require more chair time2. Have the same propensity to loosen as
the screw retained.
Advantages of screw-retained restorations.
1. Retrievability
Disadvantage of a screw-retained implantrestoration
1. The screw may loosen during function.2. Cost
CEMENT-RETAINED VERSUSSCREW-RETAINED IMPLANTCROWNSIf the screw is sufficiently tightened into theimplant crown to seat it, a clamping load orpreload is developed between the implant and thecrown.
If this clamping force is greater than theforces trying to separate the joint betweenimplant and crown, the screw will not loosen.
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Screw-Retained CrownsScrew Retained Transversal
Screw RetainedTransocclusal
Cemented Crowns