SURGICAL MANUAL - Rawex Dental · SURGICAL MANUAL. 2. CONTENTS 1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES 5 2.0 THE NEODENT IMPLANT SYSTEM 5. ... 10.2 Cleaning and care of instruments

SURGICALMANUAL

2

CONTENTS

1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES 5

2.0 THE NEODENT IMPLANT SYSTEM 5

2.1 Overview 5

2.2 CM Implant 6

2.3 WS 7

2.4 Facility 8

3.0 IMPLANT DESIGNS 9

3.1 Surface 9

3.1.1 Neoporos 9

3.1.2 Acqua 10 3.2 Implant Options 11

3.2.1 Drive CM 11

3.2.2 Titamax CM EX 11

3.2.3 Titamax CM 11

3.2.4 Alvim CM 12

3.2.5 Facility 12

3.2.6 Titamax WS 12

3.3 Options of thread according to the implant design 13

4.0 INDICATIONS AND CONTRAINDICATIONS 15

5.0 PRE-OPERATIVE PLANNING 16

5.1 Implant positioning and peri-implant tissue 16

5.1.1 Mesiodistal Positioning of the implant 17

5.1.1.1 Examples of single tooth gaps 18

3

5.1.1.2 Examples of multiple tooth gaps 19

5.1.2 Buccal-lingual implant position 21

5.1.3 Apical coronal implant position 21

5.2 Planning aids 22

5.2.1 Space Planning Instrument as a diagnosis and help for implant placement 22

5.2.2 Direction Indicator pins for the diagnosis of adjacent bone 23

5.2.3 Surgical drill template or guide 25

5.2.4 X-ray templates 26

5.2.5 Softwares for implant planning 26

6.0 SURGICAL PROCEDURES 27

6.1 Implant bed preparation 27

6.1.1 Basic implant bed preparation 27

6.1.1.1 For conical Alvim and Drive implants 29

6.1.1.2 For cylindrical Titamax implants 30

6.1.1.3 For narrow Facility implants 34

6.1.2. Fine implant bed preparation 37

6.1.2.1. Pilot Drill 37

6.1.2.2. Tap Drill 37

6.1.2.3. Example of fine implant bed preparation 38

6.2. Neodent implant packaging 40

6.1.3 Options for drilling 40

6.3. Placing the implant 43

6.3.1. Place the implants with the contra angle 43

6.3.2. Place the implants by hands 44

6.3.3. Finalize the implant positioning with the wrench 45

4

6.4. Soft tissue management 45

6.4.1 Two stage/ submucosal healing 45

6.4.2 Transmucosal healing: One stage or Immediate loading 49

6.4.2.1. Transmucosal healing: One stage 50

6.5 Overview of the healing abutments 51

6.5.1 Overview of the CM Abutments and corresponding Healing Caps 52

7. HEALING PHASE 54

8. ABUTMENT TRY IN KIT 54

9. PROSTHODONTICS GENERAL GUIDELINES 55

10. NEODENT KITS 57

10.1 Sterilization 57

10.2 Cleaning and care of instruments 57

BIBLIOGRAPHIC REFERENCES 58

1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES

The Modern Implantology era, based over clinical results on osseointegration, was originally published

on English based journals in 1977(1). Since then Dentistry had important changes and the treatment plan

of a patient today usually offer implant retained and/or supported prosthesis as an affordable and reliable

solution. The number of oral implants placed are rapidly increasing over the years(2, 3) and this treatment

concept requires specific skills and knowledge, as the surgeon’s learning curve, that are relevant for the

results(4). Based on this facts the present guide aims to provide to dental practioners and specialists basic

information and steps regarding the planning, surgical procedures and options of treatment.

This guide does not replace the instructions for use (IFU) of each product, which can be found in

our website: www.neodent.com.br.

2.1 Overview

2.0 THE NEODENT IMPLANT SYSTEM

The Cone Morse (CM) Neodent implant system offers 6 types of different implant designs, threads,

apex and two types of surface treatment. Neodent’s philosophy is to offer one implant solution adapted

to the proper indication, which is bone density, quantity and surgical technique. All implants can be

installed with the NEODENT surgical kit, except for the Facility system that requires a specific surgical kit.

Procedures are standardized and have straightforward steps.

FIGURE 1. Neodent options of implants according to their indication.

CM WS Facility

5

6

All of which have Morse taper connection. The CM implants (Drive, Alvim, Titamax EX and Titamax

cortical) have an internal total angle of 11.5° and the same prosthetic connection dimension regardless

the implant diameter (figure 2).

The platform switch concept(7) from Neodent CM has proven biological stability of the peri-implant

tissue, specially when the implants are placed 1-2mm sub crestally(8, 9, 10, 11, 12, 13).

FIGURE 2. Neodent CM implant connection has one width regardless of the implant diameter.

FIGURE 3. Neodent CM has a deep connection inside the implant designed to enhance the contact area between implant

and abutment.

2,5mm

11,5º

4,1mm

2.2 CM Implant

7

FIGURE 4. Internal index as a hexagon

created to surgically drive the implant and

to proceed with the implant impression

during the prosthetic phase.

The Neodent conical connection has an internal hexagon as an index in its bottom called Exact.

Exact is used for implant surgical placement and the repositioning of prosthetic parts when working at the

implant level.

WS (short implants) is a complementary line of cone Morse implants, suitable for special areas. WS

Implants also feature an internal angle os 11.5°, but different internal diameter and length. Therefore, a

special line of abutments is required when working with these implants. They are indicated as an alternative

for posterior free ended partially edentulous.

FIGURE 5. WS implant connections are similar and compatible.

3,0mm

2.3 WS

8

FIGURE 6. Facility is the narrowest implant

offered in the system and its abutments are

placed through friction.

TABLE 1. Offer of diameters according to the implant design.

The system has a full portfolio, adapted to the bone density/quality and patients needs.

Facility Implants also have a cone Morse connection, but with an internal angle of 5°. They are

the narrowest implants offered by Neodent and their abutments are placed through friction. Their use is

indicated to the upper lateral incisors and lower incisors areas.

Titamax

Titamax EX

Alvim

Drive

WS

Facility

Implant

Diameter

2.9 3.5 3.75 4.0 4.3 5.0 6.0

TABLE 2. Options of length according to the implant design.

* Available with Neoporos surface

Titamax*

Titamax EX

Alvim

Drive

WS*

Facility

Implant

Lenght

5 6 97 10 12 14 1611 13 15 17 18 1911,58

*

2.4 Facility

3.0 IMPLANT DESIGNS

Neodent CM implants are classified according to their macro design, thread features, apex and

microroughness.

APEX

PROS

THET

ICCO

NNE

CTIO

NIM

PLAN

TBO

DY

CM

Drive Titamax Alvim

AlvimTitamaxDrive

9

FIGURE 7. General feature of the Neodent implants.

Titamax EX

Neodent implants are offered in two types of surface treatment as presented below. The decision

about each surface is driven by the clinical indication.

Neoporos is a special process created for the Neodent implant surface. Firstly the roughness is

obtained through sandblasting, where the size of particles and the pressure are adapted to the implant

design. Posteriorly blasting, the implants are acid etched in specific conditions. Figure 8 represents this

procedure.

