presentation on dental implants

1. GOOD MORNING
BASIC PROSTHETIC CONCEPTS IN IMPLANT
DENTISTRY.

2. Today implant
dentistry is
prosthetically
driven
Start with the end in mind.

3. DIAGNOSIS AND TREATMENT
PLANNING
DON’T LET THE LAB TECHNICIAN DECIDE THE KIND OF PROSTHESIS
THAT YOU NEED

4. VISUALISING THE FINAL
PROSTHESIS BEFORE
STARTING TO PLACE THE
IMPLANTS!!

5. Classification of implant prosthesis
Misch 1989
FIXED OPTIONS
• FP 1
• FP 2
• FP 3
REMOVABLE OPTIONS
• RP 1
• RP 2

6. FIXED
OPTIONS
BASED ON TYPE OF STRUCTURE
THE PROSTHESIS REPLACE
FP 1
FP 2
FP 3

7. FP 1 ( FIXED PROSTHESIS 1 )
• Replace only anatomical
portion of the natural tooth
• Soft and hard tissue loss is
minimal
• Ideal placement possible
• Adequate volume and
position of residual bone
• Final restoration looks like
a natural crown

8. FP 2 ( FIXED
PROSTHESIS 2)
• RESTORES ANATOMICAL CROWN AND
PART OF THE ROOT
• DUE TO SOME AMOUNT OF BONE LOSS
• NO PINK

9. FP 3 ( FIXED PROSTHESIS 3 )
• Restorations appear
to replace natural
teeth crowns and
portions of soft
tissues.
• Delivered when
bone height is
reduced

10. But in the aesthetic zone, unlike FP – 2 prosthesis it can be
used in patients having normal to high lip-line because
it restores the gingival drape & interdental papillae by
pink restorative material & there by providing the teeth
having more natural appearance in shape & size.

11. Removable
options
Based on the amount of
support prosthesis receives
RP 4
RP 5

12. RP 4 ( REMOVABLE
PROSTHESIS 4 )
• Removable prosthesis completely
supported by implants
• Restoration is rigid yet removable

13. Usually 5 – 6 implants
are needed in the
mandible & 6 – 8
implants are needed
in the maxilla to
fabricate a completely
implant supported
removable
overdenture (RP – 4
prosthesis ) in
patients with
favorable dental
criteria.

14. RP 5 (REMOVABLE PROSTHESIS 5 )
• Combination of
implant and soft
tissue support
• Reduced cost
• Bone continues to
resorb
• Requires periodic
maintenance

15. The amount of implant support is variable in
this prosthesis.
In case of edentulous mandible
a. Number of implants can be 2-4
b. They can be independent to each other
except the parallelism
c. They can be splinted together to provide
retention & stability
to the prosthesis.
In case of maxilla
a. Implant number can be 4 or more
b. They are usually splinted together
because of poor bone quality & severely
compromised forces direction.

16. 1st innings
(surgical phase)

17. 2nd innings
(prosthetic phase)

18. CRITERIA FOR EVALUATION OF SUCCESSFUL
IMPLANTS AT STAGE 2 UNCOVERY
• Rigid fixation
• Absence of crestal bone loss
• Absence of pain
• Adequate zone of keratinizing gingiva
• Sulcus depth 4mm
• Absence of inflammation
• Proper hard and soft tissue contour.

19. Endosseous implants can be placed following either two-stage
technique requiring second-stage surgery or one-stage
technique, which does not involve a second surgical intervention

20. Uncovering of implants
Techniques chosen for uncovering the implant will depend on the
characteristics of the tissue that overlies the implant. The amount
of attached gingiva, the thickness of the overlying mucosa, and the
presence or the absence of interdental papillae are some of the
issues to be considered before uncovering an implant.

22. Various methods
• Scalpel incision
• Tissue Punch technique
• Laser
• Electrocautery
• Rotary bar

23. Punch Technique
When an adequate band—ie, at least 1 mm—of KM
surrounds the implant and there is no need to build up
the buccal root profile, a circular incision of the same
diameter as the implant may be made to remove the
tissue covering the implant.

