Implant armamentarium

it includes operatory instruments , parts of implant & description of implant kit

1. IMPLANT ARMAMENTARIUM BY DR RUHI BAJAJ 1

2. Dental implants can be used to retain single crowns, fixed partial dentures, full arch bridgework and removable prostheses. The use of dental implants is well established and high survival rates have been reported. Implant dentistry now forms a significant part of general dental practice and patient awareness is steadily increasing. INTRODUCTION 2

3. 3 A prosthetic device or alloplastic material implanted into the oral tissue beneath the mucosal or/and periosteal layer and/ or in the bone to provide retention and support for the fixed and removable prosthesis. GPT 2008 What is an Implant???

4. 4 CLASSIFICATION I) Depending on the placement within the tissues Epithelial implants Epiosteal / Subperiosteal implants Endosteal implants Transosteal implants

5. 5 Epithelial implants Implant is inserted into the oral mucosa Disadvantages 1. painful healing 2. requirement of continual wear

6. 6 Epiosteal / Subperiosteal Implant Receives primary bone support by resting on it Placed directly beneath the periosteum overliying the bony cortex Disadvantages : 1) Slow, predictable rejection of the implant 2) Bone loss associated with failure

7. 7 Transosteal Implant Also called as Staple Bone Implant, Transmandibular Implant Penetrates both cortical plate and passes through the entire thickness of the alveolar bone Use restricted to anterior area of mandible

8. 8 Endosteal Implants Extends into basal bone for support It transects into 1 cortical plate

9. 9 Endosteal implants Root form implants -Used over vertical column of bone Plate form implants -used over horizontal Column of bone Cylinder Screw root form Combination Ramus frame implants

10. 10 Generic implant body terminology Implant body ENDOSTEAL IMPLANTS - root form designed to use vertical column of bone , similar to root of natural tooth 3 different categories 1. cylinder implants 2. screw design implants 3. combination

11. 11 crest module ( cervical geometry ) body apex Implant Body Regions 3 parts 1. crest module ( cervical geometry ) 2. body 3. apex

12. 12 Implant Body Regions Body - designed for implant bone interface Crest module - designed to retain the prosthetic component - has a platform on which abutment is seated

13. 13 II) Depending on the materials used METALLIC IMPLANTS titanium cobalt chromium molybdenum alloy- Titanium aluminum vandium Cobalt chromium molybdenum Stainless steel Zirconium Tantalum Gold Platinum

14. 14 2 . NON – METALLIC IMPLANTS - ceramics - carbon

15. 15 Depending On Their Reaction With Bone Based on the ability of implant to stimulate bone formation Bio active Hydroxyapatite Tri Calcium Phosphate Calcium Phosphate 2. Bio inert metals

16. Console,motor and handpiece Classical surgical setup Starter bur ( no 4 round bur ) ( high speed is often necessary for the mandible in particular) Pilot drill ( 1.6 mm diameter by 11 mm long ) with internal irrigation system Osteotomy drill 24 mm long ,each with internal irrigation ( brasseler ) .all drills over 3mm in diameter should be selected in relation to the specific system of choice Armamentarium( surgical) 16

17. Bur extender ,mandrel ( internal irrigation ) to be used when adajacent teeth prevent access to bone – denar , imz and orthomatrix make one that can be used for all systems) Paralleling pins( double ended ) ,small & large Depth guage Millimeter rule An implant system of choice with bone tapper ,countersink ,final sizing drills & try in 17

18. A torque driver Surgical template ( guide for implant placement) 18

19. Surgical Setup principles Aim to keep surgical area reasonably sterile Cover sterile instruments with sterile paper if procedure is not started right away 19

20. Surgical Setup - Operatory Drape surgical tables with sterile towel / paper Instrument tray table Supply tray table Implant motor table 20

