Inplant based complete Denture

1. IMPLANTONCOMPLETEDENTUREPROSTHESIS
NORTH BENGAL DENTAL COLLEGE AND HOSPITAL

2. A prosthetic device or alloplastic material implanted into the oral
tissue beneath the mucosal or/and periosteal layer and/ or in the bone
to provide retention and support for the fixed and removable
prosthesis. - GPT
WHAT IS AN IMPLANT

3. PARTS OF AN IMPLANT
Implant components can be categorized as:-
1> Main component
I. Fixture
II. Abutment
III. Superstructure
2>ACCESSORIES
I. Surgical
II. Prosthetic

4. CLASSIFICATION OF IMPLANTS
 Endosteal
 Eposteal
 Transosteal
 Mucosal
1.Based on Their Location
2. DEPENDINGON EXPOSUREDURINGSURGERY
Submerged(two-stage surgery)
Nonsubmerged(one-stage surgery)

5. I. Edentulous patient
II. Partially edentulous patient with history of difficulty in wearingR.P.D.
III. Patient requiring long span F.P.D.treatment
IV. Patient who refuses wearing a removable prosthesis
V. Patient with severe changes in C.D.bearing tissues
VI. Poor oral muscular coordination
VII. Parafunctional habits that compromise prosthesis stability
VIII. Unrealistic patient expectation for complete denture
IX. Hyperactive gag reflex
X. Patient psycologically against removable prosthesis
XI. Unfavourable number and location of abutments
XII. Single tooth loss, avoid preparation of sound teeth
INDICATIONS OF IMPLANTS:-

6. ABSOLUTE CONTRA INDICATIONS:-
 High dose irradiated patients
 Patients with psychiatric problems
Systemic hematologic
disorders
Relative Contraindications:-
• Pathology of hard or soft tissues
• Recent extraction sites
• Patient with drug, alcohol or chewing tobacco
Low dose irradiated patient
CONTRAINDICATIONSOF IMPLANTA

8. Completely Edentulous Patient
TREATMENT OPTION
Conventional
Removal Denture
Implant Supported
Denture

9. Both fixed and removal dentures can be planned for
the completely edentulous patient.
1)Removal Prosthesis(overdenture)
2)Fixed Prosthesis
a)Full arch crowns/bridges
b)Fixed detachable bridge(hybridedenture)
A removable partial denture that covers and rests on
one or more remaining natural teeth,the roots of the
natural teeth, and/or dental implants.
OVER DENTURES
OVER DENTURE TREATMENT OPTION
Mandibular implant overdenture
Maxillary denture overdenture

10. MANDIBULAR IMPLANT OVERDENTURE
Mandibular implant overdentures are
more common because of the better quality
of bone in the anterior region.
Anterior placement is considered due to:-
I. Minimal anatomical concern
II. Optimal dentistry
III. Advantages in retention& stability
MAXILLARY IMPLANT OVERDENTURE
i. Maxillary implant overdentures require a
minimum of four implants splinted with a
bar attachment.
ii. This is due to the poor bone quality and the
lateral forces involved in that region

11. PARTS OF EDENTULOUS ARCHES
1) Anterior
2) RIGHT POSTERIOR
3) LEFT POSTERIOR

15. AIMSIN COMPLETELYEDENTULOUFPATIENTS
1. Maintain bone
2. Restore and maintain occlusal
vertical dimension
3. Maintain facial esthetics (teeth
positioned for appearance versus
facial
decreasing denture
movement )
4.Improve phonetics
5.Improve occlusion
6.Improve / regain oral
proprioception
7.Increase prosthesis success
8.Maintains muscle of
mastication and expression
9.Reduce size of prosthesis

16. •
MECHANISM OF IMPLANT BONE INTEGRATION
I. Fibro-Osseous Integration
II. Osseous Integration
KEY FACTORS IN OSSEOINTEGRATION:-
1. Implant material
2. Implant design
3. Surface area
4. Implant site
5. Implant surgery
6. Asepsis
7. Loading

