Implant prosthetic dentistry

Implant prosthetic dentistry

1. Implant ProstheTIC Dentistry

2. Contents 28/07/2018 2

3. Why and when dental implants? Replaces one or more teeth without affecting adjacent teeth. Supports a crown/bridge and eliminates the need for a removable partial denture. Provide support for a denture, making it more secure and comfortable Used for anchorage during orthodontic treatment Bone maintenance of height and width 28/07/2018 3

4. Why and when dental implants? Improved appearance. Dental implants look and feel like your own teeth leading to improved self esteem/ improved psychological health Convenient to clean Improved speech Increased stability in chewing 28/07/2018 4

5. Why choose dental implants over dental bridge? No damage to adjacent teeth Bone maintenance of height and width In distal-end situation or multiple missing teeth/long span edentulism Complete edentulous situation 28/07/2018 5

6. Introduction to fixed prosthodontics Fixed prosthodontic treatment involves the replacement and restoration of teeth by artificial substitutes that are not readily removable from the mouth. Its focus is to restore function, aesthetics, and comfort. 28/07/2018 6

7. Implant Dentistry Implantology – A substance that is placed into the jaw to support a crown or fixed or removable denture 28/07/2018 7

8. Implants Dental implant - An artificial titanium fixture which is placed surgically into the jaw bone to substitute for a missing tooth and its root(s). The implant is the endosteal dental implant that is placed within the bone during stage I surgery. It may be either a threaded or nonthreaded cylinder. It is either titanium or titanium alloy, with SLA (Sandblasted and acid-etched) treatment and then hydroxyapatite is coated on the top or without hydroxyapatite coating. 28/07/2018 8

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10. Diagnosis and treatment planning in Implant Dentistry Patient screening and medical evaluation General examination – Extra/Intraoral Classification of arches Bone evaluation Evaluation of natural teeth adjacent to implants Esthetic risk factors Diagnostic imaging Diagnostic casts 28/07/2018 10

11. Evaluation of patient’s medical history Smokers Diabetes Long-term steroid use Osteoporosis Other diseases Radiotherapy 28/07/2018 11

12. Bone evaluation 28/07/2018 12

13. Diagnostic tools Periapical radiograph Occlusal radiograph Orthopantomograph CBCT Cephalometric radiograph Computed Tomography (3D) Magnetic resonance imaging (3D) Interactive computed tomography (3D) Photographs/Study models Main goals of presurgical imaging Identify disease Determine bone quality Determine bone quantity Determine implant position Determine implant orientation 28/07/2018 13

14. Interactive computed tomography (3D) 28/07/2018 14

15. Types of dental implants Endosseous implant Subperiosteal implant Transmandibular implant Basal implants 28/07/2018 15

16. Osseointegration The phenomenon of osseointegration of titanium implants was discovered by the Swedish surgeon, Branemark in 1952. Functional ankylosis (bone adherence), where new bone is laid down directly on the implant surface and the implant exhibits mechanical stability. 28/07/2018 16

17. Implant placement video 28/07/2018 17

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19. Two-stage Surgical Protocols The original protocol for placing modern osseointegrated implants was two-stage (submerged) surgery, and it is still widely used today. The implant is placed below the soft tissue and protected from occlusal function and other forces during osseointegration . 28/07/2018 19

20. Two-stage Surgical Protocols A low-profile Cover Cap is placed on the implant to protect it from the ingress of soft tissue. Following osseointegration , a second surgery exposes the implant and a transmucosal Healing Abutment is placed to allow for soft tissue healing and development of a sulcus . Prosthetic restoration begins after soft tissue healing 28/07/2018 20

21. Single-stage Surgical Protocols Single-stage surgery leaves the implant/abutment connection exposed to the oral cavity via an integrated transmucosal element, or a removable Healing Abutment. This eliminates the need for a second surgery to expose the implant. 28/07/2018 21

22. Single-stage Surgical Protocols Although the implant is not in occlusal function, some forces can be transmitted to it through the exposed transmucosal element. Prosthetic restoration begins following osseointegration of the implant and soft tissue healing. 28/07/2018 22

23. Non-functional Immediate Restorations Single-stage surgery with non-functional immediate restoration provides patients a non- occlusal provisional prosthesis early in the treatment plan. An abutment may be placed on the implant at or shortly after surgery, and a provisional restoration secured to it with temporary cement. Alternatively, a screw-retained prosthesis may be fabricated. The provisional can help contour the soft tissue profile during healing. 28/07/2018 23

24. Immediate function restorations Single-stage surgery with immediate function is possible in good quality bone where multiple implants exhibiting excellent initial stability can be splinted together. Splinting implants together can offer a significant biomechanical advantage over individual unsplinted crowns. 28/07/2018 24