21. Surgical Setup - Operatory 21

22. Surgical Setup– Instrument Tray Mirror (A) Periosteal elevator, i.e Molt-9 (B) Periodontal probe (C) Cotton forceps (D) Instrument for removing tissue tags, i.e. Scaler (E) Castroviejo calipers (F) Needle holder, i.e. Castroviejo type(G) Suture scissors (H) Tissue forceps (I) Hemostat (K) Implant torque wrench(L) 3 4x4 gauze (M) 5 2x2 gauze (N) Topical anesthetic (O) Anesthetic cartridges (P) Anesthetic Needle (Q Anesthetic syringe (R) Round scalpel w/ 15c blade (S) 22

23. Surgical Setup– Instrument Tray A B C D E F G H I K L S R Q P O N M 23

24. Surgical Setup – Instrument Tray Biohazard bag Surgical suction Water/air syringe & Surgical handpiece 24

25. Surgical Setup – Supply tray Cotton forceps (A) Rinn kit & 2 X-ray sensors (B) Mirror kit (C) Suture (4-0, reverse cutting needle) (D) 2 alcohol wipes (E) Surgical lube & cotton tip applicator (F) Protective glasses for patient (G) Cup with ½ oz of saline (H) Cup with ½ oz of Chlorhexidine gluconate mouthrinse (I) Photo camera wrapped with barrier membrane 25

26. Surgical Setup – Supply Tray A B C D E F I H G 26

27. IMPLANT MOTOR TABLE ( IMPLANT KIT) Follow manufacturers’ guide – Usually includes Large round bur to flatten site Small round bur to mark implant site Lindeman bur for decortication ( in case of zimmer implant system) At least 2 osteotomy drills: Pilot drill Larger sizes depending on bone density and implant diameter Implant driver for handpiece + Torque wrench with implant driver Hex tool Bone tap 27

28. Contains a bur to create a hole in the cortex Osteotomy drills that create a bone preparation similar to the shape of the implant Bone taps that shape the cortical part of the bone preparation to match the implant shape Features Common to All Placement Systems 28

29. Some type of implant driver that delivers and inserts the implant into the bone preparation Shape differs by implant system. For Zimmer implants, they are hex tools A wrench that is used to torque the implant into its final position (and a certain torque in some implant systems) 29

30. Most systems are now color coded to highlight instruments used for different implant diameters Most systems feature sequential use of increasing osteotomy drills 30

31. Sequential use of drills with increasing diameters allow precise gradual widening of osteotomy . This is important as the osteotomy must be slightly narrower than the implant, so that the implant can engage just enough bone for stability, but not too much bone that would prevent insertion of the implant at a normal force. 31

32. All of the electrical circuitry ,controls for speed , irrigant , hand piece selection ,readout in rotation per minute ( rpm) and power are located on the console Even the foot controlled rheostat plugs into and is powered by the console . console 32

33. NSK Implant Motor Console Coolant flow (Level 3-5) Speed Torque Gear ratio (20:1) Coolant Flow Forward/ Reverse Torque (Ncm) Speed (rpm) Direction 33

34. NSK Implant Motor Foot Pedal Speed Coolant Flow Forward / Reverse ( Program ) 34

35. The motor housing cords plugs into the front of the console and utilizes its voltage supply The tiny motors inside the housing are commonly referred to as micromotor and they are designed to run at different speed. The most commonly used motors for root form implants turn at 20000 ,30000 and 40000 rpm. Electric motors 35

36. 36 NSK Surgic XT Implant motor Saline flow block Console Staging Block Handpiece 36

37. Surgical Setup – Implant Motor Assemble handpiece & connect to implant motor console Assemble saline supply & make sure tubing is mounted correctly in peristaltic pump Close tube lock to prevent spilling of saline while motor is not used Mount pilot drill Turn on unit to verify function IMPORTANT: Some systems have disposable tubing, others don’t – Please find out before you dispose tubing 37

38. Handpiece is any apparatus attached to an electrical or an air- or nitrogen-powered motor that accepts a bur. There are two types of handpieces: contra-angle and straight ; these enable the practitioner to increase or maintain a motor’s speed reliably. HANDPIECES 38

39. Surgical Setup – Surgical Handpiece Assemble surgical handpiece Mount no. 4 round bur Run handpiece for at least one minute over plastic cup to eliminate excess oil from handpiece 39