3.1 Surface

3.1.1 Neoporos

FIGURE 8. Physical manufacturing process of Neodent Treatment surface

MachinedSa= 0.26 µm

Sand blastedSa= 0.67 µm

Sand blasted + Acid etchedSa= 0.93 µm

10

3.1.2 Acqua

Acqua is a hydrophilic implant with the titanium surface having the valence shell changed.

The physical process from Neoporos is performed over the implants, however Acqua is manufactured

in a especial area of the Neodent production where all implants are packaged and stored in a liquid

environment, avoiding contact with the atmosphere. This isolation results in wettability (presenting

contact angle <5°) and an active physicochemical surface (with positive ions).

Implants with Acqua surface are indicated for implant placement in grafted areas, combined with

grafting procedures, post extraction and sites of poor bone density(17,18).

Surface Comparison

Hydrophobic Surface (conventional). Acqua Hydrophilic Surface.

FIGURE 9. Micro (0.3-1.3 µm) and macro (15-30 µm) structure for Acqua & Neoporos

FIGURE 10. Confocal laser scanning microscopy in the thread region(15).

Oxygen O

Titanium Ti

Nitrogen N

Note: XPS measurements on Neoporos and Acqua Surfaces

Neoporos (Atom%) Acqua (Atom%)

Carbon C

55.9 ± 0.9 59.3 ± 0.2

0.4 ± 0.6 0.6 ± 0.4

21.1 ± 0.7 22.7 ± 0.3

22.7 ± 2.0 15.3 ± 1.0

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3.2 Implant Options

(1) Offered as Acqua or Neoporos surfaces; (2) Tapered implant with internal

conical body; (3) Cervical conicity with microthreads; (4) Main threads are square

shaped with a 2.2mm thread pitch; (5) Double threaded implant; (6) Reverse cutting

chambers distributed across the implant body; (7) Bottom thread with sharp edge;

(8) Rounded apex; (10) Indicated for bone types III and IV and implant immediate

placement post-extraction; (11) Same prosthetic connections for all diameters; (12)

Implant should be positioned 1-2mm below bone level for better results (8, 9, 10, 11, 12, 13);

(13) Drill speed: 500 - 800 rpm; (14) Implant insertion speed: 30 rpm;

(15) Maximum torque for placement 60 N.cm.

(1) Offered as Acqua or Neoporos surfaces; (2) Parallel wall (cylindrical) implant;

(3) Triangular (or pyramidal) threads with 1.2 mm of thread pitch; (4) Double threaded

implant; (5) Implant apex adaptad to be inserted in a 2.0mm osteotomy; (6) Indicated for

bone types III and IV and for areas with narrow bone areas where under preparation

is indicated; (7) Contra indicated for immediate placement post extraction; (8) Same

prosthetic connection for all implant diameters; (9) The implant cervical diameter is

the same as the body diameter; (10) Implant should be positioned 1-2mm below bone

level for better results (19); (11) Drill speed: 500 - 800 rpm; (12) Implant insertion speed:

30 rpm; (13) Maximum torque for placement 60 N.cm.

(1) Only offered as NeoPoros surface; (2) Parallel wall (cylindrical) implants;

(3) Triangular (or pyramidal) threads with 1.2 mm of thread pitch; (4) Double threaded

implant; (5) Self tapping chambers; (6) Indicated for bone types I and II or grafted

areas as bone block; (6) Same prosthetic connection for all implant diameters; (7) The

implant cervical diameter is the same as the body diameter; (8) Final pilot drills are

highly recommended to be used as the implant should be positioned 1-2mm below

bone level for better results(19); (8) No tap is needed during placement; (9) Osteotomy

drill speed: 800- 1200 rpm; (10) Implant insertion speed: 30 rpm; (10) Maximum torque

for placement 60 N.cm

3.2.1 Drive CM

3.2.2 Titamax CM EX

3.2.3 Titamax CM

12

(1) Offered as Acqua or Neoporos surfaces; (2) Tapered implant; (3) Trapezoidal

threads with 1.2 mm of thread pitch; (4) Double threaded implant; (5) Conical apex with

low active chambers designed to optimize secondary stability; (6) Indicated for bone

types III and IV and implant immediate placement post-extraction; (7) Tap is needed

if indicated for bone types I and II; (8) Same prosthetic connection for all implant

diameters; (9) The implant cervical diameter is the same as the body diameter; (10)

Final pilot drills are highly recommended to be used in bone types I and II; (11) Implant

should be positioned 1-2mm below bone level for better results(19); (12) Drill speed:

800- 1200 rpm for bone type I and II; (13) Drill speed: 500 - 800 rpm for bone type III

and IV; (14) Implant insertion speed: 30 rpm; (15) Maximum torque for placement 60

N.cm.

3.2.4 Alvim CM

(1) Offered as Acqua or Neoporos surfaces; (2) narrow implant with 2.9mm

in diameter with a pure cone Morse frictional lock connection; (3) Double threaded

implant; (4) Recommended for lateral upper incisors and lower incisors; (5) Indicated for

bone types I, II, III and IV; (6) Tap is needed if used in bone types I and II; (7) The implant

cervical diameter is the same as the body diameter; (8) Implant could be positioned

1-2mm below bone level when possible; (9) Requires exclusive instruments and line of

prosthetic components; (10) Drill speed: 500 a 800 rpm; (11) Implant insertion speed:

30 rpm; (12) maximum torque for placement 45 N.cm.

3.2.5 Facility

(1) Only offered with Neoporos surface; (2) Parallel wall (cylindrical); (3) Triangular

(or pyramidal) threads with 0.6 mm of thread pitch; (4) Single threaded implant due

to the short implant length; (5) Apex with self tapping chambers; (6) Indicated for

bone types I and II; (7) Alternative for posterior free ended partially edentulous; (8)

The implant cervical diameter is the same as the body diameter; (9) Final pilot drills

are recommended depending on the implant final positioning; (10) Implant could be

positioned 1 mm below bone level when possible; (11) Requires exclusive instruments

and line of prosthetic components; (12) Pre-mounted fixture; (13) Osteotomy drill

speed : 200 a 300 rpm; (14) Implant insertion speed: 30 rpm; (15) Maximum torque for

placement 60 N.cm

3.2.6 Titamax WS

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TABLE 3. Implants indication table according to bone types (Lekholm and Zarb, 1985)

*Tap is required.

Drive CM Acqua

Implant

Bone Density

Bone Type I Bone Type II Bone Type III Bone Type IV

Drive CM

Titamax CM EX Acqua

Titamax CM EX

Titamax CM

Alvim CM Acqua

Alvim CM

Facility Acqua

Facility

Titamax WS

* *

-

-

-

- -

-

-

- -

--

* *

* *

* *

3.3 Options of thread according to the implant design

Drive:

14

Alvim:

Titamax:

15

4.0 INDICATIONS AND CONTRAINDICATIONS

Neodent implants are produced in titanium Grade 4 cold-worked in order to enhance the mechanical

strength of the fixtures, according to ASTM F67. Facility Implants feature titanium alloy, according to ASTM

F136. Table 4 presents specifics distances related to it.