17. MECHANISMOFOSSEOINTEGRATION:
First mechanism
• Integration occurs mainly through osteoconduction
• Connective tissue scaffolding
• Bone-producing cells( osteoblasts ) migrates
Second mechanism
• “de novo” bone formation wherein a mineralized interfacial matrix is
deposited along the implant surface
• Surface topography will determine the bond strength of bone to the
implant surface

18. Factors Affecting Osseointegration
1. Occlusal load
• - 2 stage implant insertion is advocated
• - overloading prematurely will cause failure
2. Biocompatibility of material
•
•
•
- commercially pure titanium
- commercially pure noibium
- hydroxyapetite
cylindrical
3. Implant design
• - most conducive -
4. Implant surface
• - mild surface roughness

19. Factors Affecting Osseointegration
5. Surgical site
• healthy site is required
6. Surgical technique
• minimum possible trauma
7. Infection control

20. 5

21. SURGICAL PHASE
ARMAMENTARIUM:-
I. Physiodispenser
II. Hand piece
III. Implant kit
IMPLANT PLACEMENT
Preoperative care
Sterilisation
Prevention of excess heat generation
Anesthesia& flap design
Preparing the osteotomy site
Placing the implant
Suturing
Postoperative care

22. Implant system broadly are of 2 types
Two stageOne stage
immediate
1. one piece implant system
implant body + prosthodontic
abutment
2. two piece implant system
implant system
prosthodontic abutment
Implantsurgery

23. INCISION AND FLAP DESIGN

24. Prosthesis fabrication
• Impression is necessary to transfer the
position and design of implant or abutment to
the master cast for prosthesis fabrication
• Transfer coping – used to position a dye in an
impression
Two types of transfer coping:-
1. direct transfer coping
2. indirect transfer coping

25. Laboratory fabrication
Analog –
• defined as something that is
analogous to something else.
• Analog is placed on the transfer coping and
the impression is poured

27. Edentulous maxilla
Edentulous mandible
Partially edentulous patients
◦ Multiunit restoration in post quadrants
◦ Single – tooth implants in post. Quadrants

28. ◦ Poor ridge form, conventional maxillary denture is
marginally stable.
◦ 2 or 4 implants will provide greater stability and security
of maxillary denture in function when the maxillary ridge
is severely resorbed and lacks resistance to lateral
forces.
◦ Intact mandibular anterior dentition but lacks posterior
Support. Implants in the maxilla can offset the
potentially destructive effects on the premaxillary region
when a mandible with natural anterior teeth and missing
posterior teeth opposes and edentulous maxilla.

29. If pt. Cannot tolerate palatal coverage.
◦ The palateless denture, which may enhance their
sensation of taste and texture or may simply provide a
psychological advantage.
◦ To inhibit gag reflex
◦ Large palatal tori
Then minimum of 4 implants with adequateA-P
spread allows the fabrication of an implant
assisted over denture without palatal coverage.

32. The maxillary sinus limits the height of bone
available for implant placement in the
posterior region. As a result, the A-P spread
is limited. If the A-P spread is inadequate to
provide support, a full-palatal-coverage
overlay denture is recommended.

33. Due to alveolar ridge resorption after tooth loss
in premaxillary region, the adequate support for
the upper lip is lacking.
Thus, in most pts. Its advisable to construct an
implant – assisted maxillary overdenture (not an
implant supported fixed prosthesis.)
Lower cost, improved hygiene access, and
predictable speech articulation benefits that favor
the use of an overlay denture in the edentulous
maxilla over an implant – supported fixed
prosthesis.

34. Implant-assisted overlay denture.
A, Clinical photograph of four-implant bar in the maxilla designed to retain a
palateless overlay denture.
B, Photograph of clip and attachment design of palateless overlay denture.
C, Cross-section of Hader bar clip attached to anterior bar (inset).
D, Axis of rotation and function of resilient attachment.

35. Mandibular complete denture is more
problematic as compared to maxilla
◦ Specially for pts. With severely resorbed atrophic
ridges
Lack of stability and retention
The 2 implant assisted over denture is the
best treatment for such patients

36. Place two implants in the anterior mandible
with a connecting bar.
One or two clips retain the denture over the
bar.
Fixed implant supported prosthesis require
4,5 or 6 implants arranged in an appropriate
arc of curvature with at least 1cm of A-P
spread.

