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Indian Dental Academy: will be one of the most relevant and exciting training

center with best faculty and flexible training programs for dental

professionals who wish to advance in their dental practice,Offers certified

courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry,

Prosthetic Dentistry, Periodontics and General Dentistry.

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Loading of dental implants / general dental courses

  1. 1. GOOD MORNINGGOOD MORNING INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. LOADING OF IMPLANTSLOADING OF IMPLANTS IMMEDIATE IMPLANT PLACEMENTIMMEDIATE IMPLANT PLACEMENT IMMEDIATE LOADINGIMMEDIATE LOADING IMMEDIATE IMPLANT PLACEMENTIMMEDIATE IMPLANT PLACEMENT DELAYED LOADINGDELAYED LOADING PROGRESSIVE BONE LOADINGPROGRESSIVE BONE LOADING www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. DEFINITIONSDEFINITIONS 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) www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4. Implant ProsthodonticsImplant Prosthodontics :: The phase ofThe phase of prosthodontics concerning the replacement ofprosthodontics concerning the replacement of missing teeth and/or associated structures bymissing teeth and/or associated structures by restorations that are attached to dentalrestorations that are attached to dental implants.implants. (As per GPT- 8) Implant SystemImplant System:: Dental implant componentsDental implant components that are designed to mate together. An implantthat are designed to mate together. An implant system can represent a specific concept,system can represent a specific concept, inventor, or patent. It consists of the necessaryinventor, or patent. It consists of the necessary parts and instruments to complete the implantparts and instruments to complete the implant body placement and abutment componentsbody placement and abutment components body and abutment.body and abutment. www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5. ImplantologyImplantology:: A term historically conceivedA term historically conceived as the study or science of placing and restoringas the study or science of placing and restoring dental implants.dental implants. (As per GPT- 8) Implant SurgeryImplant Surgery :: The phase of implantThe phase of implant dentistry concerning the selection, planning,dentistry concerning the selection, planning, and placement of the implant.and placement of the implant. (As per GPT- 8) Progressive LoadingProgressive Loading :: The gradualThe gradual increase in the application of force on a dentalincrease in the application of force on a dental implant whether intentionally done with aimplant whether intentionally done with a prosthesis or unintentionally via forces placedprosthesis or unintentionally via forces placed by adjacent anatomic structures or paraby adjacent anatomic structures or para functional loading.functional loading. (As per GPT- 8) www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6. IMMEDIATEIMMEDIATE IMPLANTIMPLANT PLACEMENTPLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. CONTENTSCONTENTS 1. INTRODUCTION 2. HISTORY 3. DIFFERENT APPROACHES TO IMPLANT INSERTION 4. ADVANTAGES, INDICATONS AND CONTRAINDICATIONS OF IMMEDIATE IMPLANT PLACEMENT 5. GUIDELINES FOR EXTRACTION IN IMMEDIATE IMPLANT PLACEMENT 6. IMPLANT PLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8. INTRODUCTIONINTRODUCTION An alternative to the complete removableAn alternative to the complete removable denture is the use of endosseous implants asdenture is the use of endosseous implants as support for a fixed prosthesis. Branemark andsupport for a fixed prosthesis. Branemark and colleagues proposed the concept ofcolleagues proposed the concept of osseointegration over 37 years ago, but totalosseointegration over 37 years ago, but total acceptance of implant based therapy has beenacceptance of implant based therapy has been hampered by the cost of treatment and limitedhampered by the cost of treatment and limited access to professional care. But one of theaccess to professional care. But one of the biggest drawbacks to implant therapy has beenbiggest drawbacks to implant therapy has been the length of time required by traditionalthe length of time required by traditional placement protocols.placement protocols.www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9. A 3 to 14 month treatment sequence isA 3 to 14 month treatment sequence is commonplace, oftencommonplace, often including multiple surgeries. Patientsincluding multiple surgeries. Patients undertaking such therapy have to resignundertaking such therapy have to resign themselves to enduring significantthemselves to enduring significant inconvenience and discomfort before they caninconvenience and discomfort before they can begin to enjoy an amelioration of theirbegin to enjoy an amelioration of their appearance, speech, masticatory function andappearance, speech, masticatory function and self-confidence.self-confidence. Immediate placement of dental implantsImmediate placement of dental implants protocol is gaining great popularity throughoutprotocol is gaining great popularity throughoutwww.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. HISTORYHISTORY The modern era of dental implant therapy beganThe modern era of dental implant therapy began with the May 1982 Toronto Conference onwith the May 1982 Toronto Conference on Osseointegration in Clinical Dentistry. TheOsseointegration in Clinical Dentistry. The conference show cased Professorconference show cased Professor Per IngvarPer Ingvar BranemarkBranemark and the concept ofand the concept of osseointegration. It was organized by Georgeosseointegration. It was organized by George Zarb and supported financially by the OntarioZarb and supported financially by the Ontario Ministry of Health and the University of Toronto.Ministry of Health and the University of Toronto. www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. At this conference, educational leaders fromAt this conference, educational leaders from North American dental schools in theNorth American dental schools in the specialties of oral and maxillofacial surgery andspecialties of oral and maxillofacial surgery and prosthodontics were exposed to the scientificprosthodontics were exposed to the scientific background of osseointegration and to thebackground of osseointegration and to the clinical success that had been achieved inclinical success that had been achieved in Sweden and in early clinical trials in Toronto.Sweden and in early clinical trials in Toronto. The conference was a watershed event inThe conference was a watershed event in prosthodontics.prosthodontics. www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. The early investigations of Branemark thatThe early investigations of Branemark that eventually led to the dental application ofeventually led to the dental application of osseointegration focused on wound healingosseointegration focused on wound healing and rheology in bone and soft tissue. The useand rheology in bone and soft tissue. The use of titanium implants (referred to as "fixtures" byof titanium implants (referred to as "fixtures" by Branemark) to support dental prostheses wasBranemark) to support dental prostheses was first described in a study on dogs. The firstfirst described in a study on dogs. The first human patient received implants inhuman patient received implants in Branemark's Gothenburg clinic in 1965. For theBranemark's Gothenburg clinic in 1965. For the next decade, the application ofnext decade, the application of osseointegration as a foundation for dentalosseointegration as a foundation for dental prostheses was carefully documented andprostheses was carefully documented and reported.reported. www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. The 1970’s saw the accumulation of sufficientThe 1970’s saw the accumulation of sufficient data relative to the predictability ofdata relative to the predictability of osseointegration to move it from experimentalosseointegration to move it from experimental to routine clinical use in European centers. Theto routine clinical use in European centers. The University of Toronto was the first NorthUniversity of Toronto was the first North American center to use osseointegrated dentalAmerican center to use osseointegrated dental implants in clinical trials. The replication ofimplants in clinical trials. The replication of Swedish success in Toronto led to the 1982Swedish success in Toronto led to the 1982 Toronto conference and, shortly thereafter, toToronto conference and, shortly thereafter, to the widespread use of osseointegrated dentalthe widespread use of osseointegrated dental implants.implants. www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. DIFFERENT APPROACHES TODIFFERENT APPROACHES TO IMPLANTIMPLANT PLACEMENTPLACEMENT IMMEDIATE IMPLANT PLACEMENTIMMEDIATE IMPLANT PLACEMENT DELAYED IMPLANT PLACEMENTDELAYED IMPLANT PLACEMENT STAGED IMPLANT PLACEMENTSTAGED IMPLANT PLACEMENT ONE STAGE IMPLANT PLACEMENTONE STAGE IMPLANT PLACEMENTwww.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. IMMEDIATE IMPLANTIMMEDIATE IMPLANT PLACEMENTPLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. IMMEDIATE IMPLANTIMMEDIATE IMPLANT PLACEMENTPLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. Gore tex membrane fixed to implant Connective tissue graft placed over the membrane and immobilised with sutures www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. DELAYED IMPLANT PLACEMENTDELAYED IMPLANT PLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. After several weeks gingival margin will cover the socket gap www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. DELAYED IMPLANT PLACEMENTDELAYED IMPLANT PLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. STAGED IMPLANT PLACEMENTSTAGED IMPLANT PLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. STAGED IMPLANT PLACEMENTSTAGED IMPLANT PLACEMENT (SOCKET SEAL SURGERY)(SOCKET SEAL SURGERY) www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23. ONE STAGE IMPLANTONE STAGE IMPLANT PLACEMENTPLACEMENT www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24. www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25. ADVANTAGES OF IMMEDIATEADVANTAGES OF IMMEDIATE IMPLANT PLACEMENTIMPLANT PLACEMENT Prevents atrophy alveolar ridges, gingival and mucosal tissues after the removal of teeth. Can be placed in the same position as the extracted teeth. Minimizes the need for severely angled abutments www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. Can position the implant more favorably than the original tooth by redirecting the burs when preparing the implant receptor site. With the extraction socket as a guide, the surgeon can also more easily determine the appropriate parallelism and alignment relative to the opposing and adjacent residual dentition and to adjacent implants when there are multiple extractions and implants. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28. Improved final function and aesthetics typicallyImproved final function and aesthetics typically result.result. Significantly shorten the overall treatment timeSignificantly shorten the overall treatment time and the interval during which the patient mustand the interval during which the patient must live in a transitional state with or without teeth.live in a transitional state with or without teeth. Consequently. more patients accept treatmentConsequently. more patients accept treatment and also increase the overall cost effectivenessand also increase the overall cost effectiveness of cases.of cases. www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29. INDICATIONS OF IMMEDIATEINDICATIONS OF IMMEDIATE IMPLANT PLACEMENTIMPLANT PLACEMENT Failed endodontically treated teeth Teeth with advanced periodontal disease Root fractures Advanced caries beneath the gingival margin www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30. CONTRAINDICATIONS OFCONTRAINDICATIONS OF IMMEDIATEIMMEDIATE IMPLANT PLACEMENTIMPLANT PLACEMENT Teeth with suppuration Teeth with large periapical infection www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. There areThere are five determining factorsfive determining factors identified to beidentified to be prerequisites for positive treatment outcomes inprerequisites for positive treatment outcomes in the immediate placement of implants:the immediate placement of implants: 1. Preservation of the bony margins of the1. Preservation of the bony margins of the alveolus during extraction.alveolus during extraction. 