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Implants the future of prosthodontics

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all the basics of implant therapy in prosthodontics.. …

all the basics of implant therapy in prosthodontics..
especially for UG's.................

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  • 1. IMPLANTS The Future of Prosthodontics Kalpa Pandya Rachayta Parikh Priyank Pareek (Final B.D.S.)
  • 2. What is an Implant??? 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
  • 3. History
    • 936 – 1013 First documented placement of implants
    • Albucasis de Condue – used ox bone to replace teeth
    • 1809 Maggiolo - Gold roots which were fixed with adjacent teeth by
    • means of spring
    • 1887 Platinum post coated with lead
    • 1895 Gold or iridium tubes were implanted – Bonewell
    • 1905 Porcelain corrugated root implant
    • 1913 Hollow basket implant meshwork or iridium , platinum , gold
    • - Greenfield
    • 1948 Insertion of first viable subperiosteal implant – Goldberg
    • 1952 Threaded implant design of pure titanium
    • Endosteal implants - Branemark
  • 4. Single/multiple missing tooth/Teeth What are the treatment options available ???????
  • 5. Single/multiple missing tooth/Teeth
    • 1. Removable Partial Denture (R.P.D.)
    • 2.Fixed Partial Denture (F.P.D.)
    • 3. Implant Prosthesis
    ?
  • 6. Removable Partial Denture (R.P.D.)
    • DISADVANTAGES :-
    • 1. do not maintain bone
    • - compromise the
    • esthetic result
    • 2. bulk – need for
    • cross arch stabilization
    • 3. food debris , plaque
    • 4. movement
    • -speech
    • -function
    • 5. highest loss of abutment teeth
  • 7. Fixed partial denture (F.P.D.)
    • DISADVANTAGES :-
    • 1. caries and endodontic
    • failure of abutment teeth is the
    • most common failure
    • 2. increased plaque retention of pontic increases caries
    • and periodontal disease risk
    • 3. damage to healthy teeth
    • 4. fracture ( porcelain , tooth )
    • 5. esthetics ( anterior region )
    • 6. uncemented restorations
  • 8. Fixed partial denture (F.P.D.)…
    • It is contra indicated in
    • Poor abutment teeth support
    • inadequate hard and soft tissue in esthetic regions
    • patient desire
    • young patients with large pulp horns
  • 9. Implants for single/multiple tooth replacement
    • ADVANTAGES :-
    • Adjacent teeth do not require splinted
    • restoration
        • - less risk of caries
        • - less risk of endodontics
        • - Less risk of porcelain fracture
        • - Less risk of uncemented restoration
        • - Less fracture of tooth
    • 2. Psychological need of patient
    • 3. Improved hygiene conditions
    • - less decay risk
    • - less pontic overhang
    • 4. Decreased cold and contact sensitivity
    • 5. Improved esthetics
    • 6. Maintains bone in site
    • 7. Decreases adjacent tooth loss
  • 10. Completely Edentulous Patient Treatment options Conventional removable dentures Implant supported prosthesis ?
  • 11. Decreased performance of conventional complete dentures
    • Bite force is decreased from 200 psi to 50 psi
    • Masticatory efficiency is decreased
    • More drugs are required to treat gastrointestinal disorders
    • Food selection is limited
    • Healthy food intake is decreased
  • 12. Implants for complete dentures
    • maintain bone
    • restore and maintain occlusal vertical dimension
    • maintain facial esthetics (teeth positioned for appearance versus
    • decreasing denture movement )
    • 4. Improve phonetics
    • 5. Improve occlusion
    • 6. Improve / regain oral proprioception
    • 7. Increase prosthesis success
    • 8. Maintains muscle of mastication and facial expression
    • 9. Reduce size of prosthesis
    • 10. Improve stability and retention of removable prosthesis
    • 11. More permanent replacement
    • 12. More psychological health
  • 13. Indications for implants
    • Edentulous patient
    • Partially edentulous patient with history of difficulty in wearingR.P.D.
    • Patient requiring long span F.P.D.treatment
    • Patient who refuses wearing a removable prosthesis
    • Patient with severe changes in C.D.bearing tissues
    • Poor oral muscular coordination
    • Parafunctional habits that compromise prosthesis stability
    • Unrealistic patient expectation for complete denture
    • Hyperactive gag reflex
    • Patient psycologically against removable prosthesis
    • Unfavourable number and location of abutments
    • Single tooth loss, avoid preparation of sound teeth
  • 14. ATTACHMENT MECHANICS
  • 15. Mechanism Of Integration Of Endosteal Implants
    • 2 concepts were proposed
    • 1 . Dr. Branemark concept
    • concept of osseointegration
    • 2. Weiss concept
    • concept of fibro – osseous integration
  • 16. WEISS THEORY
    • fibro ossseous ligament formed
    • between implant and the bone
    • collagen fibers at bone implant
    • interface
    • ligament = periodontal ligament
    • early loading of the implant was advocated
    • Fibrous connective tissue does not act as shock absorber nor resemble PDL.
