Implant prosthetic dentistry

1. IMPLANT PROSTHETIC
DENTISTRY

2. Contents
Introduction
Implant Dentistry
Implant placement
Impressions
Implant prosthesis
Occlusion
Overdentures
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3. Why and when dental implants?
Replaces one or more teeth without affecting adjacent teeth.
Supports a crown/bridge and eliminates the need for a removable
partial denture.
Provide support for a denture, making it more secure and comfortable
Used for anchorage during orthodontic treatment
Bone maintenance of height and width
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4. Why and when dental implants?
Improved appearance. Dental implants look and feel like
your own teeth leading to improved self esteem/ improved
psychological health
Convenient to clean
Improved speech
Increased stability in chewing
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5. Why choose dental implants over dental
bridge?
No damage to adjacent teeth
Bone maintenance of height and width
In distal-end situation or multiple missing
teeth/long span edentulism
Complete edentulous situation
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6. Introduction to fixed prosthodontics
• Fixed prosthodontic treatment involves the
replacement and restoration of teeth by artificial
substitutes that are not readily removable from
the mouth.
• Its focus is to restore function, aesthetics, and
comfort.
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7. Implant Dentistry
• Implantology – A substance that is placed into the jaw to
support a crown or fixed or removable denture
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8. Implants
• Dental implant - An artificial titanium fixture which is
placed surgically into the jaw bone to substitute for a
missing tooth and its root(s).
• The implant is the endosteal dental implant that is placed
within the bone during stage I surgery.
• It may be either a threaded or nonthreaded cylinder.
• It is either titanium or titanium alloy, with SLA
(Sandblasted and acid-etched) treatment and then
hydroxyapatite is coated on the top or without
hydroxyapatite coating.
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9. 28/07/2018 9

10. Diagnosis and treatment planning in
Implant Dentistry
• Patient screening and medical evaluation
• General examination – Extra/Intraoral
• Classification of arches
• Bone evaluation
• Evaluation of natural teeth adjacent to implants
• Esthetic risk factors
• Diagnostic imaging
• Diagnostic casts
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11. Evaluation of patient’s medical history
• Smokers
• Diabetes
• Long-term steroid use
• Osteoporosis
• Other diseases
• Radiotherapy
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12. Bone evaluation
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13. Diagnostic tools
• Periapical radiograph
• Occlusal radiograph
• Orthopantomograph
• CBCT
• Cephalometric radiograph
• Computed Tomography
(3D)
• Magnetic resonance
imaging (3D)
• Interactive computed
tomography (3D)
• Photographs/Study models
• Main goals of presurgical
imaging
• Identify disease
• Determine bone quality
• Determine bone quantity
• Determine implant
position
• Determine implant
orientation
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14. Interactive computed tomography (3D)
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15. Types of dental implants
• Endosseous implant
• Subperiosteal implant
• Transmandibular implant
• Basal implants
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16. Osseointegration
The phenomenon of
osseointegration of titanium
implants was discovered by the
Swedish surgeon, Branemark in
1952.
Functional ankylosis (bone
adherence), where new bone is
laid down directly on the implant
surface and the implant exhibits
mechanical stability.
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17. Implant placement video
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18. 28/07/2018 18
Implant
placement
Two-stage Surgical
Protocol
Single-stage Surgical
Protocol

19. Two-stage Surgical Protocols
• The original protocol for placing modern osseointegrated
implants was two-stage (submerged) surgery, and it is still
widely used today.
• The implant is placed below the soft tissue and protected
from occlusal function and other forces during
osseointegration.
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20. Two-stage Surgical Protocols
• A low-profile Cover Cap is placed on the implant to protect
it from the ingress of soft tissue.
• Following osseointegration, a second surgery exposes the
implant and a transmucosal Healing Abutment is placed to
allow for soft tissue healing and development of a sulcus.
• Prosthetic restoration begins after soft tissue healing
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21. Single-stage Surgical Protocols
• Single-stage surgery leaves the implant/abutment
connection exposed to the oral cavity via an integrated
transmucosal element, or a removable Healing Abutment.
• This eliminates the need for a second surgery to expose
the implant.
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22. Single-stage Surgical Protocols
• Although the implant is not in occlusal function, some
forces can be transmitted to it through the exposed
transmucosal element.
• Prosthetic restoration begins following osseointegration of
the implant and soft tissue healing.
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23. Non-functional Immediate Restorations
• Single-stage surgery with non-functional immediate
restoration provides patients a non-occlusal provisional
prosthesis early in the treatment plan.
• An abutment may be placed on the implant at or shortly
after surgery, and a provisional restoration secured to it
with temporary cement.
• Alternatively, a screw-retained prosthesis may be
fabricated.
• The provisional can help contour the soft tissue profile
during healing.
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24. Immediate function restorations
• Single-stage surgery with immediate function is possible
in good quality bone where multiple implants exhibiting
excellent initial stability can be splinted together.
• Splinting implants together can offer a significant
biomechanical advantage over individual unsplinted
crowns.
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25. The following items only require hand-
tightening (approximately 10Ncm):
Surgical Cover Caps
Healing Abutments
Cover caps for the Abutment for Screw and all impression
coping screws
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26. Impressions in implant dentistry
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27. 28/07/2018 27