To obtain more information about indications and contraindications related to each implant, please

refer to the corresponding instructions for use. Instructions for use can also be found on ifu.neodent.com.br

* Minimal ridge width: Minimal buccal-lingual ridge width, rounded off to 0.5 mm.** Minimal gap width: Minimal mesial-distal gap width for a single-tooth restoration, between adjacent teeth, rounded off to 0.5 mm.*** Only available as Neoporos.

Implant Distinctive Features Minimal ridge widht* Minimal gap widht** Avaible Lenghts

Bone type III and IV; post-extraction

5,5mm

5,5mm

5,5mm

5,5mm

4,9mm

6,0mm

5,5mm 8/10/11.5/13/16/18 mm

5,5mm 9/11/13/15/17/19 mm***

5,5mm 7/8/9/11/13/15/17mm

5,5mm 8/10/11/13/16 mm

4,9mm 10/12/14 mm

6,0mm 5/6 mm

Bone type III and IV;Promotes high bone expansion due to sub-osteotomy, ideal for

narrow bone width

Bone type I and II and areas grafted with blocks; self tapping.

Bone type III and IV; when combined to a tap drill: bone type I and II; post-extraction.

Bone type I and II; free end partially edentulous in the

posterior area.

Bone type III and IV; when combined tap drill: bone type I

and II; upper lateral incisors and lower incisors in narrow spaces.

Drive

Titamax Ex

Titamax**

Alvim

Facility

WS***

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5.0 PRE-OPERATIVE PLANNING

5.1 Implant positioning and peri-implant tissue

The implant positioning is the key to obtain the correct prosthetic restoration, and is the basis

for the surgical planning. An adequate communication amongst the patient, dentist, surgeon and lab

technician is essential for reaching the desired prosthetic result.

To establish the correct planning, with the correct spatial position, choosing the ideal implant

design (diameter and length), number and distribution of implants, it is recommended to:

- Perform a wax-up on the patient’s study cast;

- Define the edentulous space to be restored;

- Define the type of superstructure;

- Do CT scan and radiographic exams.

The wax-up can then be used to fabricate the radiographic and/or surgical template, and be used

as a temporary restoration. Physiological occlusion is determinant to the implant success in short and long

term. Immediate loading procedures couldn’t be performed in patients with problems in occlusion.

Notes: The implant abutments should always be loaded axially, and the long axis of the implant aligned with the cusps of the opposing teeth. Extreme cusp formation should be avoided, since it may lead to unphysiological overloading.

The diameter, type, position and number of implants should be individually decided for each

patient, taking into account anatomy and the prosthetic space, bad positioned or angled teeth should be

considered and analyzed. The recommendations presented here should be considered as basic guidelines

for correct biological healing, adequate restorations and that the patient may have the conditions for

efficient hygiene of the area. The restoration design has a strong impact over occlusion and hygiene and

it must be taken in consideration.

The final response of the hard and soft tissues is highly influenced by the position of the abutment,

therefore the tri-dimensional positioning of the implant needs to be studied, being these:

• Mesiodistal

• Bucco lingual

• Apical Coronal

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5.1.1 Mesiodistal Positioning of the implant

The available mesiodistal bone is an important factor when choosing the implant diameter and

quantity. It is the distance between implant to teeth and implant to implant when multiple implants are

required. The reference point is to measure the larger mesiodistal width of the implant, usually in the cervical

area. Generally implants require a minimum of adjacent bone of 1.5mm around it. The distances shown here

are rounded off minimum 0.5mm of bone.

The basic rules to be followed are:

Rule 1

Ideally, the distance of CM implants to

adjacent teeth is at least 1.5mm between

the implant widest portion and the teeth,

both on the mesial and distal aspects.

Rule 2

As implants requires at least 1.5mm of

adjacent bone, the distance to other

implants is minimum 3mm.

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5.1.1.1 Examples of single tooth gaps

For single tooth restorations, the implant should be installed in the middle of the gap. The following

example shows how to follow Rule 1.

For all Neodent CM implants, the gap size needs to be considered for the selection of the implant

diameter. Aiming to place an implant in the gap width according to the Rule 1, the following aspects can be

used as an approximation:

FIGURE 10. The distance between adjacent teeth is approximately 1mm more at the bone level because of the tooth anatomy and the interproximal contact point when compared to the real bone gap width (two times 0.5mm). So, applying Rule 1, the gap width must be 2mm wider than the implant diameter.

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Implant Diameter D (mm)

Implant Tooth Distance E1 (mm)Gap width A (mm)

Distance between adjacent teeth at bone

level B (mm)

4,9

5,5

5,75

6,0

D + 2mm

5,9

6,5

6,75

7,0 1,5

D + 3mm*

2,9

3,5

3,75

4,0

4,35,06,0

6,37,08,0

7,38,09,0

Rule

*Rule 1 applied on both implant sides

5.1.1.2 Examples of multiple tooth gaps

The following examples show how Rules 1 and 2 are applied to multiple tooth gaps. The measurements

are made at crestal bone from the adjacent tooth to the center of the implant and between implant centers.

Implant center has to be taken in consideration because of the initial drill during osteotomy. The minimum

distance of 3mm must be followed between implant shoulders (Rule 2) that is important for flap closure, to

avoid proximity of secondary components and adequate space for maintenance, emergence profile of the

restoration and oral hygiene.

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Implant Diameter D1 (mm)

Implant Diameter D2 (mm)

A B C L

2,9

3,5

3,75

4,0

4,3

5,0

6,0

2,9

3,5

3,75

4,0

4,3

5,0

6,0

3,0

3,3

3,4

3,5

3,7

4,0

4,5

5,9

6,5

6,8

7,0

7,3

8,0

9,0

3,0

3,3

3,4

3,5

3,7

4,0

4,5

11,8

13

13,5

14

14,6

16

18

Normally clinical cases have different Gaps and then

D1/D2 can be different in order to adapt the implants to every

situation. Looking for a simpler rule, the dentist has to take in

consideration that every implant requires a minimum of 1.5 mm

of adjacent bone, regardless of the implant diameter. So during

the planning it must be considered that independently of the

implant diameter, it is important to have the minimum of 1.5 mm

of mesial and distal peri implant bone.

1,5mm

Implant Tooth Distance E2 (mm)

3,0

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5.1.2 Buccal-lingual implant position

5.1.3 Apical coronal implant position

The facial and palatal bone layer must be at least 1mm in thickness so as to ensure stable hard and

soft tissue conditions. The minimum buccal-lingual width of each implant diameter is shown in table 4. Within

this limitation, a restoration-driven buccal-lingual implant position and axis should be chosen so that better

restorations are obtained. Also, the surgeon needs to know if the plan is to do a screw or cement-retained

prosthesis.

Caution: Techniques for bone augmentation are highly advisable for ridges where the orofacial bone wall is 1mm

or less or where there is bone missing on one of the sides. These procedures should be conducted only by dentists with

advanced experience in grafted bone regeneration (GBR).

CM Neodent implants were designed for a

2mm sub-crestal positioning in order to optimize

stability of hard and soft tissues and also for better

aesthetic results of the restorations, especially in

the front area(6,7,8,9,10,12).