    • The non-mineralised connective tissue results from inflammtion with a tendency to
    • proliferate, gradually increasing implant mobility.
  • 17. BRANEMARK’S THEORY OF OSSEOINTEGRATION
    • Bone is laid very close to the implant material without an intervening Connective tissue
    • “ the apparent direct attachment or connection of osseous tissue
    • to an inert alloplastic material without intervening connective tissue”
    • - G.P.T .
    • IMPLANT should be left out of function during the healing phase
  • 18. The Interface
    • Surgical area undergoes a remodelling process just like an extraction site
    • If overloading then - implant failure
    • Bone grows into the irregularities( macroscopic & microscopic )
    • of the implant surface
    • depending on the reaction with bone :-
    • 1. bioactive ( hydroyapatite )
    • 2. bio – inert ( metals )
  • 19. MECHANISM OF OSSEOINTEGRATION
    • First mechanism
    • Integration occurs mainly through osteoconduction
    • Connective tissue scaffolding
    • Bone-producing cells( osteoblasts ) migrates
    • Second mechanism
    • “ de novo” bone formation wherein a mineralized interfacial matrix is deposited along the implant surface
    • Surface topography will determine the bond strength of bone to the implant surface
  • 20. 5
  • 21. Factors Affecting Osseointegration
    • Occlusal load
        • - 2 stage implant insertion is advocated
        • - overloading prematurely will cause failure
    • 2. Biocompatibility of material
    • - commercially pure titanium
    • - commercially pure noibium
    • - hydroxyapetite
    • 3. Implant design
    • - most conducive - cylindrical
    • 4. Implant surface
    • - mild surface roughness
  • 22. Factors Affecting Osseointegration
    • 5. Surgical site
    • healthy site is required
    • 6. Surgical technique
    • minimum possible trauma
    • 7. Infection control
  • 23. CLASSIFICATION OF IMPLANTS
  • 24. I) Depending on the placement within the tissues
    • Epithelial implants
    • Epiosteal / Subperiosteal implants
    • Endosteal implants
    • Transosteal implants
  • 25. Epithelial implants
    • Implant is inserted into the oral mucosa
    • Disadvantages
    • 1. painful healing
    • 2. requirement of continual wear
  • 26. 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
  • 27. Endosteal Implants Extends into basal bone for support It transects into 1 cortical plate
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 2 . NON – METALLIC IMPLANTS - ceramics - carbon
  • 32. 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
  • 33. Most commonly used
          • Commercially pure (CP) titanium
          • Titanium-aluminum-vanadium alloy (Ti-6Al-4V) - stronger & used with smaller diameter implants
  • 34.
      • Titanium
        • Lightweight
        • biocompatible
        • corrosion resistant
        • (dynamic inert oxide layer)
        • strong & low-priced
        • It is 6 times stronger than compact bone
        • Its modulus of elasticity is 5 times greater than that of
        • compact bone
        • (thus equal mechanical stress transfer)
  • 35. PARTS OF AN IMPLANT
  • 36.  
  • 37. Generic Prosthetic Component Terminology
    • Generic language for endosteal implant was developed by Mish & Mish (1992 )
    • The order in which it is presented follows the chronology of insertion to restoration
  • 38. 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
  • 39.
    • Cylinder Implants
    • -coating or surface condition provide microscopic retention to the bone
    • hydroxyapatite
    • titanium plasma spray
    • - pushed or tapped into prepared bone site
    • - ease of placement
  • 40. Screw Design Implants - slightly smaller prepared bone site - macroscopic retentive elements Combination
  • 41. Implant Body Regions
    • 3 parts
    • 1. crest module ( cervical geometry )
    • 2. body
    • 3. apex
    crest module ( cervical geometry ) body apex
  • 42. Implant Body Regions
    • Body
    • - designed for implant bone interface
    • Crest module
    • - designed to retain the prosthetic component
    • - transition zone from implant body design to transosteal region at the crest of the ridge
    • - has a platform on which abutment is seated
    • - when it is a smooth and polished metal – cervical collar
  • 43. 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
    abutment Implant body prosthesis superstructure
  • 44. 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
  • 45. Prosthesis fabrication
    • Impression is necessary to transfer the position and design of implant or abutment to the master cast for prosthesis fabrication
    • Transfer coping – used to position a dye in an impression
  • 46. Two types of transfer coping 1. direct transfer coping 2. indirect transfer coping
  • 47. Laboratory fabrication
    • Analog –
    • defined as something that is analogous to something else
    • Analog is placed on the transfer coping and the impression is poured
  • 48. Prosthetic coping is a thin covering usually designed to fit the Implant abutment for screw retention It serves as a connection between abutment and prosthesis or superstructure
  • 49.  