2. Precise preparation of an implant bed in the2. Precise preparation of an implant bed in the apical portion or along the walls of the socket.apical portion or along the walls of the socket. 3. Tight circumferential adaptation of a barrier3. Tight circumferential adaptation of a barrier membrane as a collar around the neck of themembrane as a collar around the neck of the implant extending over the borders of theimplant extending over the borders of the alveolus by 3 – 4 mm.alveolus by 3 – 4 mm.www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32. 4. Careful management of the soft tissue flap and4. Careful management of the soft tissue flap and close flap adaptation to the neck of the implant.close flap adaptation to the neck of the implant. 5. Meticulous plaque control for the entire healing5. Meticulous plaque control for the entire healing period of approximately 6 months.period of approximately 6 months. www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. GUIDELINES FOR EXTRACTIONGUIDELINES FOR EXTRACTION WHEN PLANNING FOR IMMEDIATEWHEN PLANNING FOR IMMEDIATE IMPLANT PLACEMENTIMPLANT PLACEMENT The following guidelines for extractions areThe following guidelines for extractions are provided when planning for immediateprovided when planning for immediate placement of implants:placement of implants: Preoperative evaluationPreoperative evaluation Antibiotic therapy initiationAntibiotic therapy initiation Preservation of the bony receptor sitePreservation of the bony receptor sitewww.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34. Procedural delaysProcedural delays Avoidance of excessive pressureAvoidance of excessive pressure Osteotomy preparationOsteotomy preparation Improvements for placementImprovements for placement Bone graftsBone grafts Soft tissues closureSoft tissues closure www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36. Successful osseointegrationSuccessful osseointegration IMPLANT PLACEMENTIMPLANT PLACEMENT : An implant can be placed immediately if any one of the conditions exist at the extraction site 1. Bone is type I or II 2. Site can accommodate an implant with a length of atleast 13 mm. 3. Once placed, the implant can be completely protected from function and occlusal forces. www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37. TAPERED IMPLANTSTAPERED IMPLANTS Tapered anatomically shaped implants are theTapered anatomically shaped implants are the implants of choice for this indication.implants of choice for this indication. More closely mimic the shape of natural toothMore closely mimic the shape of natural tooth roots – wider at the cervix than at the apex.roots – wider at the cervix than at the apex. Implant Diameter – 3.5mm, 4.3mm, 5.0mm,Implant Diameter – 3.5mm, 4.3mm, 5.0mm, and 6.0mm.and 6.0mm. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. Implant Length - 10mm, 13mm, and 16 mm.Implant Length - 10mm, 13mm, and 16 mm. Implant Surface – acid etched titanium,Implant Surface – acid etched titanium, hydroxyapatite(HA) coated,hydroxyapatite(HA) coated, TPS – coatedTPS – coated www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39. ADVANTAGES OF THE TAPEREDADVANTAGES OF THE TAPERED IMPLANTSIMPLANTS Larger cervical diameter provides better buccalLarger cervical diameter provides better buccal support and helps preserve the rootsupport and helps preserve the root prominence.prominence. Larger cervical diameter also improves theLarger cervical diameter also improves the implant to bone interface.implant to bone interface. Tapered design may obviate the need to useTapered design may obviate the need to use grafting materials or membranes.grafting materials or membranes. www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. Allows implant to be placed in the sameAllows implant to be placed in the same position as the extracted teeth and avoidsposition as the extracted teeth and avoids buccal or labial wall perforation.buccal or labial wall perforation. Since the position of implant is similar to theSince the position of implant is similar to the extracted tooth, restoration is placed in moreextracted tooth, restoration is placed in more favourable position in relation to the opposingfavourable position in relation to the opposing arch thus reducing the excessive off axisarch thus reducing the excessive off axis loadingloading Can be used in cases of tooth with convergentCan be used in cases of tooth with convergent rootsroots www.indiandentalacademy.comwww.indiandentalacademy.com
  41. 41. By using a straight or maximum 15 degreeBy using a straight or maximum 15 degree angled abutment for fixed prosthesis, theangled abutment for fixed prosthesis, the occlusal table will have more acceptableocclusal table will have more acceptable buccolingual dimension.buccolingual dimension. www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42. TAPERED OSTEOTOMESTAPERED OSTEOTOMESwww.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. TAPERED OSTEOTOMESTAPERED OSTEOTOMES AdvantagesAdvantages :: In areas of soft( type III or type IV) bone canIn areas of soft( type III or type IV) bone can create a denser bony interface for the implant.create a denser bony interface for the implant. Generate no heatGenerate no heat Allow for better visibility than drills in posteriorAllow for better visibility than drills in posterior maxillamaxilla Offer the user greater tactile sensationOffer the user greater tactile sensation www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. Indications :Indications : When bone at the extraction site is type III orWhen bone at the extraction site is type III or type IV and the use of burs for the preparationtype IV and the use of burs for the preparation of the impalnt receptor site is deterimental.of the impalnt receptor site is deterimental. When the apical cortical socket of a molar orWhen the apical cortical socket of a molar or premolar abuts the floor of maxillary sinus .premolar abuts the floor of maxillary sinus . www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. BONE COMPACTIONBONE COMPACTION 2 mm pilot drill is used to achieve a purchase2 mm pilot drill is used to achieve a purchase point and to ensure proper alignment at thepoint and to ensure proper alignment at the osseous receptor site.osseous receptor site. An appropriate osteotome is selected which isAn appropriate osteotome is selected which is then placed into the sulcus , pushed andthen placed into the sulcus , pushed and rotated to the desired depth.rotated to the desired depth. Depending on the bone density a mallet mayDepending on the bone density a mallet may be used, more porous the bone more easily thebe used, more porous the bone more easily the osteotome is inserted.osteotome is inserted. www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46. Increasingly larger osteotomes are then used toIncreasingly larger osteotomes are then used to enlarge the socket until it will accommodate theenlarge the socket until it will accommodate the implant selected for the site.implant selected for the site. In posterior maxilla wider the bone less dense itIn posterior maxilla wider the bone less dense it usually is.usually is. In some osteotomy site areas of increasedIn some osteotomy site areas of increased bone density may be encountered as the sinusbone density may be encountered as the sinus floor approaches( e.g. cortical crestal areas,floor approaches( e.g. cortical crestal areas, apical portion of the osteotomy). In these casesapical portion of the osteotomy). In these cases conventional hand piece drilling may be usedconventional hand piece drilling may be used with the osteotome compaction technique.with the osteotome compaction technique.www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47. www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48. www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. DRILL METHODDRILL METHOD Basic Considerations of OsteotomyBasic Considerations of Osteotomy DrillingDrilling Following tooth removal, inspect the crest ofFollowing tooth removal, inspect the crest of the remaining bone, especially labially. Itsthe remaining bone, especially labially. Its heightheight should be within 5 mmshould be within 5 mm of that of theof that of the adjacent bone on either side. If it is greater thanadjacent bone on either side. If it is greater than 5 mm, the chance of a harmonious esthetic5 mm, the chance of a harmonious esthetic result is diminished.result is diminished. www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51. Inspect the socket and preoperativeInspect the socket and preoperative radiograph to fix in mind the amount andradiograph to fix in mind the amount and variation of available bone mesial and distal tovariation of available bone mesial and distal to socket.socket. Clinically evaluate the labial extent of theClinically evaluate the labial extent of the opening, which is most often closer to idealopening, which is most often closer to ideal than that found in healed ridges that havethan that found in healed ridges that have undergone some resorption.undergone some resorption. www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52. Twist Drill Pathway :Twist Drill Pathway : The pathway is deter­mined by the socket.The pathway is deter­mined by the socket. However, with a D3 twist drill of coordinatedHowever, with a D3 twist drill of coordinated depth, measure whether the socket depthdepth, measure whether the socket depth reaches the 13 mm required for the selectedreaches the 13 mm required for the selected implant configuration. If necessary, use the D3implant configuration. If necessary, use the D3 twist drill to deepen the socket to the depth oftwist drill to deepen the socket to the depth of the implant.the implant. The socket is usually short of that depth if theThe socket is usually short of that depth if the implant was selected according to the selectionimplant was selected according to the selection principlesprinciples www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53. Completion Of The Implant OsteotomyCompletion Of The Implant Osteotomy :: An appropriate stepped drill, is now used. ThisAn appropriate stepped drill, is now used. This drill obliterates the socket and carries thedrill obliterates the socket and carries the osteotomy to its final depth. Cleansing andosteotomy to its final depth. Cleansing and suctioning are performed before the next step.suctioning are performed before the next step. Evaluate And Test Prepared OsteotomyEvaluate And Test Prepared Osteotomy :: The depth stop on the stepped drill, coupledThe depth stop on the stepped drill, coupled with careful drilling, helps ensure accuracy.with careful drilling, helps ensure accuracy. Some practitioners test the osteotomy using aSome practitioners test the osteotomy using a coordinated bone compactor. If necessary, thecoordinated bone compactor. If necessary, the compactor can be tapped with a mallet to bringcompactor can be tapped with a mallet to bring the osteotomy to its correct depth.the osteotomy to its correct depth.www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54. Final Seating Of The ImplantFinal Seating Of The Implant :: The implant is removed from its sterileThe implant is removed from its sterile packaging by snapping the implant driver intopackaging by snapping the implant driver into the adapter screw on top of the implant.the adapter screw on top of the implant. The implant is withdrawn from the inner vial toThe implant is withdrawn from the inner vial to be placed