25. The following items only require hand-tightening (approximately 10Ncm): Surgical Cover Caps Healing Abutments Cover caps for the Abutment for Screw and all impression coping screws 28/07/2018 25

26. Impressions in implant dentistry 28/07/2018 26

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28. ACCURATE IMPRESSIONS PROVIDE A FOUNDATION FOR SUCCESSFUL IMPLANT PROSTHODONTICS 28/07/2018 28

29. Impression materials ideal requirements Complete plasticity before cure Fluidity to record fine detail Ability to wet oral tissues Dimensional accuracy Dimensional stability Complete elasticity after cure Optimal stiffness 28/07/2018 29

30. What is the benefits of Impression in implant dentistry? Position Depth Axis/ Angulation Rotation-Hex position Soft Tissue Contour (Emergence Profile) 28/07/2018 30

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32. Impression materials 28/07/2018 32

33. What you need to take an impression 28/07/2018 33

34. Classification of implant impression techniques 28/07/2018 34

35. Abutment level impression Prepared abutment 28/07/2018 35

36. Fixture / Implant level Impression Impressions are made of an implant using implant level impression copings. To create a restoration for an implant, the laboratory model needs to include an implant replica seated in the model replicating the exact implant position in the patient’s mouth. Such impressions can be made using an open tray or a closed tray technique. 36 28/07/2018

37. Fixture/Implant level Closed Tray Impression Technique During this procedure, the transfer impression coping is screwed onto the implant. A radiograph is taken to ensure proper seating of the coping. If not seated properly, the position of the implant in the oral cavity cannot be exactly recorded and replicated onto the model to be obtained. 28/07/2018 37

38. CLOSED TRAY TECHNIQUE 28/07/2018 38 1. Implant fixture 2.Copings attached to the implant body 3. Polyvinylsiloxane impression material is injected around the impression coping 4. Impression is made with a heavy body impression material. 5.Impression coping removed from the fixture 6.Coping placed in the impression

39. Closed tray video 28/07/2018 39

40. Closed Tray Impression Technique Advantages Easier Impression coping for closed tray are usually shorter, making it easier for posterior areas and for patients with limited mouth opening. Less time for impression preparation: cutting holes in the impression tray usually not needed Impression cap type techniques. 28/07/2018 40

41. Closed Tray Impression Technique Disadvantages Less accurate with multiple units. Some implant systems require more clearance than other implant systems, therefore may still necessitate cutting holes in the impression tray as with the open tray technique, and as a result, may be less accurate depending upon several factors. Positional timing error, depending upon the impression coping design. 28/07/2018 41

42. Implant/fixture level Open Tray Technique: The open tray impression technique is one of the most common impression methods used in the fabrication of implant supported prosthesis. It is also called a pick up impression because the impression coping is removed together with the impression body after the impression material hardens. In this, the screw connecting the impression coping to the fixture should be long enough to protrude from the impression tray, which should have a hole; hence the name open-tray technique. 28/07/2018 42

43. A long-cone radiograph is almost always necessary to confirm that the impression coping is fully seated and to ensure absolute accuracy before any construction of the crown begins. A polymeric standard stock tray may be used. It is relieved and perforated to allow full seating of the tray and protrusion of the guide pins through it, due to which the technique is termed as an open tray technique. If there is a large opening, it may be closed off using a baseplate wax, with the guide pins indenting or perforating the wax . 28/07/2018 43

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45. Open tray – Direct Pick-up Impression Technique 28/07/2018 45 In the Open Tray Transfer technique, the Direct Pick-up Copings remain in the impression when removed from the mouth. For this pick-up technique a custom tray or modified stock tray with screw access holes in the areas above the implants is required.

46. Open tray impression technique 28/07/2018 46 Clinical 1 - Remove healing abutment Clinical 2 - Place impression coping Clinical 3 - Try-in impression tray

47. Open tray impression technique 28/07/2018 47 Clinical 4 - Make an impression Clinical 5 - Remove coping screws

48. Open Tray Impression Technique Indications Usually used for multiple units Use non hex (non engaging) impression copings if implants are not in alignment Splint together Durelay Wire/ Durelay Advantages More accurate for multi units 28/07/2018 48

49. Open Tray Impression Technique Disadvantages More impression preparation and impression time -Test fitting impression copings and cutting holes for the impression copings Additional time to “unlock” the impression copings Adequate mouth opening required. More possibility for gagging 28/07/2018 49

50. Open tray video 28/07/2018 50

51. My Fit Healing Abutment (Innovative technique of impression developed by a friend of mine who is a lab technician in South Korea) 28/07/2018 51 1. Installing the impression healing abutment in the mouth