28. Placing the correct per mucosal
extension is of utmost importance
• Helps to form the soft tissue drape specially in upper anterior zone.
• Acts as a guideline for diameter and height of the abutment.
• Emergence profile for the future crown.
• Prevention of tissue growth over implants.
• Tenting effect in GBR.

29. HEALING ABUTMENT
/
PERMUCOSAL EXTENSION
/
GINGIVAL FORMERS
/
HEALING CAP
/
Interim Endosteal Dental
Implant Abutment

30. CRITERIA.
1. Diameter :- Healing screw diameter depends on the type and
volume of the tooth to replace. It should be wider than the implant
crest module.
Example: for a molar, a 6.0 mm diameter
screw is more appropriate than a 4.0 mm
screw.

31. 2. Appropriate collar height.
It assists in forming a soft tissue cuff. It
corresponds to the distance from the
top of the implant to the large
diameter of the healing cap. Ideally
1mm above the soft tissue level.
Example:
- if the implant is positioned 0.5 mm
below the crestal bone level and the
soft tissue height is 2mm, the
appropriate gingival height will be
2.5mm.

32. COMPLICATIONS
• EXCESS BONE FORMATION OVER THE COVER SCREW.
• SOFT TISSUE ABSCESS OR STITCH ABSCESS
• EARLY OR PREMATURE EXPOSSURE OF COVER SCREW

33. Many implant abutments are wider than the first-stage cover screw and may require
as much as 1 mm of horizontal space around the implant platform on the crest
module.
Any bone growth on the cover screws or over the surrounding region is removed
with surgical curettes or low-speed rotary uncovery burs designed to remove excess
bone, accompanied by cooled sterile saline irrigation.
As such, when bone is over or adjacent to the cover screw, the marginal bone must
be recontoured to allow complete seating of the abutment.
A bone profile drill with copious irrigation may also be used.

34. Soft tissue abscess or premature exposure

35. Replace with a healing cap
it has a drainage effect.

36. IMPRESSION TECHNIQUES

41. • The objective of implant level closed tray as well as open tray
impression techniques are to record & transfer the soft tissue
profile as well as the implant’s location & the implant’s internal
hex orientation from patient mouth to working cast.

43. Closed Tray Impression

44. HEALING ABUTMENT IN PLACE

45. CONNECT CLOSED TRAY IMP COPING

46. REMOVE THE IMPRESSION

47. Assemble the coping analog complex

48. Position it back in the impression

49. SOFT TISSUE MASK AND CAST

52. Closed Tray
Implant level
impression

53. Removal of
Healing cap

54. screwing of
transfer coping
IOPA radiograph taken to
verify the fit between the
transfer coping and the
implant.

55. Keep flat portion of
transfer coping labially
that help in re-alignment
later on in impression.
Block-out the transfer
coping hex opening with
a cotton pellet or soft
wax to facilitate access
after the impression.

56. Step-3 : making of impression
• Inject impression material
around the transfer coping.
• Fill the customized impression
tray with a heavy body
impression material and seat the
impression tray to take the
impression.
• Remove the set impression from
pt mouth. The impression will
captured the anatomy of
transfer coping , but the transfer
coping will not comes out with
the set impression because it
was screwed with the implant
body.

57. Unscrewed the
transfer coping
from patient
mouth

58. Transfer Coping
Implant Analog
The Transfer Coping
removed from the patient
mouth is now attached with
the implant analog &Place
the transfer
Coping-implant analog
assembly back into the
impression, aligning the flat
surface of the transfer coping
with the flat surface in the
impression

59. Implant Analog Inserted onto the Transfer Coping & then
aligning the flat surface of the transfer coping with the flat
surface in the impression

60. Soft tissue material is injected around the transfer
coping before pouring the stone master model.
Model fabrication
with
gingival mask

61. - Use the die stone that have greatest
compressive strength otherwise chances of
breakage of cast at the site of transfer
coping.
- TYPE-IV DIE STONE IS RECOMMENDED
Master cast :

