Dr ghazy 2012 my implant lecture for 4th year students

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Dr ghazy 2012 my implant lecture for 4th year students

  1. 1. 19/04/2012 • Implant prosthodontics : • The phase of prosthodontics Fourth year Class 2011/2012 IMPLANT–SUPPORTED FIXED PROSTHESIS concerning replacement of missing teeth and/or associated BY Dr MoHAMeD H. GHAZY structures by restorations that Febuary 12, 2012 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 Indication & contraindication Contraindications Treatment planning for implant patient • Lack of operator experience Indication &contraindication • Smoking Clinical evaluation • PregnancyIndications • Immunosuppression Adequate bone and anatomic structure• Single tooth loss (chemotherapy, HIV, etc) Visual inspection & palpation• Inability to wear a removable P.D. • Antimetabolic treatment Flabby excess tissues• Free end distal extension • Poorly controlled cardiovascular Bony ridges• Need for long span FPD with problems Sharp underlining osseous formations and undercuts • Radiographic evaluation questionable prognosis Tumoricidal radiation to implant site• Unfavorable number and location of potential natural tooth abutment • Psychiatric disorders Panoramic view with small radio opaque reference • Patients with bone diseases, such Cephalometric film to evaluate bone width as Histiocytosis X, Pagets Disease and Fibrous Dysplasia CT scan to locate inferior alveolar canal & maxillary sinuses • uncontrolled hematologic disorders Diagnostic casts such as Generalized Anemias, Study the remaining dentition Hemophilia • Patients with endocrine disorders, Evaluate residual bone such as uncontrolled Diabetes Analyze maxillo-mandibular relationship Mellitus, Pituitary and Adrenal Diagnostic waxing and surgical templates insufficiency and Hypothyroidism Bone sounding With probe judging the soft tissue thickness and bone soundness 1
  2. 2. 19/04/2012 To the left you can see a typical modern Root form Implant and to the right of Transosteal the implant is a Subperiosteal picture of a natural tooth. One can see how the implant is designed to replace the root of EndostealEndosteal plate root form a tooth by theform somewhat apparent similarity.Implant supportedprosthesis may be Screw Retained OSSEOINTEGRATION Transocclusal A direct structural and functional connection between ordered living bone and the surface of a loadScrew Retained carrying implant Transversal Swedish professor of orthopedics named Per-Ingvar Branemark in 1965 he used the first titanium dental implant into a human volunteer CementedFixed Partial Denture 2
  3. 3. 19/04/2012 Principles of Implant location Anatomic limitation Implant most commonly used from General guide lines –commercially pure (CP) titanium • Ideal bone should be 10 mm vertical and 6 – titanium-aluminum-vanadium alloy (Ti- mm horizontal 6Al-4V) - stronger & used w/ smaller diameter implants • Two mm above the superior aspect of inferior alveolar canal Why Titanium • Five mm anterior to mental foramen • lightweight • one mm from the periodontal ligament of • biocompatible adjacent tooth • corrosion resistant (dynamic inert oxide layer) • Three mm between 2 implant to ensure bone • strong & low-priced vitality.Principles of Implant location Principles of Implant location Anatomic limitation Anatomic limitationAnterior maxilla Posterior maxilla• 1- Minimum of 1 mm between the Bone less dense, larger narrow spaces, and thin cortex implant apex and nasal vestibule • 1- One implant for every tooth• 2- Implant slightly off midline on either • 2- One mm of bone between the floor of sides of incisive foramen. sinus and implant 3
  4. 4. 19/04/2012 Principles of Implant location Principles of Implant location Anatomic limitation Anatomic limitation Posterior mandible Anterior mandible • 1- Two mm above the superior aspect • 1- One implant placed through the of inferior canal entire cancellous bone • 2- More time required for integration • 2- Five mm anterior to the foramen • 3- Attachment of mylohyoid musclePrinciples of Implant location Principles of Implant location Restorative consideration Restorative considerationImplant placement Implant placement 1- Stay 1mm from the adjacent natural tooth but not so far 2- Long axis of implant should be positioned in the central to for contouring restoration fosse of the restoration Less ideal location Natural tooth Ideal implant placement 4
  5. 5. 19/04/2012Implant and restoration size Surgical guide1-Size should be considered during treatment planning Template extremely2- 4mm diameter for maxillary central useful for anterior3- 3mm for mandibular incisors implant4- 5-6mm for molars Objectives 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 Wax model of a tooth to be replaced in the surgical guide 5
  6. 6. 19/04/2012 Surgical guide template Stent used as guide for implant placementSurgical guide for correct implant placement Implant surgery Surgical access Implant placement Postoperative evaluation Implant uncover Guide drill / 2mm twist drill / Pilot drill / 3mm twist drill / Countersink 6
