TRANSITIONING OF PATIENTS.ppt

cvb

1. Good Morning

2. TRANSITIONING OF PATIENTS FROM
TEETH TO IMPLANTS.
Reddy Priya Darshini

3. Contents
•Introduction
•Transitional prosthesis
•Exiss prosthesis
•Resin bonded fixed partial dentures
•Strategic abutment
•Provisional fixed partial denture
•Transitional implants
•Immediate loading
•Conclusion
•References

4. Introduction
•Branemark recommended a 4 to 6 month period of undisturbed healing
with a 2 stage surgical protocol.
•However, during this healing period the patient requires a provisional
restoration for function, phonetics, and esthetics.
•Provisional should help patient to adapt to the form of final restoration,
while protecting the surgical site, by avoiding transmucosal loading.
Sang-Choon Cho, Fixed and Removable Provisional Options for Patients undergoing – Implant Treatment Compendium November 2007; 28 (11): 604 - 609.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

5. •If support for the removable provisional prosthesis is being
provided by the underlying soft tissue, undesired pressure
may be applied to the healing surgical site.
•This may be detrimental to final implant survival if pressure is
transmitted to the healing implants, regardless of whether
they were placed with a 1 or 2 stage protocol.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001
Sang-Choon Cho, Fixed and Removable Provisional Options for Patients undergoing – Implant Treatment Compendium November 2007; 28 (11): 604 - 609.

6. •An empirical no-loading healing period and 2 stage surgical protocol was developed to
allow for osseointegration in the absence of functional loads.
•To avoid the transmucosal loading of implants during the early healing period, patients
are required not to wear removable interim prosthesis for atleast 2 weeks after implant
placement.
•To avoid direct forces on the implants during healing period, tooth supported
provisional prostheses have been recommended. When there are insufficient
abutments for fixed provisional prosthesis , removable dentures have to be worn.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

7. Transitional Removable Prosthesis
•Interim prosthesis :
A fixed or removable dental prosthesis, or maxillofacial prosthesis, designed to
enhance esthetics, stabilization and/or function for a limited period of time,
after which it is to be replaced by a definitive dental or maxillofacial
prosthesis. Often such prostheses are used to assist in determination of the
therapeutic effectiveness of a specific treatment plan or the form and function
of the planned for definitive prosthesis. GPT – 8.

8. Advantages
•Simplicity of fabrication, cost, and ease of insertion
•Ability to modify an acrylic resin interim RPD to accommodate
any changes in the ridge anatomy for patients who may
require multiple procedures of extraction, soft and hard tissue
augmentation, and implant placement
Sang-Choon Cho, Fixed and Removable Provisional Options for Patients undergoing – Implant Treatment Compendium November 2007; 28 (11): 604 - 609.

9. Disadvantages
•Provisional restorations are bulky, interfere with speech, and may initiate an
inflammatory soft-tissue response.
•Patients with strong gag reflexes are often unable to wear removable prostheses
that partially cover the palate.
•During the initial periods of integration or after soft and hard tissue augmentation,
removable prostheses should remain passive over the implant site. Accomplishing
this may necessitate an unsightly gap between the ridge and neck of the denture
teeth
•Inability to facilitate soft-tissue contouring
Sang-Choon Cho, Fixed and Removable Provisional Options for Patients undergoing – Implant Treatment Compendium November 2007; 28 (11): 604 - 609.

10. •II stage surgical uncovery –
–low profile permucosal extension – extends 2mm through
the tissue.
•So, patients with posterior implant in partially edentulous arch
should be instructed not to wear any removable prosthesis.
•Anterior teeth – 7mm diameter hole is placed completely through
the partial denture framework around each permucosal
attachment.
•Completely edentulous – tissue surface of denture relieved atleast
5mm over and around implants and replaced by tissue
conditioner. Tissue conditioner is also relieved by few mm.

