jc 5.pptx

prosthodontics

1. Good Morning

2. Clinical Accuracy Outcomes of Closed-Tray and Open-Tray Implant Impression Techniques for Partially Edentulous Patients

3. Contents Introduction Review Objective of study Materials and Methods Statistical analysis Results Conclusion References

4. INTRODUCTION

5. Open Tray Technique / Pick Up Technique Two – piece implant transfer system with square shaped posts and long fixation screws. Heather J . Conard ,Accuracy of two impression techiques with angulated implants. J Prosthet Dent 2007; 97 ; 349-356 Scott , obtaining impressions for clinically successful implant supported restorations

6. ADVANTAGES Allows impression coping to remain in impression Reduces the effect of implant angulation Reduced the deformation of impression material upon recovery from mouth Removes the concern for replacing the coping back into its respective space in impression Disadvantages More parts to control when fastening Rotational movement of the impression coping when securing the implant anlaog Misfit of components Heather J . Conard ,Accuracy of two impression techiques with angulated implants. J Prosthet Dent 2007; 97 ; 349-356

7. Closed Tray Technique Single piece impression coping Heather J . Conard ,Accuracy of two impression techiques with angulated implants. J Prosthet Dent 2007; 97 ; 349-356 Scott , Obtaining impressions for clinically successful implant supported restorations

8. Indications Limited interarch space Gagging tendency Difficult to access an implant in the posterior region of the mouth. Advantages Visual fastening of the analog to coping more accurate Disadvantages Inaccuracy with recovery and deformation with nonparallel implants Misfit – if impression copings not repositioned exactly. Heather J . Conard ,Accuracy of two impression techiques with angulated implants. J Prosthet Dent 2007; 97 ; 349-356

9. REVIEW Daoudi (2001) – compared the closed tray technique at implant level with open tray technique at abutment level for single tooth implants and found open tray technique to be more superior and predictable Jorge (2002) – compared dimensional accuracy of 3 different resins for jig fabrication with open and closed tray impression technique. Open tray impression group showed greater inaccuracy in vertical plane. Heather J. Conard (2007) – studied the accuracy of open tray and closed tray techniques with angulated implants. He concluded that the interaction of impression technique with either the implant angulation or implant number was not significant.

10. OBJECTIVE To compare the accuracy outcomes of the open-and closed-tray implant impression techniques for partially edentulous patients

11. Materials And Methods Eleven partially edentulous spaces from seven patients Inclusion criteria patients ≥ 21 years of age with two healthy implants in the same quadrant for a multiunit fixed partial denture.

12. Closed - Tray Technique Implant-level impression copings were inserted. Custom trays loaded with polyether impression material . Impression copings were removed and mounted with implant analogs and then relocated in the impression.

13. Open - Tray Technique Open-tray implant-level impression copings Impression copings were picked up in the impression, and implant analogs were connected.

14. Impressions poured using type – IV dental stone. Verification jigs were fabricated intraorally with straight multibase abutments splinting the two implants with a resin framework

15. Digital photographs were used to calculate the angular difference between the two implants. Distances between the two implants were measured using a caliper. Microcomputed tomography (micro-CT) scanning was used to scan the gap between the abutments and the verification framework for all test and control casts Visual analog scale – assess patient perceptions regarding impression preference

16. Statistical Analysis Descriptive statistics (mean, standard deviation [SD]). Wilcoxon signed ranks test

17. Site Specific Demographics

18. Descriptive Statistics

19. Wilcoxon Signed Rank Test * The sum of negative ranks equals the sum of positive ranks. † Based on positive ranks. Closed-tray Vs Open-tray Control Vs Closed-tray Control Vs Open-tray Z .000* –1.000† –1.000† Asymp . sig. (two - tailed) P > .999 P = .317 P = .317

20. Results Ten of 11 implant casts generated were clinically accurate. A single site with misfit belonged to a single patient. This inaccuracy was a false positive for that site (both groups), suggesting that there was likely an error with the fabrication of the intraoral verification jig. The Wilcoxon signed ranks test - no statistically significant difference . Visual analog scale Mean Mesiodistal angulation of all implants was 4 (3) degrees Mean Buccolingual angulation was 3 (2) degrees.

