BETHESDA.MED.NAVY.MIL...Implant Guidelines 4 The Restorative

Implant Guidelines for Implant Guidelines for the Restorative Dentistthe Restorative Dentist

LCDR M.E. BerninghausLCDR M.E. Berninghaus

Comprehensive DentistryComprehensive Dentistry

NDS, BethesdaNDS, Bethesda

Implant Guidelines for Implant Guidelines for the Restorative Dentistthe Restorative Dentist

M.E. Berninghaus, DDSM.E. Berninghaus, DDS

Comprehensive DentistryComprehensive Dentistry

Right now my life is just one Right now my life is just one learning experience after learning experience after another……another……By the end of the week I should By the end of the week I should be a genius!be a genius!

Jeanette OsiasJeanette Osias

Implant GuidelinesImplant Guidelines

What is a dental implant?What is a dental implant?• DefinitionDefinition–an endosteal (within bone) an endosteal (within bone) alloplastic biologically alloplastic biologically compatible material surgically compatible material surgically inserted into the edentulous inserted into the edentulous bony ridgebony ridge


What is a dental implant?What is a dental implant?•UseUse–to serve as a foundation for to serve as a foundation for prosthodontic restorationprosthodontic restoration


What is a dental implant?What is a dental implant?• History (endosseous)History (endosseous)–dates to Egyptiansdates to Egyptians–Greenfield (1913) -Greenfield (1913) -–patented two-stage systempatented two-stage system

–Formiggini (1947) - Formiggini (1947) - –““father of modern implantology”father of modern implantology”–helical wire spiral helical wire spiral


What is a dental implant?What is a dental implant?• History (endosseous)History (endosseous)–single stagesingle stage–one-piece from bone through oral mucosa one-piece from bone through oral mucosa

(crystal sapphire implants)(crystal sapphire implants)–two-stagetwo-stage–bony implant separate from transmucosal bony implant separate from transmucosal

portionportion–variable design & materialsvariable design & materials


What is a dental implant?What is a dental implant?•BiomaterialsBiomaterials–most commonly used most commonly used –commercially pure (CP) titaniumcommercially pure (CP) titanium–titanium-aluminum-vanadium alloy titanium-aluminum-vanadium alloy

(Ti-6Al-4V) (Ti-6Al-4V) - stronger & used w/ smaller - stronger & used w/ smaller diameter implantsdiameter implants


What is a dental implant?What is a dental implant?• Titanium Titanium –lightweightlightweight–biocompatiblebiocompatible–corrosion resistant corrosion resistant

(dynamic inert oxide layer)(dynamic inert oxide layer)

–strong & low-pricedstrong & low-priced


What is a dental implant?What is a dental implant?• Fixture typesFixture types

–HA coatedHA coated–Ti surface modifiedTi surface modified–tap or self-tappingtap or self-tapping–screw or press fitscrew or press fit


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –Bränemark - late 1980’sBränemark - late 1980’s–direct structural & functional direct structural & functional

connection between ordered, living connection between ordered, living bone & surface of a load-carrying bone & surface of a load-carrying implantimplant


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –similar soft-tissue relationship to similar soft-tissue relationship to

natural dentition natural dentition (sulcular epithelium)(sulcular epithelium)

–hemi-desmosome like structures hemi-desmosome like structures connect epithelium to titanium connect epithelium to titanium surfacesurface


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –circumferential and perpendicular circumferential and perpendicular

connective tissueconnective tissue–no connective tissue insertionno connective tissue insertion–no intervening Sharpey’s fiber no intervening Sharpey’s fiber

attachmentattachment


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –bone-implant bone-implant interfaceinterface–osteoblasts in close proximityosteoblasts in close proximity to interfaceto interface–separated from implant by thin separated from implant by thin

amorphous proteoglycan layeramorphous proteoglycan layer–osseointegration - highly predictable osseointegration - highly predictable


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –bone-implant bone-implant interfaceinterface–osteoblasts in close proximityosteoblasts in close proximity to interfaceto interface–separated from implant by thin separated from implant by thin

amorphous proteoglycan layer amorphous proteoglycan layer –osseointegration - highly predictable osseointegration - highly predictable


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –bone-implant bone-implant interfaceinterface–oxide layer continues to grow-oxide layer continues to grow- (2000 A at 6 yrs) - mineral ion interaction (2000 A at 6 yrs) - mineral ion interaction – increase in trabecular patternincrease in trabecular pattern–bone deposition & remodeling in bone deposition & remodeling in

response to stressresponse to stress


What is a dental implant?What is a dental implant?• ““Osseointegration” Osseointegration” –bone-implant bone-implant interfaceinterface–oxide layer continues to grow-oxide layer continues to grow- (2000 A at 6 yrs) - mineral ion interaction(2000 A at 6 yrs) - mineral ion interaction– increase in trabecular patternincrease in trabecular pattern–bone deposition & remodeling in bone deposition & remodeling in

response to stressresponse to stress


What is a dental implant?What is a dental implant?•Components & terminologyComponents & terminology

–coping or prosthesis screw coping or prosthesis screw (top)(top)–copingcoping–analoganalog» implant bodyimplant body»abutment abutment

–transfer coping (indirect or direct)transfer coping (indirect or direct)


What is a dental implant?What is a dental implant?•Components & terminologyComponents & terminology

–hygiene screwhygiene screw–abutmentabutment» for screw, cement or attachmentfor screw, cement or attachment

–second stage permucosal abutmentsecond stage permucosal abutment–first stage cover screwfirst stage cover screw–implant body or fixture implant body or fixture (bottom)(bottom)



What is a dental implant?What is a dental implant?•Modern typesModern types–implants are smallimplants are small - - –standard abutmentstandard abutment - usually 3.75mm - usually 3.75mm

or larger in diameteror larger in diameter

–wide-body or wide-platformwide-body or wide-platform - up to - up to 6.0mm6.0mm


What is a dental implant?What is a dental implant?•Modern typesModern types–lengthslengths - - typically range from abouttypically range from about

7 to 18mm7 to 18mm–Navy uses Navy uses “external hex”“external hex”

– good research literaturegood research literature– able to be maintained able to be maintained – (3i or Nobel Biocare systems)(3i or Nobel Biocare systems)


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–FixturesFixtures–StandardStandard