11. Procedure Diet Occlusal materialOcclusal contacts
Healing abutment
Preliminary impression
Soft - -
Transitional prosthesis I
Final impression
Soft Acrylic Absent
Transitional prosthesis II
Metal try-in, modify
transitional prosthesis I
Soft Acrylic Limited to those
directly on implant
body
Final prosthesis
Adjust occlusion
harder Metal or porcelainImplant protective
occlusion
Final prosthesis
Final cementation
Normal Metal or porcelainImplant protective
occlusion

12. Essix Provisional
•The Essix provisional is made either in the laboratory or in the dental office from clear
thermoplastic sheets to retain pontics for missing teeth.
•The pontic is fabricated by applying the vacuum form sheet under high pressure and
heat over the denture teeth.
•Advantages :
–Quick and inexpensive and is therefore convenient to fabricate.
–Pressure on the surgical sites is easily avoided because the Essix provisional is
tooth retained.
–This prosthesis replaces the missing teeth and avoids transmucosal loading of the
healing site after tooth extraction, implant placement or implant surgery.
Sang-Choon Cho, Fixed and Removable Provisional Options for Patients undergoing – Implant Treatment Compendium November 2007; 28 (11): 604 - 609.

13. Disadvantages
•May not be appropriate as long-term provisional restorations
because they are esthetically unacceptable to the patient.
•They derive their support by covering the adjacent teeth in
the arch and make chewing difficult.
•Occlusal wear may limit their durability.
Sang-Choon Cho, Fixed and Removable Provisional Options for Patients undergoing – Implant Treatment Compendium November 2007; 28 (11): 604 - 609.

14. Methods for transition
•Resin bonded fixed partial dentures
•Use of strategic abutments
•Provisional fixed partial dentures
•Transitional implants
•Immediate loading

15. Resin-bonded prosthesis
•A fixed dental prosthesis that is luted to tooth structures, primarily
enamel, which has been etched to provide mechanical retention for the
resin cement.
•Early design incorporated perforations on the lingual plate (Rochette
Bridge) through which the resin bonded material passed to achieve a
mechanical lock;
•subsequently, use of acid etching of the metal plate (Maryland Bridge)
eliminated the need for perforations ( GPT – 8 )
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

16. Resin bonded fixed partial dentures
•Resin –retained FPD have had variable popularity since the
technique of splinting lower anteriors with perforated metal
casting - described by Rochette in 1973.
•Means of attaching fixed partial dentures to teeth by less
destructive means
•Design of retainer with retention holes allows for predictable
removal and recementation at time of surgery.
•Acrylic allows pontic to be bonded directly to tooth when
required, for additional stability.
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708
Thomas ; practical implant dentistry, 2005

17. Hybrid bridge
•Rochette retainers + full preparation retainers.
•Used – where there are large spaces, bounded at one end by
a tooth that needs a crown and at the other by a tooth that is
inappropriate to crown
Thomas ; Practical implant dentistry, 2005

18. Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

19. Strategic Abutments
•Complex reconstructions that require implants for
support take time to complete
•this length of treatment is exacerbated when bone
grafts are required.
•Maintaining some natural tooth abutments for this
period of time to retain a fixed provisional
restoration is one of the best methods to maintain
function and aesthetics while the graft and implant
sites are healing.
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

20. •Strategic abutments are commonly used in
full arch situations when the patient’s existing
dentition is failing due to periodontal disease.
•When implant supported reconstruction is
planned with all teeth for eventual
extraction, then
•Implant sites are selected first, then those
teeth occupying the implant sites are
removed and the remaining teeth are used to
support a provisional restoration.
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

21. •Immediate denture can also be made, but
•If onlay grafting is required, the pressure exerted by the
removable prosthesis can accelerate resorption of the graft
and negate the surgeon’s initial efforts.
•Maintaining a few teeth to retain a fixed transitional
prosthesis provides both physiological and psychological
advantages for the patient, one of the most important being
the psychological security of a fixed prosthesis in social
settings.
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

22. •When integration of the implants is confirmed, the strategic
abutments are extracted and the reconstruction with implants as
the source of support can continue.
•Advantages
–Maintaining the patient in a fixed prosthesis.
–Protecting surgical and implant sites during the healing phase.
•Disadvantages
–increased cost for the patient and the possible adverse sequelae to
implant integration should retained abutments become infected during
the integration
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

23. Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

24. Transitional Implants
•The primary function of transitional implants is to absorb
masticatory stress during the healing phase, ensuring stress-
free maturation of the bone around the submerged implants
and allowing them to heal uneventfully.
•Transitional implants were developed to enable undisturbed
healing and fulfil the patient demand for uninterrupted
immediate function and aesthetics.
Khaled Bohsali ; modular transitional implants to support the interim maxillary overdenture. Compendium / oct
1999.

