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Implant prosthodontics :
Fourth Year Class 2012/2013

IMPLANTSUPPORTED FIXED PROSTHESIS

BY Dr Mohamed H. GHAZY February 10, 2013

The phase of prosthodontics concerning replacement of missing teeth and/or associated structures by restorations that are attached to dental implants

What is a dental implant ?

A prosthetic device of alloplastic material implanted into the oral tissue beneath the mucosal or/and periosteal tissue for fixed or removable prosthesis.

Indication & contraindication

Contraindications Lack of operator experience

Treatment planning for implant patient

Indication &contraindication Clinical evaluation
Adequate bone and anatomic structure Visual inspection & palpation Flabby excess tissues Bony ridges Sharp underlining osseous formations and undercuts Panoramic view with small radio opaque reference Cephalometric film to evaluate bone width CT scan to locate inferior alveolar canal & maxillary sinuses Study the remaining dentition Evaluate residual bone Analyze maxillo-mandibular relationship Diagnostic waxing and surgical templates With probe judging the soft tissue thickness and bone soundness

Indications

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

Smoking Pregnancy Psychiatric disorders Tumoricidal radiation to implant site Antimetabolic treatment Uncontrolled cardiovascular problems Immunosuppression (chemotherapy,
HIV, etc)

Radiographic evaluation

Bone diseases, such as Histiocytosis X,

Paget's Disease and Fibrous Dysplasia

Uncontrolled hematologic disorders

such as Generalized Anemias, Hemophilia

Diagnostic casts

Endocrine disorders, such as

uncontrolled Diabetes Mellitus, Pituitary and Adrenal insufficiency and Hypothyroidism

Bone sounding

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Subperiosteal

Transosteal

To the left you can see a typical modern Root form Implant and to the right of the implant is a picture of a natural tooth.

Endosteal plate form

Endosteal root form

One can see how the implant is designed to replace the root of a tooth by the somewhat apparent similarity.

Implant supported prosthesis may be

Screw Retained Transocclusal

OSSEOINTEGRATION
A direct structural and functional connection between ordered living bone and the surface of a load carrying implant Swedish professor of orthopedics named Per-Ingvar Branemark

Screw Retained Transversal

Cemented Fixed Partial Denture

in 1965 he used the first titanium dental implant into a human volunteer

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Implant most commonly used from

*Commercially pure (CP) titanium *Titanium-aluminum-vanadium alloy
(Ti-6Al-4V) - stronger & used w/ smaller diameter
implants

Principles of Implant location

Anatomic limitation
General guide lines Ideal bone should be 10 mm vertical and 6

Why Titanium
lightweight biocompatible corrosion resistant (dynamic inert oxide
layer)

mm horizontal Two mm above the superior aspect of inferior alveolar canal Five mm anterior to mental foramen one mm from the periodontal ligament of adjacent tooth Three mm between 2 implant to ensure bone vitality.

strong & low-priced

Principles of Implant location

Anatomic limitation

Principles of Implant location

Anatomic limitation

Anterior maxilla 1- Minimum of 1 mm between the

Posterior maxilla
Bone less dense, larger narrow spaces, and thin cortex

implant apex and nasal vestibule 2- Implant slightly off midline on either sides of incisive foramen.

1- One implant for every tooth 2- One mm of bone between the floor of

sinus and implant

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Principles of Implant location

Anatomic limitation

Principles of Implant location

Anatomic limitation

Anterior mandible 1. One implant placed through the

Posterior mandible 1.Two mm above the superior aspect

entire cancellous bone 2. Five mm anterior to the foramen

of inferior canal 2. More time required for integration 3. Attachment of mylohyoid muscle

Principles of Implant location

Restorative consideration Implant placement
1- Stay 1mm from the adjacent natural tooth but not so far

Principles of Implant location

Restorative consideration Implant placement
2- Long axis of implant should be positioned in the central

to for contouring restoration

fosse of the restoration

Less ideal location Natural tooth Ideal implant placement

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Implant and restoration size

2- 4mm diameter for maxillary central 3- 3mm for mandibular incisors 4- 5-6mm for molars

Surgical guide
Objectives
Template extremely useful for anterior implant

1-Size should be considered during treatment planning

1- Delineate the embrasures 2- Locate the implant within the restoration contour 3- Align the implant within the long axis of the restoration 4- Identify the level of CIJ or tooth emergence from the 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 placement

Implant 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 restorations

Significant factors for success 1- Precise placement 2- A traumatic surgery 3- Unloaded healing 4- Passive restoration

Fourth year Class 2012/2013 IMPLANTSUPPORTED FIXED PROSTHESIS

BY Dr MoHAMeD H. GHAZY February 17, 2011

Components of an implant restoration

Screw- retained implant restorations consist of three components.
(a) Implant fixture (b) Abutment (c) Restoration

Restoration Composite resin Gutta percha Retaining screw

Abutment screw

Abutment

Implant fixture

- The abutment screw secures the abutment to the fixture - The prosthetic retention screw secures the prosthesis to the abutment.

