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5/15/19
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The Surgical/Restorative Connection in Dental ImplantTreatment for the
General Practitioner: Why, Where, When and How for a Successful Outcome
§ Diagnosis and treatment planning for a successful surgical/restorative connection
§ What are the differences between natural teeth restorations and implant restorations?
§ What is a restoratively driven treatment plan?
§ When is site preparation indicated and does it affect the surgical/restorative connection?
§ Does the timing of implant placement affect the restorative plan?
§ Surgical and prosthetic considerations for successful implant/restorative therapy summary
Course Objectives
What is the Surgical/Restorative Connection in Dental Implant Treatment and How do We Achieve Success?
What are the Keys to Success?
Fundamental Rules and Guidelines
The Surgical/Restorative Connection in Dental Implant Treatment
The Surgical/Restorative Connection in Dental Implant Treatment: Where We Were!Surgically Driven (by the presence of adequate bone)
The Surgical/Restorative Connection in Dental Implant Treatment: Where We Were!Surgically Driven (by the presence of adequate bone)
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The Surgical/Restorative Connection in Dental Implant Treatment: Where We Are Now!
Restoratively Driven Treatment Planning =Restorative Success
Team Approach: Who are the Players?
The Surgical/Restorative Connection in Dental Implant Treatment
Restorative Dentist Implant Surgeon Lab Technician
Team Approach: Who are the Players?
The Surgical/Restorative Connection in Dental Implant Treatment
Implant Company Hygienest Patient
§ The tissue is the issue
§ The bone sets the tone
§ The mission is the dentition
Remember:
The Surgical/Restorative Connection in Dental Implant Treatment
The long term prognosis is affected differently by different treatment options for the same diagnosis
The goal is always to minimize risk and maximize the long term prognosis
The Surgical/Restorative Connection in Dental Implant Treatment
Patients don’t attend our offices for implants but rather for teeth that function, look good and have a long term prognosis
The Surgical/Restorative Connection in Dental Implant Treatment
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Diagnosis andTreatment Planning
§ Science of diagnosis and treatment planning: literature defining the parameters that should be considered when making a final diagnosis
§ Art of diagnosis and treatment planning: results when the clinician combines objective science with a subjective component based on personal experience
§ Integration of both is science and art
Rationale for Treatment Planning
Diagnosis Basis
Treatment Planning
§ Visibility of site§ Availability of bone
§ Models, radiographs§ Occasionally other investigations
§ Soft tissue§ Periodontal status of adjacent teeth§ Patient expectations
Evaluate:
Problematic Areas: Mandible
MENTAL FORAMENMENTAL NERVEINFERIOR ALVEOLAR NERVE
MAXILLARY SINUS/SCHNEIDERIAN MEMBRANE
Problematic Areas: Maxilla Evaluation of Implant Site(s)
§ Single tooth space§ Tooth or root present§ Normal ridge form§ No inflammation§ No recession at adjacent teeth§ Low lip line
Positive Factors Negative Factors§ Multiple teeth missing§ Atrophy of edentulous space§ Inflammation of soft tissue§ Recession at adjacent teeth§ Highly visible site
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Criteria for Case Selection
Planning for Success
Diagnosis and Treatment Planning
Basic Patient Selection and Treatment Planning in Implant
Dentistry
Treatment Planning
What is the prosthetic situation?§ Completely edentulous
§ Partially edentulous
§ Single tooth
Treatment Planning
General Considerations§ Maxilla or mandible
§ Anterior or posterior
§ Fixed or removable
Local Soft Tissue Condition:§ Pathology?
§ Inflammatory§ Neoplastic§ Keratinized vs non-keratinized mucosa
§ Tissue Phenotype/Biotype:Thick or thin?
Treatment Planning
Residual Ridge Form:
§ Height?
§ Width?
§ Facial and lingual contours?
Treatment Planning
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Adjacent Teeth:
§ Periodontal condition
§ Angulation
§ Length of edentulous space
§ Inter-arch space
Treatment Planning Esthetic ZoneDoes it show?