–Mk IIMk II


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–AbutmentsAbutments–StandardStandard–CeraOneCeraOne–EsthetiConeEsthetiCone–MirusConeMirusCone–Angulated 17º (new) or 30ºAngulated 17º (new) or 30º


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–StandardStandard–no anti-rotational propertiesno anti-rotational properties–can use for multiple unitscan use for multiple units–can use for hybrid denturescan use for hybrid dentures


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–CeraOneCeraOne–single tooth esthetic replacementsingle tooth esthetic replacement–abutment attached to fixture w/ abutment attached to fixture w/

restoration cemented to abutmentrestoration cemented to abutment–accommodation for fixture misalignmentaccommodation for fixture misalignment–can provisionalizecan provisionalize


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–EsthetiConeEsthetiCone–esthetic FPD restorationsesthetic FPD restorations–machined gold cylinder abutment allows machined gold cylinder abutment allows

crown margin to seat close to fixture crown margin to seat close to fixture (within 1mm)(within 1mm)


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–MirusConeMirusCone–esthetic FPD restorationsesthetic FPD restorations–use when decreased vertical heightuse when decreased vertical height–allows 4.5mm clearanceallows 4.5mm clearance


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–Angulated abutment 17º or 30ºAngulated abutment 17º or 30º–use to achieve better esthetic result use to achieve better esthetic result

where complicated anatomy existswhere complicated anatomy exists–use if less than ideal fixture placementuse if less than ideal fixture placement–use where esthetic cervical margin use where esthetic cervical margin

requiredrequired


What is a dental implant?What is a dental implant?•Modern types Modern types ((Nobel Biocare)Nobel Biocare)–CeraOneCeraOne–EsthetiConeEsthetiCone–MirusConeMirusCone–Angulated abutmentsAngulated abutments

• All come with narrow, regular or wide All come with narrow, regular or wide platforms (NP, RP, WP)platforms (NP, RP, WP)


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–FixturesFixtures–MicroMiniplantMicroMiniplant–MiniplantMiniplant–StandardStandard–Wide Diameter Wide Diameter

(( surface area to use where surface area to use where vertical height) vertical height)


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–FixturesFixtures–ICE (ICE (incremental cutting edge)incremental cutting edge)» super self-tapping implantsuper self-tapping implant»uses tapered cutting flutesuses tapered cutting flutes»allows more placement controlallows more placement control» rapid bone engagement & implant rapid bone engagement & implant

stabilizationstabilization


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–AbutmentsAbutments–EP (conical) - (esthetic profile)EP (conical) - (esthetic profile)–Gold UCLA-typeGold UCLA-type–Two-piece abutment postTwo-piece abutment post–STA (standard)STA (standard)–Pre-AngledPre-Angled–New Gold Standard ZR (zero rotation)New Gold Standard ZR (zero rotation)


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–Gold UCLA-type abutment Gold UCLA-type abutment –screw-retained at fixture levelscrew-retained at fixture level–non-segmented abutmentnon-segmented abutment–screw-retained crown to implantscrew-retained crown to implant–uses larger screw because it runs all the uses larger screw because it runs all the

way to the fixtureway to the fixture


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–Gold UCLA-type abutment Gold UCLA-type abutment – thin buccal-lingual tissues thin buccal-lingual tissues – limited inter-occlusal distance limited inter-occlusal distance (as little as 4.5mm)(as little as 4.5mm)–single or multiple unitssingle or multiple units


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–EP (conical) EP (conical) - (esthetic profile) - (esthetic profile) –screw-retained crown to the abutmentscrew-retained crown to the abutment–gold cylindergold cylinder–non-parallel implant placementnon-parallel implant placement–single or multiple unitssingle or multiple units–minimum 7mm inter-occlusal distance minimum 7mm inter-occlusal distance

requiredrequired


What is a dental implant?What is a dental implant?•Modern types Modern types (3i)(3i)–Two-piece abutment postTwo-piece abutment post–non-rotationalnon-rotational–cement-retained crown to the abutmentcement-retained crown to the abutment–simplicity of treatment - chairside simplicity of treatment - chairside

preparationpreparation–use when access to posterior region w/ use when access to posterior region w/

screw driver is limitedscrew driver is limited


What is a dental implant?What is a dental implant?•What’s new?What’s new? (3i)(3i)–Prep-Tite Posts Prep-Tite Posts

»screw retained abutmentscrew retained abutment»standard impression procedurestandard impression procedure»cemented restorationcemented restoration»6º taper with 3 vertical grooves6º taper with 3 vertical grooves»multiple collar heightsmultiple collar heights


What is a dental implant?What is a dental implant?•What’s new?What’s new? (3i) (3i) –Osseotite Osseotite (“clot retentive surface”)(“clot retentive surface”)

»specific micro-topographic acid-etched specific micro-topographic acid-etched implant surface design Vs. machined-implant surface design Vs. machined-surface implantsurface implant»single stage implantsingle stage implant» loaded after 2 months loaded after 2 months »claim 98.5% success after 3 yearsclaim 98.5% success after 3 years


What is a dental implant?What is a dental implant?•Remember….Remember…. –For FPD’sFor FPD’s–plan for screw-retained restorationsplan for screw-retained restorations–no anti-rotational propertiesno anti-rotational properties–always use at least 2 fixtures when always use at least 2 fixtures when

restoring posterior spaces not bound by restoring posterior spaces not bound by natural teeth! natural teeth!