  7. 7. 19/04/2012 Fourth year Class 2011/2012 IMPLANT–SUPPORTED FIXED PROSTHESIS BY Dr MoHAMeD H. GHAZYImplant restorations February 19, 2011Significant factors for success1- Precise placement2- A traumatic surgery3- Unloaded healing4- Passive restoration Components of an implant restoration Composite resin Gutta percha Screw- retained implant restorations consist of Retaining screw three components. Abutment screw Abutment (a) Implant fixture (b) Abutment (c) Restoration - The abutment screw secures Implant fixture the abutment to the fixture - The prosthetic retention screw secures the prosthesis to the abutment. 7
  8. 8. 19/04/2012 • Lekholm and Zarb bone type classification Type I bone homogenous, compact bone Type II bone a thick layer of compact bone surrounding a core of dense trabecular bone Type III bone a thin layer of cortical bone surrounding a core of dense trabecular bone of good strength Type IV bone thin layer of cortical bone surrounding core of low density .Implant insertion into the prepared socket Unscrewing the abutment from the implant fixture, screw covering and suturing 8
  9. 9. 19/04/2012 The abutment removed from the implant Removal of the cover screw in the 2nd stage and abutment fixture attached to the fixture as a coping ready for impression Abutment prepared to its final form in theAbutment and its implant analog and working cast repositioned in the impression 9
  10. 10. 19/04/2012 Prepared abutment and final restoration Implant restorations Impression post Closed tray in the patient mouth Impression Imp post & analog Polyether soft tissue Imp post & analog injected around relocated on the analog before impression pouringPoured cast Impression coping locates the analog in Contouring of the the same position in soft tissue material the cast as the implant in the mouthZirconia abutment Zirconia abutmentfor cement retained seated on cast Zirconia abutmentrestoration selected seated in the mouth 10
  11. 11. 19/04/2012 Prosthetic Crown Clinical Implant system components Look and feel of real tooth. Implant body Easily replaced. Is the component placed within the bone during 1st stage surgery Abutment Secures the crown to the Dental Implant. Can bestraight or angled depending Titanium screw on implant location Hydroxyl Titanium screw Dental Implant Apatite Should promote bone in- coated Titanium plasma growth. Structure and Hydroxyl cylinder sprayed cylinder geometry differences are appetite the selling point for most coated companies. screw Two images showing two different types of tapered, Cover screwcylindrical implants. One looks like a Christmas tree with fins It is the component placed over the dental implant during theprojecting out to the sides; the other shows a special surface osseointegration phase to seal the occlusal surface of the treatment consisting of spherical titanium beads. 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. 11
  12. 12. 19/04/2012Healing abutmentDome shaped 2-10 mmscrew placed on the implant Healing Abutmentsafter the 2 and stagesurgery & before insertion  Transgingival Titanium piece whichof the prosthesis will form the soft tissue  Selected considering the A- screw into implant Emergence Profile needed for the restoration and the tissue height B- Screw into abutment (healing cap) Healing Abutments EP® (Emergence Profile)Necessary Information: Height Healing Abutment Height Platform Diameter (normally same as Restorativ implant diameter ) e Platform Healing Abutment Diameter (EP Profile 12
  13. 13. 19/04/2012 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(standard) or conical(estheticone) in shape. Abutment screw 15º Pre-Angled - are secured with an (green)abutment screw that is Straighttightened to 20 Ncm. Abutment (red) Abutment (Cemented restoration) Engages Engages - Cera One abutment Implant 12 Point Hex Double Hex - secured with a square head screw tightened to 32 Ncm. Click Zone 13
  14. 14. 19/04/2012 Open tray impression Concept 2 impression techniques Open tray impression Closed tray impression Implant & impression post Intraoral situation Analog & impression post Education Impression procedure Impression procedure Remove closure screw or healing abutment  Take impression with an open tray Insert impression post and hand tighten screw with the  Use an elastomeric impression material screwdriver 55 Education 56 Education 14
  15. 15. 19/04/2012 Types of impression posts Impression procedure When impression material is set, unscrew and remove the impression A one piece coping Two piece coping Two piece coping Screw into the abutment Screw into the implant Screw into the abutment used if the abutment does not used if the abutment does used to orient the anti- need to be changed on the not need to be rotational feature or to 57 Education lab cast changed on the lab make impression of cast very divergent implant Impression with laboratory analog to make the master cast. Two piece Impression coping Impression coping attached to the implant analog • The impression posts attached to the implants fixtures. The master cast is that one used to fabricate the final prosthesis. 15
  16. 16. 19/04/2012Laboratory analogsComponents made to represent the top ofthe implant fixture or the abutment in thelaboratory cast Fixture analog Abutment analog{Duplicate implant top} {Duplicate abtument top} 16