§ Consider smile line
§ Consider appearance of other teeth
§ Consider patient demands
Treatment Planning
Surgical placement
§ Implant position: restoratively driven
§ Reconstruction (Bone? Soft tissue?) if required:• At time of implant placement?• As a separate procedure?
DISCUSS thoroughly with your patient:
§ Multiple stages may be required§ Deficiencies may need to be disguised
prosthetically
§ Treatment may have to be repeated
Treatment Planning
§ Where ?
§ When ?
§ How ?
Immediate Implants
Surgical Planning
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Pre-Surgical Planning: Set Up/Wax Up or Scan (intra oral or model) ??
Factors Influencing Treatment Outcomes with ImplantTherapy and Their Relationship with Each Other
Classification and Descriptive Terms for the Timing of Implant Placement after Tooth Extraction
Esthetic Risk Assessment (ERA)
What are the Advantages and Disadvantages of the Different Treatment Options for Implant
PlacementTiming?
Advantages:
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Disadvantages:
Favorable and Unfavorable Conditions for the Four Timing
Options for Implant Placement after Tooth Extraction
Treatment Approach – Timing of Implant Placement after Tooth
Extraction
Favourable Clinical Conditions Unfavourable Clinical Conditions
Immediate Placement(Type 1)
• In the esthetic zone, sites with a low esthetic risk based on the ERA- Thick tissue biotype- Intact thick facial bone wall- Low lip line- Single-tooth gap
• Intact bone walls• Single-rooted sites• Sites with no infection
• In the esthetic zone, sites with a high esthetic riskbased on the ERA- Thin tissue biotype - Thin facial bone wall (≤ 1 mm)- High lip line- Facial bone defect- Multi-tooth gaps
• Bone wall defects• Multi-rooted sites• Local infection at the extraction site• Large apical bone defects where initial stability may
be compromised
Early Placement with Soft-Tissue Healing (Type 2)
• In the esthetic zone with a low to high esthetic risk, most cases can be managed with a Type 2 approach
• Single-rooted sites• Local infection involving the tooth
• Large apical bone defects where initial stability may be compromised
Early Placement with Partial Bone Healing (Type 3)
• Multi-rooted sites• Local infection involving the tooth• Large apical bone defects where initial stability with a Type 1 or Type 2
approach is compromised
• Initially wide defects of the facial bone where extended flattening of the facial bone surface is expected
Late Placement (Type 4) • In growing patients• In situations where increased time for bone healing and modelling is
desired, e.g., large cystic lesions, sinus floor• Medical or other patient-related factors that may require treatment
after extraction to be significantly delayed
• Narrow orofacial dimensions of the socket at extraction where a delay of over 4 months will lead to an insufficiently wide crest
• Initially wide defects of the facial bone where extended flattening of the facial bone surface is expected
Restoratively Driven Treatment Plan: Clinical Case
Restoratively Driven Treatment Plan
Merging CBCT & Scan Data
Virtual Fixture Placement
Restoratively Driven Treatment Plan
Surgical Template Design
Surgical Guide & Abutment Temporary Crowns
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Incorrect m-d implant position results in…
Restoratively Driven Treatment Plan
Checking Surgical Guide Fit CRITICAL!
When implants and crowns are used to replace lost oral structures, the factors influencing gingival architecture around implant crowns are different from those factors for natural teeth
§ Teeth possess a scallopedconnective tissue attachment
§ Root forms vary in length and shape
§ Crowns have anatomical forms
§ Implants have hemi-desmosomal(no CT) attachment§ Implants are round, cylindrical or tapering§ Implant crowns have variable emergence profiles
Natural Teeth and Implant/Restorations:Are There Differences?
§ Bony contours—volume and quality§ Implant/crown contours and position§ Bone crest to proximal crown contact§ Biotypes/phenotypes§ State of periodontal disease§ Harmony with facial profiles/arch forms
What Factors Influence Gingival Architecture: Implants/Crowns?
Bony contours: volume and quality determine gingival form
What Factors Influence Gingival Architecture: Implants/Crowns?