What is a dental implant?What is a dental implant?•AdvantagesAdvantages

–no preparation of tooth/adjacent teethno preparation of tooth/adjacent teeth–bone stabilization & maintenancebone stabilization & maintenance– retrievabilityretrievability– improvement of functionimprovement of function–psychological improvementpsychological improvement


What is a dental implant?What is a dental implant?•DisadvantagesDisadvantages

– risk of screw looseningrisk of screw loosening– risk of fixture failurerisk of fixture failure– length of treatment timelength of treatment time–need for multiple surgeriesneed for multiple surgeries–challenging estheticschallenging esthetics

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase““Diagnosis begins with a complete Diagnosis begins with a complete

patient evaluation”patient evaluation”–guidelines for “decision-making” guidelines for “decision-making”

processprocess– treat the “entire” patienttreat the “entire” patient– restore form, function & estheticsrestore form, function & esthetics

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–problem list & patient desiresproblem list & patient desires–initial evaluationinitial evaluation–chief complaintchief complaint–medical/dental history reviewmedical/dental history review– intra/extraoral examintra/extraoral exam–evaluation of existing prosthesisevaluation of existing prosthesis

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–initial evaluationinitial evaluation–diagnostic impressions/articulated castsdiagnostic impressions/articulated casts– radiographs - panoramic and periapical radiographs - panoramic and periapical

(CT scan or tomography - as indicated)(CT scan or tomography - as indicated)–photographsphotographs

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–treatment options/informed consenttreatment options/informed consent–explanation of long-term commitmentexplanation of long-term commitment–restorative - surgical joint consultrestorative - surgical joint consult–two-stage surgery two-stage surgery –stage I stage I –stage IIstage II

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–two-stage surgery two-stage surgery – (use of clear acrylic surgical stent is (use of clear acrylic surgical stent is

mandatory!)mandatory!)

–stage I stage I -- implant fixture placement w/ implant fixture placement w/ cover screw (left submerged)cover screw (left submerged)

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–stage I stage I - - healing phasehealing phase–3 month minimum (mandible ) - usually 6 3 month minimum (mandible ) - usually 6

months for posterior regionsmonths for posterior regions–6 month minimum (maxilla) - usually 6-9 6 month minimum (maxilla) - usually 6-9

months for all regionsmonths for all regions

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–stage II stage II - - uncovering & placement of uncovering & placement of

transmucosal healing abutment transmucosal healing abutment

–healing phasehealing phase–4-6 weeks for soft tissue healing4-6 weeks for soft tissue healing

Implant GuidelinesImplant GuidelinesConsultation AppointmentConsultation Appointment • Treatment planning phaseTreatment planning phase–restorative phaserestorative phase–maintenance and regular recallmaintenance and regular recall–fee & payment policyfee & payment policy–goal to restore form, function & goal to restore form, function &

estheticsesthetics

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–teethteeth–periodontiumperiodontium–radiographic analysisradiographic analysis–surgical analysissurgical analysis–esthetic analysisesthetic analysis

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–occlusal analysisocclusal analysis–advs/disadvs of proposed treatmentadvs/disadvs of proposed treatment–referrals/specialty consultsreferrals/specialty consults–appointment sequencingappointment sequencing–treatment alternativestreatment alternatives


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–teeth teeth - number & existing condition- number & existing condition–prognosis of remaining teethprognosis of remaining teeth–size, shape & diameter of existing size, shape & diameter of existing

dentitiondentition– tooth & root angulations & proximitytooth & root angulations & proximity–mesiodistal width of edentulous spacemesiodistal width of edentulous space

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–teeth teeth - number & existing condition- number & existing condition–minimum 6-7mm between teeth to minimum 6-7mm between teeth to

facilitate implant placement facilitate implant placement (based on 3mm fixture)(based on 3mm fixture)–> 1.5mm between implant & natural teeth> 1.5mm between implant & natural teeth–7mm from center of implant - to center 7mm from center of implant - to center

of implant for edentulous areaof implant for edentulous area

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–teeth teeth - number & existing condition- number & existing condition–more than 10mm mesiodistal space - more than 10mm mesiodistal space -

single tooth implant single tooth implant notnot recommended recommended– (multiple abutments should be splinted)(multiple abutments should be splinted)


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium - - bone support bone support –Lekholm & Zarb classificationLekholm & Zarb classification–qualityquality - - best - thick compact cortical best - thick compact cortical

bone w/core of dense trabecular bone w/core of dense trabecular cancellous bonecancellous bone–best region - mandibular symphysis; best region - mandibular symphysis;

poorest in posterior regionspoorest in posterior regions

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium - - bone support bone support –quantityquantity - - required for implant - required for implant - –6mm buccal-lingual width w/sufficient 6mm buccal-lingual width w/sufficient

tissue volumetissue volume–8mm interradicular bone width8mm interradicular bone width–10mm alveolar bone above IAN canal or 10mm alveolar bone above IAN canal or

below maxillary sinusbelow maxillary sinus

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium - - bone support bone support –quantityquantity - - required for implant - required for implant - – if inadequate bone support may need if inadequate bone support may need

ridge or site augmentation ridge or site augmentation » ramus or chin graft (autograft)ramus or chin graft (autograft)»DFDBA (allograft)DFDBA (allograft)»Bio-Oss(xenograft)Bio-Oss(xenograft)

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium - - bone supportbone support –place implants minimum of 2mm from place implants minimum of 2mm from

IAN canal or below maxillary sinusIAN canal or below maxillary sinus–crown/root ratiocrown/root ratio–mobilitymobility–furcationsfurcations–probing depthsprobing depths

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium –mucogingival problems mucogingival problems –need sufficient tissue volume to recreate need sufficient tissue volume to recreate

gingival papillagingival papilla–need some attached gingiva to maintain need some attached gingiva to maintain

peri-implant sulcusperi-implant sulcus–1st year post-op bone resorption ~ 1mm1st year post-op bone resorption ~ 1mm *crest of bone optimal 2- 3mm below CEJ*crest of bone optimal 2- 3mm below CEJ

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium–mucogingival problemsmucogingival problems –place implant 2-3mm apical to free place implant 2-3mm apical to free

gingival margin of adjacent tooth gingival margin of adjacent tooth – recreates biologic width of peri-implant recreates biologic width of peri-implant

sulcussulcus– *soft tissue height < 2mm or > 4mm may *soft tissue height < 2mm or > 4mm may

create challenge!create challenge!