21. Conclusion Closed tray impression had no statistically significant difference compared to open tray technique for multiunit partially edentulous situation when implants have less than 10 degree of angulation

22. References Conrad HJ. Accuracy of two impression techniques with angulated implants . J Prosthet Dent 2007;97:349–356. Lee YJ. Accuracy of different impression techniques for internal - connection implants. Int J Oral Maxillofac Implants 2009;24:823–830. De La Cruz JE . Verification jig for implant-supported prostheses: A comparison of standard impressions with verification jigs made of different materials. J Prosthet Dent 2002;88:329–336. Sorrentino R . Effect of implant angulation , connection length, and impression material on the dimensional accuracy of implant impressions: An in vitro comparative study. Clin Implant Dent Relat Res 2010;12( suppl 1): e63–e76. Gallucci GO . Treatment of completely edentulous patients with fixed implant-supported restorations: Three consecutive cases of simultaneous immediate loading in both maxilla and mandible. Int J Periodontics Restorative Dent 2005;25:27–37.

23. Thank you

24. Brief overview of the procedure & Components

25. Healing abutments and cover screw After an implant is placed, the internal components are covered with either a healing abutment, or a cover screw. A cover screw is flush with the surface of the dental implant, and is designed to be completely covered by mucosa . After an integration period, a second surgery is required to reflect the mucosa and place a healing abutment A healing abutment passes through the mucosa, and the surrounding mucosa is adapted around it. Healing abutments are available in varying heights and diameters which are selected based on clinical situations. traditional two-stage procedure The healing abutment pierces through the soft tissues and is exposed within the oral cavity, allowing the soft tissues to heal around it

26. Laboratory analogue Laboratory analogue are metal replicas that duplicate the implant head or abutment connected to the implant which are used in laboratory to construct working model.

27. Impression copings Impression copings have been designed for making final impression after the soft tissue has matured. These copings have the same flare as the healing abutments and should fully support the soft tissue around the head of the implant . They are various types of copings available which are selected based on the impression techniques In transfer type the coping is retained in the mouth when set impression is removed. In pick up type the coping gets incorporated in the impression and it is removed from the mouth with the set impression .[Schaefer O, Schmidt M, et al 2012]3

28. To make a fixture head /implant level impression the healing abutment is removed and an impression coping is then screwed onto the implant head and a silicone impression is taken.

29. The impression is then sent to the dental technician, who will manufacture the restoration . Whilst the restoration is being manufactured the healing abutment is screwed back onto the implant head

30. Pick up type /open tray The impression coping incorporated in the impression and is removed from the mouth together with the set impression and is known as a pick up type/open impression They require access to the retaining screw to allow release of the screw prior to removal of the impression coping — impression assembly, the analogues are attached to the impression copings while they are embedded in the impression tray(Fig no.12) A custom tray with access to the impression coping screws is required.

31. Making a radiograph when the impression coping/implant or impression coping/abutment is below the level of the mucosa to insure seating of the impression copings Using vinyl gloves when a polyvinyl siloxane impression is used to prevent retardation of setting of the impression material from the interaction of latex gloves with the material . It has been shown that the pick up type impression coping is the more accurate type of impression as errors occur on removal and replacement of the transfer type impression copings, especially in the occlusogingival direction.

32. Indications  More accurate for multi unit impressions  In cases with implant/abutment angulations and path of insertion withdrawal

33. Advantages of Open Tray  An advantage of this technique is the dentist can confirm the laboratory preparation and contour of the provisional prosthesis to achieve the desired healing and soft tissue contour before final crown fabrication.  Reduces the effect of the implant angulation  Reduces the deformation of the impression material.  Removes the concern for replacing the coping back into its respective space in the impression.

34. Disadvantage of Open Tray The movement of impression copings inside the impression material during clinical and laboratory phases may cause inaccuracy in transferring the spatial position of implants from the oral cavity to the master cast.

35. The open technique can be further subdivided into splinted and non-splinted techniques. The splinting procedure is recommended in case of multiple implants to decrease the amount of distortion and to improve impression accuracy and implant stability. Splinting of the transfer copings prevents rotational movement of impression copings in the impression material during analog fastening, which provides better results than not splinting

36. Transfer type/ closed tray The copings are connected to the implant and after the removal of impressions they are retained on the implant. These copings are then removed from the implant, attached to the implant analogues and reinserted in the impression. They remain in the mouth on removal of the set impression. No custom tray is required for this type of impression.

37. Indications  Limited inter arch space  Tendency to gag  Difficult access in the posterior region of the mouth

38. Advantages of Closed Tray  Easier  Suitable for short inter arch distance.  Visual fastening of the analog to the coping is more accurateConrad H. (2007) Disadvantages of Closed Tray  Inaccuracies with recovery and subsequent deformation of impression material may be encountered with nonparallel implants.  Not Suitable for deeply placed implants.