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Prosthetic Crown
Look and feel of real tooth. Easily replaced.

Implant Abutment
Secures the crown to the Dental Implant. Can be straight or angled depending on implant location

Dental Implant
Should promote bone in-growth. Structure and geometry differences are the selling point for most companies.

Lekholm and Zarb bone type classification

Type I bone
homogenous, compact bone

Impression post

Implant restorations
Closed tray Impression
Imp post & analog

Type II bone

Thick compact bone layer surrounding a core of dense trabecular bone

Type III bone

Thin cortical bone layer surrounding a core of dense trabecular bone of good strength

Type IV bone

Thin cortical bone layer surrounding core of low density .

Imp post & analog relocated on the impression

Bone density is a key factor when predicting implant stability.

Imp post & analog connected

Polyether soft tissue injected around analog before pouring

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Poured cast
Contouring of the soft tissue material Impression coping locates the analog in the same position in the cast as the implant in the mouth

Zirconia abutment for cement retained restoration selected

Zirconia abutment seated on cast

Zirconia abutment seated in the mouth

Unscrewing the abutment from the implant fixture, screw covering and suturing
Implant insertion into the prepared socket

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Removal of the cover screw in the 2nd stage and abutment attached to the fixture as a coping ready for impression

The abutment removed from the implant fixture

Abutment and its implant analog and repositioned 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

Prosthetic Crown
Look and feel of real tooth. Easily replaced.

Implant Abutment
Secures the crown to the Dental Implant. Can be straight or angled depending on implant location

Dental Implant
Should promote bone in-growth. Structure and geometry differences are the selling point for most companies.

Clinical Implant system components

Implant body
Is the component placed within the bone during 1st stage surgery

Two images showing two different types of tapered, cylindrical implants. One looks like a Christmas tree with fins projecting out to the sides; the other shows a special surface treatment consisting of spherical titanium beads.

Titanium screw
Titanium screw

Hydroxyl appetite coated screw

Hydroxyl Apatite coated cylinder

Titanium plasma sprayed cylinder

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Cover screw

It is the component placed over the dental implant during the osseointegration phase to seal the occlusal surface of the implant and prevent tissue from proliferating into the internal portion of the implant body
It should be of low profile to facilitate the suturing of soft tissue tension _free.

Healing abutment
Dome shaped 2-10 mm screw placed on the implant after the 2 and stage surgery & before insertion of the prosthesis

A- screw into implant

B- Screw into abutment (healing cap)

Healing Abutments

Healing Abutments
EP (Emergence Profile)

Transgingival Titanium piece which will form the soft tissue Selected considering the Emergence Profile needed for the restoration and the tissue height

Necessary Information:
Healing Abutment Height Platform Diameter (normally same as implant diameter ) Healing Abutment Diameter (EP Profile

Height

Restorative Platform

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Healing Abutments

Abutment
Component of the implant system that screw directly into the implant to support and or retains a prosthesis or implant superstructure

Abutment
(Screw retained restoration)

can be either parallel (standard) or conical (estheticone) in shape. are secured with an abutment screw that is tightened to 20 Ncm.

Abutment screw
(green)

15 Pre-Angled Straight

Abutment (red)

Abutment
(Cemented restoration)

Cera One abutment

Secured with a square head screw tightened to 32 Ncm.

Engages Implant Hex

Click Zone

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Closed Tray Impression

Two impression techniques

Remove The Healing Abutment Place The Impression Coping

Open tray impression

Closed tray impression

Closed Tray Impression

Closed Tray Impression

Remove the impression Remove the impression post from implant Mount impression post onto the analog (same color) Reposition and snap back into the impression

Syringe around the impression coping to capture the flat sides

Education

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Open tray impression Concept

Impression procedure
Remove closure screw or healing abutment Insert impression post and hand tighten screw with the screwdriver

Implant & impression post

Intraoral situation

Analog & impression post

Education

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Education

Impression procedure
Take impression with an open tray
Use an elastomeric impression material

When impression material is set, unscrew and remove the impression

Impression procedure

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Education

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Education

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Types of impression posts

Two piece Impression coping

Impression coping attached to the implant analog

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 antirotational feature or to make impression of very divergent implant

Impression with laboratory analog to make the master cast.