62. Exact reproduction of
the patient‘s
situation after
removal of transfer
coping from the set
master cast

63. After removal of the transfer coping , place titanium
abutment onto the implant analog in the stone model. The
titanium abutment is then prepared on the cast .
It is important to leave enough height and thickness on the
titanium abutment to protect the hex hole. Over-modification
of the titanium abutment may result in a collapse of the
abutment or lack of surface area for cementation

64. Wax a coping over the prepared titanium abutment. Cast the
coping in precious or semiprecious alloy. Finish the coping
and seat passively onto the abutment
Apply porcelain

65. Try-in the crown, evaluate occlusion and esthetics.
Block-out the screw access hole with a cotton pellet
and cement it onto the titanium abutment.
Equilibrate occlusion as necessary.

68. Open tray impression
Broad
rectangular
surfaces
with large
undercuts

78. Open tray impression
technique
or
pickup impression technique:-

79. In this technique, a custom tray or modified stock tray
with a screw access hole in the area above the
implant is required.
The Screw that holds the transfer Coping in place
while the impression is made is removed through the
access hole after the material sets.
The transfer Coping remains in the impression when it
is removed from the mouth.
The Implant Analog is screw to the embedded
transfer coping and a working model is poured.

80. First on the
Osseointegrated
implant place the
transfer coping and
screw it in the position
& verify its placement
radiographically similar
to closed tray
technique.
Long screw is used in
this technique
Step 1: placement of transfer coping

81. a custom tray or modified
stock tray with a screw
access hole in the area
above the implant is
required.
Step 2: selection of trays
Screw access hole

82. • An alginate impression in a stock
tray made.
• Then the transfer copings are
removed from the mouth and
placed in alginate impression
along implant analogs.
• This impression is then poured and
a study cast is made
Step 3 : fabrication of custom tray :

83. • On this study cast a custom tray is made
• In this custom tray holes over implant
position or topless area is made so that
access to the screw inside the transfer coping
is made possible.

84. • Coping screw holes are blocked with wax or cotton pellet.
• Inject the medium / light body materials around the transfer
coping & then the tray loaded with medium body impression
materials placed in mouth using the holes to locate the
correct position of tray.
• Remove the excess materials flows out through the hole
without disturbing the setting impression.
Step 4 : Making impression :

85. • After setting of impression materials remove the wax or
cotton pellets from the transfer coping screw holes.
• Then the Screw that holds the transfer Coping in place while
the impression is made is removed through the access hole
after the material sets. On doing so the transfer coping will no
more attached with the implant body.
• Next when impression is removed from patients mouth the
transfer coping embeded within the set impression will
comes out with the impression eg the set impression is
picking up the transfer coping that’s why pickup impression
technique.

86. The Implant Analog is
screw to the embedded
transfer coping and a
working model is poured
in dental stone,
providing a replica of the
implant’s location in the
patient’s mouth.

89. Abutment Level Impression
• An abutment is pre-selected by the dentist, placed and
torqued onto the implant. An appropriate abutment level
impression coping is used to transfer the position of the
abutment from the patient’s mouth to a model. The
restoration is fabricated to fit on top of the abutment.

90. Direct technique
Abutment level impression
Inside the patients mouth abutment is screwed to implant body
with a hand torque of 5 – 15 N-cm & checked radiographically
for proper placement. Once abutment seating is confirmed
the abutment is finally tighten upto 30 N-cm.
Abutment is prepared

91. Make the rubber base impression of the
prepared abutment , pour the cast in die
stone & on the resultant master cast
prosthesis is fabricated like conventional
prosthodontic method.

92. Advantages:
1. Preparation of the abutments is done intraorally.
2. Minimum prosthetic parts is required.
3. Similar to conventional crown and bridges prosthetic
techniques.