into its prepared osteotomy.be placed into its prepared osteotomy. www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56. When the implant is placed into the osteotomy,When the implant is placed into the osteotomy, the driver is unsnapped and an implant seatingthe driver is unsnapped and an implant seating instrument is carefully positioned to nest snuglyinstrument is carefully positioned to nest snugly into the adapter screw supplied with theinto the adapter screw supplied with the implant, such that the long axis of its handle isimplant, such that the long axis of its handle is parallel with that of the implant.parallel with that of the implant. With several sharp taps, the implant isWith several sharp taps, the implant is malleted to its final position. The adapter screwmalleted to its final position. The adapter screw is removed with a O.9-mm hex-driver.is removed with a O.9-mm hex-driver. www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57. If the coronal ridge of the implant is not entirelyIf the coronal ridge of the implant is not entirely below the ridge crest, tap again with the mallet.below the ridge crest, tap again with the mallet. Do not remove the implant once it has beenDo not remove the implant once it has been malletted into position.malletted into position. www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58. When using the single stage procedure, theWhen using the single stage procedure, the implant should be positioned so that theimplant should be positioned so that the platform is either even with or 1mm above theplatform is either even with or 1mm above the crestal bone. Depending on the thickness of thecrestal bone. Depending on the thickness of the soft tissue, either profile(3mm) healingsoft tissue, either profile(3mm) healing abutment or a cover screw is placed into theabutment or a cover screw is placed into the implants.implants. After hard and soft tissue healing, the top ofAfter hard and soft tissue healing, the top of the implant will protrude above the muco-the implant will protrude above the muco- gingival tissues, therefore circumventing thegingival tissues, therefore circumventing the need for a second stage procedure to exposeneed for a second stage procedure to expose the implantthe implant www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59. www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60. IMMEDIATEIMMEDIATE LOADING OFLOADING OF IMPLANTSIMPLANTS www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61. CONTENTSCONTENTS 1. INTRODUCTION 2. DEFINITIONS 3. EVOLUTION 4. IMPLANT STABILITY 5. ADVANTAGES, DISADVANTAGES, INDICATONS AND CONTRAINDICATIONS OF IMMEDIATE LOADING OF IMPLANTS 6. NOVUM CONCEPT 7. RESCUE PROCEDURE FOR NOVUM 8. EARLY AND IMMEDIATE IMPLANT LOADING PROTOCOL 9. DISCUSSION www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62. INTRODUCTIONINTRODUCTION Immediate loading or function in implantImmediate loading or function in implant dentistry is a fairly new technique that allowsdentistry is a fairly new technique that allows certain types of patients to have their teethcertain types of patients to have their teeth removed and implants placed, along with theremoved and implants placed, along with the prosthesis, in the same day. Providingprosthesis, in the same day. Providing immediate implant loading requires a great dealimmediate implant loading requires a great deal of previous experience, as well as advancedof previous experience, as well as advanced knowledge of implant dentistry and significantknowledge of implant dentistry and significant surgical and prosthodontic skills.surgical and prosthodontic skills.www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63. Because immediate implant loading requires theBecause immediate implant loading requires the cooperation of many different practitioners,cooperation of many different practitioners, hence the importance of teamwork in thehence the importance of teamwork in the achievement of satisfactory results in successachievement of satisfactory results in success rates, function and esthetics, all of which arerates, function and esthetics, all of which are required for success in any treatmentrequired for success in any treatment employing implants cannot be undermined.employing implants cannot be undermined. www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64. DEFINITIONSDEFINITIONS Immediate Occlusal LoadingImmediate Occlusal Loading : An implant: An implant is placed with adequate primary stability itsis placed with adequate primary stability its corresponding restoration has full centriccorresponding restoration has full centric occlusion in maximum intercuspation and mustocclusion in maximum intercuspation and must be placed within 48 hours post surgery.be placed within 48 hours post surgery. www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65. Early loadingEarly loading : Early Loading Protocol is wherein: Early Loading Protocol is wherein a provisional prosthesis was inserted at aa provisional prosthesis was inserted at a subsequent visit prior to osseointegration (betweensubsequent visit prior to osseointegration (between 2 days to 3 months after surgery). Though the2 days to 3 months after surgery). Though the implants, were not loaded the same day, thisimplants, were not loaded the same day, this protocol directly challenged the healing process byprotocol directly challenged the healing process by introducing loading during wound healing. Aintroducing loading during wound healing. A fundamental goal of early loading is improvingfundamental goal of early loading is improving bone formation in order to support occlusal loadingbone formation in order to support occlusal loading at two months.at two months. www.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66. Conventional Loading ProtocolConventional Loading Protocol : is the: is the original healing periods as envisaged byoriginal healing periods as envisaged by different implant systems, typically after 12 todifferent implant systems, typically after 12 to 24 weeks.24 weeks. Delayed Loading ProtocolDelayed Loading Protocol : is one in which: is one in which the healing period was extended due to thethe healing period was extended due to the compromised host site conditions and, typically,compromised host site conditions and, typically, prosthesis connection is later than theprosthesis connection is later than the conventional healing period.conventional healing period. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. Occlusal loadingOcclusal loading : means that the: means that the immediately or early loaded prosthesis is inimmediately or early loaded prosthesis is in contact with the opposing dentition.contact with the opposing dentition. Non-occlusal loadingNon-occlusal loading : means that the: means that the immediately or early loaded prosthesis is not inimmediately or early loaded prosthesis is not in contact with the opposing dentition. It shouldcontact with the opposing dentition. It should be recognized that in non-occlusal loading,be recognized that in non-occlusal loading, forces on implants could be generated throughforces on implants could be generated through the oral musculature and food bolus.the oral musculature and food bolus. www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. Immediate Non Occlusal LoadingImmediate Non Occlusal Loading : An: An implant is placed with adequate primaryimplant is placed with adequate primary stability but is not in functional occlusion. Thesestability but is not in functional occlusion. These implant restorations are essentially used forimplant restorations are essentially used for esthetic purposes, frequently in single tooth oresthetic purposes, frequently in single tooth or short span applications. Immediate nonshort span applications. Immediate non occlusal loading is often performed to provideocclusal loading is often performed to provide the patient with aesthetic or psychologicalthe patient with aesthetic or psychological benefit during implant therapy, particularlybenefit during implant therapy, particularly when a provisional removable prosthesis iswhen a provisional removable prosthesis is undesirable during the healing period.undesirable during the healing period. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. EVOLUTIONEVOLUTION 1990 Schnitman1990 Schnitman et al initially describedet al initially described immediate loading off mandibular implants withimmediate loading off mandibular implants with a detachable hybrid prosthesis, however aa detachable hybrid prosthesis, however a statistically significant number of thestatistically significant number of the immediately loaded implants failed.immediately loaded implants failed. www.indiandentalacademy.comwww.indiandentalacademy.com
  70. 70. 1994 Henry et al placed 61994 Henry et al placed 6 mandibular implantsmandibular implants in a series of 5 patients 4/6 implantsin a series of 5 patients 4/6 implants immediately loaded with provisional removableimmediately loaded with provisional removable overdentureoverdenture then , at 7 weeks a permanentthen , at 7 weeks a permanent prosthesis was placed. 100% implant success.prosthesis was placed. 100% implant success. 1997 Tarnow et al,1997 Tarnow et al, landmarklandmark study withstudy with immediate loading of implants in both mandibleimmediate loading of implants in both mandible and maxilla.and maxilla. www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71. 1999 – Branemark published initial report1999 – Branemark published initial report on the Novum systemon the Novum system 50 patients, 150 implants50 patients, 150 implants 3 implants placed in the anterior mandible3 implants placed in the anterior mandible andand immediately loading with hybrid dentureimmediately loading with hybrid denture Failure of 3/150 implantsFailure of 3/150 implants Failure of 1 prosthesisFailure of 1 prosthesis Initial introduction of a mainstream immediateInitial introduction of a mainstream immediate load implant systemload implant system www.indiandentalacademy.comwww.indiandentalacademy.com
  72. 72. 20002000 RandowRandow et al compared one stage andet al compared one stage and two stage technique for hybrid dentures intwo stage technique for hybrid dentures in patients with edentulous mandibles.patients with edentulous mandibles. 20012001 ChiapascoChiapasco et al prospectively comparedet al prospectively compared delayeddelayed v/sv/s immediate load mandibularimmediate load mandibular hybridhybrid dentures using Branemarke MKII implants.dentures using Branemarke MKII implants. 20032003 EngstrandEngstrand et al 5 yr follow up of 95et al 5 yr follow up of 95 patients treated with Novumpatients treated with Novum system.system. 93.7%93.7% implant success rate andimplant success rate and 99% prosthesis99% prosthesis survival.survival. www.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. 2003 Henry et al2003 Henry et al 1 yr survival rates of1 yr survival rates of NovumNovum system in 51 ptssystem in 51 pts 91% implant survival91% implant survival 94% prosthesis94% prosthesis surivivalsurivival www.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74. IMPLANT STABILITYIMPLANT STABILITY A fundamental requisite for IOL is adequateA fundamental requisite for IOL is adequate primary implant stability. While stability wasprimary implant stability. While stability was traditionally achieved through a period oftraditionally achieved through a period of undisturbed healing( i.e. osseointegration )undisturbed healing( i.e. osseointegration ) primary stability is now achieved via aprimary stability is now achieved via a mechanical phenomenon of screw stability andmechanical phenomenon of screw stability and splintingsplinting Each implant system tolerates micromotionEach implant system tolerates micromotion differently.differently. www.indiandentalacademy.comwww.indiandentalacademy.com
