Recommended
More Related Content
Similar to progressive bone loading.pptx
Similar to progressive bone loading.pptx (20)
Recently uploaded
Recently uploaded (20)
progressive bone loading.pptx
- 1. Progressive bone loading Ashwini Narayankar Reader, Department of Prosthodontics S B Patil Dental college, Bidar
- 2. Progressive bone loading Bone density Bone implant interface Progressive bone loading protocol Procedure Partially edentulous arches Completely edentulous arches
- 3. • Crestal bone loss – in 1st year • 5.9% of implants restored were lost from the impression to initial delivery of the prosthesis • Root laboratory: statistics report on implant and prosthesis failure during the first year, 1992, Leawood, Kan
- 4. Bone density • Wolff’s law • Every change in the form and function of bones or of their function alone is followed by certain definite changes in their internal architecture, and equality definite alteration in their external confrontation, in accordance with mathematical laws
- 5. • Generalized loss of bone volume and density – tooth loss • Decreased microstrain • Orban B: Oral histology and embryology, 3rd edition, St Louis, 1953, Mosby, pp 87-104
- 6. • Bone cells sense mechanical load • Cell level strains are 10 times greater than tissue level strains • Cellular mechanism – membrane deformation, intracellular and extracelluar action • Cowin SC et al, bone remodeling I, theory of adaptive elasticity 1976;6:313:326
- 7. • Misch et al • D1 – 100% • D2 – 75% • D3 – 50% • D4 – 25%
- 8. Bone implant interface • Continuously loaded – stable • Lamellar bone • Highly organized • 1 yr to mineralize • Woven bone • Unorganized • Fastest • 16 wks – 70% mineralized
- 9. Progressive bone loading protocol • Increases density • Decreases failure • Decrease crestal bone loss Occlusal contacts Prosthesis design Occlusal material Diet Time
- 10. Time • Initial implant placement and stage II uncovery – 3 to 8 months • Healing time • D1 – 3 months • D2 – 4 months • D3 – 5 months • D4 – 6 months
- 11. Time • Gradual loading • D1 – 1 week • D2 – 2 weeks • D3 – 3 weeks • D4 – 4 weeks or more
- 12. Diet • Initial healing phase • Avoid chewing in that area • After uncovery • Soft diet – pasta and fish – 10psi • Initial delivery of prosthesis • Meat – 21psi • Final restoration • Raw vegetables – 27psi
- 13. Occlusal material • Initial steps – no occlusal material • Acrylic material
- 14. Occlusion • Initial healing – no occlusal contacts • Transitional prosthesis – out of occlusion • Final restoration – occlusal contacts
- 15. Prosthesis design • Initial healing – no load • 1st transitional prosthesis • No occlusal contact and no cantilevers • Splint implants – reduce stress • 2nd transitional prosthesis • Occlusal contacts on implants and not on cantilevers • Final restoration • Narrow occlusal table implant protective occlusion
- 16. Progressive loading phases • Stage II uncovery • Evaluate clinical mobility, bone loss, zones of attached gingiva, sulcus depth • Permucosal extension – 2mm • No loading
- 17. • Partially edentulous arch • Not to wear denture • Anteriors – 7 mm diameter hole • Completely edentulous arch • 5 mm diameter relieve • Tissue conditioner – few mm relieved
- 18. Procedure Final delivery and evaluation Initial abutment selection and primary impression Metal superstructure try in and transitional prosthesis II Initial insertion of final prosthesis Final impression and transitional prosthesis I
- 19. Step Procedure Diet Occlusal material Occlusal contacts 1 Healing abutments and primary impression Soft 0 0 2 Transitional prosthesis I , final impression Soft Acrylic P – none C – no cantilever 3 Transitional prosthesis II and metal try in Soft Acrylic Contacts on implants and not on cantilevers 4 Final prosthesis, adjust occlusion Harder Metal or porcelain Implant protected occlusion 5 Final prosthesis, cementation Harder Metal porcelain Narrow occlusal table
- 20. First appointment • Initial abutment selection and primary impression • Remove permucosal extension • Insert abutments or indirect impression transfers or direct impression transfer • Finger pressure
- 21. • Make impression – implant body analogs • Reinsert healing caps • Occlusal bite registration in centric relation • Instruction – not to chew in the region and brush with chlorhexidine
- 22. Laboratory phase I • Pour the impression • Mount it with opposing arch with bite • Prepare implant abutments for height, parallelism and position
- 23. • Fabricate first transitional prosthesis • Out of occlusion
- 24. Second appointment • Final impression and transitional prosthesis I • After 1 – 4 wks • Remove permucosal extension • Abutment screw – finger pressure – 10N/cm
- 25. • Radiograph • Final abutment preparation
- 26. • Final impression • Record centric relation registration • Face bow record
- 27. • Lute first transitional prosthesis with noneugenol zinc oxide cement with no occlusal contacts • Modified – petroleum jelly