25. •The scope of transitional implants can be expanded into diverse applications such
as
–undisturbed healing of bone grafts and provisionalisation of fully and partially edentulous
patients.
–Elimination of transmucosal load that a removable prosthesis can place over the conventional
implants or augmented bone, allowing for improved healing.
–When bone quality is not adequate for immediate loading of the definitive implants but the
patient requests a fixed transitional prosthesis.
–For the clinician they allow evaluation of aesthetics, phonetics and function in the interim phase.
–Patients can return to their daily activities with a fixed restoration and avoid social embarrassment
Khaled Bohsali ; modular transitional implants to support the interim maxillary overdenture. Compendium / oct
1999.

26. •Disadvantage –
–On occasion the volume of bone used for their placement may be of
strategic value during treatment and risks being destroyed by fibrous
tissue formation or bone resorption when loaded immediately
–if a definitive implant fails, the alternate site has already been used
and is unavailable
–Incapacity of placement of enough provisional implants to sustain
fixed prosthesis
–Inadequate space between primary implants
–Lack of cortical bone for implant stabilization
–Interocclusal space should not be less than 6mm to 7mm.
Khaled Bohsali ; modular transitional implants to support the interim maxillary overdenture. Compendium / oct
1999.
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

27. •Provisional implants are used
–To deliver a fixed prosthesis in immediate loading with no risk to primary
implants
•Removed after osseointegration period.
•Allow for immediate esthetics and function
•Can be of some assistance in retention of surgical guides
•Used as anchorage in orthodontic treatments
•More commonly used in fully edentulous patients, promotes protection of
primary implants
Jose Manuel Mendes; Provisional implants in dental implant therapy
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

28. Immediate Temporary Implant Systems
Company Name Diameter Lengths Prosthetic neck and
connected abutment
head
Dentatus
USA Ltd
Modular
Transitional
Implants (MTI)
1.8mm 7mm
10mm
14mm
7mm
IMTEC
corporation
Mini Dental
Implants (MDI)
1.8mm 10mm
13mm
15mm
18mm
4mm
Nobel
BioCare
USA
Immediate
Provisional
Implant (IPI)
2.8mm 14mm 7mm
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

29. Surgical Technique
•Diagnostic casts mounted
•Diagnostic wax-up for fixed temporary prosthesis
•Duplication of wax-up to create surgical template, radiographic template and
temporary prosthesis.
•Flap reflection and site preparation, placement of conventional implants in
ideal position.
•Conventional implants to be placed 6mm to 8mm apart to allow room for
transitional implants.
•Position of Conventional implants must be ideal to satisfy the needs of final
restoration
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

30. •Transitional implants should be placed at a minimum distance of 2mm to
3mm from conventional implants or from teeth
•As many temporary implants as possible should be used to support a
temporary prosthesis.
•A wide anterior – posterior distribution of transitional implants will help
better support of temporary prosthesis.
•All required bone augmentation procedures can be performed in
customary way.
•Cortical crestal bone is penetrated with twist drill and prepared to desired
length. For primary implant stability, transitional implants should engage
the cortical bone.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

31. •Implants must be stable at the time of placement
•Parallel pins are available to ensure parallelism and a path of insertion for
temporary restoration.
•After implant placement slight corrections in angulations can be achieved
by using available bending tools.
•Then tissues are sutured, leaving abutment portion of transitional
implants exposed.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

32. Prosthetic Technique
•Direct technique ( chairside )
•Indirect technique ( laboratory )

33. Direct Technique
•Copings are placed on the temporary implants
•Blocking out exposed undercuts and
lubricating the soft tissue and sutures with
petroleum jelly,
•Then processed acrylic shell can be used to
pick up copings with autopolymerizing acrylic
in a reline procedure.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

34. Indirect Technique
•Impression of the copings on the implants must be made.
•A bite registration and an impression of the opposing arch is also made.
•Temporary implant analogs for cast fabrication, must be placed into
copings and poured in hard stone.
•Then cast mounted on the articulator, and provisional prosthesis
fabricated.
•Then tried in patient’s mouth and cemented as in direct procedure
technique.
Laura Minsk; Interim implants for immediate loading of temporary restorations. Compendium / March 2001