  75. 75. For implants with roughened surfaces, toleranceFor implants with roughened surfaces, tolerance is in the range of 50 to 150 micrometers,is in the range of 50 to 150 micrometers, machined surfaces can withstandmachined surfaces can withstand approximately 100 micrometers ofapproximately 100 micrometers of micromovement.micromovement. Regardless of the type of implant selected, allRegardless of the type of implant selected, all restorative procedures should be completedrestorative procedures should be completed with in two days of implant placement,with in two days of implant placement, according to the specific needs of the patientaccording to the specific needs of the patient and after which time of bone healing andand after which time of bone healing and implant stability may be disrupted by suchimplant stability may be disrupted by suchwww.indiandentalacademy.comwww.indiandentalacademy.com
  76. 76. INDICATIONSINDICATIONS Adequate bone quality ( type I, II and III)Adequate bone quality ( type I, II and III) Sufficient bone height ( i.e. approximatelySufficient bone height ( i.e. approximately 12mm ) for a minimum length of 10 mm implant12mm ) for a minimum length of 10 mm implant Sufficient bone width ( i.e. approximately 6 mm)Sufficient bone width ( i.e. approximately 6 mm) Ability to achieve an adequate antero posteriorAbility to achieve an adequate antero posterior spread between the implants. A poor APspread between the implants. A poor AP spread decreases the mechanical advantagespread decreases the mechanical advantage gained by splinting and the ability to cantilevergained by splinting and the ability to cantilever the restorationthe restoration www.indiandentalacademy.comwww.indiandentalacademy.com
  77. 77. CONTRAINDICATIONSCONTRAINDICATIONS Poor systemic healthPoor systemic health Severe parafunctional habitsSevere parafunctional habits Bone of poor quality ( e.g. type IV)Bone of poor quality ( e.g. type IV) Bone height less than 10 mmBone height less than 10 mm Bone width less than 6 mmBone width less than 6 mm Inability to achieve an adequate AP spreadInability to achieve an adequate AP spread www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. ADVANTAGESADVANTAGES Eliminates the need for and maintenance ofEliminates the need for and maintenance of aa removable provisional prosthesisremovable provisional prosthesis Provides emotional benefit for a patientProvides emotional benefit for a patient scheduled to rendered edentulousscheduled to rendered edentulous Improves bone healingImproves bone healing Facilitates soft tissue shapingFacilitates soft tissue shaping Eliminates premature implant exposure oftenEliminates premature implant exposure often associated with wearing of a removableassociated with wearing of a removable prosthesis during healing periodprosthesis during healing periodwww.indiandentalacademy.comwww.indiandentalacademy.com
  79. 79. DISADVANTAGESDISADVANTAGES Cannot be applied to every implant patientCannot be applied to every implant patient Requires more chair side time at the time ofRequires more chair side time at the time of implant placement of both the patient and theimplant placement of both the patient and the restorative practitionerrestorative practitioner www.indiandentalacademy.comwww.indiandentalacademy.com
  80. 80. Immediate implant loading requires effectiveImmediate implant loading requires effective communication and coordination betweencommunication and coordination between surgical and restorative teams, as there is asurgical and restorative teams, as there is a degree of flexibility involved in the delivery ofdegree of flexibility involved in the delivery of the prosthesis. For example the surgical andthe prosthesis. For example the surgical and restorative procedures may be completed in arestorative procedures may be completed in a single appointment for straight forward casessingle appointment for straight forward cases for others prosthesis may be most appropriatelyfor others prosthesis may be most appropriately delivered one or two days after the placementdelivered one or two days after the placement of implant .of implant . www.indiandentalacademy.comwww.indiandentalacademy.com
  81. 81. Hence careful patient screening andHence careful patient screening and selection is required when an IOLselection is required when an IOL procedure isprocedure is treatment consideration.treatment consideration. www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82. THETHE NOVUMNOVUM CONCEPTCONCEPT Per Ingvar BranemarkPer Ingvar Branemark www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83. INTRODUCTIONINTRODUCTION According to the Classic procedure screw- shaped fixtures( generally between 4 to 6) made of pure titanium (standard 3.75mm) are placed in the anterior part of the mandible. This concept, first applied clinically in 1965, was based on available knowledge relating to the healing of bone, for example after fractures or osteotomies, and subsequently involved a healing period of 3 to 6 months before functional load was gradually applied. www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84. The distinctive feature of Novum is that itThe distinctive feature of Novum is that it requires only 6 to 8 hours for the entirerequires only 6 to 8 hours for the entire reconstruction and thus gives the patient areconstruction and thus gives the patient a third dentition in just 1 day.third dentition in just 1 day. www.indiandentalacademy.comwww.indiandentalacademy.com
  85. 85. HISTORYHISTORY The Novum ConceptThe Novum Concept was conceived in 1980was conceived in 1980 After 15 years of system design initial clinicalAfter 15 years of system design initial clinical application was done in 1996application was done in 1996 Initial report (1999)Initial report (1999) 50 patients, 150 implants 50 patients, 15050 patients, 150 implants 50 patients, 150 implantsimplants 3 implants placed in the anterior mandible3 implants placed in the anterior mandible and immediately loading withand immediately loading with hybrid denturehybrid denture Failure of 3/150 implantsFailure of 3/150 implants www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86. Failure of 1 prosthesisFailure of 1 prosthesis System includes 4 drill templates and 8 drill guidesSystem includes 4 drill templates and 8 drill guides to allow precise positioning of 3 implants in theto allow precise positioning of 3 implants in the anterior mandibleanterior mandible Prefabricated lower Ti bar placed on 3 implantsPrefabricated lower Ti bar placed on 3 implants Prefabricated upper bar forms base of hybridPrefabricated upper bar forms base of hybrid denturedenture Upper bar and denture screwed to lower bar andUpper bar and denture screwed to lower bar and implants allowing delivery of Teeth in a Dayimplants allowing delivery of Teeth in a Daywww.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. www.indiandentalacademy.comwww.indiandentalacademy.com
  88. 88. BRANEMARK NOVUMBRANEMARK NOVUM ADVANTAGESADVANTAGES Surgery and delivery of prosthesis in one daySurgery and delivery of prosthesis in one day Reduced cost of surgical phaseReduced cost of surgical phase Reduced cost of restorative phaseReduced cost of restorative phase www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89. BRANEMARK NOVUMBRANEMARK NOVUM DISADVANTAGESDISADVANTAGES Limited to Class I and III occlusionLimited to Class I and III occlusion Very demanding surgical procedure compared toVery demanding surgical procedure compared to traditional techniquetraditional technique Limited patient selection due to anatomic limitationsLimited patient selection due to anatomic limitations Surgical template does not fit all mandiblesSurgical template does not fit all mandibles Loss of 1 implant can be catastrophicLoss of 1 implant can be catastrophic Initial cost of surgical kit $2500Initial cost of surgical kit $2500www.indiandentalacademy.comwww.indiandentalacademy.com
  90. 90. HYPOTHESIS IN FAVOUR OFHYPOTHESIS IN FAVOUR OF NOVUMNOVUM It may be that during the critical period of 0 toIt may be that during the critical period of 0 to 16 weeks, the quality of osseointegration may16 weeks, the quality of osseointegration may be better at comparable times in the one-stepbe better at comparable times in the one-step procedure as compared to the two-stepprocedure as compared to the two-step procedure.procedure. www.indiandentalacademy.comwww.indiandentalacademy.com
  91. 91. The effects of any misalignment of a prosthesisThe effects of any misalignment of a prosthesis and the fixtures may be less hazardous andand the fixtures may be less hazardous and minimized in the long run by a one-stepminimized in the long run by a one-step procedure. It is clear from the experimentalprocedure. It is clear from the experimental data of Branemark (1997, 1998) that thedata of Branemark (1997, 1998) that the elastic modulus and pull-out strength of anelastic modulus and pull-out strength of an osseointegrated fixture are smallest just after itosseointegrated fixture are smallest just after it has been placed.has been placed. www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92. The stresses caused by misalignment of aThe stresses caused by misalignment of a prosthesis may be dissipated during the earlyprosthesis may be dissipated during the early weeks of osseointegration in the one-stepweeks of osseointegration in the one-step procedure. The initial stresses must be borneprocedure. The initial stresses must be borne by the old lamellar bone present. As this boneby the old lamellar bone present. As this bone is resorbed, these stresses may be relieved.is resorbed, these stresses may be relieved. The new woven bone growing in will probablyThe new woven bone growing in will probably not reinstate the misalignment stresses. Thisnot reinstate the misalignment stresses. This suggests the intriguing hypothesis that residualsuggests the intriguing hypothesis that residual stresses caused by misalignment may bestresses caused by misalignment may be relieved by the sequence of remodelingrelieved by the sequence of remodeling processes leading to osseointegration. In aprocesses leading to osseointegration. In a two-step procedure, residual stresses may betwo-step procedure, residual stresses may be locked in indefinitely.locked in indefinitely.www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93. HOWEVER THESE HYPOTHESIS MERITHOWEVER THESE HYPOTHESIS MERIT EXPERIMENTAL VERIFICATIONEXPERIMENTAL VERIFICATION www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94. Also it may be remarked that the two stepAlso it may be remarked that the two step procedure by limiting the load applied duringprocedure by limiting the load applied during the first phase, provides a margin of safetythe first phase, provides a margin of safety against clinical factors, such as accidentalagainst clinical factors, such as accidental damage to bone by overheating at initialdamage to bone by overheating at initial placement, survival of osseointegration in caseplacement, survival of osseointegration in case of minor infection, poor bone quality orof minor infection, poor bone quality or accidental trauma.accidental trauma. www.indiandentalacademy.comwww.indiandentalacademy.com
  95. 95. Routine clinical procedure involves the use ofRoutine clinical procedure involves the use of prefabricated templates for preplanned,prefabricated templates for preplanned, precision placement of three fixtures in theprecision placement of three fixtures in the anterior mandible. The precisely positionedanterior mandible. The precisely positioned anchoring elements are to be immediatelyanchoring elements are to be immediately connected with a predesigned lower bar . Thisconnected with a predesigned lower bar . This bar was intended to prevent individual torquebar was intended to prevent individual torque and multidirectional load on the individualand multidirectional load on the individual fixture and thus eliminate relative motion duringfixture and thus eliminate relative motion during the initial healing phase.the initial healing phase. www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. www.indiandentalacademy.comwww.indiandentalacademy.com