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–periodontiumperiodontium –oral hygiene - oral hygiene - important pre & post important pre & post

–systemic manifestations - systemic manifestations - ie. diabetics ie. diabetics are predisposed to delayed healingare predisposed to delayed healing–destructive habits - destructive habits - smokingsmoking is is

contraindicated - delayed or inadequate contraindicated - delayed or inadequate tissue healing & osseointegration noted tissue healing & osseointegration noted


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–radiographic analysisradiographic analysis–periapical pathologyperiapical pathology–radiopaque/radiolucent regionsradiopaque/radiolucent regions–adequate vertical bone heightadequate vertical bone height–adequate space above IAN or below adequate space above IAN or below

maxillary sinusmaxillary sinus

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–radiographic analysisradiographic analysis–adequate interradicular areaadequate interradicular area–bone quality & quantitybone quality & quantity–radiographs - radiographs - panoramic and periapical panoramic and periapical

(CT scan or tomography - as indicated) (CT scan or tomography - as indicated)

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–radiographic analysisradiographic analysis–radiographsradiographs - - aid to determine amount aid to determine amount

of “space”& bone availableof “space”& bone available–CT (computed tomography) scan - gives CT (computed tomography) scan - gives

more accurate & reliable assessment of more accurate & reliable assessment of bone (quality, quantity & width) & locale bone (quality, quantity & width) & locale of anatomic structuresof anatomic structures

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–radiographic analysisradiographic analysis - -–radiographic stentradiographic stent - - (can double as (can double as

surgical stent) surgical stent) –acrylic stent with lead beads or ball -acrylic stent with lead beads or ball -

bearings (5mm) placed in proposed fixture bearings (5mm) placed in proposed fixture locationslocations– allows more accurate radiographic allows more accurate radiographic

interpretation interpretation

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–radiographic analysisradiographic analysis - -–distortion (distortion (common to all X-rays)common to all X-rays)–Panorex ~ 25% vertical; horizontal varies Panorex ~ 25% vertical; horizontal varies

w/ head position (1.20-1.25x)w/ head position (1.20-1.25x)–CT ~ 1:1; 1-2mm vertical error; CT ~ 1:1; 1-2mm vertical error; *most accurate (1.0-1.1x)*most accurate (1.0-1.1x)–Lateral Ceph ~ 8%Lateral Ceph ~ 8%–Periapical ~ 2.5-5%Periapical ~ 2.5-5%


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–surgical analysissurgical analysis - -–surgical guide stentsurgical guide stent - - *one of the most *one of the most

critical factors for obtaining an ideal surgical critical factors for obtaining an ideal surgical & esthetic result& esthetic result–used during fixture installation as guide used during fixture installation as guide

for optimal B/L and M/D positionfor optimal B/L and M/D position–use of buccal channel drill guide allows use of buccal channel drill guide allows

improved access & visibilityimproved access & visibility

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–surgical analysissurgical analysis - -–implant length/diameterimplant length/diameter–determined by quantity of bone apical to determined by quantity of bone apical to

extraction site extraction site –use longest implant safely possibleuse longest implant safely possible–diameter dictated by corresponding root diameter dictated by corresponding root

anatomy at crest of boneanatomy at crest of bone

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–surgical analysissurgical analysis –treatment optionstreatment options–immediateimmediate - - place implant at time of place implant at time of

tooth extractiontooth extraction–delayed immediatedelayed immediate - - 8-10 week delay8-10 week delay–delayeddelayed - - 9-10 months or longer9-10 months or longer

• immediate will not allow bone resorption, but immediate will not allow bone resorption, but delayed allows bone fill for stabilizationdelayed allows bone fill for stabilization

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–surgical analysissurgical analysis –proper surgical technique during proper surgical technique during

implant placement is critical implant placement is critical –minimal heat generation importantminimal heat generation important–< 47º Celsius for one minute or less < 47º Celsius for one minute or less

provides most predictable healing provides most predictable healing response response


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations

–esthetic analysisesthetic analysis–smile line - smile line - high in maxilla; low in high in maxilla; low in

mandiblemandible–lip shape - lip shape - full Vs. thinfull Vs. thin

–existing ridge defect - existing ridge defect - if visible w/ if visible w/ high smile line will need augmentationhigh smile line will need augmentation

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–esthetic analysisesthetic analysis–implant emergence profile implant emergence profile (360º)(360º)– restored implant should appear to restored implant should appear to

“grow” or emerge from the gingiva“grow” or emerge from the gingiva–very natural & desirable in appearancevery natural & desirable in appearance–avoid avoid “tomato on a stick” “tomato on a stick” crowns or crowns or

periodontal problems may developperiodontal problems may develop


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–occlusal analysisocclusal analysis–improvement of function and/or improvement of function and/or

esthetics (?)esthetics (?)–parafunctional habits parafunctional habits –can be destructivecan be destructive– teeth lost to occlusal trauma or teeth lost to occlusal trauma or

parafunction - less success w/ implants parafunction - less success w/ implants

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–occlusal analysisocclusal analysis–diagnostic casts diagnostic casts (mounted to determine opposing occlusion)(mounted to determine opposing occlusion)

–ridge width ridge width –existing inter-arch vertical space existing inter-arch vertical space 14-15mm minimum for complete denture; 14-15mm minimum for complete denture;

partially edentulous varies by implant type partially edentulous varies by implant type

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–occlusal analysisocclusal analysis–maxillo-mandibular relationsmaxillo-mandibular relations

jaw classifications jaw classifications –Class II may have greatest benefitClass II may have greatest benefit–Class III requires surgical interventionClass III requires surgical intervention


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–advs/disadvs of proposed treatmentadvs/disadvs of proposed treatment–are as individual as the case being are as individual as the case being

treatment planned!treatment planned!»costcost»patient desirespatient desires»clinician abilitiesclinician abilities»etc.etc.


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–referrals/specialty consultsreferrals/specialty consults–can prognosis be improved with (?):can prognosis be improved with (?):

»orthodonticsorthodontics»periodontal therapyperiodontal therapy»endodontic therapyendodontic therapy

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–referrals/specialty consultsreferrals/specialty consults

»pre-prosthetic surgerypre-prosthetic surgery extractionsextractions ridge contouring or exostosis removalridge contouring or exostosis removal osteotomyosteotomy bone or soft tissue augmentationbone or soft tissue augmentation


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations

–appointment sequencingappointment sequencing–length of treatment timelength of treatment time–need for multiple surgeriesneed for multiple surgeries


Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• Problem list & treatment considerationsProblem list & treatment considerations–treatment alternativestreatment alternatives–fixed partial denturesfixed partial dentures–removable partial denturesremovable partial dentures–resin-bonded fixed partial denturesresin-bonded fixed partial dentures–orthodonticsorthodontics–do nothing!do nothing!