40. If any of the following are noted while the motor is in use, action must be taken: • The practitioner feels a loss of speed with vibration of the handpiece head. (This can cause gear stripping and handpiece failure.) • The bur wobbles or chatters during cutting. (This causes friction to the handpiece and can burn and injure the bone.) Troubleshooting 40

41. • The sound of the motor changes, or the motor begins to growl or buzz. (This may indicate a drop in speed and power as a result of an internal problem in the gear housing.) • The motor and handpiece begin to feel warm and get progressively hotter over time. (This may indicate a worn gear assembly.) 41

42. In such instances, the rheostat should be used to increase motor speed, because this may help reduce the difficulties. To prevent these problems, the practitioner should: 1. Make smaller increases in drill diameters 2. Use new, sharp burs and drills at appropriate velocities and change them often 3. Stay within the proper handpiece power zones 42

43. Round Bur Sometimes used to prepare implant site before creating osteotomy Used to create flat ridge prior to osteotomy creation so that implant platform is level with surrounding bone 43

44. Pilot drill First rotary instrument Cuts bone at tip and at sides Used to mark osteotomy site Used to cut through cortex at osteotomy Also used to correct osteotomy location or direction by removing bone from side of ostetomy Zimmer Lindeman Bur is gold-colored 44

45. Osteotomy drills Creates osteotomy shaped like implant Mostly cuts at tip. Depth marks indicate implant lengths Drill-tip (called “Y-point”) is 0.5 mm long in addition to indicated length (i.e. 11.5 mm = 12 mm actual length) 45

46. Paralleling Tool ( Direction indicator) Used after creating first, narrow osteotomy. Shows direction of osteotomy clinically and radiographically Often features hole to tie floss through it so it is less likely to be aspirated Sometimes features markings Simply a metal pin of the same size than the first osteotomy drill. Think of it as “dummy implant” to show where implant would be 46

47. Implant Driver Used to deliver implant into osteotomy site Two varieties with different attachments One for use in Implant handpiece (Top) Other for use in Implant wrench (Bottom) Different size of hex for different implant platforms One for 3.7, 4.1 and 4.5 mm diameter implants Other for 6 mm implants 47

48. Implant wrench ( zimmer ) Can be used both sides: Arrow facing you: Inserts implant Arrow facing tissue: Backs out implant 48

49. 49 Surgical Guide Place surgical guide in 70% ethanol for at least 15 minutes prior to surgery and wash with sterile water/saline before use 49

50. To effectively carry out any procedure, it is crucial to familiarise oneself with the components involved The first step is to determine the implant system used (eg Nobel Replace, Nobel Brånemark System, AstraTech Osseospeed , Straumann SLActive , alfa bio etc) , as this will dictate the type of impression components used. ARMAMENTARIUM ( prosthetic ) 50

51. Each implant system has its own set of impression components that are designed to fit accurately onto the fixture head of the implant, which is machined to specific geometry. Irrespective of the implant system used, the impression components and techniques are broadly very similar. 51

52. Nobel Replace fixture heads Brånemark fixture head 52

53. An implant screwdriver is a critical piece of equipment used to screw and unscrew various components onto the fixture head. Depending on the implant system, screwdrivers heads can be slotted, hexagonal, star shaped, etc . Screwdrivers Screwdrivers (from left to right) with a hexagonal head ( AstraTech ) and star shaped heads ( Straumann and Nobel Biocare ) 53

54. Screwdrivers are often designed to fit into a manual or motor driven torque device, which can be used to tighten components to a predetermined torque . Manual torque device 54

55. The fixture head is usually at the level of the alveolar bone crest, therefore, in order to provide access to the fixture head, a removable transmucosal component known as a healing abutment/cap is screwed onto the fixture head by the surgeon, either at the time of implant placement or as a second surgical procedure. Healing abutment/caps 55

56. 56

57. Healing abutments/caps vary in height, width and profile. An appropriate healing abutment is selected to mould the peri -implant tissues during healing and prevent tissue overgrowth. healing abutments 57