  97. 97. The purpose of the upper bar was toThe purpose of the upper bar was to standardize and facilitate the prostheticstandardize and facilitate the prosthetic procedure as well as allow easyprocedure as well as allow easy modifications of topography and materialsmodifications of topography and materials relating to the prosthetic dentition.relating to the prosthetic dentition. www.indiandentalacademy.comwww.indiandentalacademy.com
  98. 98. www.indiandentalacademy.comwww.indiandentalacademy.com
  99. 99. Predetermined fit of substructuresPredetermined fit of substructures and suprastructuresand suprastructures www.indiandentalacademy.comwww.indiandentalacademy.com
  100. 100. Sample orthopantograph showing theSample orthopantograph showing the topographical position of anchoring fixtures intopographical position of anchoring fixtures in relation to the anatomy of the mandiblerelation to the anatomy of the mandiblewww.indiandentalacademy.comwww.indiandentalacademy.com
  101. 101. Novum theory assumed that it would beNovum theory assumed that it would be possible to position the anchoring fixtures sopossible to position the anchoring fixtures so precisely that the prosthetic base could also beprecisely that the prosthetic base could also be predesigned. This would not only reduce thepredesigned. This would not only reduce the clinical treatment time, but also connect andclinical treatment time, but also connect and thus adequately secure the prostheticthus adequately secure the prosthetic components in passive fit, which wouldcomponents in passive fit, which would minimize undue stress and mobility.minimize undue stress and mobility. www.indiandentalacademy.comwww.indiandentalacademy.com
  102. 102. The various directions ofThe various directions of functional load that mayfunctional load that may occur at an individualoccur at an individual fixture if it is notfixture if it is not connected to adjacentconnected to adjacent fixtures.fixtures. www.indiandentalacademy.comwww.indiandentalacademy.com
  103. 103. Concept of control of functional load by precisionConcept of control of functional load by precision connection of three fixtures according to theconnection of three fixtures according to the Novum principle.Novum principle. www.indiandentalacademy.comwww.indiandentalacademy.com
  104. 104. Continued clinical application revealed decisiveContinued clinical application revealed decisive parameters related to preoperative radiographicparameters related to preoperative radiographic and clinical evaluations as well as gentleand clinical evaluations as well as gentle surgery and controlled prosthetics. Optimizedsurgery and controlled prosthetics. Optimized healing at the abutment interface and control ofhealing at the abutment interface and control of initial tissue injury and edema could beinitial tissue injury and edema could be obtained with surgical templates, meticulousobtained with surgical templates, meticulous control of mechanical and thermal injury (ie,control of mechanical and thermal injury (ie, never to exceed 42°C), and careful handling ofnever to exceed 42°C), and careful handling of the soft tissue-with particular focus onthe soft tissue-with particular focus on controlling the barrier to the oral cavity.controlling the barrier to the oral cavity. www.indiandentalacademy.comwww.indiandentalacademy.com
  105. 105. More recently, it has been suggested that theMore recently, it has been suggested that the cyclic deformation of bone tissue undercyclic deformation of bone tissue under functional loading is likely to promote the flowfunctional loading is likely to promote the flow of fluid within the various spaces in the matrixof fluid within the various spaces in the matrix (e.g., canaliculi connecting lacunae) as well as(e.g., canaliculi connecting lacunae) as well as possibly connecting to the open circulation inpossibly connecting to the open circulation in the marrow. This phenomenon may have athe marrow. This phenomenon may have a controlling influence on the rationale of thecontrolling influence on the rationale of the remodeling phase, which enables the boneremodeling phase, which enables the bone adjacent to the fixture to adapt to the functionaladjacent to the fixture to adapt to the functional load of mastication.load of mastication.www.indiandentalacademy.comwww.indiandentalacademy.com
  106. 106. 6 – 8 hours6 – 8 hours Sequence of events according to the precisionSequence of events according to the precision clinical protocol.clinical protocol.www.indiandentalacademy.comwww.indiandentalacademy.com
  107. 107. Single stage surgery with immediate loadingSingle stage surgery with immediate loading concepts are well established in the mandible,concepts are well established in the mandible, they should be considered experimental inthey should be considered experimental in maxilla until long term evidence-based datamaxilla until long term evidence-based data and guidelines are established. Nevertheless,and guidelines are established. Nevertheless, limited reports are accumulating and indicatelimited reports are accumulating and indicate that in certain circumstances, successful resultsthat in certain circumstances, successful results can be achieved.can be achieved. www.indiandentalacademy.comwww.indiandentalacademy.com
  108. 108. RESCUE PROCEDURE FOR THERESCUE PROCEDURE FOR THE BRANEMARK NOVUM PROTOCOLBRANEMARK NOVUM PROTOCOL In the event of a lost or failed implant with the Novum protocol, rescue components are available that allow the recovery of stabilized function without modification to the existing restoration. The rescue set contains drills and templates for immediately replacing the failed implant in either the central or distal sites, enabling subsequent immediate use of the original bar structures at the same appointment. The precision in implant placement required for this intervention is the same as in the original procedure. www.indiandentalacademy.comwww.indiandentalacademy.com
  109. 109. The surgical approach for rescue in this caseThe surgical approach for rescue in this case involved removal of the upper and lower barsinvolved removal of the upper and lower bars and exposure of the failed implant and theand exposure of the failed implant and the surrounding bone adjacent to the centralsurrounding bone adjacent to the central implant.implant. www.indiandentalacademy.comwww.indiandentalacademy.com
  110. 110. The rescue set includes templates for replacingThe rescue set includes templates for replacing either the distal or central implants and drillseither the distal or central implants and drills and drill guides for resizing the osteotomy.and drill guides for resizing the osteotomy. www.indiandentalacademy.comwww.indiandentalacademy.com
  111. 111. www.indiandentalacademy.comwww.indiandentalacademy.com
  112. 112. www.indiandentalacademy.comwww.indiandentalacademy.com
  113. 113. IMMEDIATE AND EARLY LOADINGIMMEDIATE AND EARLY LOADING PROTOCOLS WITH THE FIXEDPROTOCOLS WITH THE FIXED PROSTHESISPROSTHESIS Edentulous mandible The initial impetus for this novel approach was the anterior zone of the mandible. High success rates (>90%) in short to medium term studies. It was concluded that in the rehabilitation of an edentulous patient at least 4 implants be placed in an edentulous mandible to support a fixedwww.indiandentalacademy.comwww.indiandentalacademy.com
  114. 114. Edentulous maxillaEdentulous maxilla The success outcomes for the maxilla, althoughThe success outcomes for the maxilla, although high, are limited since the data werehigh, are limited since the data were confounded by grouping of completely andconfounded by grouping of completely and partially edentulous patients, including implantspartially edentulous patients, including implants placed in both the jawbones and extractionplaced in both the jawbones and extraction sites.sites. Around 5 to 8 number of implants wereAround 5 to 8 number of implants were required to rehabilitate an edentulous maxillarequired to rehabilitate an edentulous maxilla but with airborne particle abraded, large grit,but with airborne particle abraded, large grit, acid etched( SLA; sand blasted, large grit, acidacid etched( SLA; sand blasted, large grit, acid etched ) surfaces.etched ) surfaces. www.indiandentalacademy.comwww.indiandentalacademy.com
  115. 115. Although the comparative short term caseAlthough the comparative short term case series studies did suggest that rough-surfaceseries studies did suggest that rough-surface implants performed better than machinedimplants performed better than machined implants, the outcomes were confounded byimplants, the outcomes were confounded by the use of the variety and number of implants,the use of the variety and number of implants, the limited number of patients, and lack ofthe limited number of patients, and lack of improperly defined success outcomes.improperly defined success outcomes. www.indiandentalacademy.comwww.indiandentalacademy.com
  116. 116. The Partially Edentulous PatientsThe Partially Edentulous Patients The implant surface deserves specialThe implant surface deserves special consideration within context of the partiallyconsideration within context of the partially edentulous patients.edentulous patients. The use of an oxidized implant improved theThe use of an oxidized implant improved the success rate up to 97%, even though 76% ofsuccess rate up to 97%, even though 76% of the implants were placed in soft bone. Implantsthe implants were placed in soft bone. Implants (machined and modified surfaces) placed in the(machined and modified surfaces) placed in the posterior maxilla integrated when the surgicalposterior maxilla integrated when the surgical technique was modified by under preparationtechnique was modified by under preparation and partial tapping of the osteotomy sites ,and partial tapping of the osteotomy sites , implying that if primary stability is obtained,implying that if primary stability is obtained, osseointegration is possible irrespective of theosseointegration is possible irrespective of the surface.surface. www.indiandentalacademy.comwww.indiandentalacademy.com
  117. 117. Implants placed in fresh extraction sitesImplants placed in fresh extraction sites The rationale proposed for implant placementThe rationale proposed for implant placement in fresh extraction sites was to preserve softin fresh extraction sites was to preserve soft tissue esthetics and to further reduce thetissue esthetics and to further reduce the treatment time and associated costs bytreatment time and associated costs by avoiding an intermediate stage of removableavoiding an intermediate stage of removable denture wear. The conclusions that can bedenture wear. The conclusions that can be reached from these studies are limited becausereached from these studies are limited because of the study design, short follow-up times in theof the study design, short follow-up times in the majority of reports, and lack of site specificmajority of reports, and lack of site specific outcomes.outcomes. www.indiandentalacademy.comwww.indiandentalacademy.com
  118. 118. Furthermore, not all extraction sockets wereFurthermore, not all extraction sockets were used as implant sites since, in some situations,used as implant sites since, in some situations, the extraction site was obliterated due tothe extraction site was obliterated due to surgical reduction of the residual ridge, not allsurgical reduction of the residual ridge, not all studies stated clearly how the extraction sitesstudies stated clearly how the extraction sites were managed, making comparison difficult.were managed, making comparison difficult. Within these limitations, the studies suggestedWithin these limitations, the studies suggested that success was not compromised bythat success was not compromised by placement in extraction sockets as long asplacement in extraction sockets as long as primary stability was achieved. Nevertheless,primary stability was achieved. Nevertheless, success was reduced when implants weresuccess was reduced when implants were placed in morphologically compromisedplaced in morphologically compromised jawbone sites.jawbone sites. www.indiandentalacademy.comwww.indiandentalacademy.com