39. Abutment level Following confirmation from the radiograph of complete seating they are then definitively secured by tightening the retaining screws with a torque device. Incorrect seating may be due to Failure to ensure that the abutment correctly engages an anti rotation features. The presence of soft tissue or bone encroaching on the head of the implant. Prepared abutments are usually supplied in various materials such as alumina,zirconium and titanium,zirconium and titanium.

40. The manufacturer typically supplies these as stock shaped abutments, which can be as stock shaped abutments , which can be placed directly on the implants and placed directly on the implants and modified by the clinician in the mouth modified by the clinician in the mouth. The technique of preparing them is similar to traditional crown and bridge techniques, crown and bridge techniques. Preparation can be carried out directly in the mouth. This will allow the margins of the abutment to follow the gingival contour . Utilizing standard crown and bridge principle, an impression can be recorded of the prepared abutments directly in the mouth.

41. Advantages of Abutment level impressions  Simple provisional restoration fabrication  Selecting abutments in the laboratory  For custom-made abutments

42. Indirect technique Abutment placed at the implant site ---Impression cap snapped onto the abutment ---Tray material used to make an impression---Impression cap picked up by the impression---Implant analogue attached to abutment---Impression poured(Fig no.14) Direct technique Here impression is taken with abutment and transfer coping. The abutment is then removed from the patients mouth and this same abutment is used for casting and fabrication of the prosthesis. Since we use the abutment directly it is called direct technique. In indirect technique, the abutment remains in patients mouth, we use implant analogue. Since we are not directly fabricating onto the abutment,but use analouge , it is called indirect technique

43. SPLINTED IMPRESSION COPINGS

44. The open technique can be further subdivided into splinted and non-splinted techniques. The splinting procedure is recommended in case of multiple implants to decrease the amount of distortion and to improve impression accuracy and implant stability. Splinting of the transfer copings prevents rotational movement of impression copings in the impression material during analog fastening, which provides better results than not splinting9

45. SPLINTED IMPRESSION COPINGS PROCEDURE Impression copings were splinted with dental floss and autopolymerizing acrylic resin. The transfer copings were tied up with four complete loops of dental floss and splinted with autopolymerizing acrylic resin (pattern resin) and allowed to set for 3 minutes

46. The heavy consistency polyvinylsiloxane impression material was loaded inside the impression tray and light consistency polyvinylsiloxane impression material was meticulously syringed around the impression copings to ensure complete coverage of the copings Implant analogs were fastened to the impression copings in the impressions. The impression was now poured to create a model

47. Snap-fit (press fit) plastic impression coping

48. Cementation of implant crown

49. risk factors including excess dental cement may have a significant role in early onset of peri-implantitis The initial phase of soft tissue inflammation around the peri -implant mucosa is called as perimucositis . Per-mucositis leads to peri-implantitis which is destructive inflammatory process that causes bone damage that is beyond repair Multiple methods to reduce excess dental cement have been reported in literature

50. Screw retained crown The main types of crown materials are either ceramic fused to metal or metal‑free prosthesis like full zirconium crowns The restoration is sent back from the laboratory as one piece for delivery

51. Healing the abutment removal: The healing abutment is unscrewed with the manual screw‑driver and peri ‑implant mucosa should be assessed for the absence of inflammation

52. The crown is soaked in chlorhexidine mouthwash for sanitization for 2 min then it is placed onto the implant and tightened with the manual screw‑driver • After the adjustment of the contour and occlusion of the crown as necessary [Figure 16], a resilient material like a small cotton plug is placed into the screw access channel

53. teflon or dental wax could be used for the same purpose; this allows easy access to the abutment screw in the future. The remainder of the channel is filled with a temporary filling [Figures 18a and b].

54. Screwing the restoration may cause pressure on the peri ‑implant mucosa; this may result in a short‑term ischemia of the soft tissues

55. A periapical radiograph along the long axis of the implant is necessary to ensure that the abutment is seated completely on the implant After the confirmation of crown fit on X‑ray, the patient is allowed to use the new restoration for few weeks.

56. Then the previous temporary filling is removed, and the abutment screw is re‑tightened to the recommended torque value (e.g.: 25 Ncm ) using a calibrated torque wrench [Figure 21a] attached to a compatible screw‑diver

57. Teflon or wax is placed again into the screw access channel [Figure 23b]; the opening is filled with a composite resin restoration

58. A record peri ‑apical X‑ray, after delivery of the final prosthesis is necessary at this point; this radiograph will be useful for follow‑up and maintenance comparisons of bone level with later radiographs [Figures 25a‑c].

59. The next follow‑up visit should not exceed 4 months after delivery of the crown. The patient also should receive appropriate oral hygiene instructions prior to being discharged till next recall visit.

60. Cement retained crown