28. ACCURATE IMPRESSIONS
PROVIDE A FOUNDATION FOR
SUCCESSFUL IMPLANT
PROSTHODONTICS
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29. Impression materials ideal requirements
Complete plasticity before cure
Fluidity to record fine detail
Ability to wet oral tissues
Dimensional accuracy
Dimensional stability
Complete elasticity after cure
Optimal stiffness
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30. What is the benefits of Impression in
implant dentistry?
Position
Depth
Axis/Angulation
Rotation-Hex position
Soft Tissue Contour (Emergence Profile)
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31. 28/07/2018 31

32. Impression materials
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33. What you need to take an impression
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34. Classification of implant impression techniques
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Impression
techniques for
implants
Fixture level
Closed tray
technique
Open tray
technique
Abutment
level

35. Abutment level impression
• Prepared abutment
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36. Fixture / Implant level Impression
• Impressions are made of an implant using implant level
impression copings.
• To create a restoration for an implant, the laboratory
model needs to include an implant replica seated in the
model replicating the exact implant position in the
patient’s mouth.
• Such impressions can be made using an open tray or a
closed tray technique.
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37. Fixture/Implant level Closed Tray
Impression Technique
• During this
procedure, the
transfer
impression
coping is
screwed onto the
implant.
• A radiograph is
taken to ensure
proper seating of
the coping.
• If not seated
properly, the
position of the
implant in the
oral cavity
cannot be
exactly recorded
and replicated
onto the model
to be obtained.
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38. CLOSED TRAY TECHNIQUE
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1. Implant fixture 2.Copings attached to
the implant body
3. Polyvinylsiloxane
impression material is
injected around the
impression coping
4. Impression is made
with a heavy body
impression material.
5.Impression coping
removed from the
fixture
6.Coping placed in
the impression

39. Closed tray video
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40. Closed Tray Impression Technique
Advantages
Easier
Impression coping for closed tray are usually
shorter, making it easier for posterior areas and
for patients with limited mouth opening.
Less time for impression preparation: cutting
holes in the impression tray usually not needed
Impression cap type techniques.
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41. Closed Tray Impression Technique
Disadvantages
• Less accurate with multiple units.
• Some implant systems require more clearance
than other implant systems, therefore may still
necessitate cutting holes in the impression tray as
with the open tray technique, and as a result, may
be less accurate depending upon several factors.
• Positional timing error, depending upon the
impression coping design.
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42. Implant/fixture level Open Tray Technique:
• The open tray impression technique is one of the most
common impression methods used in the fabrication of
implant supported prosthesis.
• It is also called a pick up impression because the
impression coping is removed together with the
impression body after the impression material hardens.
• In this, the screw connecting the impression coping to the
fixture should be long enough to protrude from the
impression tray, which should have a hole; hence the
name open-tray technique.
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43. • A long-cone radiograph is almost always necessary to
confirm that the impression coping is fully seated and to
ensure absolute accuracy before any construction of the
crown begins.
• A polymeric standard stock tray may be used.
• It is relieved and perforated to allow full seating of the
tray and protrusion of the guide pins through it, due to
which the technique is termed as an open tray
technique.
• If there is a large opening, it may be closed off using a
baseplate wax, with the guide pins indenting or
perforating the wax.
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44. 28/07/2018 44

45. Open tray – Direct Pick-up Impression
Technique
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In the Open Tray Transfer technique, the Direct Pick-up
Copings remain in the impression when removed from the
mouth. For this pick-up technique a custom tray or modified
stock tray with screw access holes in the areas above the
implants is required.

46. Open tray impression technique
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Clinical 1 - Remove healing abutment
Clinical 2 - Place impression coping
Clinical 3 - Try-in impression tray

47. Open tray impression technique
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Clinical 4 - Make an impression
Clinical 5 - Remove coping screws

48. Open Tray Impression Technique
Indications
• Usually used for multiple units
• Use non hex (non engaging) impression copings if
implants are not in alignment
Splint together
• Durelay
• Wire/Durelay
Advantages
• More accurate for multi units
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49. Open Tray Impression Technique
Disadvantages
• More impression preparation and impression time
-Test fitting impression copings and cutting holes
for the impression copings
- Additional time to “unlock” the impression
copings
• Adequate mouth opening required.
• More possibility for gagging
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50. Open tray video
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51. My Fit Healing Abutment
(Innovative technique of impression developed by a friend of
mine who is a lab technician in South Korea)
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1. Installing the impression healing abutment in the
mouth

52. My Fit Healing Abutment
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2. Taking impression

53. Restorative options
• Cement-retained Restorations
• Cement-retained implant restorations are very
similar to crown & bridge restorations. A
prepared implant abutment is screwed onto the
implant.
• The crown or restoration is cemented to the
prepared abutment, much like a prepared tooth.
• Indications
• Single or multiple-unit implant restorations
• Totally edentulous or partially edentulous arch
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54. Restorative options
• Limitations
• Ease of retrievability
• Advantages
• Conventional crown & bridge procedures
• Maximum control of occlusion
• More esthetic than screw-retained Implant-level
Cement-retained Restorations
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55. Fixed implant supported restorations
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56. 28/07/2018 56