  119. 119. To conclude, these short to medium termTo conclude, these short to medium term studies suggested that implant placementstudies suggested that implant placement should be restricted to extraction sitesshould be restricted to extraction sites without a history of periodontal diseaseswithout a history of periodontal diseases and limited to the anterior mandible,and limited to the anterior mandible, Further long term clinical research isFurther long term clinical research is required to support these observations torequired to support these observations to determine the efficacy of a similar protocoldetermine the efficacy of a similar protocol in other jawbone sites.in other jawbone sites. www.indiandentalacademy.comwww.indiandentalacademy.com
  120. 120. Single Implant StudiesSingle Implant Studies The studies of single implant-supportedThe studies of single implant-supported prostheses reported good treatment outcomes.prostheses reported good treatment outcomes. Low success rates were reported with implantLow success rates were reported with implant placement in fresh extraction sites, which mayplacement in fresh extraction sites, which may have been compromised by the presence ofhave been compromised by the presence of infection. The reasons for tooth extractioninfection. The reasons for tooth extraction included trauma, retained root and rootincluded trauma, retained root and root resorption, and non restorable crowns.resorption, and non restorable crowns. Contraindications are active periodontal andContraindications are active periodontal and per apical infection, suggesting that placementper apical infection, suggesting that placement of implants in fresh extraction sites should beof implants in fresh extraction sites should be avoided in clinical situations with ongoingavoided in clinical situations with ongoing inflammatory processes.inflammatory processes. www.indiandentalacademy.comwww.indiandentalacademy.com
  121. 121. There were failures as well as success withThere were failures as well as success with occclusal and non-occlusal loadingoccclusal and non-occlusal loading suggesting that studies are required tosuggesting that studies are required to conclusively determine the role ofconclusively determine the role of occlusion in these clinical situations. Sameocclusion in these clinical situations. Same is true in relation to bone quality.is true in relation to bone quality. www.indiandentalacademy.comwww.indiandentalacademy.com
  122. 122. IMMEDIATE LOADING OF IMPLANTS WITHIMMEDIATE LOADING OF IMPLANTS WITH OVERDENTURE PROSTHESISOVERDENTURE PROSTHESIS Implant retained overdentures proved to be aImplant retained overdentures proved to be a predictable and effective method in thepredictable and effective method in the management of edentulous patients. In earlymanagement of edentulous patients. In early progressive loading, the dentures are not wornprogressive loading, the dentures are not worn for 1 to 2 weeks, or else worn, but completelyfor 1 to 2 weeks, or else worn, but completely relieved from the healing abutment. Typically,relieved from the healing abutment. Typically, the prosthesis is then relined for 3 to 4 monthsthe prosthesis is then relined for 3 to 4 months when the definitive prosthesis and attachmentswhen the definitive prosthesis and attachments (ball or bar assembly) are connected.(ball or bar assembly) are connected. www.indiandentalacademy.comwww.indiandentalacademy.com
  123. 123. In early functional loading, the dentures are notIn early functional loading, the dentures are not worn for 2 weeks or are relined after surgery.worn for 2 weeks or are relined after surgery. The retentive components (ball attachments)The retentive components (ball attachments) are then connected within 3 weeks.are then connected within 3 weeks. In immediate early functional loading, theIn immediate early functional loading, the retentive attachments are connected within 5retentive attachments are connected within 5 days. In this, the retentive components are adays. In this, the retentive components are a bar/clip assembly.bar/clip assembly. www.indiandentalacademy.comwww.indiandentalacademy.com
  124. 124. Studies have suggested that implants shouldStudies have suggested that implants should be splinted together with ,1 bar within a shortbe splinted together with ,1 bar within a short period of time to prevent axial rotation andperiod of time to prevent axial rotation and implant micro motion. However, other studiesimplant micro motion. However, other studies have used fewer implants (minimum of 2) thathave used fewer implants (minimum of 2) that were left exposed and unsplinted after an initialwere left exposed and unsplinted after an initial healing phase of 2 to 3 weeks. Therefore, ithealing phase of 2 to 3 weeks. Therefore, it would be argued that splinting of implants is notwould be argued that splinting of implants is not a definite requirement for osseointegration witha definite requirement for osseointegration with these protocols in the anterior mandible.these protocols in the anterior mandible. However, it should be noted that healing wasHowever, it should be noted that healing was unobstructed for the first couple of weeks andunobstructed for the first couple of weeks and led to a high success rate with such protocols.led to a high success rate with such protocols. www.indiandentalacademy.comwww.indiandentalacademy.com
  125. 125. In most of these studies, the loading wasIn most of these studies, the loading was progressive, with the next stage involvingprogressive, with the next stage involving relining for a few weeks. Final attachment and,relining for a few weeks. Final attachment and, presumably, full functional loading typicallypresumably, full functional loading typically progressed within 3 to 4 months, while othersprogressed within 3 to 4 months, while others constructed the frameworks within 2 to 3 week.constructed the frameworks within 2 to 3 week. The peri-implant soft tissues appeared to beThe peri-implant soft tissues appeared to be comparable to conventional protocols and didcomparable to conventional protocols and did not compromise implant outcomes. However,not compromise implant outcomes. However, others observed a change in the mucosa,others observed a change in the mucosa, mainly describing it as soft-tissue shrinkage.mainly describing it as soft-tissue shrinkage. This suggests that a period of soft tissueThis suggests that a period of soft tissue healing, along with a change, is to be expectedhealing, along with a change, is to be expected following surgery.following surgery. www.indiandentalacademy.comwww.indiandentalacademy.com
  126. 126. It is, therefore, safe to assume that time shouldIt is, therefore, safe to assume that time should be allowed for optimal soft tissue health. If not,be allowed for optimal soft tissue health. If not, it could be hypothesized that the denturesit could be hypothesized that the dentures would require relining to maintain the bestwould require relining to maintain the best possible adaptation of the prosthesis to thepossible adaptation of the prosthesis to the tissue. Peri-implant bone behavior wastissue. Peri-implant bone behavior was observed with intraoral radiographs orobserved with intraoral radiographs or panoramic radiographs corrected forpanoramic radiographs corrected for magnification. The observed bone loss wasmagnification. The observed bone loss was with in 0.2 mm / year and immediate loadingwith in 0.2 mm / year and immediate loading was not a high risk factor for early or latewas not a high risk factor for early or late marginal bone loss when compared tomarginal bone loss when compared to conventional loading protocols.conventional loading protocols. www.indiandentalacademy.comwww.indiandentalacademy.com
  127. 127. CONCLUSIONS ON IMMEDIATELYCONCLUSIONS ON IMMEDIATELY ANDAND EARLY LOADING PROTOCOLSEARLY LOADING PROTOCOLS Patients should be healthy or a controlled medical condition Cigarette smokingCigarette smoking Primary stability of the implant is an underlyingPrimary stability of the implant is an underlying for predictable results. Primary stability isfor predictable results. Primary stability is virtually guaranteed with screw shaped implantvirtually guaranteed with screw shaped implant in the anterior mandible and in other jaw sites.in the anterior mandible and in other jaw sites.www.indiandentalacademy.comwww.indiandentalacademy.com
  128. 128. However a modified surgical protocol mayHowever a modified surgical protocol may improve the success likeimprove the success like 1.avoiding /reducing bone tapping of the1.avoiding /reducing bone tapping of the osteotomy site or tapping. osteotomies sites inosteotomy site or tapping. osteotomies sites in dense bone only;dense bone only; 2.avoiding countersinking or limiting it to2.avoiding countersinking or limiting it to cancellous bone conditionscancellous bone conditions 3.engaging both cortices where available to3.engaging both cortices where available to provide bicortical stabilizationprovide bicortical stabilization 4.performing under preparation of the osteotomy4.performing under preparation of the osteotomy site using narrower twist drills or the osteotomesite using narrower twist drills or the osteotome 5. using wider implant when primary stability was5. using wider implant when primary stability was not obtained with the initial implantnot obtained with the initial implant www.indiandentalacademy.comwww.indiandentalacademy.com
  129. 129. It is tempting to propose that in the anteriorIt is tempting to propose that in the anterior mandible, the traditional protocol may suffice,mandible, the traditional protocol may suffice, whereas a modified surgery may be advisablewhereas a modified surgery may be advisable for other sites. Also the minimum implant lengthfor other sites. Also the minimum implant length of 10 mm is necessary for immediate and earlyof 10 mm is necessary for immediate and early loading protocol but further studies are requiredloading protocol but further studies are required on this aspect. Atleast 4 implants should beon this aspect. Atleast 4 implants should be placed in the edentulous anterior mandible toplaced in the edentulous anterior mandible to support a fixed prosthesis. Caution is requiredsupport a fixed prosthesis. Caution is required with a fewer number of implants due towith a fewer number of implants due to potential complete prosthodontic failure if onepotential complete prosthodontic failure if one implants fails to osseointegrate..implants fails to osseointegrate.. www.indiandentalacademy.comwww.indiandentalacademy.com
  130. 130. Studies suggest that to achieve predictableStudies suggest that to achieve predictable result in extraction sites, implant placementresult in extraction sites, implant placement should be restricted to sites without a history ofshould be restricted to sites without a history of perio­dontal involvement. Finally, the marginalperio­dontal involvement. Finally, the marginal bone loss measured, irrespective of prosthesisbone loss measured, irrespective of prosthesis design was of the same magnitude asdesign was of the same magnitude as presented for the conventional load­ingpresented for the conventional load­ing approachapproach www.indiandentalacademy.comwww.indiandentalacademy.com
  131. 131. DISCUSSIONDISCUSSION The requisites for predictable osseointegrationThe requisites for predictable osseointegration of immediately loaded implants have yet to beof immediately loaded implants have yet to be determined. One parallel consideration isdetermined. One parallel consideration is whether provisional loading of a tissue bornewhether provisional loading of a tissue borne prosthesis over an implant during theprosthesis over an implant during the osseointegration (healing) period will affect theosseointegration (healing) period will affect the integration of that implant. To date there is nointegration of that implant. To date there is no scientific evidence (and no clearly documentedscientific evidence (and no clearly documented subjective clinical evidence ) that early failure ofsubjective clinical evidence ) that early failure of dental implant can be attributed to early -dental implant can be attributed to early -www.indiandentalacademy.comwww.indiandentalacademy.com