In a scalloped situation, place the implant

at the bone level according to the inner bone wall,

depending on the clinical case some osteotomy has

to be made as abutments have limits in transmucosal

height. The implant should be fully covered of bone

or grafted with biomaterials to avoid dehisence of

the titanium.

For further information about the implant

positioning, please refer to specific basic literature.

FIGURE11: Example of screw-retained implant positioned (A) and cemented crown (B), where there is access to the retainaly screw.

(A) (B)

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5.2 Planning aids

5.2.1 Space Planning Instrument as a diagnosis and help for implant placement

By using the 7/9mm Space Planning Instrument in the patient’s mouth or on a model, an initial

analyses of the spatial relations can be obtained aimming to select the implant diameter and prosthetic

reconstruction. The Space Planning has two tips with 7 and 9 mm in width and a mark exactly in the middle

(of 3.5 or 4.5 mm), it works as a reference for the surgeon when placing implants respecting the 1.5 mm rule

of minimum adjacent periimplant bone.

The 1.5 mm rule is important for implant placement according to the teeth position, implants and

anatomical structures as nerves, for example, the Space Planning Instrument can help positioning an implant

closer to a foramen.

FIGURE 12: Space Planning Instrument for diagnosis of the spaces and implant placement.

FIGURE 13: Detail on the Space Planning Instrument tip of 7 mm for analysis of the gaps, the mark is on

3.5mm.

FIGURE 14: Using the Space Planning Instrument for positioning the drills for implant placement.

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5.2.2 Drill Positioner pins for the diagnosis of adjacent bone

FIGURE 15: The pin lower (2 mm), medium (implant diameter) and upper part (last drill from the basic osteotomy).

TABLE 4: Options of color coded pins. The medium part of the pins has the same width as the implants, based on the values written at the upper part.

Every Drill Positioner pin in Neodent has different designs aiming to analyze the quantity of bone

around an osteotomy. All pins have: (1) lower, (2) medium and (3) upper part.

The inferior part of all pins has 2.0 in diameter to be adapted after the first osteotomy. The medium

part of the pin has the respective diameter of the implants. All diameters are color coded as presented in

figure 09.

Lower UpperMedium

Indicators Medium Upper

3,5

4,3

3,75

5,0

3,3

5,0

6,0

2,8

3,6

3,0

4,3

4,0

4,3

6,3

Diameter

24

The upper part of each Drill Positioner has the same diameter of the last drill before implant placement,

according to the osteotomy protocols from Neodent. The Drill Positioner allows the surgeon to check the

adjacent bone as illustrated below.

Also, there are Drill Positioners that allow the surgeons to evaluate the abutment angle before implant

placement. These pins are offered in two angles (17o and 30o) and are inserted in the 2.0 mm osteotomy.

FIGURE 16: Drill Positioner inserted after the initial drill and adapted inside the last osteotomy based on drill protocol. It helps the analysis of the remaining adjacent bone when positioned.

FIGURE 17: Angled Direction Pins for abutment selection.

3,753,0

25

FIGURE 18: Titanium tweezers calibrated in

millimeters

5.2.3 Surgical drill template or guide

A custom made surgical drill template manufactured by the lab technician facilitates the preparation

of the implant bed and enables precise use of the cutting instruments. The planning basis for fabricating this

template should be the desired prosthetic result.

Models can be drilled with 2.0mm drills at the implant position and guides for sleeves of 2.0mm in

diameter are adapted over it. Wax or vacuum formed templates are built with the sleeves engaged inside.

After the template asepsis, it’s used during the surgery and its sleeves will guide the initial drilling during the

surgical procedure.

FIGURE 19: Sleeves of 2.0 mm in diameter and guides to be adapted in the patient`s model.

2,02,0

2,0

Notes: Neodent Titanium tweezers have a rule in their tips helping surgeons in analyzing all edentulous area.

26

5.2.4 X-ray templates

The X-ray templates are used for measurement and comparison, and assist in the planning phase

since they assist the dentist in selecting the suitable implant type, diameter and length. The NEODENT X-ray

template has the following implants printed:

• Titamax;

• Alvim;

• Drive;

• Facility;

• WS.

In the two dimensions:

1:1 – to be used on 1:1 Periapical radiographs and 1:1 CBCT scans, and can be superimposed due to the

transparency of the template.

4:1 – the images of the implants are 25% larger than the normal size, and can be used on Panoramic

radiographs that came with a 25% distortion. Due to the digital Panoramic machines, these distortions are

slowly being adapted.

FIGURE 20: X Ray template for CM Neodent implants.

5.2.5 Softwares for implant planning

Neodent has partnership with the main softwares companies for implant analysis (for example coDiagnostiX©)

and they can be used as an important tool for previous treatment plan.

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6.0 SURGICAL PROCEDURES

6.1 Implant bed preparation

Diameter, position and number of implants should be selected taking into account anatomy and

spacial circunstances. The measurements should be in accordance to the basic guidelines.

Basic implant bed preparation involves ridge preparation and twist drilling with water cooling, for

which the diameter and the design (if cylindrical or conical) of the selected implant determine the instruments

to be used.

Fine implant bed preparation involves profile drilling and tapping, for which the type of implant and

bone density determine the instruments to be used.

InstrumentationSteps

1. Basic implant bed preparation

Ridge preparation

Twist drilling

Initial drill

Twist drill 2.0mm; Direction indicator pin; Depth gauge

Drills shape to be defined according to the implant design and drill step by step and diameter according the implant width

Tapping

2. Fine implant bed preparation

Conical or cylindrical drills and profile drilling

Tap for Alvim or Facility in bone type I and II

Note: Titamax, Titamax EX, Alvim, Drive and WS implants can be placed using the same kit, where the Alvim and Drive implants

have conical drills for the implant bed preparation and Titamax and WS also have their specific drills. WS implants of 6.0mm in diameter

request extra drills present at one cassette for WS. The Facility implants have their own instrument kit as well.

6.1.1 Basic implant bed preparation

After opening a flap and exposing the bone, the preparation of the alveolar ridge begins. Once the

position of the implant has been decided previously and with surgical guide aids, the cervical cortical layer is

perforated with the initial drill (step1) and verified visually for its spatial positioning. The indicated rotations

per minutes (rpm) for drilling relies basically on the bone density, where in bone type I and II is applied 800-

1.200 rpm and type III and IV 500-800 rpm. Although short implants WS request a drilling protocol of 200-300

rpm, regardless of the bone density. This initial perforation works as a guide. After this, the 2.0mm twist drill

is used to reach the desired depth for the chosen implant, always remembering to consider the 1-2 mm sub

crestal insertion of the CM implant. Then a next drill is used to prepare the osteotomy following a sequence

according to the implant type and diameter, as chosen in the preoperative planning. All drills are adapted to

contra angles according to the ISO 1797-1 – Dental rotary instruments - Shank.

28

Step 1 - Preparing the implant site and initial drill

Carefully reduce and smooth to provide a flat bone surface

before marking the position of the implant with the initial

drill. Use the initial drill about 5-7 mm with the rpm in

accordance to the bone density. For WS implants, this

initial drilling should be very carefully, about 3-4mm and

under 200-300 rpm.