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• IndicationsIndications–good general healthgood general health–adequate bone quality & volumeadequate bone quality & volume–appropriate occlusion & jaw relationsappropriate occlusion & jaw relations– inability to wear conventional prosthesisinability to wear conventional prosthesis–unfavorable number/location of abutmentunfavorable number/location of abutment–single tooth losssingle tooth loss

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase•ContraindicationsContraindications–unrealistic patient expectationsunrealistic patient expectations–alcohol/drug dependence alcohol/drug dependence (smoking)(smoking)–parafunctional habitsparafunctional habits–psychological factorspsychological factors–anatomical factorsanatomical factors– inadequate ridge/interarch dimensionsinadequate ridge/interarch dimensions– immunosuppressionimmunosuppression

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase•Contraindications Contraindications (relative)(relative)– (need surgical intervention)(need surgical intervention)–ramus graftramus graft– inadequate bone at implant siteinadequate bone at implant site–excessive bony concavitiesexcessive bony concavities

–sinus lift or IAN transpositionsinus lift or IAN transposition– inadequate vertical space for implantinadequate vertical space for implant

Implant GuidelinesImplant GuidelinesTreatment planning phaseTreatment planning phase• ““Osseointegrated implants can be Osseointegrated implants can be

placed in the irradiated mandibles of placed in the irradiated mandibles of selected patients without hyperbaric selected patients without hyperbaric oxygen treatment”oxygen treatment”

Niini, Ueda, Keller, Worthington; Niini, Ueda, Keller, Worthington; Experience withExperience withOsseointegrated Implants Placed in Irradiated Tissues in Japan Osseointegrated Implants Placed in Irradiated Tissues in Japan and the United Statesand the United States, Intl J Oral Maxillofac Implants 1998; , Intl J Oral Maxillofac Implants 1998; 13:407-41113:407-411


MaintenanceMaintenance• Criteria for successCriteria for success

• Maintenance and RecallMaintenance and Recall

• Hygiene AidsHygiene Aids

• ProblemsProblems


MaintenanceMaintenance• Primary goal is to protectPrimary goal is to protect and and

maintain “tissue-integration”; maintain “tissue-integration”;

good oral hygienegood oral hygiene is a key is a key element!element!


MaintenanceMaintenance• ““Implant patients should be Implant patients should be

thoroughly instructed in thoroughly instructed in maintenance therapy with the maintenance therapy with the understanding that the patient understanding that the patient serves as co-therapist”serves as co-therapist”

Grant et al, Grant et al, Periodontics, in the Tradition of Periodontics, in the Tradition of Gottlieb and OrbanGottlieb and Orban, ed 6. St. Louis, CV Mosby Co,, ed 6. St. Louis, CV Mosby Co,1988, pp1075-1094.1988, pp1075-1094.


MaintenanceMaintenance• ““Any practitioner wishing to Any practitioner wishing to

practice dental implantology must practice dental implantology must be knowledgeable concerning be knowledgeable concerning postinsertion maintenance of the postinsertion maintenance of the implant”implant”

1988 National Institutes of Health Consensus 1988 National Institutes of Health Consensus Development ConferenceDevelopment Conference







MaintenanceMaintenance• Criteria for success:Criteria for success:(most important is good diagnosis!)(most important is good diagnosis!)–no peri-implantitisno peri-implantitis–no associated radiographic no associated radiographic

radiolucencyradiolucency–marginal bone loss 1.0-1.5mm first marginal bone loss 1.0-1.5mm first

year; then < 0.1mm annually thereafteryear; then < 0.1mm annually thereafter


Maintenance• Criteria for success:Criteria for success:–tissue integration: bone/soft tissue tissue integration: bone/soft tissue

“osseointegration”“osseointegration”–absence of mobilityabsence of mobility–no progressive soft tissue changes or no progressive soft tissue changes or

bone lossbone loss–stable clinical attachment levelstable clinical attachment level


Maintenance• Criteria for success:Criteria for success:–absence of bleeding upon absence of bleeding upon

probing/excessive probing depthsprobing/excessive probing depths–absence of discomfortabsence of discomfort–success rate varies with bone quality, success rate varies with bone quality,

loading dynamics, etc.loading dynamics, etc.


Maintenance• Criteria for success:Criteria for success:–anticipated success rate of anticipated success rate of +97% anterior mandible; 90% maxilla; +97% anterior mandible; 90% maxilla; decreases in posterior quadrantsdecreases in posterior quadrants due to poorer bone quality due to poorer bone quality (10 yrs)(10 yrs)–best bone: good cortical with some best bone: good cortical with some

cancellous for vascular supplycancellous for vascular supply







MaintenanceMaintenance• Maintenance & Recall:Maintenance & Recall:–Four elements Four elements –home-care regimenhome-care regimen–periodic recalls reinforcing regimenperiodic recalls reinforcing regimen–strict adherence to recall schedule & strict adherence to recall schedule &

verification of function, comfort, and verification of function, comfort, and esthetics esthetics – lifetime maintenance commitmentlifetime maintenance commitment


MaintenanceMaintenance• Maintenance & Recall:Maintenance & Recall:–Frequency of recall Frequency of recall – immediate post-deliveryimmediate post-delivery–24 hours24 hours–one weekone week– two weeks (re-torque if needed)two weeks (re-torque if needed)–6 months6 months–bi-annual or annual evaluation bi-annual or annual evaluation


MaintenanceMaintenance• Maintenance & Recall:Maintenance & Recall:–Clinical Parameters of Evaluation Clinical Parameters of Evaluation –oral hygiene including plaque indexoral hygiene including plaque index– implant stability (evaluate mobility)implant stability (evaluate mobility)– retrievabilityretrievability–peri-implant tissue healthperi-implant tissue health–crevicular probing depthscrevicular probing depths


MaintenanceMaintenance• Maintenance & Recall:Maintenance & Recall:–Clinical Parameters of Evaluation Clinical Parameters of Evaluation –bleedingbleeding– radiographic assessment (serial) radiographic assessment (serial) »crestal bone level & integrity of crestal bone level & integrity of

attachment systemsattachment systems–proper torque on screw jointsproper torque on screw joints–occlusionocclusion