35. Transitional Implant
•Jose Manuel Mendes - Provisional implants don’t compromise
the integration of primary implants and provide a fixed oral
provisional which is a important tool in implant therapy.
Jose Manuel Mendes; Provisional implants in dental implant therapy

36. Provisional implants with attachments
•Attachment system in provisional implants can be used in cases of
extraction and immediate implant placement when provisional fixed
prosthesis is required.
•During first stage surgery of the primary implants the provisional implants
are placed.
•In this stage the attachments are placed inside the provisional prosthesis
and secured in place with self curing resin.
•The fixed provisional prosthesis is cemented with provisional cement .
Jose Manuel Mendes; Provisional implants in dental implant therapy

37. Dental implant loading
•The process of placing axial or tangential force on a dental implant usually
associated with the intentional exposure of the dental implant either at
the time of initial surgical placement of the dental implant or subsequent
surgical exposure. Such forces may come from any of a variety of sources
including intentional or/and unintentional occlusal loading, unintentional
forces from the tongue or other oral tissues, food bolus, as well as
alveolar/osseous deformation. Generally application of intentional
occlusal forces may be termed immediate loading, progressive loading, or
delayed loading. (as per GPT – 8).

38. Immediate loading
•Immediate Loading : Placing full occlusal/incisal loading upon
a dental implant.
•Axial Loading : The force directed down the long axis of a
body. Usually used to describe the force of occlusal contact
upon a natural tooth, dental implant or other object, “axial
loading” is best described as “the force down the long axis of
the tooth” or whatever body is being described. (As per GPT- 8)

39. •According to Misch 2004
–Immediate occlusal loading
•Refers to full finctional loading of an implant within 2 weeks of placement
–Early occlusal loading
•Functional loading between 2 weeks and 3 months of implant placement
–Non functional immediate restoration
•Implant prosthesis placed within 2 weeks of implant placement with no
direct functional loading
–Non functional early restoration
•Implant prosthesis delivered between 2 weeks and 3 months from
implant placement

40. •Wang et al 2006,
–Based on Consensus from International Congress of Oral
Implantologists
•Immediate loading is described as a technique in which implant
supported restoration is placed into fuctional occlusal loading within 48
hrs of implant insertion.
•In cases where immediate restoration for aesthetic purposes were made,
the restoration was placed out of occlusal contacts true immediate
loading

41. Immediate loading
•Effective way of transitioning patients from teeth to complete arch
implant supported restoration
•Important parameter for immediate loading – primary stability – stability
dependent on proper surgical technique and type of bone.

44. •The following recommendations should be considered to maximise
success
–The bone quality and quantity should be adequate. A minimum bone height of
10 mm is desirable, and adequate bone quality (Type I or II) is ideally required
– Implants should be at least 10 mm long
–There should be an adequate number and distribution of implants to provide
crossarch stabilisation
– Good initial stability of the implant with minimum insertion torques of
35-50 cm
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

45. –Passive fit of provisional restoration
–Sufficient interocclusal space should be present to allow fabrication of a
provisional restoration with adequate rigidity
–Even occlusal contacts
–Cantilevers should be avoided or minimised to one premolar
–Removal of the provisional restoration should be avoided during the
osseointegration period
–Patients with parafunctional habits may not be ideal candidates.
Jiv raj ; transitioning patients from teeth to implants; British Dental Journal 2006, 201, 699-708

46. •Factors to be considered for Patient selection :
–Surgery related
•Primarily to implant stability and surgical technique
–Host related
•Bone quality and quantity and good healing environment
–Implant related
•Structure and design of implant system
–Occlusion related
•Importance of proper prosthetic design under occlusal forces.
Charles A Babbush, Dental Implants : The Art And Science, 2
nd
Edition

47. •A fundamental requisite for Immediate occlusal loading is adequate primary
implant stability. While stability was traditionally achieved through a period
of undisturbed healing( i.e. osseointegration ) primary stability is now
achieved via a mechanical phenomenon of screw stability and splinting
•Each implant system tolerates micromotion differently.
•For implants with roughened surfaces, tolerance is in the range of 50 to 150
micrometers, machined surfaces can withstand approximately 100
micrometers of micromovement.
Charles A Babbush, Dental Implants : The Art And Science, 2
nd
Edition

48. •Sobella et al, 1992
in a different controlled micromotion model involving dog femur,
showed that 150 μm of micromotion was tolerated by CaP coated
titanium alloy implants. Where as under the same loading conditions, the
titanium alloy plasma sprayed implants were encapsulated in fibrous
tissue.
when submitted to 500 μm of micromotion, the CaP coated and non
coated titanium alloy implants failed to osseointergate.