Note: the reduction/preparation of the bone needs to be considered in

the preoperative planning since it influences the choice of the implant

diameter and length.

Step 3 - Twist drill 2.0

Use the 2.0mm twist drill to reach the planned

preparation depth. The use of the surgical probe is

recommended to control the depth.

Note: 1 - a periapical X-ray at this point would be recommended for

checking vertical bone availability, or checking the axis in relation to

adjacent roots, for example. The Direction Indicator pin is fully inserted

into the drilled area, allowing to visualize the drill hole in relation to the

anatomical structures.

Step 2 - Check the implant axis

After using the initial drill, check the implant axis

using the Direction Indicator pins. Implant diameters and

adjacent bone can be rechecked as described in 3.2.2.

2 - the 2.0 twist Neodent drill has an active tip that can be

used as an initial drill. This can be performed in situations were there

is a flat bone ridge and so the use of the initial drill can be avoided.

29

Step 4 - Conical Drill 3.5

The tip of the tapered drill 3.5 adapts in the 2.0 mm

osteotomy and so the prepared bone guides this drilling.

This is the last basic drill step for the conical implants of

3.5 mm.

Note: an X-ray at this point would be

recommended for analysis of the bone

availability or to check the axis in relation

to adjacent roots. A radiographic pin of

the 3.5 implant is inserted into the drilled

area.



osteotomy, guiding the drilling. This is the last basic drill

step for the conical implants of 4.3

Note: an X-ray at this point would be recommended for analysis of the

bone availability or to check the axis in relation to adjacent roots. A

radiographic pin of the 4.3 implant is inserted into the drilled area.



osteotomy, guiding the drilling. This is the last basic drill

step for the conical implants of 5.0

Note: an X-ray at this point would be recommended for analysis of the

bone availability or to check the axis in relation to adjacent roots. A

radiographic pin of the 5.0 implant is inserted into the drilled area.

6.1.1.1 For conical Alvim and Drive implants

6.1.1.2 For cylindrical Titamax implants

30

Step 4 - Implant placement

Titamax EX implants are designed to undersized osteotomy.

So regardless of the implant diameter (Titamax Ex is

offered as 3.5, 3.75 and 4.0), the implant can be placed

after the 2.0mm drill.

Note: In cases where there is a thick cortical layer (over 3 mm) the 2.8 drill

can be used about 1/3 of the planned implant length in order to reduce

the stress over this area.


This is the last drill basic step for the Titamax 3.5 as this

implant design avoids the use of tap drill. Although fine

preparation is requested in bone types I and II.

Widen the implant bed to 2.8mm, you may correct the

positioning if necessary, and reach the final preparation

depth. Check the preparation with the Direction Indicator

pin 3.5 as described in 5.2.2.

For Titamax Ex

For cylindrical implant Titamax 3.5

Note 1: all Alvim drills have similar marks referred to each implant lenght, regardless of the drill diameter.

Note 2: all drills are available in short and some are available in a long version.

Note 3: Due to its function, alvim drills are maximum 0.5mm longer than the implant. This additional length has

to be planned before the surgery.

31

Step 5 - Pilot drill 2/3

Use the 2/3 pilot drill to widen the initial portion of the

implant bed in situations where the drill 3.0 is requested as

a next step. Insert the drill until the mark is reached.


After the preparation with the pilot 2/3 drill, widen the

whole implant bed to 3.0mm and check with the 3.75

Direction Indicator pin as described in 3.2.2. 3.0 drill can

be used as a last basic step drill or an intermediate drill of

a sequence, depending on the implant diameter chosen to

be placed.

Note: This is the last basic drill step for the Titamax implants of 3.75 mm

as this implant design avoid the use of tap drill. Although fine preparation

is requested in bone types I and II.


This is the last drill basic step for the Titamax and WS

implants of 4.0mm as these implant designs avoid the

use of tap drill. Although fine preparation is requested in

bone types I and II. Widen the implant bed to 3.3 mm, you

may correct the positioning if necessary, and reach the

final preparation depth. Check the preparation with the

Direction Indicator pin 4.0 as described in 5.2.2.

For cylindrical implants Titamax and WS


For cylindrical implants Titamax and WS 4.0

32

Step 7 - Pilot drill 3.0/3.75

Use the 3.0/3.75 pilot drill to widen the initial portion of the

implant bed in situations where the drill 3.8 is requested

as a next step. Insert the drill until the 2nd mark is reached.


Widen the implant bed to 3.8 mm as this step is required in

the drill sequence of implants with 5.0 and 6.0 in diameter.


This is the last drill basic step for the Titamax and WS

implants of 5.0 mm as these implant designs avoid the

use of tap drill. Although fine preparation is requested in

bone types I and II. Widen the implant bed to 4.3 mm, you

may correct the positioning if necessary, and reach the

final preparation depth. Check the preparation with the

Direction Indicator pin 5.0 as described in 5.2.2.




33

Step 10 - Pilot drill 4.3/5.3

Use the 4.3/5.3 pilot drill to widen the initial portion of the

implant bed in situations where the drill 5.3 is requested as

a next step: for implants of 6.0 in diameter. Insert the drill

until the 2nd mark is reached.


This is the last drill basic step for the WS implants of 6.0 mm

as this implant design avoids the use of tap drill. Although

fine preparation is requested in bone types I and II. Widen

the implant bed to 5.3 mm and reach the final preparation

depth. Check the preparation with the Direction Indicator

pin 6.0 as described in 5.2.2.

For cylindrical implants WS

For cylindrical implants WS

Note: all Twist drills have similar marks referred to each Titamax implant length, regardless of the drill diameter

34

6.1.1.3 For narrow Facility implants

Each Facility implant has one specific drill according to their lengths. Depending on the chosen

implant, each drill has a mark at the bone level or a reference at 2 mm over its length.

The following sequences summarize the use of instruments for the basic bed preparation according

to the implant diameter and type.

Note: all Twist drills have similar marks referred to each Facility implant length.

Note: There are X ray positioners for

checking the Facility implant axis

35

Titamax Ex

* The sequence can start direct from drill 2.0 if the bone bed is flat.

* The sequence can start direct from drill 2.0 if the bone bed is flat.** Optional in cases of a thick cortical layer using about 1/3 of the planned implant length.

Instruments for basic implant bone preparation Diameters (mm)

Step

1 -Preparing the

implant site and

initial initial drill*

3- Twist drill 2.0*

2- Check the

implant axis

4- Twist drill 2.8**

103.170

103.162

128.019

103.163

Direction

indicator 3.5

Twist Drill 2.8

Twist Drill 2.0

Initial Drill 800

800

800

-

Art. n° Product Max RPM Image Ø 3.5 Ø 3.75 Ø 4.0


Step

1 -Preparing the

implant site and


2- Check the

implant axis

3- Conical drill 2.0*

4- Conical drill 3.5

103.170

103.171

103.172

103.173

103174

129.009

129.013

129.014

128.019

128.022

128.023

128.019

Initial drill

Tapered drill 2.0

Tapered drill 3.5

Tapered drill 4.3

Tapered drill 5.0

Tapered X-ray positionerHelix 3.5



Direction Indicator 2.8/3.5



Direction

Indicator 2.8

800

800

800

800

800

-

-

-

-

-

-

-



Art. n° Product Max RPM Image Ø 3.5 Ø 4.3 Ø 5.0

- -

-

103.220

103.219

103.216

300

300

300

9- Pilot Drill 4.3/5.0



Pilot Drill 4.3/5.0

Pilot Drill 4.3/5.0

Pilot Drill 2.8/3.5 Optional

Optional

Optional

36

Titamax and WS


** This is the only Direction Indicator pin for WS implant.

Note: All narrow parts of the drill positioner pin can be used for checking the implant axis as indicated in page 23.