  • 50. Implant surgery 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
  • 51. 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
  • 52. 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
  • 53. PROSTHETIC OPTIONS IN IMPLANT DENTISTRY
  • 54. Types of prosthesis can be given
    • 1. fixed
    • 2. removable
    • FP 1 : Fixed prosthesis
    • Replaces only crown
    • Looks like natural tooth
  • 55. Types of prosthesis can be given…
    • FP – 2 :
    • fixed prosthesis
    • replaces crown and portion of root
    • hyper-contoured gingival half
  • 56. Types of prosthesis can be given…
    • FP – 3 : Fixed prosthesis
    • Replaces missing crown ,gingival color and portion of edentulous site
  • 57. Types of prosthesis can be given…
    • RP – 4
    • Removable prosthesis Overdenture supported completely by implant
  • 58. Types of prosthesis can be given…
    • RP – 5 :
    • Removable prosthesis, overdenture supported both by soft tissue and implant
  • 59. Dental examination
    • Bone density classification
    • Dense cortical (D1) bone
    • Highest bone implant
    • contact (BIC) > 80%
    • Anterior region of mandible very dense compact bone
  • 60. Dental examination…
    • Dense to thick porous cortical and coarse trabecular bone (D2)
    • BIC = 70%
    • Dense to porous compact bone on the outside and coarse trabecular bone on the inside
    • Anterior and posterior mandible
  • 61. Dental examination…
    • Thin porus cortical and fine trabecular bone (d3)
    • BIC = 50 %
    • Thinner porous compact bone and fine trabecular bone
    • Anterior or posterior maxilla and posterior mandible
    • Implants coated with hydroxyapatite are indicated
  • 62. Dental examination…
    • Fine trabecular bone (d4)
    • BIC = < 25 %
    • No cortical crestal bone
    • posterior maxilla in long term edentulous patients
  • 63. CONTRAINDICATIONS
  • 64. Absolute Contraindications For Implant Treatment
    • High dose irradiated pt
    • Patient with psychiatric problems
    • Systemic Hematologic disorders
  • 65. Relative Contraindications
    • Pathology of hard or soft tissues
    • Recent extraction sites
    • Patient with drug, alcohol or chewing tobacco
    • Low dose irradiated patient
  • 66. Posterior Single Tooth Implant local contraindications for a posterior single tooth implant indications for a posterior three unit fpd inadequate bone volume faciopalatal < 5 mm mesiodistal < 6.5 mm inadequate bone volume inadequate intertooth space < 6.5 mm lack of intertooth boney height Moderate to advanced mobility of 2 – 4 adjacent teeth Adjacent teeth are mobile Limited time for patient treatment Reduced time of treatment
  • 67. Limiting Factors For Anterior Single Tooth Implant
  • 68. Age Limitations
    • Growth and development may be affected by an implant as it may act as an ankylosed tooth.
    • As a general rule, implant insertion is delayed for female patient till atleast 15 years and in male patients until 18 yrs of age.
  • 69. Mesio-distal Space
    • A traditional 2 piece implant Should be atleast 1.5mm from an adjacent tooth. When the implant is closer than this, any bone loss will cause the implant and the adjacent tooth to lose bone rapidly.
    • This will compromise the inter-proximal aesthetics and sulcular health of the implant and the natural teeth.
  • 70. Bone height
    • The ideal mid-crestal position of the edentulous site should be 2mm apical from the facial CEJ of the adjacent teeth.
    • When the bone crest is above this, a bone graft procedure may be performed.
    • The inter-proximal
    • bone should be
    • scalloped 3mm more
    • incisal than the
    • mid-crestal position.
  • 71. Challenging Aesthetics
    • Cross sections of teeth are not round and are often larger in facio-palatal dimensions.
    • The cervical emergence profile of a crown on a round implant needs to be created prosthetically.
  • 72. Crown Height Space
    • The implant abutment will be too short for the proper retention.
  • 73. EVIDENCE BASED STUDIES ON IMPLANT DENTISTRY
  • 74. Do implant retained or supported dentures improved masticatory performance??? -Fueki K, Kimoto K, Ogawa T, Garrett NR published in J Prosthet Dent. 2007 Dec; 98(6):470-7.