  132. 132. -loading or overload resulting from a tissue--loading or overload resulting from a tissue- supported interim prosthesis being worn over asupported interim prosthesis being worn over a recently placed dental implant. Loading ofrecently placed dental implant. Loading of implant through the use of an interimimplant through the use of an interim restoration has not been documented as arestoration has not been documented as a cause of early implant failure. It is also safe tocause of early implant failure. It is also safe to state that, at this time , there is no scientificstate that, at this time , there is no scientific evidence that the factor associated with implantevidence that the factor associated with implant restoration (provisional or restorative) have arestoration (provisional or restorative) have a predictable impact on the survival of thepredictable impact on the survival of the supporting implant.supporting implant. www.indiandentalacademy.comwww.indiandentalacademy.com
  133. 133. This apparent lack of effect may be deceiving, inThis apparent lack of effect may be deceiving, in that very real determinants of implant successthat very real determinants of implant success or failure are likely to be related directly to theor failure are likely to be related directly to the prosthodontic aspects of the treatment.prosthodontic aspects of the treatment. Unfortunately, those as yet unidentifiedUnfortunately, those as yet unidentified determinants are hidden from the view ofdeterminants are hidden from the view of clinicians.clinicians. www.indiandentalacademy.comwww.indiandentalacademy.com
  134. 134. Immediate post insertion impressions andImmediate post insertion impressions and modelmodel 1. Placement of transfer coping and cap1. Placement of transfer coping and cap 2. Direct bone impressioning2. Direct bone impressioning 3. Place the sealing screw3. Place the sealing screw 4. Inter occlusal arch registration4. Inter occlusal arch registration www.indiandentalacademy.comwww.indiandentalacademy.com
  135. 135. 5. Post insertion soft tissue procedure5. Post insertion soft tissue procedure 6. Final closure – suturing6. Final closure – suturing 7. Provisional prosthesis option7. Provisional prosthesis option Flipper optionFlipper option Bonded tooth optionBonded tooth option www.indiandentalacademy.comwww.indiandentalacademy.com
  136. 136. www.indiandentalacademy.comwww.indiandentalacademy.com
  137. 137. www.indiandentalacademy.comwww.indiandentalacademy.com
  138. 138. BONDED TOOTH OPTIONBONDED TOOTH OPTION www.indiandentalacademy.comwww.indiandentalacademy.com
  139. 139. Post Insertion Home Care InstructionsPost Insertion Home Care Instructions 1.Trauma1.Trauma 2. Prophylactic antibiotic medication2. Prophylactic antibiotic medication 3. Comfort medication3. Comfort medication 4. Cleanliness4. Cleanliness 5. Diet/Function5. Diet/Function www.indiandentalacademy.comwww.indiandentalacademy.com
  140. 140. PROGRESSIVPROGRESSIV EE BONEBONE www.indiandentalacademy.comwww.indiandentalacademy.com
  141. 141. CONTENTSCONTENTS 1. INTRODUCTION1. INTRODUCTION 2. PRORESSIVE BONE LOADING PROTOCOL2. PRORESSIVE BONE LOADING PROTOCOL 3. PHASES OF PROGRESSIVE BONE3. PHASES OF PROGRESSIVE BONE LOADINGLOADING 4. PROGRESSIVE BONE LOADING4. PROGRESSIVE BONE LOADING APPOINTMENT SEQUENCE FORAPPOINTMENT SEQUENCE FOR CEMENT RETAINED PROSTHESISCEMENT RETAINED PROSTHESIS www.indiandentalacademy.comwww.indiandentalacademy.com
  142. 142. INTRODUCTIONINTRODUCTION The surgical and prosthetic protocols for aThe surgical and prosthetic protocols for a predictable direct bone-to-implant interface withpredictable direct bone-to-implant interface with root form implants were developed androot form implants were developed and reported by Branemark. However, to reducereported by Branemark. However, to reduce early implant failure, attention must be broughtearly implant failure, attention must be brought to the strength of the bone-to-implant interfaceto the strength of the bone-to-implant interface during early implant loading.during early implant loading. Once an initialOnce an initial direct bone-to-implant interface has beendirect bone-to-implant interface has been obtained and confirmed at the posthealingobtained and confirmed at the posthealing Stage II surgery, the implant is most at risk forStage II surgery, the implant is most at risk for failure or crestal bone loss within the first year.failure or crestal bone loss within the first year.www.indiandentalacademy.comwww.indiandentalacademy.com
  143. 143. This occurs primarily as a result of excessiveThis occurs primarily as a result of excessive stress and/or poor bone strength at thestress and/or poor bone strength at the interface. If the treatment plan is satisfactory forinterface. If the treatment plan is satisfactory for adequate support, the three most commonadequate support, the three most common causes of early prosthetic-related implantcauses of early prosthetic-related implant failure are non passive superstructures,failure are non passive superstructures, partially unretained restorations, and loading ofpartially unretained restorations, and loading of the implant support system beyond the strengththe implant support system beyond the strength of the bone-to-implant interface. The concept ofof the bone-to-implant interface. The concept of progressive or gradual bone loading was firstprogressive or gradual bone loading was first proposed during prosthetic reconstruction toproposed during prosthetic reconstruction to decrease crestal bone loss and early implantdecrease crestal bone loss and early implant failure of endosteal implants in 1980 on thefailure of endosteal implants in 1980 on the basis of empirical information.basis of empirical information. www.indiandentalacademy.comwww.indiandentalacademy.com
  144. 144. Over the years this was evaluated andOver the years this was evaluated and modified to incorporate time intervals, diet,modified to incorporate time intervals, diet, occlusion, prosthesis design and occlusalocclusion, prosthesis design and occlusal materials.materials. www.indiandentalacademy.comwww.indiandentalacademy.com
  145. 145. PRORESSIVE BONE LOADINGPRORESSIVE BONE LOADING PROTOCOLPROTOCOL www.indiandentalacademy.comwww.indiandentalacademy.com
  146. 146. TIMETIME The two surgical appointments used for initialThe two surgical appointments used for initial implant placement and Stage II uncovery areimplant placement and Stage II uncovery are separated by 4 to 8 months depending on theseparated by 4 to 8 months depending on the bone density at the initial surgerybone density at the initial surgery The macroscopic coarse trabecular bone healsThe macroscopic coarse trabecular bone heals approximatelyapproximately 50%50% faster tnan dense corticalfaster tnan dense cortical bone. However,D1 bone has the greatestbone. However,D1 bone has the greatest strength and greater bone contact so evenstrength and greater bone contact so even though it heals in a slower fashion, the bone tothough it heals in a slower fashion, the bone to implant contact at the interface is high andimplant contact at the interface is high and ofof lamellar type.lamellar type. www.indiandentalacademy.comwww.indiandentalacademy.com
  147. 147. Therefore the healing time between the initialTherefore the healing time between the initial and second stage surgeries is kept similar forand second stage surgeries is kept similar for D1 and D2 boneD1 and D2 bone A longer time is suggested for the initial healingA longer time is suggested for the initial healing phasephase of D3 anof D3 and D4 bone (6 and 8 months,d D4 bone (6 and 8 months, respectively) becauserespectively) because ofof the lesser bonethe lesser bone contact and decreased amount of cortical bonecontact and decreased amount of cortical bone An implant surgery may initially trigger anAn implant surgery may initially trigger an increase in the amount of bone in the region.increase in the amount of bone in the region. However, to improve the bone density andHowever, to improve the bone density and strength long term, the implant must be loaded.strength long term, the implant must be loaded. www.indiandentalacademy.comwww.indiandentalacademy.com
  148. 148. When multiple implants are used, the weakest bone area determines the gradual load protocol. www.indiandentalacademy.comwww.indiandentalacademy.com
  149. 149. DIETDIET The diet of the patient is controlled to preventThe diet of the patient is controlled to prevent overloading during the early phases of theoverloading during the early phases of the restorative-phaserestorative-phase The patient is limited to a soft diet such asThe patient is limited to a soft diet such as pasta and fish, from the initial transitionalpasta and fish, from the initial transitional prosthesis delivery until the initial delivery of theprosthesis delivery until the initial delivery of the final prosthesis. The masticatory force for thisfinal prosthesis. The masticatory force for this type of food is approximately 10 pounds/in oftype of food is approximately 10 pounds/in of force.force. www.indiandentalacademy.comwww.indiandentalacademy.com
  150. 150. This not only minimizes the masticatory forceThis not only minimizes the masticatory force on the implants but also decreases the risk ofon the implants but also decreases the risk of temporary restoration fracture or partiallytemporary restoration fracture or partially uncemented restoration.uncemented restoration. After the initial delivery of the final prosthesis,After the initial delivery of the final prosthesis, the patient may include meat in the diet, whichthe patient may include meat in the diet, which requires approximately 21 pounds/in sq. biterequires approximately 21 pounds/in sq. bite force. The final restoration can bear the greaterforce. The final restoration can bear the greater force without risk of fracture or uncementation.force without risk of fracture or uncementation. After the final evaluation appointment, theAfter the final evaluation appointment, the patient may include raw vegetables into thepatient may include raw vegetables into the diet.diet. www.indiandentalacademy.comwww.indiandentalacademy.com
  151. 151. It takes 27 pounds/ in sq. force to chew a rawIt takes 27 pounds/ in sq. force to chew a raw carrot. A normal diet is permitted after the finalcarrot. A normal diet is permitted after the final prosthesis function, occlusion and properprosthesis function, occlusion and proper cementation are evaluated.cementation are evaluated. OCCLUSAL MATERIALOCCLUSAL MATERIAL The occlusal material may be varied toThe occlusal material may be varied to gradually load the bone-to-implant interface.gradually load the bone-to-implant interface. During initial steps there is no occlusal materialDuring initial steps there is no occlusal material over the implant. During subsequentover the implant. During subsequent appointments, acrylic is used as the occlusalappointments, acrylic is used as the occlusal material, with the benefit of a lower impactmaterial, with the benefit of a lower impact force than metal or porcelain.force than metal or porcelain. www.indiandentalacademy.comwww.indiandentalacademy.com