37. Implant-assisted overlay denture.
A, Clinical view of overdenture in occlusion.
B, Photograph of mandibular overlay denture (tissue-bearing surface) designed
for an implant bar attached to two implants in the anterior mandible.
C, Clinical view of bar attached to two implants in the anterior mandible.
D, Illustration demonstrating how axis of rotation allows denture to rotate
around the bar.

38. Decreased performance of conventionalcomplete
dentures
• Bite force is decreasedfrom 200 psi to 50psi
• Masticatory efficiency isdecreased
• More drugs are required to treat gastrointestinaldisorders
• Food selection is limited
• Healthy food intake isdecreased

39. Implants for completedentures
1. maintain bone
2. restore and maintain occlusalvertical
dimension
3. maintain facial esthetics (teeth positionedfor
appearance versus
facial
decreasing denture movement)
4. Improve phonetics
5. Improve occlusion
6. Improve / regain oral proprioception
7. Increaseprosthesis success
8. Maintains muscle of masticationand
expression
9. Reducesizeof prosthesis
10.Improve stability and retention ofremovable
prosthesis
11.More permanentreplacement
12.More psychological health

48. ProstheticAttachment
Abutment
portion of the implant that supports or retains a prosthesis
or implant superstructure
Superstructure
metal framework that attaches to the implant abutment
and provides either retention for removable prosthesis
or framework for fixed prosthesis
prosthesis
superstructure
abutment
Implant body

49. Categories of implant abutment
based on method by which prosthesis or
superstructure is retained to the abutment
• Screw retention
• cement retention
• for attachment
• attachment device to retain a removable
prosthesis

50. Prosthetic coping is a thin covering usually designed to fit the
Implant abutment for screw retention
It serves as a connection between abutment and prosthesis or
superstructure

52. Implantsurgery
Two stage surgery
1st surgery
- implant body placed below the soft tissue
-
after initial bone healing has occurred
2nd surgery
-soft tissue are reflected
-permucosal element or abutment is attached
One stage surgery
1st surgery
-implant and permucosal element placed
after initial bone healing has occurred
abutment replaces the permucosal element without
reflection of flap

53. Prosthesis screw
coping
Analog
A)implant body
B) abutment
Transfer coping
A) direct
B) indirect
Hygiene screw
Abutment
A) for screw retentin
B) for cement retention
C) for attachment
Second stage permucosal extension
or healing abutment
First stage cover screw
Implant body

54. PROSTHETIC OPTIONS IN IMPLANT
DENTISTRY

55. Types of prosthesis can be given
•
•
1. fixed
2. removable
FP 1 : Fixed prosthesis
•
•
Replaces only crown
Looks like natural tooth

56. Types of prosthesis can be given…
portion
• FP – 2 :
• fixed prosthesis
replaces crown and
of root
• hyper-contoured gingival half

57. Types of prosthesis can be given…
• FP – 3 : Fixed prosthesis
• Replaces missing crown
,gingival color and portion of
edentulous site

58. Types of prosthesis can be given…
RP – 4
• Removable prosthesis
Overdenture supported
completely by implant

59. Types of prosthesis can be given…
RP – 5 :
• Removable
prosthesis,
overdenture
supported
both by soft
tissue and
implant

60. Dental examination
Bone density classification
Dense cortical (D1) bone
• Highest bone implant
contact (BIC) > 80%
• Anterior region of mandible very
dense compact bone

61. Dental examination…
• Dense to thick porous
cortical and coarse
trabecular bone (D2)
• BIC = 70%
5. Dense to porous compact
bone on the outside and
coarse trabecular bone on
the inside
6. Anterior and posterior
mandible

62. Dental examination…
• Thin porus cortical and fine
trabecular bone (d3)
BIC = 50 %
4. Thinner porous compact bone
and fine trabecular bone
6. Anterior or posterior maxilla
and posterior mandible
8. Implants coated with
hydroxyapatite are indicated

65. •

66. Posterior Single Tooth Implant

68. Age Limitations
• Growth and
development may
be affected by an
implant as it may act
as an ankylosed
tooth.
• As a general rule,
implant insertion is
delayed for female
patient till atleast 15
years and in male
patients until 18 yrs
of age.