    • Results
    • 18 articles met the criteria for inclusion. Experimental studies showed:
    • 1. fixed implant-supported partial dentures do not provide significant improvement in masticatory performance compared to conventional
    • removable partial dentures for Kennedy Class I and II partially edentulous mandibles.
    • 2. the combination of a mandibular implant-supported or retained overdenture (IOD) and maxillary conventional complete denture (CD) provides significant improvement in masticatory performance compared to CDs in both the mandible and maxilla for a limited population having persistent functional problems with an existing mandibular CD due to severely resorbed mandible.
  • 75. Do implant retained or supported dentures improved masticatory performance??? -Fueki K, Kimoto K, Ogawa T, Garrett NR.
    • Results…
    • 3. the type of implant and attachment system for mandibular IODs has a limited impact.
    • Well-designed, experimental studies showed ;
    • i. mandibular fixed implant-supported complete dentures provide significant improvement in masticatory performance compared to mandibular CDs in subjects dissatisfied with their CDs; and
    • ii. implant-supported mandibular resection dentures have an advantage over conventional dentures in masticatory performance on the defect side of the mouth.
  • 76. Do implant retained or supported dentures improved masticatory performance??? -Fueki K, Kimoto K, Ogawa T, Garrett NR…...
    • Conclusions
    • While a number of studies on masticatory performance have been conducted in patients with various designs of implant-supported or retained dentures, high-level evidence supporting advantages in masticatory performance of implant-supported or retained dentures over conventional dentures is limited.
  • 77. Do implant retained or supported dentures improved masticatory performance??? -Fueki K, Kimoto K, Ogawa T, Garrett NR…...
    • Moreover, two RCTs that compared IOD with new complete dentures concluded that IOD enhanced the masticatory improvement compared with conventional complete dentures. This difference reached statistical significance at 1 year follow-up.
    • In conclusion, subjects with low ridge or severe ridge resorption profit from implant-supported overdentures by increased masticatory performance and totally edentulous patients profit from fixed implant-supported complete denture from a masticatory point of view in general.
    • Finally, it must be kept in mind that masticatory performance based on the ability of the subjects to chew hard food is only a part of oral health related quality of life. Other factors such as, satisfaction with treatment and oral confidence of the subjects also play a major role.
  • 78. Recent Advances
  • 79. Immediate Function Implants
    • Today, modern implant design and the use of 3D CAT Scans allow experienced dental professionals to insert the implants, and immediately place the new teeth on the implants. Research has shown that when properly applied, this one-stage approach results in as good or better implant success rates as the traditional two-stage approach.
    • Benefits of Immediate Function
    • ● Shortened treatment time (it is possible to go from tooth loss to having functional
    • and aesthetic teeth in one treatment session),
    • ● Better clinical efficiency,
    • ● Greater patient comfort,
    • ● The elimination of bone grafts and sinus lifts, and
    • ● Patients always leave with teeth!
  • 80. All – on – 4 Implant
    • The All-on-4 Dental Implant Procedure uses four implants, with the back implants angulated to take maximum advantage of existing bone.
    • Special implants also were developed that could support the immediate fitting of replacement teeth.
    • This treatment is attractive to those with dentures or in need of full upper and/or lower restorations.
    • With the All-on-4 Procedure, qualified patients receive just four implants and a full set of new replacement teeth in just one appointment—without bone grafts!
  • 81.
    • All four titanium implants are placed so that the bone will
    • grow around and secure them in place
    • With only four implants, there is much less invasive and
    • lengthy surgery.
  • 82.
    • Once the implants are in place, the Oral Surgeon attaches abutments to which the new replacement teeth can be secured.
    • The Prosthodontist fits the replacement teeth on the abutments and adjusts the
    • bite for comfort and a beautiful smile
  • 83. Interdenatal Esthetics
    • A number of cases show deficiency of papilla in the interdental papilla between the implant or between implants and teeth, which poses an esthetic problem.
    • This is counteracted by injection of hyaluronic acid, commonly available as Restylane.
    • Its effect lasts for 6 – 24 months after which a new dose is administered.
  • 84. Conclusion
    • Appropriate case selection, good occlusal harmony, careful management of hard and soft tissues, and maintainance of oral hygiene all contribute the success and predictability of dental implants.
    • All health care proffesionals, today are compelled to become knowledgeable in all aspects of dental implant therapy and continue their education as new information and evidence becomes available. Thus implants can truly be regarded as the…
    • “ BRIGHT FUTURE OF PROSTHODONTICS” !!
  • 85. References
    • Contemporary implant dentistry- Carl Misch
    • Osseointegration and occlusal rehabilitation- Sumiya Hobo
    • J Prosthet Dent. 2007 Dec; 98(6):470-7 .
  • 86.