Clinical Parameters of EvaluationClinical Parameters of Evaluation • oral hygiene (plaque index)oral hygiene (plaque index)–plaque is 1º etiologic factor in tissue plaque is 1º etiologic factor in tissue

destruction (peri-implant and natural tooth)destruction (peri-implant and natural tooth)– review oral hygiene instructionreview oral hygiene instruction–monitor through plaque indicesmonitor through plaque indices–same requirements as for natural teethsame requirements as for natural teeth–use neutral sodium fluoridesuse neutral sodium fluorides


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • implant stability (evaluate mobility)implant stability (evaluate mobility)–may be the may be the key indicatorkey indicator of fixture health of fixture health–minimal mobility w/ osseointegrated fixtures: minimal mobility w/ osseointegrated fixtures:

17- 57um buccal;17- 66um lingual)17- 57um buccal;17- 66um lingual)–no significant difference in osseointegrated no significant difference in osseointegrated

fixture mobility relative to fixture length fixture mobility relative to fixture length (Sekine et al)(Sekine et al)– implants may sustain extensive bone loss implants may sustain extensive bone loss

w/o inc mobility if critical amount bone leftw/o inc mobility if critical amount bone left


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • retrievabilityretrievability– failing implant may be masked if connected to failing implant may be masked if connected to

same prosthesissame prosthesis– important to remove FPD to evaluate important to remove FPD to evaluate –annual removal recommended for multiple-unit annual removal recommended for multiple-unit

prosthesisprosthesis–early failure detection will minimize fibrous early failure detection will minimize fibrous

tissue zone size & may allow placement of wider tissue zone size & may allow placement of wider diameter fixturediameter fixture


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • peri-implant tissue healthperi-implant tissue health–visual inspection: signs of pathoses?visual inspection: signs of pathoses?

– Alterations in color, contour & consistencyAlterations in color, contour & consistency–alveolar mucosa may surround implant & alveolar mucosa may surround implant &

appear more erythematous than gingivaappear more erythematous than gingiva– tissue movement when adjacent tissues tissue movement when adjacent tissues

retracted may affect soft-tissue-implant retracted may affect soft-tissue-implant attachment ~ (detrimental)attachment ~ (detrimental)–perimucosal keratinized tissue is bestperimucosal keratinized tissue is best


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • crevicular probing depthscrevicular probing depths–most accurate means of detecting peri-most accurate means of detecting peri-

implant destruction implant destruction ((use plastic probes)use plastic probes)–probing measurements closely approximate probing measurements closely approximate

actual bone levelsactual bone levels–avoid during first 3 months after abutment avoid during first 3 months after abutment

connection to avoid damaging weak connection to avoid damaging weak epithelial attachmentepithelial attachment–may be difficult if threads supra-osseousmay be difficult if threads supra-osseous


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • bleedingbleeding–controversy as to significance of BOP at controversy as to significance of BOP at

peri-implant interfaceperi-implant interface–BOP may precede clinical signs of BOP may precede clinical signs of

inflammationinflammation–BOP & radiographic changes are most valid BOP & radiographic changes are most valid

indicators of peri-implant breakdownindicators of peri-implant breakdown– recommend continued use of peri-implant recommend continued use of peri-implant

sulcus probing to monitor implant successsulcus probing to monitor implant success


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment–one of most valuable measures of implant one of most valuable measures of implant

successsuccess–of value when of value when – cannot probe area due to constricted implant cannot probe area due to constricted implant

neck, and neck, and – to assess future mobility without FPD removalto assess future mobility without FPD removal– to accurately determine amount of bone loss in to accurately determine amount of bone loss in

absence of increased crevicular depth absence of increased crevicular depth


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment–compare bony changes with stable compare bony changes with stable

landmarks - implant threads -landmarks - implant threads -– (one-half thread = 0.3mm)(one-half thread = 0.3mm)

–compare horizontal/vertical implant compare horizontal/vertical implant dimensions between serial radiographsdimensions between serial radiographs–periapical radiographs = 2.5 - 5% image periapical radiographs = 2.5 - 5% image

magnification Vs. direct clinical magnification Vs. direct clinical measurementsmeasurements


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment–bone level determination should be based only bone level determination should be based only

upon standardized periapical radiographs upon standardized periapical radiographs – threads of implant must appear sharp & well-threads of implant must appear sharp & well-

delineated on X-ray to be accurate delineated on X-ray to be accurate –X-ray beam: direct X-ray beam: direct 9º from line perpendicular 9º from line perpendicular

to long axis of implantto long axis of implant–keep film parallel & close to implantkeep film parallel & close to implant


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment– recommend kVp of not < 60 (best 65-70)recommend kVp of not < 60 (best 65-70)–exposure time determined so internal exposure time determined so internal

mechanical structure of fixture is clearly mechanical structure of fixture is clearly visiblevisible–use long-cone paralleling technique w/ use long-cone paralleling technique w/

paralleling film holderparalleling film holder–can use intra-oral landmarks and film holder can use intra-oral landmarks and film holder

to standardize horizontal angulationto standardize horizontal angulation


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment–quality in film development is paramount!!!quality in film development is paramount!!!–post-op radiographic intervals:post-op radiographic intervals:– not between fixture placement to abutment not between fixture placement to abutment

connectionconnection– one week after abutment insertionone week after abutment insertion– immediately following fixed prosthesis immediately following fixed prosthesis

insertion, then 6 months laterinsertion, then 6 months later– annually for first 3 years, then every 2 yearsannually for first 3 years, then every 2 years


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment–expect 1.0mm marginal bone loss during expect 1.0mm marginal bone loss during

first year postinsertion; first year postinsertion; 0.1mm per year 0.1mm per year anticipated thereafter anticipated thereafter

–greater bone loss observed in maxillagreater bone loss observed in maxilla


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment– rapid bone loss seen if:rapid bone loss seen if:– fractured fixturefractured fixture– initial osseous trauma at insertioninitial osseous trauma at insertion– fixture over-tighteningfixture over-tightening– occlusal traumaocclusal trauma– poor adaptation of prosthesis to abutmentpoor adaptation of prosthesis to abutment– ““normal” physiologic response normal” physiologic response – plaque-associated infection (peri-implantitis)plaque-associated infection (peri-implantitis)


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • radiographic assessmentradiographic assessment–REMEMBER ………REMEMBER ………

Endosseous implants may lose Endosseous implants may lose extensive amounts of bone support extensive amounts of bone support without showing rather obvious without showing rather obvious radiographic changes or increase in radiographic changes or increase in mobility detectable in periodontally mobility detectable in periodontally involved teeth !!!involved teeth !!!