Facial Bony Contours
Labial thicknesses vary
Facial Thickness Varies
What Factors Influence Gingival Architecture: Implants/Crowns?
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Implant/crown contours and position determine gingival form
Natural root forms are varied
Implants are consistently smaller and round
Labial thicknesses vary
Implant-crown contours and position determine gingival form
Crown form assumes an unnatural contour
The crown attaches to a small fixture and emerges quickly to a larger form:“Emergence profile”
Loss of oral structures: both a surgical and prosthetic problem
For the implant surgeon and restorative dentist, the challenge is to restore lost dental and periodontal structures to the “normal” with a smaller, round, cylindrical implant and a modified crown form.
With the use of implants and crowns, how can one restore to normal gingival architecture and pleasing esthetics?
Ideally, all treatments should be restoratively or prosthetically guided
Loss of oral structures: both a surgical and prosthetic problem
A prosthetically guided plan for implant-borne restorations
A Restoratively Guided Treatment Plan for Implant Borne Restorations
(1) Staged treatments: where there is insufficient bone/gingiva quality or quantity, but augmentation potential is good
(2) Immediate treatments: where existing bone/gingiva contours and volume are good, treatment can be expedited
A Restoratively Guided Treatment Plan for Implant Borne RestorationsAdequate diagnostics (CBCT Scan) and Surgical Guide
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Incorrect implant placement (crown position?)
Incorrect m-d implant position results in…
Incorrect mesial-distal implant position results in…
Incorrect crown form
A Restoratively Guided Treatment Plan for Implant Borne Restorations
Incorrect m-d implant position results in…
Implant to the facial
Example of buccal implant placement
Example of facial implant placement
A Restoratively Guided Treatment Plan for Implant Borne Restorations
Incorrect implant placement (crown position?)
Incorrect m-d implant position results in…
Implant in vertically deficient bone…
Results in long crown formResults in longcrown form
A Restoratively Guided Treatment Plan for Implant Borne Restorations
Incorrect implant placement (crown position?)
Incorrect m-d implant position results in…
Implant positioned too far to the lingual…
RESULTS IN POOR CROWN FORM AND
INCLEANSABILITY
Results in poor crown form and uncleansibility
A Restoratively Guided Treatment Plan for Implant Borne Restorations
Incorrect implant placement (crown position?)
Vertical root fracture: tooth # 21
Mesial and distal bone levels are acceptable
A Restoratively Guided Treatment Plan for Implant Borne Restorations
Soft Tissue Augmentation
Incorrect m-d implant position results in…
Soft tissue augmentationAfter tooth removal, bone grafting, and implant placement, a ridge with horizontal and vertical gingival deficiency remains
A Restoratively Guided Treatment Plan for Implant Borne Restorations
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Incorrect m-d implant position results in…
Provisional restoration of implants
Papillae are fully mature, 3 months
Favorable gingival contours, ready for final crown
A Restoratively Guided Treatment Plan for Implant Borne Restorations
Radiography and Imaging:What areToday’s Standards for Implant
Treatment?
§ Digital panorex
§ Digital periapical
§ CBCT scan
§ CAD/CAM technology
§ Treatment planning software
Radiography and Imaging
§ Digital radiographs are useful, however, are still two dimensional
§ CBCT scan gives accurate three dimensional model of the implant site
§ CBCT scans can be used with software designed to allow implants to be placed in the computer model, e.g.,
Radiography and Imaging
Radiographic Examination
§ Bone quality§ Bone quantity§ Anatomical structures§ Inferior alveolar nerve
§ Maxillary sinuses and nasal cavity
§ Roots of adjacent teeth
Incorrect m-d implant position results in…
3D Imaging: CBCT Scan
What is the Rationale?
Does it Impact the Surgical/Restorative Connection?
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Incorrect m-d implant position results in…
What is the Rationale for 3D Imaging?
Surgical Guide: Is it Necessary??