  17. 17. 19/04/2012Attach Analog Push Analog/Impression Coping Assembly into Impression Twist and Lock Grooves into Impression 17
  18. 18. 19/04/2012Waxing sleeves Prosthesis retaining screw Screw used to secure thePlastic waxing sleeve tightened Gold cylinder tightened to a prosthesis to the implant or the transmucosal to a laboratory analog laboratory analog abutment Combination Components of an implant Prosthetic retaining screw restoration Prosthetic Composite resin retaining screw Gutta percha Screw retained implant restorations Retaining screw consist of three components. Abutment screw (a) Implant fixture Abutment (b) Abutment Have a slot or hex head (c) Restoration Access is usually covered by a combination of gutta - The abutment retaining screwImplant fixturepercha and composite. secures the abutment to the fixture used to retain the prosthesis to the abutment. - The prosthetic retaining screw Tightened to 10 Ncm. secures the prosthesis to the abutment. 18
  19. 19. 19/04/2012 Slot Screw Screw retained implant crown Driver - Used to remove or replace slotted prosthetic retention screws. - Tighten to 10 Ncm Hex Screw Driver Abutment Screw Driver- Used to remove or replace hex prosthetic retention screws. - Used to remove or replace abutment screws for standard or conical (estheticone / mirus cone) abutments.- Tighten to 10 Ncm. - Tighten to 20 Ncm. 19
  20. 20. 19/04/2012 Impression tray without impression material: Square Screw Driver After the impression tray is prepared, it should be checked to see that it fits and fully covers the area of the impression and that the hole in the tray is aligned with the guide pin. Impression tray with impression material in the jaw: The coping must be completely covered by impression material and the tray be fully seated. It is very important that the guide pin protrudes through the impression tray in order to open it with the hex driver.- Used to remove or replace Cera One abutment screw.- Tighten to 32 NcmInverted impression tray with Stone model prepared with simulatedemphasized hex: gingiva and implant analogThe hexagon of the impression copingcan be seen. It is very important to In the final stage in impression taking, acheck that the position of the stone model of the gingiva and teethimpression coping has been accuratelyrecorded and that the hex is clear of should be cast, and the simulated gingivaany impression material. should remain on the model. After the stone is hardened, the impression coping can be released from the model by removing the guide pin.Inverted impression showing gingiva beingsyringed around analog The impression tray can now beThe analogue can now be attached to the separated from the modelimpression coping by screwing in the guidepin. It should be confirmed that thecoping is attached to the analoguewith no misalignment of gaps. At thisstage, injecting impression materialaround the neck of the analog cansimulate the gingiva. 20
  21. 21. 19/04/2012 Silicone index and wax model of tooth Option 1: Placing the gold plastic cylinder abutment on the stone model When the wax model of the Following the construction of the silicone index a gold plastic cylinder abutment with hexagon can be selected. tooth is appropriately positioned a silicon key can be prepared that will serve as a good replica of the missing tooth. Option 1: Wax Carving The plastic part of the gold plastic cylinder abutment can now be grind to the appropriate height on the stone model, taking into account the height of the adjacent teeth. After the gold abutment and the plastic cylinder have been prepared, it is possible to carve the wax to the desired shape. Following the carving of the wax on the gold abutment and the plastic cylinder they will be cast.Option 1: Silicon indexwith wax up Option 1: Porcelain in mouthThe silicon index will be After placing the crown, the screwused to check that the of the gold abutment shoulddimensions of the wax- be tightened to 20 Ncm utilizingup are appropriate toits the TORKIT wrench.surroundings. This will minimize the chances of the screw opening. After theOption 1: Metal casting screw has been tightened, theWhen fabricating P.F.M crown, screw hole should be closed.using the direct wax-uptechnique on the cap to get ametal frameonto which the porcelain firingtakes place.Checking the metal on the stonemodel and the seating of theexternal hex of the goldabutmnentin the internal hex of theimplant analog. 21