58. The impression coping is the component that fits onto the implant fixture head or an implant abutment while making an impression. There are two types of impression copings: . one that is used with a closed tray and retained in the mouth after the impression is removed . the second, used with an open custom tray, in which the impression is removed with the coping in situ within the impression Impression coping 58

59. Once cast, the impression copings transfer the position of the implant fixture head/abutment onto the working model. closed tray impression coping open tray fixture level impression coping 59

60. 60 IMPLANT LEVEL IMPRESSION TECHNIQUES CLOSED TRAY IMPRESSION TECHNIQUE Transfer copings connected to implants

61. 61 Impression Made

62. 62 Impression removed leaving copings behind Coping-Implant analogue assembly inserted into impression Impression poured

63. 63 Pick Up/Open Tray Transfer copings and guide pin assembly attached to implant

64. 64 Syringe material injected around transfer copings Tray filled with Impression material and impression made Impression material allowed to polymerize

65. 65 Coping-pin-implant analogue assembly inserted to impression Impression poured

66. 66 abutment Implant body prosthesis superstructure Prosthetic Attachment Abutment portion of the implant that supports or retains a prosthesis or implant superstructure Superstructure metal framework that attaches to the implant abutment and provides either retention for removable prosthesis or framework for fixed prosthesis

67. 67 Categories of implant abutment based on method by which prosthesis or superstructure is retained to the abutment Screw retention cement retention for attachment attachment device to retain a removable prosthesis

68. Prefabricated stock abutments are off-the-shelf components produced in a variety of collar heights, widths and angulations . These are available in titanium, gold and ceramic and can be screwed (or press fitted with some systems) directly to the fixture head before impression making. Prefabricated stock abutments 68

69. Some standard abutments come with individual impression copings (eg Easy Abutment, Snappy Abutment, etc, Nobel Biocare ) 69

70. Prefabricated abutments are relatively cheap and they simplify impression making by moving the restoration margin coronally DISADVANTAGE . However, they come in a relatively limited number of shapes and sizes and are inappropriate in all circumstances, especially when the fixture head is deeply subgingival . ADVANTAGE 70

71. For implant retained overdentures , prefabricated abutments with a variety of attachment mechanisms (eg ball, magnets, LOCATOR, etc) are available in a series of different heights and widths, with its own specifically designed impression coping 71

72. Custom abutments, individualised for each restoration, can be used where prefabricated abutments are inadequate. They are often made using CAD/CAM techniques and are available in a variety of metals and ceramics . CUSTOM ABUTMENT 72

73. Custom abutments are generally more expensive than prefabricated abutments. However, they can be designed so that the abutment-crown junction is hidden to ensure superior aesthetics. 73

74. Depending upon retention Abutment for screw retention Abutment for cement retention Abutment for attachment Depending upon angulation • Straight abutment • Angled abutment 74 Types of abutment

75. – Steri oss abutment – Paragon abutment – Ceraone abutment – Ceradapt abutment – UCLA abutment – Noble bio care abutment – Estheticone abutment – Mirus cone abutment – Noble pharma single tooth abutment – Branemark system angulated abutment – Astra abutment 75 Commercially available abutment

76. ONE PIECE IMPLANT One-piece implants incorporate an integral abutment. This abutment is usually prepared using special burs designed to cut titanium. Care must, however, be taken to ensure that the implant is not overheated and the abutment is not excessively reduced. 76

77. 77 Implant system broadly are of 2 types Two stage One stage immediate one piece implant system implant body + prosthodontic abutment 2. two piece implant system implant system prosthodontic abutment Implant surgery

78. 78 Implant surgery… Two stage surgery 1 st surgery - implant body placed below the soft tissue after initial bone healing has occurred 2 nd surgery -soft tissue are reflected - permucosal element or abutment is attached One stage surgery 1 st surgery - implant and permucosal element placed after initial bone healing has occurred -abutment replaces the permucosal element without reflection of flap