57. Fixed implant supported restorations
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58. Occlusion
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59. Introduction - Occlusion
• Occlusion is not defined solely as the
nature of occlusal contact between
opposing teeth but more broadly refers to
the dynamic relation between the teeth, the
neuromuscular system, the TMJ and their
interactive relationship on the craniofacial
environment.
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60. Occlusion
• Achieving proper occlusion for a patient is
as fundamental to success as function or
esthetics and is of paramount importance
when providing implant supported
prosthesis to the patient.
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61. Wide central fossa
Non steep slope of the
cusp
No contact on maximum
intercuspation
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62. Minimal Occlusal Goals
Bilateral simultaneous contact
No prematurities in retruded
contact position (RCP)
Smooth, even, lateral excursive
movements with no interferences
Equal distribution of occlusal
forces
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63. Additional Goals
Freedom from deflective
contacts in intercuspation
position
Anterior guidance
whenever possible.
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64. AIMS IN DESIGNING
IMPLANT OCCLUSION
Maximize occlusal
function.
Minimize harm to
opposing and
adjacent teeth.
Minimize wear of
occlusal surfaces
Minimize risk of
fracture of the
implant
superstructure.
Reduce the risk of
fracture of the
implant body and its
connecting
components.
Protect the implant
host interface.
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65. • Consequences of biomechanical overload
Implant occlusion
• Early implant failure
• Early crestal bone loss
• Intermediate to Late implant failure
• Intermediate to Late implant bone loss
• Screw loosening
• Cement debonding
• Component fracture
• Porcelain fracture
• Prosthesis fracture
• Periimplantitis (secondary to bone loss )
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66. • Then why we should have a different
occlusal consideration for implants
supported prosthesis ?
• How implants are different ?
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67. Lateral mobility of an implant: 10-50 microns.
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68. Implant occlusion
Disadvantages
• No shock absorption
• Stresses concentrated at
the crestal bone
• Crestal bone loss
• Prosthetic component
fracture
And all this with no
WARNING SIGN
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69. Warning signs in a natural tooth
• Wear facets
• Cold sensitivity
• Fremitus
• Mobility (reversible sometimes)
• Orthodontic movement
• AND MOST IMPORTANT THING REPAIR
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70. How to check cuff height
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71. Implant overdenture
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72. Implant overdenture
• For those patients requiring more retention and
stability for an upper and lower denture, the all
implant-supported overdenture may be the
answer.
• A removable implant overdenture is a prosthesis
which is removable by the patient and is
supported or retained by dental implants.
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73. Implant overdenture
• The prosthesis has to be removed for the
purpose of cleaning around the abutments
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74. Implant overdenture
• Overdenture: Any
removable dental prosthesis
that covers and rests on
one or more remaining
natural teeth, the roots of
natural teeth, and/or dental
implants; a dental
prosthesis that covers and
is partially supported by
natural teeth, natural tooth
roots, and/or dental
implants.
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79. Implant overdenture
Advantages
• Prevents bone loss
• Improved esthetics
• Improved stability (reduces or
eliminates prosthesis
movement)
• Improved occlusion
(reproducible centric relation
occlusion)
• Decrease in soft tissue
abrasions
• Improved chewing
efficiency(20%) and
force(300%)
• Increased occlusal efficiency
• Improved retention
• Improved support
• Improved speech
• Reduced prosthesis size
(eliminates palate, flanges)
• Improved maxillofacial
prostheses
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80. Advantages of Implant Overdenture
versus Fixed Prosthesis
• Fewer implants
• Compromised sites can be avoided
• Less specific placement mesiodistally because
prosthesis covers the abutments
• Improved esthetics
• Labial flange
• Denture teeth
• Soft tissue drape
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81. Advantages of Implant Overdenture
versus Fixed Prosthesis
• Speech
• Denture extends onto the soft tissue and
prevents escape of air and saliva.
• Lower cost
• Fewer implants
• Sites which require grafting can be avoided
• Easy repair
• Decreased laboratory costs
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82. Implant overdenture
Disadvantages
• Psychological (need for non-removable teeth)
• Greater abutment crown height space required
Hader clip O-ring
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83. Implant overdenture
Disadvantages
• Long-term maintenance
• Attachment (susceptible to wear)
• Relines (RP-5)
• New prosthesis every 7 years(wear of denture
teeth)
• Continued posterior bone loss
• Food impaction
• Movement (RP-5)
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84. Meg Rhein
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85. Overdenture chairside technique
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86. References
• Rathee M, Bhoria M. Basics of clinical diagnosis in
implant dentistry. J Int Clin Dent Res Organ [serial online]
2015 [cited 2018 Jul 23];7, Suppl S1:13-8. Available
from: http://www.jicdro.org/text.asp?2015/7/3/13/172929
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