69. Mesio-distal Space
• A traditional 2 piece implant
Should be atleast 1.5mm from
an adjacent tooth. When the
implant is closer than this, any
bone loss will cause the
implant and the adjacent
tooth to lose bone rapidly.
• This will compromise the inter-
proximal aesthetics and
sulcular health of the implant
and the natural teeth.

70. Bone height
• The ideal mid-crestal position of the edentulous site should be 2mm apical
from the facial CEJ of the adjacent teeth.
• When the bone crest is above this, a bone graft procedure may be
performed.
•The inter-proximal
bone should be
scalloped 3mm more
incisal than the
mid-crestal position.

71. Challenging Aesthetics
• Cross sections of teeth are not round and are often larger in
facio-palatal dimensions.
• The cervical emergence profile of a crown on a round implant
needs to be created prosthetically.

76. Do implant retained or supported dentures improved
masticatory performance???
-Fueki K, Kimoto K, Ogawa T, Garrett NR…...
Conclusions
• While a number of studies on masticatory performance have
been conducted in patients with various designs of implant-
supported or retained dentures, high-level evidence
supporting advantages in masticatory performance of
implant-supported or retained dentures over conventional
dentures is limited.

77. Do implant retained or supported dentures improved
masticatory performance???
-Fueki K, Kimoto K, Ogawa T, Garrett NR…...
• Moreover, two RCTs that compared IOD with new complete dentures
concluded that IOD enhanced the masticatory improvement compared
with conventional complete dentures. This difference reached statistical
significance at 1 year follow-up.
• In conclusion, subjects with low ridge or severe ridge resorption profit
from implant-supported overdentures by increased masticatory
performance and totally edentulous patients profit from fixed implant-
supported complete denture from a masticatory point of view in general.
• Finally, it must be kept in mind that masticatory performance based on
the ability of the subjects to chew hard food is only a part of oral health
related quality of life. Other factors such as, satisfaction with treatment
and oral confidence of the subjects also play a major role.

78. Recent Advances

79. Immediate Function Implants
• Today, modern implant design and the use of 3D CAT Scans allow
experienced dental professionals to insert the implants, and
immediately place the new teeth on the implants. Research has
shown that when properly applied, this one-stage approach results in
as good or better implant success rates as the traditional two-stage
approach.
• Benefits of Immediate Function
● Shortened treatment time (it is possible to go from tooth loss to
having functional
and aesthetic teeth in one treatment session),
● Better clinical efficiency,
● Greater patient comfort,
● The elimination of bone grafts and sinus lifts, and
● Patients always leave with teeth!

80. All – on – 4 Implant
• The All-on-4 Dental Implant Procedure uses four implants, with the back
implants angulated to take maximum advantage of existing bone.
• Special implants also were developed that could support the immediate
fitting of replacement teeth.
• This treatment is attractive to those with dentures or in need of full upper
and/or lower restorations.
• With the All-on-4 Procedure, qualified patients receive just four implants
and a full set of new replacement teeth in just one appointment—without
bone grafts!

81. •All four titanium implants are placed so that the bone will
grow around and secure them in place
•With only four implants, there is much less invasive and
lengthy surgery.

82. •Once the implants are in place, the Oral Surgeon attaches abutments to which the
new replacement teeth can be secured.
•The Prosthodontist fits the replacement teeth on the abutments and adjusts the
bite for comfort and a beautiful smile

83. Interdenatal Esthetics
• A number of cases show deficiency of papilla in the interdental
papilla between the implant or between implants and teeth, which
poses an esthetic problem.
• This is counteracted by injection of hyaluronic acid, commonly
available as Restylane.
• Its effect lasts for 6 – 24 months after which a new dose is
administered.

84. Conclusion
•

85. References
• Contemporary implant dentistry- Carl Misch
• Osseointegration and occlusal rehabilitation- Sumiya Hobo
• J Prosthet Dent. 2007 Dec; 98(6):470-7.