Diameters (mm)

Image

Ø 4.0Ø 3.5 Ø 5.0Ø 3.75 Ø 6.0

-

-

Instruments for basic implant bone preparation

Step

1 -Preparing the

implant site and


2- Check the

implant axis

3- Twist drill 2.0*

4- Twist drill 2.8

103.170

103.162

103.163

103.164

128.021

128.022

103.220

103.215

128.025

128.024

103.169

103.221

128.019

103.217

128.020

103.218

103.213

103.166

103.168

103.167

128.019

Initial drill


Pilot drill4.3/5.0

Pilot drill4.3/5.3



Twist Drill 5.3

Pilot drill5.3/6.0

Pilot drill 2/3

Pilot drill3.3/4.0


Pilot Drill 3.0/3.75



Direction

Indicator 2.8

1200

1200

300

1200

1200

1200

1200

300

1200

1200

300

300

-

1200

300

6- Twist Drill 3.0

7- Twist Drill 3.3

Twist Drill 3.3

Twist Drill 3.0

10- Twist Drill 4.3

Twist Drill 4.3

Twist Drill 2.8

Twist Drill 3.8

Twist Drill 2.0

8- Pilot drill 3.3/4.0

9- Twist Drill 3.8



13- Twist Drill 5.3


5- Pilot Drill 2/3

Art. n° Product Max RPM Image

-

-

-

-

-

-

-

-

-

-

-

-

-

- -

- -

-

-

- -

-

**

Facility



Step

1 -Preparing the

implant site and


3- Check the

implant length

2- Facility twist

drill 2.0*

4- Facility drill 10



103.330

129.016

103.331

103.341

103.342

103.343

Facility Twist

drill 2.0

Facility Drill 14

Facility Drill 12

Facility Drill 10

Facility X Ray

positioner

Facility Initial

Drill800

800

800

800

800

Art. n° Product Max RPM Image

-

-

-

-

Ø 10 Ø 12 Ø 14

37

FIGURE 21: Pilot drill for the fine implant bed preparation. It helps the implant coronal positioning in areas of bone with higher density: if bone level, 1, 2 or 3mm subcrestal. It is not necessity for Drive CM implants.

bone level

1mm subcrestal

2mm subcrestal

3mm subcrestal

FIGURE 22: Tap drills were engineered to be used in bone bed types I and II for Alvim and Facility implants.

6.1.2. Fine implant bed preparation

6.1.2.1. Pilot Drill

6.1.2.2. Tap Drill

The fine bed preparation encompasses (1) pilot drilling and (2) tapping, when needed. Instrumentation

depends on the implant type, the implant diameter and the type of bone. Osteotomy in bone type I and II

requires final pilot drills in because of the final implant positioning. Tap drills are only requested for the use

of Alvim and Facility implants in areas of high bone density.

Pilot drills are used to prepare the implant bed

when widening from one twist drill to another in the basic

drilling procedure. For fine bone preparation, pilot drills help

in positioning the platform of the CM implant according to

the bone bed, if at the bone level, 1, 2 or 3mm subcrestal in

areas of a higher cortical layer is present. So usually they

are only used in bone type I and II and indicated as optional

in bone types III-IV. Drive CM implants don’t request the use

of this drill because of its coronal design. The rpm used for

the pilot drills is maximum 300.

Tapping prepares the bed for a specific thread type. It is a step used

for bone type I and II in order to keep the insertion torque in a desirable range.

The tap drill is available for Alvim and Facility.

Tapping is performed by coupling the tap to the contra angle or

wrench. While for Facility it is indicated to be started by the contra angle and

finalized with the wrench, for Alvim there are two options of use: with the

contra angle handpiece and the WS implant driver (hexagon connection) or

with the torque wrench (WS implant driver for torque wrench – with a hexagon

connection). The rpm should be of 15-30 rpm when using a contra angle and a

slow clockwise rotating movement for the use with wrench, for removing in the

counterclockwise direction. The maximum torque of use should be 60 N.cm for

the Alvim and 45 N.cm for Facility.

38

FIGURE 23. Option for taping with Alvim.

FIGURE 24. Options for taping with Facility. First start with the contra angle and finish with the wrench.

105.002105.001

+

+

+

+

+

105.111

104.050

104.050

111.037111.037

111.035

111.035

Contra-Angle

+

Contra-Angle

+

39

*Optional.** Only in bone type I and II.

Note: Neodent surgical drills can be used about 25 times in bone type III/IV and 20 times in type I/II since conditions of use and indications, as irrigation and rotation, are respected. Regardless of this suggestion of times for use, all drills have to be checked about their sharpening conditions. The cleaning of all drill has to be made one to one, avoiding mechanical contact of the blades during this procedure.

The following table summarizes the use of Pilot and Tap drills for the fine bone preparation.

Facility tap drill can be used in contra angle and wrench.

Instruments for basic implant bone preparation Implants

Art. n° Titamax Alvim Drive Facility WSTitamax ExProduct Max RPM Image

Pilot drill

2.8/3.5

Pilot drill

3.6/4.3

Alvim tap

drill 3.5

Pilot drill

3.0/3.75

Pilot drill

4.3/5.0

Alvim tap

drill 4.3

Pilot drill

3.3/4.0

Pilot drill

5.3/6.0

Alvim tap

drill 5.0

Facility

tap drill

103.216

103.219

111.036

103.217

103.220

111.037

103.218

103.221

111.038

111.035

300 Ø3.5 Ø3.5*

Ø4.0

Ø5.0

- -

- - - -

- -

-- -

- - - --

- -

-- -

- - - --

- -

-- -

- - - -

- -

-- -

- - -

-

Ø5.0* Ø5.0

Ø4.3**

Ø2.9*

Ø3.75

Ø4.3 Ø4.3*

Ø3.5**

Ø5.0**

Ø6.0

300

30

300

300

30

300

300

30

30

Step 1- Pilot Drill

Perform the osteotomy with the conical drills and

depending on the planned level for final implant

positioning (bone level, 1 or 2 mm sub crestal), use the

pilot drill for the implant placement.

Step 2- Tapping the threads in dense bone

Tap the full length of the planned implant with the

Alvim tap drill.

6.1.2.3. Example of fine implant bed preparation

Here follows an example of fine bed preparation for an Alvim implant of ø 4.3 mm and length of 13 mm

placed in bone type I or II, turning the use of taping and pilot drills necessaries. The steps described followed the

basic implant bed preparation (6.1.1.1).