- 28. • Instructions • Avoid that area while eating • Soft food
- 29. Laboratory phase II • Pour final impression • Mount models • Full contour wax up and cut down of 2 mm for porcelain • Metal superstructure • Occlusal index to indicate occlusal registration
- 30. Third appointment • Metal try in • 1 – 4 wks • Remove 1st transitional prosthesis • Metal superstructure is tried in • Verify centric relation with occlusal acrylic index • If not matching – new registration with addition silicone
- 31. • Second transitional prosthesis • New or modification of first • Modified occlusal table • Addition of acrylic resin on occlusal contact areas • No lateral excursive contacts
- 32. Laboratory phase II • Final prosthesis • Occlusal contacts in long axis of implant
- 33. Fourth appointment • Initial prosthesis delivery • 1 to 4 wks • Remove transitional prosthesis • Insert final restoration and evaluate • Occlusal adjustment with no occlusal contacts in excursions
- 34. • Radiograph as baseline • Harder food - meat
- 35. Fifth appointment • Final delivery and cementation • 4 weeks • Remove the prosthesis • Evaluate soft tissue condition • Cementation of the final prosthesis • Diet – hard foods – raw vegetables • Maintenance – 3 to 4 months
- 36. Completely edentulous patient Final delivery and evaluation Initial abutment selection and primary impression Metal superstructure try in and transitional prosthesis II Initial insertion of final prosthesis Final impression and transitional prosthesis I
- 37. First appointment • Initial abutment selection and primary impression • Treatment prosthesis – OVD • Clear template over treatment prosthesis • Bite registration to opposing arch • Insert abutments • Minor corrections
- 38. • Fill the template with addition silicone and make impression • Remove abutments, attach abutment analogs • Reinsert permucosal extension • And relieve soft liner
- 39. • Very soft food • Remove denture in night • Parafunction – major concern • Implants not splinted
- 40. Laboratory phase I • Pour primary impression • Mount the casts • Adjust implant length, angulations and clearance • Wax up using denture teeth • Clear template
- 41. • Transitional acrylic prosthesis • Using clear template • No posterior cantilever • Pontics – out of occlusion • Implant loaded axially • No posterior contacts during lateral excursions
- 42. • Occlusal rims over the abutments
- 44. Second appointment • Final impression and transitional prosthesis I • Remove permucosal extension • Insert final abutments • Clear template of final wax up is placed • Minor corrections
- 45. • Insert 1st transitional prosthesis • Make an final impression
- 46. • If not ideal • Occlusal rims are adjusted • Centric relation record is made • Anterior tooth shape and size is selected • Face bow record done • Non eugenol cement • Occlusal contacts • Diet – very soft
- 47. Laboratory phase II • Mount master cast using face bow record and occlusal registration • Index of incisal edge and facial tooth form of temporary or wax rim • Wax up of final restoration • Cut back of 2mm for porcelain • Metal framework • White wax to evaluate anteriors • Acrylic occlusal index to check OVD
- 48. Third appointment • Metal try in and transitional prosthesis II • Metal framework try in • Acrylic occlusal index – centric relation and OVD • White wax – evaluate anterior esthetics • Final crown contour and shade selection
- 49. • Modify first transitional prosthesis • Eliminate nonworking and working occlusal contacts • Softer diet
- 50. Fourth appointment • Initial delivery • 2 to 4 wks • Adjust final occlusion • Implants loaded axially • OPG and bite wing R/g • Hard food
- 51. Fifth appointment • Final delivery • 4 wks later • Improve difficult access for hygiene • Soft tissue health • No posterior contacts during lateral excursions • Zinc phosphate cement • Maintenance every 3 – 4 months
- 52. Clinical assessment Bone divisions Periotest values (PTV) D1 bone – uncovery After progressive loading Average PTV decrease -8 to -3 -8 to -4 <1 D2 bone - uncovery After progressive loading Average PTV decrease D3 bone - uncovery After progressive loading Average PTV decrease -5 to 0 -8 to 0 1 -3 to +1 -5 to 0 2 D4 bone - uncovery After progressive loading Average PTV decrease -2 to +6 -4 to +2 4
- 53. Crestal bone loss • Progressive bone loading • 2 months – 0.13 ± 0.05 mm • 4 months – 0.18 ± 0.10 mm • 6 months – 0.24 ± 0.12 mm • 12 months – 0.32 ± 0.16 mm • Control group • 2 months – 0.31 ±0.08 mm • 4 months – 0.35 ± 0.13 mm • 6 months – 0.41 ± 0.22 mm • 12 months – 0.47 ± 0.47 mm
- 54. References • Misch CE, dental implant prosthetics, 3rd edition, 2008, Elsevier publication, St. Louis, Missouri, pp 511 - 530 • Root laboratory: statistics report on implant and prosthesis failure during the first year, 1992, Leawood, Kan
- 55. • Orban B: Oral histology and embryology, 3rd edition, St Louis, 1953, Mosby, pp 87- 104 • Cowin SC et al, bone remodeling I, theory of adaptive elasticity 1976;6:313:326