2016-08-06

Level Five Class summer 2016

IMPLANTSUPPORTED
FIXED PROSTHESIS
BY Dr
Mohamed H. GHAZY
August 6, 2016

What is your 1st line of treatment to

restore this missing tooth

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Implant prosthodontics :
The phase of prosthodontics
concerning with 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.

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Indication & contraindication

Indications

Contraindications
Lack of operator experience
Smoking
Pregnancy
Psychiatric disorders
Tumoricidal radiation to implant site
Antimetabolic treatment
Uncontrolled cardiovascular problems

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

Immunosuppression (chemotherapy,
HIV, etc)

Bone diseases, such as Histiocytosis X,

Paget's Disease and Fibrous Dysplasia

Uncontrolled hematologic disorders

such as Generalized Anemias,
Hemophilia

Endocrine disorders, such as

uncontrolled Diabetes Mellitus, Pituitary
and Adrenal insufficiency and
Hypothyroidism

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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

Radiographic evaluation

Panoramic view with small radio opaque reference

Cephalometric film to evaluate bone width
CT scan to locate inferior alveolar canal & maxillary sinuses

Diagnostic casts

Study the remaining dentition

Evaluate residual bone
Analyze maxillo-mandibular relationship
Diagnostic waxing and surgical templates

Bone sounding

With probe judging the soft tissue thickness and bone soundness

Subperiosteal

Endosteal plate
form

Transosteal

Endosteal
root form

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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.
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

Screw Retained
Transversal

Cemented
Fixed Partial Denture

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

Implant most commonly used from

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

* Ceramic

Why Titanium

High biocompatibility and bonding

ability with the bone

Light weight and high strength
Corrosion resistant

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Principles of Implant location

Anatomic limitation
General guide lines
Ideal bone should be 10 mm

vertical and 6 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.

Principles of Implant location

Anatomic limitation

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.

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Principles of Implant location

Anatomic limitation

Posterior maxilla
Bone less dense, larger 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 location

Anatomic limitation

Anterior mandible
1. One implant placed through the entire

cancellous bone
2. Five mm anterior to the foramen

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Principles of Implant location

Anatomic 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 location

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

to for contouring restoration

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Principles of Implant location

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

fosse of the restoration

Less ideal location

Natural
tooth

Ideal
implant
placement

Optimal emergence profile: implant positioned

2-3 mm inferior to emergence position of the restoration

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Implant and restoration size

1. Size should be considered during treatment planning

2. 4mm diameter for maxillary central

3. 3mm for mandibular incisors
4. 5-6mm for molars

Template extremely
useful for anterior
implant
Objectives

Surgical guide

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

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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

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Surgical guide for correct

implant placement

Computer aided
surgical stent
(Stereolithrography)

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Implant surgery
Surgical access

Implant placement
Postoperative evaluation
Implant uncover

Implant restorations

Significant factors for success

1- Precise placement
2- A traumatic surgery
3- Unloaded healing
4- Passive restoration

Guide drill / 2mm twist drill / Pilot drill / 3mm twist drill / Countersink

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Components of an
implant restoration
Screw- retained implant
restorations consist of
three components.

Restoration
Composite resin
Gutta percha
Retaining screw
Abutment screw

(a) Implant fixture

(b) Abutment

Abutment

(c) Restoration
Implant fixture

- The abutment screw secures

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

Components of an
implant restoration
Screw- retained implant
restorations consist of
three components.
(a) Implant fixture
(b) Abutment

Restoration
Composite resin
Gutta percha
Prosthetic retaining
screw
Abutment retaining
screw

Abutment

(c) Restoration
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.

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Lekholm and Zarb bone type classification

Type I bone
homogenous, compact bone
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 .

Bone density is a key factor when predicting implant stability.

Implant restorations

Impression post

Closed tray
Impression
Imp post & analog

Imp post & analog

connected

Imp post & analog

relocated on the
impression

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

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Fourth year Class 2013/2014

IMPLANTSUPPORTED FIXED PROSTHESIS
BY Dr
MoHAMeD H. GHAZY
march 18, 2014

Implant insertion into

the prepared socket

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Unscrewing the abutment from the implant

fixture, screw covering and suturing

Removal of the cover screw in

the 2nd stage and abutment
attached to the fixture as a
coping ready for impression

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The abutment removed from the implant

fixture

Abutment and its implant analog and

repositioned in the impression

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Abutment prepared to its final form in the

working cast

Prepared abutment and final restoration

in the patient mouth

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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.

Clinical Implant system components

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

Titanium screw
Titanium
screw

Hydroxyl
appetite
coated
screw

Hydroxyl
Apatite
coated
cylinder

Titanium plasma
sprayed cylinder

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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.

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.