40

6.1.3 Options for drilling

Neodent Alvim drills are offered as long (35 mm) or regular (43 mm) because of mouth opening

limitations or due to drilling procedures between two teeth. In case of necessity a Drill extension can be used

for other drills from the system.

FIGURE 25. Options of Alvim drill length (35 mm and 43 mm long).

FIGURE 26. Neodent drill extension, a 1.2 driver is used to tight the screw that open and retain the drills. The maximum torque of use should be 30 N.cm.

6.2. Neodent implant packaging

The Neodent packaging was especially updated for easy

handling and safe clinical procedures, delivering practicality from

the housing of the implants to pick-up and carrying to the implant

bed. The characteristics of the implant such as type, diameter

and length are easily identifiable on the on the outside of the

package.

Three peel-off labels are provided for the patient’s

treatment record and for communicating with the prosthodontics

team.

41

Instructions on opening the implant package

Step 1

Step 2

Step 3

Step 5

Step 4

Step 6

Open blister and remove the vial, pouring

it onto a sterile area

After breaking the sterility seal in the

blister, hold the package and twist the

cap to open.

Note: for Acqua implants keep the vial upright to prevent the liquid from flowing out

Remove the implant from the tube lifting

the cap, it has the implant attached.

Note: for Acqua implants keep the vial upright to prevent the liquid from flowing out

Capture the implant using the contra

angle hand piece. Grip the stand and

rotate it in order to find the perfect

seating between the drive at the contra

angle and the implant. Make sure that

the implant driver is fully seated into the

implant

While gripping the stand, remove the cap

Transport the implant to the implant bed

42

Instructions on opening the conventional implant package

Step 1

Step 2

Step 3

Step 5

Step 4

Open blister and remove the vial, pouring

it onto a sterile area

After breaking the sterility seal in the

blister, hold the pacakeg and pull the cap

to open

The implant is holded at the tube

Make sure that the implant driver is fully

seated into the implant and take it into

position

Capture the implant using the contra

angle hand piece. Grip the stand and

rotate it in order to find the perfect

seating between the drive at the contra

angle and the implant.

43

6.3. Placing the implant

CM Neodent implant were planned to start placing with the contra angle or by hands and finalize it

with the wrench. The maximum speed recommended in the surgical motors is of 30 rpm and the torque of

45N.cm.

The following instructions present the step by step of how CM Neodent implant is handled with the

contra angle for placement.

6.3.1. Place the implants with the contra angle

Step 1- Adapt the hand piece implant driver

Hold the implant through its blister and attach

the hand piece driver of the CM implant. All

hand pieces drivers present a ring in the active

tip in order to keep the implant stable during

carrying. Implant drivers for torque wrench

don’t have the rubber for keeping implants in

positioning for transport.

Step 2- Place the implant with the contra angle

into the implant bed.

Place the implant into its final positioning with a

maximum torque of 45 N.cm and 30 rpm turning

it clockwise.

Caution: Corrections of the vertical positioning

through reverse rotations during the surgery may

lead to decrease of initial/mechanical stability.

44

Step 3 - Implant final positioning

CM Neodent implants have an internal hexagon index called

Exact. Make sure that the final implant positioning has one

of the dots bucally positioned for prosthetic orientation.

The implant drivers have six dots that coincide with the

six sides of Exact. Position one of the dots on the driver

buccally to ensure optimal placement of CM abutments

indexed with Exact.

AA

Note 1: There are three similar marks at 1mm intervals on the contra angle

and the wrench implant carries. They will guide the depth of the implant

final placement as following: 1st strip to 1 mm subcrestal, 2nd to 2 and the

3rd to 3 mm. Every full turn over the implants will result in: (1) 0.6mm in WS

implants; (2) 2.2 mm Drive implants; (3) 1.4 mm in Alvim; and (3) 1.2 mm for

all the other offered implants.

Note 2: One important difference from the contra angle driver to the wrench

one is that the contra angle driver has a rubber in the tip that keeps the

implant in position. So wrench drivers are not indicated to transport the

implant from the blister to the mouth.

All sequence described below can be repeated

by hands using the Manual implant driver – Contra Angle

(C.A.) instead of the contra angle.

6.3.2. Place the implants by hands

FIGURE 27. Any instrument for contra angle can be adapted in the Manual implant driver –C.A.

CM Implant DriverContra-Angle

CM Implant DriverTorque Wrench - Long

Manual Implant DriverContra-Angle

bone level1mm subcrestal

2mm subcrestal

3mm subcrestal

CM Implant DriverContra-Angle

45

Remove the contra angle driver from the implant and adapt

the driver for the wrench for final implant positioning and

torque measurement. There are 2 options of wrench driver:

long and short. First adapt the driver inside the implants

with the fingers, and then engage the wrench over the

driver. No wrench drivers should be used to transport the

implant from a place to another, because the fixture may

fall. Apply torque until the implant reaches its final position.

All wrenches show the torques of 10/15/20/32/45 and

60N.cm, and torques over 60 N.cm are contra indicated.

Caution: Corrections of the vertical positioning through reverse rotations during the surgery may lead to decrease of initial/mechanical stability.

For submucosal healing (under a closed mucoperiostal flap)

the use of a cover screw is indicated. A second surgical

procedure is required for uncovering the implant and

insertion of the desired secondary component.

The NEODENT system has two cover screws, which are sold

separately and are packed sterile, at implant level and 2.0

mm (above implant shoulder) because of the subcrestal

positioning.

Cover Screw

2mm Cover Screw

6.3.3. Finalize the implant positioning with the wrench

6.4. Soft tissue management

After implantation, the implant is closed with a cover screw or a healing cap (or healing abutment)

to protect the implant. The surgeon can choose between submucosal or transmucosal healing and has

all options available for soft tissue management made possible through a set of secondary healing

components.

6.4.1 Two stage/ submucosal healing

CM Implant DriverTorque Wrench - Long

CM Implant DriverTorque Wrench - Short

46

Step 1- Inserting the cover screw

Ensure that the internal configuration is clean and bloodless.

Pick up the cover screw with the 1,2mm screwdriver, the

perfect fit secures the transport to the implant, and hands

tighten the screw.

Step 2- Close of the flap

Adapt the flaps and suture with tension free sutures.

47

Step 4- Reopening and removal of cover screw

Second surgery- after the bone regeneration period for each implant/bone type,

locate the implant with the aid of the surgical guide, X-rays or measurements, and

with the desired technique, make an incision to reach the implant and remove the

cover screw with the 1.2mm screwdriver

Step 3 - Regeneration period

Remove sutures after approximately 7 days, or once they have lost their function

and wait the regeneration phase of the bone.

Note: Beware when using the 2.0mm cover screw as it can be exposed when placed in bone level implants in a thin mucosa area. The exposure of this piece permits mechanical contacts with removable dentures and it’ll result in failure of the implant.

48

Step 5- Insertion healing abutment

Rinse the exposed internal connection of the implant with

sterile saline solution, insert a healing abutment (or an

abutment if it can be chosen). Adapt the soft tissue and

suture around the component. More info about healing

abutments options can be found at #4.5.

Step 6 - Wound closure

Adapt the soft tissue and suture around the component.