93. 1. Less accurate in comparison to indirect method.
2. Increased chair side time because the abutment is
need to be prepared intraorally.
3. Increased heat generation – affects hard & soft
tissue health.
4. The work needs to be done under indirect vision.
5. Traumatic injury to gingiva may compromise the
esthetic.
Disadvantage :

96. Digital Impression
 Scan body

99. ABUTMENT SELECTION FOR IMPLANT
RESTORATIONS

100. PREFABRICATED OR STOCK ABUTMENTS
EMERGENCE COMPONENT
1. the diameter of the implant platform (eg,
narrow, regular, or wide, determined from
your referring surgeon)
2. the collar or cuff height (the distance
between the implant platform and the
gingival margin)
PROSTHETIC COMPONENT
1. the interocclusal height (the distance
between the implant platform and the
opposing dentition)
2. whether a straight or angled abutment is
needed.

101. Abutment /
Preparation
height
Preparation angle
Gingival margin
Ideal abutment angle for retention is 6°
Prefabricated abutments commonly are designed with this angle
Consider an abutment height of min. 5 mm
Below 4 mm a screw-retained restoration is indicated
Keep preparation margin perigingival to facilitate removal of excess
cement and to limit flow of excess cement into the sulcus*
* S Holst, Univ Erlangen, Germany, 2012, personal communication
Preparation / geometric guidelines for cement-retained restorations
Clinical considerations on cement-retained

102. Abdul motin Ostagar

106. 3mm 3.4mm 3.8mm 4.5mm
5.5 mm
Straight abutment

107. Angled abutment
3mm 3.4mm 3.8mm 4.5mm
5.5mm

108. Multi unit abutments

109. Abutments for overdenture
Ball abutment
Locator attachment
ERA attachment
Dalbo
O-Ring
EDS
Magnetic abutment
Dolder bar
3.17 4.85 5.82 6.14
6.22mm
Locator ERA Dalbo O-Ring

110. CONTRAINDICATION TO PREFABRICATED
ABUTMENTS
1. There is insufficient interocclusal space, where the abutment would not
have sufficient height to retain a crown.
2. The implant requires an angle of correction greater than 15º.
3. The collar height (the distance between the implant platform and the
more than 1 mm greater than the largest collar height offered by the
4. The need for splinting three or more implants in a quadrant when
required. If the clinician desires to splint three or more implants together
quadrant, preparation for parallelism can be quite challenging.

111. Poulomi Das
<5mm

114. CUSTOM ABUTMENTS
CASTABLE
PLASTIC
ABUTMENT
Ti Base
MILLED
All titanium
All zirconia
Titanium
zirconia hybrids

116. The standard angulated abutment can
correct angulation from placement upto
15 degress.

117. For angulation beyond 15 degress the cast
to base abutment is the abutment of
choice to customise an angled abutment.

120. What Are the Advantages of Custom Milled Abutments?
Custom milled abutments have many advantages:
•They help achieve a passive fit
•The final restorations are manufactured to the patient’s exact gingival
architecture, achieving an optimal emergence profile and a more
esthetically pleasing outcome
•It is easier to correct the angulation of the implants
•Fewer chair-side adjustments are required, and appointments can be
smoother and faster, helping to increase the efficiency of a dental office

125. Prosthetic options

126. Screw-retained restoration
Cement-retained restoration
Prerequisites and considerations
The two most common options
for restoring an implant are:
• Screw-retained
• Cement-retained
Cement-retained and screw-retained restorations

127. CEMENT RETAINED

129. 139
Disclaimer: Some products may not be regulatory cleared/released for sale in all markets.
Please contact the local Nobel Biocare sales office for current product assortment and availability.
Cement-retained
+
No screw access hole
More esthetic solution
Provisionals easier to fabricate
-
Cement excess removal issue
Cement excess may lead to inflammation and periimplantitis
Restoration more difficult to retrieve
Proper cement selection and cementation procedure might be a challenge
Always 2 piece superstructure
Needs min. 5mm abutment height
Source: Lee et al. Implant Dentistry / Volume 19, Number 1, 2010
Cement-retained: advantages - disadvantages
Prerequisites and considerations

130. Pauletto N, Lahiffe BJ, Walton JN. Complications associated with excess
cement around crowns on osseointegrated implants: A clinical report. Int J
Oral Maxillofac Implants 1999;14:865-868.
It was in 1999 when
retained cement was
first reported as a
source of peri-implant
mucosal swelling,
mucosal recession, and
bone loss