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • proper torque on screw jointsproper torque on screw joints– loosened screws are the most common loosened screws are the most common

problemproblem–can result in localized inflammation, loose can result in localized inflammation, loose

restorations, and discomfortrestorations, and discomfort– if re-torquing a loose abutment - care not to if re-torquing a loose abutment - care not to

strip or “round-off” the hexstrip or “round-off” the hex–excessive force can fracture screw/implant excessive force can fracture screw/implant

or create increased stresses in the boneor create increased stresses in the bone


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • occlusionocclusion–excessive force concentrations - result in excessive force concentrations - result in

extensive bone loss and implant fractureextensive bone loss and implant fracture–MAJOR CAUSE: poor abutment prosthesis MAJOR CAUSE: poor abutment prosthesis

adaptationadaptation– poor force distribution & improperly planned poor force distribution & improperly planned

occlusal schemes also factorsocclusal schemes also factors– recommend anterior guidance ** BEST recommend anterior guidance ** BEST –group function/balanced occlusion also group function/balanced occlusion also


Clinical Parameters of Evaluation Clinical Parameters of Evaluation • occlusionocclusion–goal to prevent lateral forces on posterior goal to prevent lateral forces on posterior

implants concentrated in cervical areaimplants concentrated in cervical area– relationship between parafunctional activity relationship between parafunctional activity

& increased marginal bone loss& increased marginal bone loss– ideal is “light centric” occlusion only; no ideal is “light centric” occlusion only; no

contact in lateral excursionscontact in lateral excursions–no contact in MI, but with hard clench will no contact in MI, but with hard clench will

hold shim stock (.0001”)hold shim stock (.0001”)







MaintenanceMaintenance• Hygiene Aids:Hygiene Aids:–plastic scalersplastic scalers - ONLY! - - ONLY! - forfor abutment abutment

scaling to prevent easy abrasion of soft scaling to prevent easy abrasion of soft titanium; use in only one direction starting titanium; use in only one direction starting at the gingiva (best are from 3i)at the gingiva (best are from 3i)–ultrasonic scalersultrasonic scalers - NO! - - NO! - do not use do not use

Titan-S or ultrasonic scalers unless special Titan-S or ultrasonic scalers unless special non-metal tips usednon-metal tips used


MaintenanceMaintenance• Hygiene Aids:Hygiene Aids:–prophy jetsprophy jets - use with caution! - use with caution!

–fine prophy pastefine prophy paste or flour of pumiceor flour of pumice -- OK! OK! -- use with blue rubber tips or rubber prophy use with blue rubber tips or rubber prophy cupscups –Super-Floss or Post-careSuper-Floss or Post-care - nylon fibers - - nylon fibers -

thread for interproximal use between thread for interproximal use between abutments and under extensionsabutments and under extensions


MaintenanceMaintenance• Hygiene Aids:Hygiene Aids:–end-tufted & small interdental end-tufted & small interdental

brushesbrushes (Proxibrushes) (Proxibrushes) -- for cleaning for cleaning buccal & lingual abutment surfaces; all buccal & lingual abutment surfaces; all metal surfaces must be nylon coatedmetal surfaces must be nylon coated–electric toothbrushes electric toothbrushes -- use at discretion use at discretion

of dentist; may be useful if limited manual of dentist; may be useful if limited manual dexteritydexterity


MaintenanceMaintenance• Hygiene Aids:Hygiene Aids:–chlorhexidine chlorhexidine - use during peri-surgical - use during peri-surgical

periods or as needed if episodes of acute periods or as needed if episodes of acute soft tissue inflammation occur soft tissue inflammation occur –fluoride rinses or gels fluoride rinses or gels -- use neutral use neutral

sodium fluoride to avoid damage to titanium sodium fluoride to avoid damage to titanium fixtures that may occur with acidulated typesfixtures that may occur with acidulated types







MaintenanceMaintenance• Problems:Problems:–soft tissue reactionssoft tissue reactions–fractured or loosened screwsfractured or loosened screws–failing or failed fixturefailing or failed fixture–broken attachments/ componentsbroken attachments/ components

Implant GuidelinesImplant GuidelinesProblems:Problems:

–soft tissue reactionssoft tissue reactions–most common due to loose screwsmost common due to loose screws–poor oral hygiene can lead to poor oral hygiene can lead to “ “peri-implantitis” - may result in progressive bone peri-implantitis” - may result in progressive bone

lossloss

– lack of attached periabutment soft tissuelack of attached periabutment soft tissue– failed or failing implantsfailed or failing implants


Problems:Problems:–soft tissue reactionssoft tissue reactions–treatmenttreatment::» remove offending screw, tighten remove offending screw, tighten

abutment & reinsert prosthesisabutment & reinsert prosthesis» reinforce oral hygienereinforce oral hygiene»soft-tissue autograftsoft-tissue autograft

» replacement of failed implantreplacement of failed implant


Problems:Problems:–fractured or loosened screwsfractured or loosened screws–1st suspicion when complaint of “loose” 1st suspicion when complaint of “loose”

implant or discomfortimplant or discomfort–use correct screwdriver for screw head use correct screwdriver for screw head

without excess force or can “round off” without excess force or can “round off” hexhex– if retrieving (“teasing out”) fractured if retrieving (“teasing out”) fractured

screw caution not to damage hexscrew caution not to damage hex


Problems:Problems:–failing or failed fixturefailing or failed fixture

»failing implant Vs failing implant Vs failedfailed implant implant

–““implantitis” Vs implantitis” Vs periodontal diseaseperiodontal disease


Problems:Problems:–failing or failed fixturefailing or failed fixture–failing implantfailing implant»clinical signsclinical signs: progressive crestal : progressive crestal

bone loss; soft tissue pocketing; BOP bone loss; soft tissue pocketing; BOP w/ possible purulence; tenderness to w/ possible purulence; tenderness to percussion or torquepercussion or torque