Laboratory analogs

Components made to represent the top of the implant fixture or the abutment in the laboratory cast

The impression posts attached to the implants fixtures. The master cast is that one used to fabricate the final prosthesis.

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 Impression Twist and Lock Grooves into Impression

Waxing sleeves

Plastic waxing sleeve tightened to a laboratory analog

Gold cylinder tightened to a laboratory analog

Combination

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Prosthetic retaining screw

Prosthesis retaining screw

Screw used to secure the prosthesis to the implant or the transmucosal abutment

Prosthetic retaining screw

Have a slot or hex head Access is usually covered by a combination of gutta percha and composite.

used to retain the prosthesis to the abutment.

Tightened to 10 Ncm.

Components of an implant restoration

Composite resin

Screw retained implant crown

Screw retained implant restorations

(a) Implant fixture
(b) Abutment (c) Restoration

Gutta percha Retaining screw

consist of three components. Abutment screw

Abutment

The abutment retaining screw Implant fixture

secures the abutment to the fixture The prosthetic retaining screw secures the prosthesis to the abutment.

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Slot Screw Driver

Abutment Screw Driver

- Used to remove or replace slotted prosthetic retention screws. - Tighten to 10 Ncm

- Used to remove or replace abutment screws for standard or conical (estheticone / mirus cone) abutments. - Tighten to 20 Ncm.

Hex Screw Driver

Square Screw Driver

- Used to remove or replace hex prosthetic retention screws. - Tighten to 10 Ncm.

- Used to remove or replace 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 the impression and that the hole in the tray is aligned with the guide pin.

Inverted impression tray with emphasized hex:

The hexagon of the impression coping can be seen. It is very important to check that the position of the impression coping has been accurately recorded and that the hex is clear of any impression material.

Impression tray with impression material in the jaw:

The coping must be completely covered by impression material and the tray be fully seated. It is very important that the guide pin protrudes through the impression tray in order to open it with the hex driver.
Inverted impression showing gingiva being syringed around analog

The analogue can now be attached to the impression coping by screwing in the guide pin. It should be confirmed that the coping is attached to the analogue with no misalignment of gaps. At this stage, injecting impression material around the neck of the analog can simulate the gingiva.

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Stone model prepared with simulated gingiva and implant analog

In the final stage in impression taking, a stone model of the gingiva and teeth should be cast, and the simulated gingiva should remain on the model. After the stone is hardened, the impression coping can be released from the model by removing the guide pin. The impression tray can now be separated from the model

Silicone index and wax model of tooth

When the wax model of the tooth is appropriately positioned a silicon key can be prepared that will serve as a good replica of the missing tooth.

Option 1: Silicon index with wax up

Option 1: Placing the gold plastic cylinder abutment on the stone model

Following the construction of the silicone index a gold plastic cylinder abutment with hexagon can be selected.

The silicon index will be used to check that the dimensions of the wax-up are appropriate to its surroundings.

Option 1: Metal casting

When fabricating P.F.M crown, using the direct wax-up technique on the cap to get a metal frame onto which the porcelain firing takes place. Checking the metal on the stone model and the seating of the external hex of the gold abutment in the internal hex of the implant analog.

Option 1: Wax Carving

The plastic part of the gold plastic cylinder abutment can now be grind to the appropriate height on the stone model, taking into account the height of the adjacent teeth. 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 plastic cylinder they will be cast.

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Option 1: Porcelain in mouth

After placing the crown, the screw of the gold abutment should be tightened to 20 Ncm utilizing the TORKIT wrench.

Option 2: Placing the plastic cylinder on the stone model

Following the construction of the silicon index a plastic cylinder with hexagon can be selected

This will minimize the chances of the screw opening. After the screw has been tightened, the screw hole should be closed.

Option 2: Wax Carving

The plastic cylinder can now be grind to the appropriate height on the stone model, taking in the account the height of the adjacent teeth. After 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 plastic cylinder they will be cast.

Option 2: Silicon index with wax up

The silicon index will be used to check that the dimensions of the wax-up are appropriate to its surroundings. MT-HHR13
Option 2: Metal casting

Option 2: Check the casting in the mouth

After completion of the casting, a check must be made in the paients mouth using the screw MD-SO220 to connect it.