§ For pre-surgical determination of ideal location and angulation of the implant sites
§ Developed by the restorative dentist to visualize the final restoration and provide a guide for the surgeon
Surgical Guide
Rationale:§ Provide a means of communication between the
restorative dentist, surgeon and laboratory technician
§ In some cases, functions as a radiographic guide
§ Should not interfere with flap elevation
The Surgical Guide Should:
Surgical Guide
§ Mounted study casts for diagnostic work-up and determining implant location or scan models or intra-oral scan: “crown down/restoratively driven implant placement”
§ A diagnostic wax-up is essential to assist the surgeon and restorative dentist in proper implant placement or scan
Mounted Study Casts and Diagnostic Wax-UpSurgical Guide
Why Guided Surgery?
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Non-Guided Surgery
Correct Implant Positioning
The Surgical/Restorative Connection
Principle 1: Fixture must be in the bone housing
Correct Implant Positioning
The Surgical/Restorative Connection
Principle 2: Establish the abutment G/H -3mm for Posterior, 4mm for Anterior
Correct Implant Positioning
The Surgical/Restorative Connection
Principle 3: Establish the Occlusal Space - 9mm for Posterior, 10mm for Anterior
Correct Implant Positioning
The Surgical/Restorative Connection
Principle 3: Establish the Occlusal Space - 9mm for Posterior, 10mm for Anterior
* If the occlusal height is less than 9mm, adjust the fixture depthIncorrect m-d implant
position results in…
Immediate Implant PlacementImmediate Tooth Replacement Problems
§ Recession
§ Discoloration
§ Facial Contour
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The Surgical/Restorative Connection:The Critical Zone!
The Surgical/Restorative Connection:The Critical Zone!
Sclar A 2003
IMPLANT:
§ Lack of CT
§ Hypovascular, hypocellular zone adjacent to the implant
§ Absence of PDL blood supply
Tissue seal=position stability
The Surgical/Restorative Connection:The Critical Zone!
As narrow as possible=soft tissue thicknessAs wide as necessary=maintenance of gingival stability
Ikiru A et al. Journal of Prosth Res 60:3–11, 2016
The Surgical/Restorative Connection:The Critical Zone!
Incorrect m-d implant position results in…
The Surgical/Restorative Connection:The Critical Zone!
Decision Making Process for Restoring Single Implants Clavijo V and Blasi A (2017)
Incorrect m-d implant position results in…
The Surgical/Restorative Connection:The Critical Zone!
Decision Making Process for Restoring Single Implants Clavijo V and Blasi A (2017)
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Incorrect m-d implant position results in…
The socket-shield technique to support the buccofacial
tissues at immediate implant placement
What is the Socket Shield Procedure: Does it Work?The Surgical/Restorative Connection
Gluckman H et al. , International Dentistry Vol.5 No.3 2018
Incorrect m-d implant position results in…
Procedures to Manage Post Extraction Resorption
Incorrect m-d implant position results in…
Literature Review on the Socket Shield Technique
Conclusion: At present the technique is highly promising and holds significant potential for the field of aesthetic and restorative implant dentistry
Platform Switching: Is it Beneficial and Is it Necessary?
Incorrect m-d implant position results in…
Platform Switching for Marginal Bone Preservation Around Dental Implants; A Systematic Review and Meta-Analysis
Atieh MA et al. J Periodontol. Oct. 81(10), 2010
CONCLUSIONS:§ The marginal bone loss around platform switched implants was
significantly less than around platform matched implants
§ No statistically significant difference was detected for implant failures between PS and PM implants
§ Subgroup analysis showed that an implant abutment diameter difference > or = 0.4mm was associated with a more favorable bone response
Incorrect m-d implant position results in…
Peri-implant Bone Levels Around Implants With Platform Switched Abutments Preliminary Data From a Prospective Study
Hurzeler M et al. J Oral Maxillofac. Surg. July 65(7 suppl 1) 2007
CONCLUSIONS:§ The concept of platform switching appears to limit crestal
resorption and seems to preserve peri-implant bone levels
§ The reduction of the abutment of 0.45mm on each side (5mm implants and 4.1mm abutment) seems sufficient to avoid peri-implant bone loss
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Incorrect m-d implant position results in…
Systematic Review: Platform Switch and Dental Implants
Chrcanovic BR et al. J Dent. Jun 43 (6) 2015
CONCLUSIONS:§ There was less marginal bone loss with platform switching than at
implants with platform matching (mean difference 0.29)
§ An increase of the mean difference of MBL between the procedures was observed with: (a) increase in the follow up time and (b) increase of the mismatch between the implant platform and the abutment
Incorrect m-d implant position results in…
Impact of Platform Switching on Marginal Peri-implant Bone Level Changes: A Systematic Review and Meta-Analysis
Strietzel F et al. Clin Oral Implants Research 2015
CONCLUSIONS:§ The meta-analysis revealed a significantly less mean MBL change
at implants with a PS compared to PM implant abutment configuration
Incorrect m-d implant position results in…
Impact of Platform Switching on Marginal Peri-implant Bone Level Changes: A Systematic Review and Meta-Analysis
Strietzel F et al. Clin Oral Implants Research 2015
CONCLUSIONS:What do we need?