131. 141
141
Keep preparation margin perigingival, to facilitate removal of excess cement and to limit flow of
excess cement into the sulcus
Pictures courtesy of Dr Baldwin Marchack (1,2) and IvoclarVivadent (3)
1 2
3
Crown margin too deep, proper
removal of excess cement almost
impossible
Crown margin nicely located perigingivally Perigingivally located crown margin allows
for easy and proper clean-up of excess
cement
Management of cement excess
Clinical considerations on cement-retained
Location of preparation margin
3

132. 142
142
Limit amount of excess cement by appropriate application technique:
Place a retraction cord into the sulcus
Using a brush, apply a thin layer of cementation material onto the inner aspects of the
crown walls.
Alternatively control the amount of cement in the lumen by using a custom putty trial die
(see example on next slide)
Management of cement excess
Clinical considerations on cement-retained
Application techniques
Consider not filling the entire lumen of the crown with cement. Overfilling produces
excess cement material which can lead to complications.
X 4
Pictures from NobelProcera cementation guide
Picture (4) courtesy of IvoclarVivadent

133. Custom abutment (left)
Custom putty abutment
(right)
The custom putty abutment replica fitted inside complete crown, permitting extraoral
elimination of most of the excess cement. Only a thin layer of cement remains inside
complete crown, minimizing the amount of cement extruded into soft tissues.
A simple cementation method to prevent material extrusion into the periimplant tissues.
Suzanne Caudry, PhD, MSc, David Chvartszaid, DDS, MSc, and Nicholas Kemp, BDS, DDS
Faculty of Dentistry, University of Toronto, Toronto, Canada
The Journal of Prosthetic Dentistry, Inc. 2009. 102(2).130-1.
Reproduced with permission from the Editorial Council for The Journal of Prosthetic Dentistry, Inc.
143
Management of cement excess
Clinical considerations on cement-retained
Application techniques

134. Cement excess induced tissue inflammation
and periimplantitis.
It is key to avoid cement excess and to
remove cement excess thoroughly.
Consider this issue also specifically in
immediate loading cases (excess cement
potentially flowing into implant surgery site …)
144
The Positive Relationship Between Excess Cement and Peri-Implant Disease: A Prospective Clinical Endoscopic Study
Thomas G. Wilson Jr., J Periodontol 2009:1388-1392.
Excess dental cement was associated with signs of periimplant disease in the majority (81 %) of the cases. Clinical and
endoscopic signs of peri-implant disease were absent in 74 % of the test implants after the removal of excess cement.
Management of cement excess
Clinical considerations on cement-retained

135. Zinc-Phosphate
cement
Glas-Ionomer cement
Resin cements
Example
materials
145
Conventional cementation Adhesive cementation
Temporary cementation
e.g. Zincoxide
based cements
Cementation material options and selection
Clinical considerations on cement-retained

151. SCREW RETAINED

157. Screw retained milled hybrid zirconia crown

162. 173
Disclaimer: Some products may not be regulatory cleared/released for sale in all markets.
Please contact the local Nobel Biocare sales office for current product assortment and availability.
Screw-retained
+
No cement excess (- no cement-excess induced inflammation)
Restoration easy to retrieve for maintenance etc.
Screw-retained crown / bridge (Procera Implant Bridge) as straight forward
and efficient one piece superstructure solution
Possible with < 4 mm abutment height, use in limited interocclusal space
Provisionals: better tissue response and communication with technician
-
Screw access hole (to be obturated)
Esthetic considerations (screw access hole)
Higher maintenance need (screw loosenings / fractures, higher risk of
restoration ceramic fractures)
Potential occlusal interferences around screw access hole obturation
Manipulation of components (screw, screw driver) in posterior area, sufficient
interocclusal space required
Source: Lee et al. Implant Dentistry / Volume 19, Number 1, 2010
Screw-retained: advantages - disadvantages
Prerequisites and considerations

163. SCREW CEMENT RETAINED. (SCR)

174. Sumita Roy

181. THANK YOU
DR. DIPANJANA SINHA
MDS PROSTHODONTIST
DIPLOMATE ICOI
+91 9836250905