79. 79 Implant body First stage cover screw Second stage permucosal extension or healing abutment Abutment A) for screw retentin B) for cement retention C) for attachment Hygiene screw Transfer coping A) direct B) indirect Analog A)implant body B) abutment coping Prosthesis screw

80. Alpha-Bio Tec specializes in developing and producing advanced dental solutions, focusing on the field of implants and prosthetics. The unique and simple system makes the dentist's work extremely convenient and accomplishes several major advantages: • Wide range of products with proven clinical biocompatibility. • Fast and easy insertion. • High primary stability. • High predictability. • High success rates, in immediate loading. Alfa bio 80

81. Surgical drills – internal irrigations The surgical drills are available in sequential diameters and in two lengths . The drills are made of surgical titanium and are to be used with internal irrigation . All drills are color and groove coded for easy identification during surgery . Drills are groove marked for lengths Surgical instrumentation 81

82. 2 mm 2.8 mm 3.2 mm 3.65 mm 4.3 mm 5.2 mm 82

83. Surgical drills –external irrigation The surgical drills are available in sequential diameters and in two lengths . The drills are made of stainless steel and are to be used with external irrigation . 83

84. 2 mm 2.8 mm 3.2 mm 3.65 mm 4.3 mm 5.2 mm 84

85. Straight drills are intended for close sinus lift and for drilling close to anatomic structures . Straight drills Stopper 85

86. Drill stopper( titanium) To prevent over drilling. Use HTD 1.25 for fixation 86

87. DRILL EXTENSION - Extends drill by 17.5 mm. INSERTION TOOLS 2.5 mmd (ITD) ( stainless steel ) Used for placing threaded implants with internal hex 2.5mm . Hexagonal 6.35mm or square head 4mm 87

88. 6.35mm 4 mm 2.5 mm contraangle –motor mount insertion tool ( IT 1.25 88

89. HEX DRIVER ( 1.25 mm) HTD ( Stainless steel) For all types of cover screws, healing abutment and prosthetic pieces . Hexagonal 6.35mm or square head 4mm 89

90. 6.35mm 2.5mm 14.5mm 4mm 11.5 mm contraangle –motor mount hex driver ( HT (1.25 m) 90

91. RATCHET WRENCH ( stainless steel) for 6.35 hexagonal head UNIVERSAL TORQUE / RATCHET ( stainless steel) Allows the clinicians to accurately apply the recommended preload torque for surgery and prosthetics 91

92. Parallel / depth pin ( titanium ) For accurate measurement of x ray distortion . Each step is 1 mm. 3mm 1.9 mm 1 mm 10mm 92

93. Parallel guide Used for precise spacing and parallel placement of implant 2.3 mm 7 mm 93

94. IDG IMPLANT DEPTH PROBE ( STAINLESS STEEL) Its gently rounded apex simplifies depth measurements and provides easy tactile examination of bone preparation and sinus membrane 8mm 10 11.5 13 16 94

95. Sinus lift instruments Subantral membrane elevator New innovation for hydraulic sinus lift . reduces risks of membrane tears Single use , supplied sterile 95

96. OSTEOTOMES Use for implant placement ,sinus elevation , ridge expansion and Site preparation . STRAIGHT OSTEOTOME ANGLED OSTEOTOME 96

97. STOPPERS FOR DRILLS OR OSTEOTOME To prevent overdrilling Use HTD 1.25 for fixation 97

98. 98 BIBLIOGRAPHY Carl E Misch : Contemporary Implant Dentistry Charles M Weiss : Principles And Practice Of Implant Dentistry Steven , Friedrickson and Geiss : Implant Prosthodontics -Clinical and Laboratory Procedure Maurice J Fagan :Implant prosthodontics : Block Kant : Endosseous Implant For Maxillofacial Reconstruction Norman Cranin :Atlas of Oral Implantology Michael Norton :Dental Implants- Guide for General Practitioner British Dental Journal Vol 201;77 Journal Of Prosthetic Dentistry Vol 89;611 Alfabio tech manual

99. 99 Thank You