When fabricating P.F.M crown, using the direct wax-up technique on the plastic cylinder a metal frame onto which the porcelain firing takes place. Checking the metal on the stone model and the seating of the external hex of the casting (what was previously the external hex. of the plastic cylinder MD-CPH13), in the internal hex of the implant analog.

Option 2: Porcelain on plaster model

Following the selection of the appropriate color, the porcelain is fired on the metal casting.

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Option 2: Porcelain in mouth After placing the crown, the screw of the plastic cylinder should
be tightened to 20 Ncm utilizing the TORKIT wrench.

IMPLANT RESTORATIVE OPTIONS

Distal-extension Implant Restoration.

There are two distal-extension restorative options.

This will minimize the chances of the screw opening. After the screw has been tightened the screw hole should be closed.

1. Tooth-implant supported restoration Place an implant distal to the most posterior natural abutment and fabricate a fixed prosthesis connecting the implant with the natural tooth. However, there are problems

2. Implant supported restoration Place two or more implants posterior to the most distal natural tooth and fabricate a completely implant-supported restoration ).

associated with implants connected to natural teeth .

If the crown-to-implant ratio is favorable, two implants to support a three-unit fixed 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 a complete denture or those supporting a prosthesis in the anterior part of the mouth).

IMPLANT RESTORATIVE OPTIONS

Distal-extension Implant Restoration.

Long Edentulous Span Restoration.

IMPLANT RESTORATIVE OPTIONS

Distal-extension Implant Restoration.

1. Multiple implants placed between the remaining natural teeth to fabricate a fully implant-supported restoration. 2. One or two implants can be placed in the long edentulous span and the final restoration connected to natural teeth.
When it is necessary to connect implants and the natural teeth, protecting the teeth with telescopic copings is recommended . In this manner, prosthesis retrievability can be maintained.

Long Edentulous Span Restoration.

Single-tooth Implant Restoration.

Indicated in the following situations:

1. An otherwise intact dentition 2. spaces difficult to treat with conventional fixed prosthodontics 3. Distally missing teeth. 4. A prosthesis that needs to closely mimic the missing natural tooth

The requirements for single-tooth implant crowns are:

Some long edentulous spans require the reconstruction of soft and hard tissue and teeth. using resin teeth processed to a metal substructure rather than a conventional metal-ceramic restoration is recommended. Soft tissue esthetics can be more easily and accurately mimicked with heat-processed resin .

This type of restoration has been called a hybrid because it combines the principles of conventional fixed and removable prosthodontics.

1. Esthetics 2. Ant rotation to avoid prosthetic component loosening 3. Simplicity-to minimize the amount of components used 4. Accessibility-to maintain optimum oral health 5. Variability-to allow the clinician to control the height, diameter, and angulations of the implant restoration

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IMPLANT RESTORATIVE OPTIONS

Distal-extension Implant Restoration.

Long Edentulous Span Restoration. Single-tooth Implant Restoration.

Fixed Restoration in the Completely Edentulous Arch.

1.The hybrid prosthesis is a cast alloy framework with processed denture resin and teeth. Five implants in the mandible and six in the maxilla. Suitable for patients who have had moderate bone loss, the prosthesis restores both bone and soft tissue contours. 2. The metal-ceramic rehabilitation also requires five implants in the mandible and six in the maxilla. Only if minimal bone loss has occurred and is best suited for patients who have recently lost their natural teeth (within 5 years). 3. For patients with severe bone loss, there is probably only one option: a removable restoration .
Minimal resorption Metal ceramic restorations Moderate sever resorption resorption resin to Over denture metal restorations

CEMENT-RETAINED VERSUS SCREW-RETAINED IMPLANT CROWNS

Zinc phosphate, glass ionomer, and composite resin cements have all been suggested for this purpose.

CEMENT-RETAINED VERSUS SCREW-RETAINED IMPLANT CROWNS

If the screw is sufficiently tightened into the implant crown to seat it, a clamping load or preload is developed between the implant and the crown. If this clamping force is greater than the forces trying to separate the joint between implant and crown, the screw will not loosen.

Advantages of cement-retained restorations. 1. Simplicity 2. Less expensive. 3. Allow minor angle correction. 4. More esthetically pleasant Disadvantages of cement-retained restorations. 1. Require more chair time 2. Have the same propensity to loosen as the screw retained. Advantages of screw-retained restorations. 1. Retrievability Disadvantage of a screw-retained implant restoration 1. The screw may loosen during function. 2. Cost

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Screw-Retained Crowns

Screw Retained Transversal

Screw Retained Transocclusal

Cemented Crowns

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