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

A- screw into implant

B- Screw into abutment

(healing cap)

Healing Abutments

Transgingival Titanium piece which

will form the soft tissue
Selected considering the
Emergence Profile needed for the
restoration and the tissue height

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EP (Emergence
Profile)

Healing Abutments
Necessary Information:

Height

Healing Abutment Height

Platform Diameter (normally same as implant

diameter )

Restorative
Platform

Healing Abutment Diameter (EP Profile)

Healing Abutments

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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 or conical in

shape.

are secured with an abutment

screw that is tightened to 20 Ncm.

Abutment
screw
(green)

Abutment
(red)

(Cemented restoration)

Secured with a square head

screw tightened to 32 Ncm.

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15 Pre-Angled
Straight

Engages
Implant
Hex
Click Zone

Impression posts
Component used during the impression procedure
to transfer the intra oral location of the implant
or the abutment the laboratory cast

Abutment type
Fixture type

Two piece
(pick-up) type

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Two impression techniques

Closed tray impression

Open tray impression

Closed Tray Impression

Remove The Healing Abutment
Place The Impression Coping

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Closed Tray Impression

Syringe around the impression

coping to capture the flat sides

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

Education

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Open tray impression Concept

Implant & impression post

Intraoral situation

Analog & impression

post
Education

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

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Education

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

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Education

Impression procedure

When impression material is set,

unscrew and remove the impression

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Education

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Pick-Up Technique

Whats it for:
Single or Multiple units
A MUST in single non-parallel implants
Advantages:
More Precise

30 per
implant

Disadvantages:
Vertical Height (pick up coping is long)
Tray needs a hole in it for impression
screw (customized or standard)

Types of impression posts

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

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Two piece Impression coping

Impression coping attached to the implant analog

Impression with laboratory analog to make the master cast.

The impression posts attached to the

implants fixtures.

The master cast is that one used to fabricate the

final prosthesis.

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Laboratory analogs

Components made to represent the top of

the implant fixture or the abutment in the
laboratory 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 Impression

Twist and Lock Grooves into Impression

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Waxing sleeves

Plastic waxing sleeve tightened

to a laboratory analog

Gold cylinder tightened to a

laboratory analog

Combination

Place screw into waxing sleeve and engage onto

the implant analog in the working model.

Adjust waxing sleeve using a lowspeed handpiece

After the wax-up is complete, remove from

model and mark the gingival margin with a black
marker.

When the abutment is placed back on the model,

the black line will indicate the margin in relation
to the soft tissue. Adjust as required, relieve
undercuts and finalize surface smoothness

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Prosthesis retaining
screw
Screw used to secure the
prosthesis 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 gutta percha
and composite.
Used to retain the prosthesis to the abutment.
Tightened to 10 Ncm.

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Components of an implant
restoration
Composite resin
Gutta percha

Screw retained implant restorations

Retaining screw

consist of three components.

Abutment screw
(a) Implant fixture

Abutment

(b) Abutment
(c) Restoration

The abutment retaining screw Implant fixture

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

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 replace abutment screws for

standard or conical (estheticone / mirus cone)
abutments.
- Tighten to 20 Ncm.

Square Screw Driver

- Used to remove or replace Cera One

abutment screw.
- Tighten to 32 Ncm

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IMPLANT RESTORATIVE
OPTIONS

Distal-extension Implant Restoration.

Distal-extension Implant Restoration.

Long Edentulous Span Restoration.
Single-tooth Implant Restoration.
Fixed Restoration in the Completely
Edentulous Arch.

1. Tooth-implant supported restoration

One implant distal to the most posterior
natural abutment -------------Fixed
prosthesis connecting the implant with
the natural tooth.
2. Implant supported restoration
Two or more implants posterior to the
most distal natural tooth ----------Completely implant-supported restoration.

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IMPLANT RESTORATIVE
OPTIONS
Long Edentulous Span Restoration.

Distal-extension Implant Restoration.

Long Edentulous Span Restoration.
Single-tooth Implant Restoration.
Fixed Restoration in the Completely
Edentulous Arch.

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.

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.

IMPLANT RESTORATIVE OPTIONS

Single-tooth Implant Restoration.

Distal-extension Implant Restoration.

Long Edentulous Span Restoration.
Single-tooth Implant Restoration.
Fixed Restoration in the Completely
Edentulous Arch.

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:

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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Distal-extension Implant Restoration.

Long Edentulous Span Restoration.
Single-tooth Implant Restoration.
Fixed Restoration in the Completely
Edentulous Arch.

IMPLANT RESTORATIVE
OPTIONS

Distal-extension Implant Restoration.

Long Edentulous Span Restoration.
Single-tooth Implant Restoration.
Fixed Restoration in the Completely
Edentulous Arch.

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
Minimal resorption
probably only one option: a removable
Metal ceramic
restoration .
restorations

Moderate
resorptionresin to
metal restorations

sever resorption
Over denture

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CEMENT-RETAINED VERSUS SCREWRETAINED IMPLANT CROWNS

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

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

CEMENT-RETAINED VERSUS SCREWRETAINED 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.

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Screw-Retained Crowns

Screw Retained Transversal

Screw Retained Transocclusal

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Cemented Restoration

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