49. •Clinically the torque during implant placement is a good predictor of
implant stability.
•Studied have reported that implants placed with a torque greater than 30-
35 Ncm resulted in higher success rates for immediate loading.
•Occlusal scheme for immediately loaded implants is one for maximal
interocclusal contacts without lateral contacts.
•Patients with parafunctional habits or compromised occlusion should not
be considered for immediate loading.

50. •De Bruyn,
–Immediate loading of fixed prosthesis, 4 implants should be placed in
the edentulous mandible to support an immediately loaded prosthesis.
This method requires implants to be a minimum of 10mm in length.
•Although many studies suggested a requirement of 8-12
implants in edentulous maxilla, studies by Jaffin and Olsson
showed a similar success rates with 5-8 implants
De Bruyn; fixed mandibular restorations on 3 early loaded regular platform branemark implants. Clin Impla Dent Relat Res, 2001, 3 176-184
Charles A Babbush, Dental Implants : The Art And Science, 2
nd
Edition

51. •Teeth in A Day protocol
–Attachment of all implants immediately into full arch
–Second molar to second molar screw retained all acrylic fixed
prosthesis
–Rigidly splinting all inserted implants to control occlusal loads during
the initial 12 weel healing period
Charles A Babbush, Dental Implants : The Art And Science, 2
nd
Edition

52. •Balshi etal 2003, in a 5 year study
–Rigidly splinting the implants, while at the same time distributing
occlusal loads bilaterally allows undisturbed bone – implant
regeneration to occur during initial stages of osseointegration
•Adherence to soft diet is important to avoid unwanted
occlusal force overload from interfering with successful
osseointegration.

53. Indications
•Adequate bone quality ( type I, II and III)
•Sufficient bone height ( i.e. approximately 12mm ) for a minimum length of
10 mm implant
•Sufficient bone width ( i.e. approximately 6 mm)
•Ability to achieve an adequate antero posterior spread between the
implants. A poor AP spread decreases the mechanical advantage gained by
splinting and the ability to cantilever the restoration

54. Contraindications
•Poor systemic health
•Severe parafunctional habits
•Bone of poor quality ( e.g. type IV)
•Bone height less than 10 mm
•Bone width less than 6 mm
•Inability to achieve an adequate AP spread

55. Advantages
•Eliminates the need for and maintenance of a removable
provisional prosthesis
•Provides emotional benefit for a patient scheduled to rendered
edentulous
•Improves bone healing
•Facilitates soft tissue shaping
•Eliminates premature implant exposure often associated with
wearing of a removable prosthesis during healing period

56. Disadvantages
•Cannot be applied to every implant patient
•Requires more chair side time at the time of implant placement

57. CONCLUSION

58. References
•Carl E Misch, contemporary implant dentistry.
•Charles A Babbush, Dental Implants: The Art and
Science, 2
nd
edition.
•Thomas ; practical implant dentistry, 2005

59. References
•Jiv raj ; transitioning patients from teeth to
implants; British Dental Journal 2006, 201, 699-708
•Jose Manuel Mendes; Provisional implants in dental
implant therapy
•Laura Minsk; Interim implants for immediate
loading of temporary restorations. Compendium /
March 2001

60. References
•Khaled Bohsali ; modular transitional implants to
support the interim maxillary overdenture.
Compendium / oct 1999.
•Sang-Choon Cho, Fixed and Removable Provisional
Options for Patients undergoing – Implant
Treatment Compendium November 2007; 28 (11):
604 - 609.

61. References
•Rochette , Attachment of a splint to enamel of lower
anterior teeth, J Prosthet Dent, 1973 oct.
•Livaditis , Etched castings: An improved retentive
mechanism for resin-bonded retainers, J Prosthet
Dent, 1982, jan.
•Jivraj , Transitioning Patients From Teeth to Implants
Utilizing Fixed Restorations. CDA journal, 2008, Aug.

62. References
•De Bruyn; fixed mandibular restorations on 3 early
loaded regular platform branemark implants. Clin
Impla Dent Relat Res, 2001, 3 176-184

63. THANK YOU …