52. My Fit Healing Abutment 28/07/2018 52 2. Taking impression

53. Restorative options Cement-retained Restorations Cement-retained implant restorations are very similar to crown & bridge restorations. A prepared implant abutment is screwed onto the implant. The crown or restoration is cemented to the prepared abutment, much like a prepared tooth. Indications Single or multiple-unit implant restorations Totally edentulous or partially edentulous arch 28/07/2018 53

54. Restorative options Limitations Ease of retrievability Advantages Conventional crown & bridge procedures Maximum control of occlusion More esthetic than screw-retained Implant-level Cement-retained Restorations 28/07/2018 54

55. Fixed implant supported restorations 28/07/2018 55

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57. Fixed implant supported restorations 28/07/2018 57

58. Occlusion 28/07/2018 58

59. Introduction - Occlusion Occlusion is not defined solely as the nature of occlusal contact between opposing teeth but more broadly refers to the dynamic relation between the teeth , the neuromuscular system, the TMJ and their interactive relationship on the craniofacial environment. 28/07/2018 59

60. Occlusion Achieving proper occlusion for a patient is as fundamental to success as function or esthetics and is of paramount importance when providing implant supported prosthesis to the patient. 28/07/2018 60

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62. Minimal Occlusal Goals 28/07/2018 62

63. Additional Goals 28/07/2018 63

64. AIMS IN DESIGNING IMPLANT OCCLUSION 28/07/2018 64

65. Consequences of biomechanical overload Implant occlusion Early implant failure Early crestal bone loss Intermediate to Late implant failure Intermediate to Late implant bone loss Screw loosening Cement debonding Component fracture Porcelain fracture Prosthesis fracture Periimplantitis (secondary to bone loss ) 28/07/2018 65

66. Then why we should have a different occlusal consideration for implants supported prosthesis ? How implants are different ? 28/07/2018 66

67. Lateral mobility of an implant: 10-50 microns. 28/07/2018 67

68. Implant occlusion Disadvantages No shock absorption Stresses concentrated at the crestal bone Crestal bone loss Prosthetic component fracture And all this with no WARNING SIGN 28/07/2018 68

69. Warning signs in a natural tooth Wear facets Cold sensitivity Fremitus Mobility (reversible sometimes) Orthodontic movement AND MOST IMPORTANT THING REPAIR 28/07/2018 69

70. How to check cuff height 28/07/2018 70

71. Implant overdenture 28/07/2018 71

72. Implant overdenture For those patients requiring more retention and stability for an upper and lower denture, the all implant-supported overdenture may be the answer. A removable implant overdenture is a prosthesis which is removable by the patient and is supported or retained by dental implants. 28/07/2018 72

73. Implant overdenture The prosthesis has to be removed for the purpose of cleaning around the abutments 28/07/2018 73

74. Implant overdenture Overdenture : Any removable dental prosthesis that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and/or dental implants; a dental prosthesis that covers and is partially supported by natural teeth, natural tooth roots, and/or dental implants. 28/07/2018 74

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79. Implant overdenture Advantages Prevents bone loss Improved esthetics Improved stability (reduces or eliminates prosthesis movement) Improved occlusion (reproducible centric relation occlusion) Decrease in soft tissue abrasions Improved chewing efficiency (20%) and force(300%) Increased occlusal efficiency Improved retention Improved support Improved speech Reduced prosthesis size (eliminates palate, flanges) Improved maxillofacial prostheses 28/07/2018 79

80. Advantages of Implant Overdenture versus Fixed P rosthesis Fewer implants Compromised sites can be avoided Less specific placement mesiodistally because prosthesis covers the abutments Improved esthetics Labial flange Denture teeth Soft tissue drape 28/07/2018 80

81. Advantages of Implant Overdenture versus Fixed Prosthesis Speech Denture extends onto the soft tissue and prevents escape of air and saliva. Lower cost Fewer implants Sites which require grafting can be avoided Easy repair Decreased laboratory costs 28/07/2018 81

82. Implant overdenture Disadvantages Psychological (need for non-removable teeth) Greater abutment crown height space required Hader clip O-ring 28/07/2018 82

83. Implant overdenture Disadvantages Long-term maintenance Attachment (susceptible to wear) Relines (RP-5) New prosthesis every 7 years(wear of denture teeth) Continued posterior bone loss Food impaction Movement (RP-5) 28/07/2018 83

84. Meg Rhein 28/07/2018 84

85. Overdenture chairside technique 28/07/2018 85

86. References Rathee M, Bhoria M. Basics of clinical diagnosis in implant dentistry. J Int Clin Dent Res Organ [serial online] 2015 [cited 2018 Jul 23];7, Suppl S1:13-8. Available from:  http:// www.jicdro.org/text.asp?2015/7/3/13/172929 28/07/2018 86