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss–failing implantfailing implant»causescauses: surgical compromises (bone : surgical compromises (bone

overheating, lack of initial stability); overheating, lack of initial stability); nonpassive superstructures; too rapid nonpassive superstructures; too rapid initial loading; functional overload; initial loading; functional overload; inadequate screw joint closure; inadequate screw joint closure; infection infection


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss–failing implantfailing implant»treatmenttreatment::» remove and replace with larger remove and replace with larger

diameter fixture; or treat infectiondiameter fixture; or treat infection & re- evaluate& re- evaluate» interim - remove prosthesis & interim - remove prosthesis &

abutments & irrigate area w/ CHX; abutments & irrigate area w/ CHX; disinfect components & reinsertdisinfect components & reinsert


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss–failedfailed implant implant»clinical signsclinical signs: mobility; “dull” : mobility; “dull”

percussion sound; peri-implant percussion sound; peri-implant radiolucency radiolucency » (connective tissue implant (connective tissue implant

encapsulation may not be visible on encapsulation may not be visible on radiograph)radiograph)


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss–failed failed implant implant (most noted at Stage II)(most noted at Stage II)

»causescauses: surgical compromises (bone : surgical compromises (bone overheating, lack of initial stability); overheating, lack of initial stability); nonpassive superstructures; too rapid nonpassive superstructures; too rapid initial loading; functional overload; initial loading; functional overload; inadequate screw joint closure; inadequate screw joint closure; infection infection


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss–failed failed implant implant (most noted at Stage II)(most noted at Stage II)–treatmenttreatment::» removal of implantremoval of implant


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss– ““implantitis” Vs periodontitisimplantitis” Vs periodontitis»clinical signsclinical signs:similar clinical :similar clinical

presentation w/ same pathogenic presentation w/ same pathogenic microorganismsmicroorganisms

»causescauses:poor oral hygiene; bacteria; :poor oral hygiene; bacteria; cause may be unknown (?)cause may be unknown (?)


Problems:Problems:–failing or failed fixture fixture lossfailing or failed fixture fixture loss– ““implantitis” Vs periodontitisimplantitis” Vs periodontitis»treatmenttreatment::»consults to provider - consider consults to provider - consider

remake or guided tissue regeneration, remake or guided tissue regeneration, etc.etc.» interim - remove prosthesis & interim - remove prosthesis &

abutments & irrigate area w/ CHX; abutments & irrigate area w/ CHX; disinfect components & reinsertdisinfect components & reinsert


Problems:Problems:–broken attachments/ componentsbroken attachments/ components– remove offending attachment remove offending attachment (if possible) and replace or (if possible) and replace or

provisionalizeprovisionalize

–be careful not to damage external hex or be careful not to damage external hex or scratch titanium fixture or abutmentscratch titanium fixture or abutment


Case SelectionCase Selection• Implant recommendedImplant recommended–replacement of teeth #27,19 & 30replacement of teeth #27,19 & 30

• Implant Implant not not recommendedrecommended–replacement of tooth #28sreplacement of tooth #28s

Case #1Case #1


Implant recommendedImplant recommended• 46 y/o male presented with failing 46 y/o male presented with failing

NSRCT #27 and severe localized NSRCT #27 and severe localized periodontitis periodontitis • tooth deemed hopeless and tooth deemed hopeless and

extractedextracted


Implant recommendedImplant recommended• 4.0 x 18mm Nobelpharma fixture 4.0 x 18mm Nobelpharma fixture

placedplaced


Implant recommendedImplant recommended• Cera-One abutment restored with Cera-One abutment restored with

cemented (Ketac Cem) PFM crowncemented (Ketac Cem) PFM crown

Case # 2Case # 2


Implant recommendedImplant recommended• 31 y/o female presented with 31 y/o female presented with

missing #19 & 30, and retained missing #19 & 30, and retained #17 & 32 (third molars)#17 & 32 (third molars)


Implant recommendedImplant recommended• mesial-angulated #18 & 31 with mesial-angulated #18 & 31 with

inadequate mesial-distal and inadequate mesial-distal and interarch spacing due to super-interarch spacing due to super-erupted opposing # 3 & 14erupted opposing # 3 & 14


Implant recommendedImplant recommended• buccal-lingual ridge widths in areas buccal-lingual ridge widths in areas

of missing #19 and #30 also of missing #19 and #30 also deficientdeficient


Implant recommendedImplant recommended• teeth # 17 & 32 extracted and teeth # 17 & 32 extracted and

bilateral ramus grafts placed at bilateral ramus grafts placed at edentulous sites (#19 & 30)edentulous sites (#19 & 30)


Implant recommendedImplant recommended• molar uprighting of teeth #18 & 31 molar uprighting of teeth #18 & 31

completed to create adequate completed to create adequate space for implantsspace for implants


Implant recommendedImplant recommended• 5.0 x 11.5mm 3i fixtures placed 5.0 x 11.5mm 3i fixtures placed

bilaterallybilaterally


Implant recommendedImplant recommended• restoration of fixtures with screw-restoration of fixtures with screw-

retained non-segmented UCLA retained non-segmented UCLA abutments w/ PFM crownsabutments w/ PFM crowns


Implant recommendedImplant recommended• restoration of teeth # 3 & 14 with restoration of teeth # 3 & 14 with

PFM crowns to re-establish proper PFM crowns to re-establish proper occlusal planeocclusal plane

Case # 3Case # 3


Implant Implant notnot recommended recommended• 34 y/o male presented with past 34 y/o male presented with past

history of supernumerary #28history of supernumerary #28• Note: dilacerated root to mesial on Note: dilacerated root to mesial on

#28#28


Implant Implant notnot recommended recommended• edentulous site presented with edentulous site presented with

inadequate facial bone, and inadequate facial bone, and inadequate spacing existed inadequate spacing existed between #27 & 28 root apices to between #27 & 28 root apices to allow implant placementallow implant placement


Implant Implant notnot recommended recommended• after two years of orthodontic after two years of orthodontic

therapy, #28 failed to move to therapy, #28 failed to move to facilitate implant placementfacilitate implant placement


Implant Implant notnot recommended recommended• edentulous area restored with a edentulous area restored with a

resin-bonded fixed partial denture resin-bonded fixed partial denture (RBFPD #27-28)(RBFPD #27-28)

QUESTIONS ???QUESTIONS ???

USS BRIDGEUSS BRIDGE

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