  22. 22. 19/04/2012Option 2: Placing the plastic Option 2: Silicon index withcylinder on the stone model wax up The silicon index will beFollowing the construction of the used to check that thesilicon index a plastic cylinder dimensions of the wax-upwith hexagon can be selected are appropriate to its surroundings. MT-HHR13 Option 2: Metal casting When fabricating P.F.M crown, usingOption 2: Wax Carving the direct wax-up technique on theThe plastic cylinder can now be grind plastic cylinder a metalto the appropriate height on the stone frame onto which the porcelainmodel, taking in the account the firing takes place.height of the adjacent teeth. Checking the metal on the stone model and the seating of theAfter the plastic cylinder have been external hex of the casting (whatprepared, it is possible to carve the waswax to the desired shape. previously the external hex. of theFollowing the carving of the wax on plastic cylinder MD-CPH13), in thethe plastic cylinder they will be cast. internal hex of the implant analog. Option 2: Check the casting Option 2: Porcelain in mouth in the mouth After placing the crown, the screw of the plastic cylinder should After completion of the be tightened to 20 Ncm utilizing the casting, a check must be TORKIT wrench. made in the paient’s mouth using the This will minimize the chances of the screw MD-SO220 to connect screw opening. After the screw has been tightened the screw hole it. should be closed. Option 2: Porcelain on plaster model Following the selection of the appropriate color, the porcelain is fired on the metal casting. 22
  23. 23. 19/04/2012IMPLANT RESTORATIVE IMPLANT RESTORATIVEOPTIONS OPTIONS Distal-extension Implant Restoration.Distal-extension Implant Restoration.There are two distal-extension restorative options. Long Edentulous Span Restoration.1. Tooth-implant supported restoration 1. The clinician may choose to have multiple implants placed between the remainingPlace an implant distal to the most natural teeth and to fabricate a fully posterior natural abutment and implant-supported restoration. fabricate a fixed prosthesis 2. One or two implants can be placed in the connecting the implant with the long edentulous span and the final natural tooth. However, there are problems restoration connected to natural teeth. associated with implants connected to natural teeth When it is necessary to connect implants and the . natural teeth, protecting the teeth with2. Implant supported restoration telescopic copings is recommended . In this manner, prosthesis retrievability can bePlace two or more implants posterior to maintained.the most distal natural tooth and Some long edentulous spans require thefabricate a completely implant-supported reconstruction of soft and hard tissue and teeth. using resin teeth processed to a metalrestoration ). substructure rather than a conventional metal- If the crown-to-implant ratio is favorable, two implants to support a three-unit ceramic restoration is recommended. Soft tissue esthetics can be more easily and fixed prosthesis. accurately mimicked with heat-processed resin If implants are short and crowns are long, one implant to replace each missing tooth. and large defects . If doubt remains, more implants are used when heavier forces are expected (e.g., This type of restoration has been called a hybrid posterior part of the mouth in patients with evidence of parafunctional activity). because it combines the principles of Fewer implants are used when lighter forces are expected (e.g., those opposing a conventional fixed and removable prosthodontics. complete denture or those supporting a prosthesis in the anterior part of the mouth).IMPLANT RESTORATIVEOPTIONSDistal-extension Implant Restoration.Long Edentulous Span Restoration.Single-tooth Implant Restoration.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 toothThe 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 23
  24. 24. 19/04/2012IMPLANT RESTORATIVE CEMENT-RETAINED VERSUS SCREW-RETAINED IMPLANTOPTIONS CROWNSDistal-extension Implant Restoration.Long Edentulous Span Restoration.Single-tooth Implant Restoration. Zinc phosphate, glass ionomer, and compositeFixed Restoration in the Completely resin cements have all been suggested for this purpose.Edentulous Arch. Advantages of cement-retained restorations.1.The hybrid prosthesis is a cast alloy 1. Simplicityframework with processed denture resin 2. Less expensive.and teeth. It requires a minimum of five 3. Allow minor angle correction.implants in the mandible and six in the 4. More esthetically pleasantmaxilla. Suitable for patients who have hadmoderate bone loss, the prosthesis Disadvantages of cement-retained restorations. 1. Require more chair timerestores both bone and soft tissue 2. Have the same propensity to loosen as thecontours. screw retained.2. The metal-ceramic rehabilitation also Advantages of screw-retained restorations.requires five implants in the mandible andsix in the maxilla. Only if minimal bone loss 1. Retrievabilityhas occurred and is best suited for Disadvantage of a screw-retained implantpatients who have recently lost their restorationnatural teeth (within 5 years). 1. The screw may loosen during function. 2. Cost3. For patients with severe bone loss,there is probably only one option: a Moderate sever resorption Minimal resorptionremovable restoration . —Metal ceramic resorption —resin to —Over denture metal restorations restorationsCEMENT-RETAINED VERSUSSCREW-RETAINED IMPLANTCROWNSIf the screw is sufficiently tightened into the Screw Retainedimplant crown to seat it, a clamping load orpreload is developed between the implant and thecrown. TransocclusalIf this clamping force is greater than theforces trying to separate the joint betweenimplant and crown, the screw will not loosen. 24
  25. 25. 19/04/2012 Screw RetainedScrew-Retained Crowns Transversal Cemented Crowns 25

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