  152. 152. Either metal or porcelain can be used for theEither metal or porcelain can be used for the occlusal aspect of the final prosthesis. Ifocclusal aspect of the final prosthesis. If parafunction or cantilever length causeparafunction or cantilever length cause concern, the softer diet and acrylic restorationconcern, the softer diet and acrylic restoration phase may be extended several months.phase may be extended several months. OCCLUSIONOCCLUSION The occlusal contacts are gradually intensifiedThe occlusal contacts are gradually intensified during prosthesis fabrication. There are noduring prosthesis fabrication. There are no occlusal contacts during initial healing. The firstocclusal contacts during initial healing. The first transitional prosthesis is left out of occlusion intransitional prosthesis is left out of occlusion in partially edentulous patients.partially edentulous patients. www.indiandentalacademy.comwww.indiandentalacademy.com
  153. 153. The occlusal contacts are then similar to thoseThe occlusal contacts are then similar to those of the final restoration for areas supported byof the final restoration for areas supported by implants. However, there are no occlusalimplants. However, there are no occlusal contacts on any cantilevers.contacts on any cantilevers. The occlusal contacts of the final restorationThe occlusal contacts of the final restoration follow the IPO concepts.follow the IPO concepts. The occlusal contacts are very important toThe occlusal contacts are very important to address because parafunction is common andaddress because parafunction is common and generates greater stresses in magnitude andgenerates greater stresses in magnitude and duration than eating food.duration than eating food. www.indiandentalacademy.comwww.indiandentalacademy.com
  154. 154. PROSTHESIS DESIGNPROSTHESIS DESIGN During initial healing, an attempt is made toDuring initial healing, an attempt is made to avoid any load on the implants, including softavoid any load on the implants, including soft tissue loads. The first transitional acrylictissue loads. The first transitional acrylic restoration in partially edentulous patients hasrestoration in partially edentulous patients has no occlusal contact and no cantilevers. It’sno occlusal contact and no cantilevers. It’s purpose is to splint the implants together, topurpose is to splint the implants together, to reduce stress by the biomechanical advantage,reduce stress by the biomechanical advantage, and to have implants sustain masticatory forcesand to have implants sustain masticatory forces solely from chewing. The second acrylicsolely from chewing. The second acrylic transitional restoration has occlusal contactstransitional restoration has occlusal contacts above implants with occlusal tables similar toabove implants with occlusal tables similar to the final restoration but no cantlevers in non-the final restoration but no cantlevers in non- esthetic regions.esthetic regions. www.indiandentalacademy.comwww.indiandentalacademy.com
  155. 155. The final restoration has final occlusalThe final restoration has final occlusal table and cantilevers and has occlusaltable and cantilevers and has occlusal contacts following IPO guidelines.contacts following IPO guidelines. www.indiandentalacademy.comwww.indiandentalacademy.com
  156. 156. GOOD MORNINGGOOD MORNING www.indiandentalacademy.comwww.indiandentalacademy.com
  157. 157. The progressive bone-loading appointmentThe progressive bone-loading appointment sequence for cement-retained prostheses issequence for cement-retained prostheses is as follows :as follows : 1. Initial abutment selection and preliminary1. Initial abutment selection and preliminary impressionimpression 2. Final impression and transitional prosthesis I2. Final impression and transitional prosthesis I 3. Metal superstructure try-in and transitional3. Metal superstructure try-in and transitional prosthesis IIprosthesis II 4. Initial insertion of final prosthesis4. Initial insertion of final prosthesis 5. Final delivery and evaluation5. Final delivery and evaluation www.indiandentalacademy.comwww.indiandentalacademy.com
  158. 158. FIRST APPOINTMENTFIRST APPOINTMENT Initial Abutment Selection and PreliminaryInitial Abutment Selection and Preliminary ImpressionsImpressions goal of this first prosthetic appointment is to assess the implant and soft tissues this appointment may occur during either the suture removal appointment after StageII surgery or during the uncovery procedure The Stage II permucosal extensions are removed by the restoring dentist, and straight abutments for cement retention or indirect impression transfers are inserted. www.indiandentalacademy.comwww.indiandentalacademy.com
  159. 159. The abutment for cement retention is placed with finger pressure and no torque wrench because of' the immature interface and also because the abutment will be removed at the end of this appointment. If abutments diverge more than 30 degrees, the preliminary impression will be very difficult to remove from the mouth The occlusal plane is also corrected to the proper curves of Wilson and Spee at this appointment hefore the impressions as indicated. www.indiandentalacademy.comwww.indiandentalacademy.com
  160. 160. The abutments for cement are removed, implant body analogs are attached, and the abutments are inserted into the corresponding position within the impression. The low-profile permucosal healing caps are reinserted into the implant bodies. An occlusal bite registration is made in centric relation occlusion. The patient is dismissed, with instructions not to chew in the region and to gently brush the permucosal extensions with chlorhexidine. www.indiandentalacademy.comwww.indiandentalacademy.com
  161. 161. www.indiandentalacademy.comwww.indiandentalacademy.com
  162. 162. LABORATORY PHASE ILABORATORY PHASE I pour the impression and attached analogs with dental stone mounted to the opposing arch with the bite registration The implant abutments are prepared for height, parallelism, and position within the prosthesis contours. www.indiandentalacademy.comwww.indiandentalacademy.com
  163. 163. www.indiandentalacademy.comwww.indiandentalacademy.com
  164. 164. Two transitional acrylic prostheses may then be fabricated. Ideally, for partially edentulous patients, the first transitional restoration is completely out of occlusion. www.indiandentalacademy.comwww.indiandentalacademy.com
  165. 165. SECOND APPOINTMENTSECOND APPOINTMENT Final Impression and Transitional Prosthesis IFinal Impression and Transitional Prosthesis I The patient returns after 1 to 4 weeks, depending on the bone density. The permucosal extensions are removed from the implant bodies. A one-piece straight abutment is used for multiple abutment restorations when possible. An anaerobic setting sealer is used on the abutment screw, and the abutment is hand-threaded into position with approximately 10 N-cm force. www.indiandentalacademy.comwww.indiandentalacademy.com
  166. 166. The complete seating of the abutment is verified with a radiograph For a single tooth or angled implant, a two piece abutment is inserted using a counter torque system and torque wrench to preload the abutment screw at a 20 to 35 N-cm force, depending on screw material and design. One-piece abutments do not need preload, as long as the preparation has one or two flat sides on the abutments to prevent unthreading or rotation within the prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  167. 167. Final abutment preparation is performed at this appointment. The transitional prosthesis may also be relined to create an emergence profile below the tissue, if necessary. Another alternative is to remove the abutment, place it into an implant analog, and prepare it out of the mouth. The margins of the restoration may be extended to the abutment margin and develop the emergence profile of the final crown. An impression may then be made of the abutment, and a separate die may be poured in dental stone. www.indiandentalacademy.comwww.indiandentalacademy.com
  168. 168. The abutment post is reinserted into the implant body and tightened to 10 N-cm6 (with anaerobic cement). A final impression is obtained. The centric occlusal registration is recorded with a closed mouth centric position when centric relation is harmonious with centric occlusion. The closed mouth centric recording reduces the need for an exact face-bow and hinge-axis location. An earbow/face-bow record is made, along with protrusive and check bites when required. www.indiandentalacademy.comwww.indiandentalacademy.com
  169. 169. www.indiandentalacademy.comwww.indiandentalacademy.com
  170. 170. The first transitional prosthesis is luted with a non eugenol zinc oxide cement, and there is a total absence of occlusal contacts . Petroleum jelly may be added to the cement when the restoration is very retentive, to facilitate the transitional prosthesis retrieval at the next appointment. LABORATORY PHASE IILABORATORY PHASE II Porcelain fracture is more common on implants than teeth, and unsupported porcelain is more common on small diameter implant abutments. www.indiandentalacademy.comwww.indiandentalacademy.com
  171. 171. A full-contour wax-up and cut down of 2 mm in regions of porcelain is made for the prosthesis framework. A precious metal superstructure is fabricated. An occlusal acrylic index is also fabricated www.indiandentalacademy.comwww.indiandentalacademy.com
  172. 172. THIRD APPOINTMENT Metal Try-inTHIRD APPOINTMENT Metal Try-in The patient returns in 1 to 4 weeks (or more) depending on the bone density. The first transitional restoration is removed The metal superstructure is tried-in. The centric relation can be checked. If the patient bites into the laboratory occlusal acrylic index, the previous record was accurately registered. If incorrect, the occlusion is evaluated and corrected as indicated, and a closed mouth centric occlusal registration is recorded using a rigid addition silicone on top of the casting. www.indiandentalacademy.comwww.indiandentalacademy.com
  173. 173. The second transitional prosthesis is delivered This may be a new transitional prosthesis or the first transitional with a modified occlusal table through the addition of acrylic on the occlusal contact areas. Occlusion is evaluated using a heavy bite force occlusal adjustment. Occlusal contacts are limited to those directly on Implant bodies. The diet remains soft with pasta, fish, or softer food types. www.indiandentalacademy.comwww.indiandentalacademy.com
  174. 174. www.indiandentalacademy.comwww.indiandentalacademy.com
  175. 175. LABORATORY PHASE IIILABORATORY PHASE III The prosthesis is completed with an occlusalThe prosthesis is completed with an occlusal scheme that follows IPO guidelines and withscheme that follows IPO guidelines and with occlusal contact, corresponding to the long axisocclusal contact, corresponding to the long axis of each implant body. The laboratory evaluatesof each implant body. The laboratory evaluates the first model of the preliminary impression.the first model of the preliminary impression. Angled implant bodies are noted, so theAngled implant bodies are noted, so the occlusal contacts may be modified to be in theocclusal contacts may be modified to be in the long axis of the implant body, or reduced inlong axis of the implant body, or reduced in intensity.intensity. www.indiandentalacademy.comwww.indiandentalacademy.com
  176. 176. FOURTH APPOINTMENTFOURTH APPOINTMENT Initial Prosthesis DeliveryInitial Prosthesis Delivery The next appointment follows 1 to 4 weeks later depending on the bone density The final restoration is inserted and carefully evaluated relative to occlusal contacts. After a light bite force is used to equilibrate the occlusal contacts, a heavy bite force occlusal adjustment is made, with no lateral contacts in excursions www.indiandentalacademy.comwww.indiandentalacademy.com
  177. 177. A radiograph is obtained and used as a baseline for future radiographic evaluation for crestal bone loss and implant health. If crestal bone loss is observed when compared with the Stage II uncovery appointment, parafunction is suspected, and night guards are fabricated to control stresses. The bone is now more mineralized and exhibits improved load-bearing capability than at the first transitional prosthesis delivery. www.indiandentalacademy.comwww.indiandentalacademy.com
  178. 178. www.indiandentalacademy.comwww.indiandentalacademy.com

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