§ Platform switch of at least 0.4mm
§ Strong material for platform switch implant and abutments
§ A very stable conical connection
Screw vs. Cement Retained Implant Prosthesis??
Incorrect m-d implant position results in…
Screw vs. Cement Retained Implant Prosthesis
Incorrect m-d implant position results in…
Choice of retention type might not have a crucial influence on the overall prosthesis but may increase chances of complications
Wittenben JG et al. IJOMI Jan 2:29, 2014
Screw vs. Cement Retained Implant Prosthesis
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When do we choose cement retention?
§ Adequate inter-ridge space
§ Areas where esthetics are of concern
§ Implant is not positioned in the prosthetically ideal location
Screw vs. Cement Retained Implant Prosthesis
When do we choose screw retention?
§ Brannemark system validated screw retention
§ Screws are used to attach the prosthesis to an implant and the abutment to the crown
§ Different screws have different properties, size, design and composition
Screw vs. Cement Retained Implant Prosthesis
When do we choose screw retention?
§ Limited inter-ridge space (Chee et al. British Dental Journal Oct 21:201, 2008)
§ Implant is placed in the prosthetically ideal position
Screw vs. Cement Retained Implant Prosthesis
Incorrect m-d implant position results in…
Screw vs. Cement Retained Implant ProsthesisDecision Making Tree
Types of Cementation
§ Permits retrievability
§ Risk of leakage and loss of retention is higher
Screw vs. Cement Retained Implant Prosthesis
Provisional Cementation:
Definitive Cementation:§ Very difficult to retrieve
§ Prosthesis may be lost in the case of a failure
What Factors Need to be Considered During Decision Making?
§ Retrievability
§ Esthetics and provisionalization
Screw vs. Cement Retained Implant Prosthesis
§ Clinical performance
§ Occlusion
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What Factors Need to be Considered During Decision Making?
§ Retention
§ Implant placement
Screw vs. Cement Retained Implant Prosthesis
§ Passivity
Summary
§ Single, short span§ Narrow diameter crowns§ Inadequate inter-occlusal space
§ Cantilevered prosthesis (may require more maintenance)§ Patients who are at higher risk for gingival recession
Screw vs. Cement Retained Implant Prosthesis
§ Large, full arch cases (complications can be more common)
Cement Retention Preferred When:
Screw Retained Preferred When:
Chee et al. British Dental Journal Oct 21:201, 2008
Summary
§ Restoring mal-aligned implants
§ Periodontally compromised cases when expected to lose more teeth
§ Minimal occlusal space <4mm
Screw vs. Cement Retained Implant Prosthesis
§ Removal of excess cement would be very difficult§ Cases in which biologic complications are anticipated
Cement Retention Preferred When:
Screw Retained Preferred When:
Chee et al. British Dental Journal Oct 21:201, 2008
ConclusionScrew vs. Cement Retained Implant Prosthesis
No clear evidence that one system of retention is better than the other however several authors suggest screw retained over cement retained
The overall survival of the implant is not dictated by the type of prosthesis retention but may be a predisposing factor for certain biological and technical complications
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