49

A variety of healing caps and abutments are available in the Neodent CM system, shaping the soft-

tissue during transmucosal healing right after implant placement. The components can be for intermediate

use, where they are replaced with the definite abutment in the final restoration phase, or with the definite

abutment with a temporary restoration. This phase can be defined as one stage surgery (if the healing

abutment is chosen after the surgery) or immediate loading (if the proper abutment is chosen).

The final implant placement torque determines the protocol to be defined. Proper and physiological

patient’s occlusion is determinant to define the protocol to be used. Patients without good occlusion are

contra indicated for immediate loading protocols. Table 05 exemplify the criteria to be observed in order to

select the correct protocol.

6.4.2 Transmucosal healing: One stage or Immediate loading

TABLE 05: Healing protocol according to torque level

Torque (N.cm) Healing Protocol General characteristics

≤20 N.cm

<20 to < 32 N.cm

≤ 32 to ≤ 60 N.cm

Submucosal healing with

selection of the cover screw

One stage/transmucosal healing

with healing abutment selection

Immediate loading or

abutment selection

• Avoid exposure of the

implant or cover screw.

• Mechanical lateral load over the

components is contra indicated.

• Mechanical lateral load over the

temporary crowns is contra indicated.

• Periodontally compromised patients

have to be previously controlled

specially when any component is

exposed at the patient oral cavity.

• Periodontally compromised patients

have to be previously controlled when

any component is exposed at the

patient oral cavity.

• Patients need to present

physiological or proper occlusion.

50

6.4.2.1. Transmucosal healing: One stage

Step 1- Healing abutment insertion after implant placement

Ensure that the internal configuration is clean and without

blood, insert the healing abutment with the 1.2mm

screwdriver and hand tighten it.

Step 2- Wound closure

Adapt the soft tissue to the component and suture with

tension free sutures.

51

6.5 Overview of the healing abutments

The Neodent system has a variety of healing abutments, with different diameters and trasmucosal

heights to suit to the definitive abutment. Therefore the correct choice is of utmost importance to have the

right healing of the soft tissues, with controlled pressure and respect of the biological width.

Basically there are different shapes of CM healing abutments to be adapted to the surgeon

necessities:

Transm

uco

sal H

eig

ht

Ø3.3 Ø4.5

0.8mm 0.8mm

Transmucosal

heigth from 0.8 - 5.5mm

Healing Abutments

Height Measurer

for Facility

4,5mm

2,5mm3,5mm

3,5mm3,5mm

5,5mm5,5mm

1,5mm

1,5mm1,5mm

0,8mm

Height Measurer

for CM

Ø of 3.3 or 4.5

1.5mm 1.5mm

2.5mm 2.5mm

3.5mm 3.5mm

4.5mm 4.5mm

5.5mm

6.5mm

5.5mm

6.5mm

Aiming to select the proper abutment and to check

the measurement of the remaining mucosa for component

selection, there are 3 options of Height Measurer (for CM,

WS and Facility) which are used adapted in the implants

serving as a reference to select the right component.

The height of the components varies from 0.8mm to 6.5mm and should be chosen according to

the gingival height. Since the internal design of the healing abutment is identical to that of the definite

component, if the height of the healing cap was chosen too high, the soft tissue will heal accordingly. If the

height of the definite component is not compatible, let´s say lower, then it will exert a lot of pressure on

the soft tissues and the patient will complain of pain due to compression. Therefore the choice of healing

caps with the same width and transmucosal height are recommended. If the definite component needs to

be changed, then the patient needs to be anesthetized and an adequate timing given for the soft tissue to

readapt.

52

6.5.1 Overview of the CM Abutments and corresponding Healing Caps

All Neodent healing abutments were strategically designed to create the correct emergence profile

adapted to the margin of all abutments in a way it stays 0.9mm under the mucosa.

0,9mm

2,5mmA

butm

ent

Corr

esp

ond

ing

Healin

g A

butm

ent

Transmucosal

Heights

Transmucosal

Heights

Type Pro Peek Abutment

4.5mm 6.0mm

4.5mm 4.5mm

0.8mm

0.8mm 0.8mm

0.8mm

1.5mm

1.5mm 1.5mm

1.5mm

2.5mm

2.5mm 2.5mm

4.5mm

4.5mm 4.5mm

2.5mm

4.5mm

3.5mm

3.5mm 3.5mm

5.5mm

5.5mm 5.5mm

3.5mm

5.5mm

Available Ø

Temporary abutment options

Available Ø

Ab

utm

ent

Corr

esp

ond

ing

Healin

g A

butm

ent

Type Miniconical Microconical CM Abutment EquatorMiniconical(angled and exact)

4.8mm

4.5mm

4.8mm

4.5mm

3.3mm

3.3mm

4.8mm

4.5mm

4.8mm

4.5mm

0.8mm

0.8mm

0.8mm

0.8mm

0.8mm

0.8mm

0.8mm

0.8mm

0.8mm

0.8mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

4.5mm

4.5mm

4.5mm

4.5mm

4.5mm

4.5mm

4.5mm

4.5mm

4.5mm

4.5mm

5.5mm

5.5mm

5.5mm

5.5mm

5.5mm

5.5mm

5.5mm

5.5mm

Available Ø

Screw retained CM options

Available Ø

Transmucosal

Heights

Transmucosal

Heights

Ab

utm

ent

Corr

esp

ond

ing

Healin

g A

butm

ent

TypeCM Anatomic

abutment (and Exact)

CM Anatomic abutment

(and Exact)

Universal Post (straight, angled

and Exact)

Universal Post (straight, angled

and Exact)

3.3mm6.0 mm(buccal)/

5.0 mm (lateral)

4.7 mm(buccal)/

4.3 mm (lateral)4.5mm

4.5mm 4.5mm 3.3mm 4.5mm

0.8mm 0.8mm

0.8mm 0.8mm

1.5mm 1.5mm1.5mm 1.5mm

1.5mm 1.5mm1.5mm 1.5mm

2.5mm 2.5mm2.5mm 2.5mm

2.5mm 2.5mm2.5mm 2.5mm

3.5mm 3.5mm3.5mm 3.5mm

3.5mm 3.5mm3.5mm 3.5mm

4.5mm 4.5mm

4.5mm 4.5mm

5.5mm 5.5mm

5.5mm 5.5mm

Available Ø

Cement retained CM options

Available Ø

Transmucosal

Heights

Transmucosal

Heights

53

54

Ab

utm

ent

Corr

esp

ond

ing

Healin

g A

butm

ent

Type Microconical

Facility Anatomic abutment

Equator

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

1.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

2.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

3.5mm

4.5mm

4.5mm

Options for Facility

Transmucosal

Heights

Transmucosal

Heights

Note 1: for Facility, the 1.5mm healing cap is also used as cover screw

Ab

utm

ent

Ab

utm

ent

Corr

esp

ond

ing

Healin

g A

butm

ent

Corr

esp

ond

ing

Healin

g A

butm

ent

Transmucosal

Heights

Transmucosal

Heights

Transmucosal

Heights

Transmucosal

Heights

Note 2: for WS, there is a specific cover screw and healing cap

Type TypeWS MiniConical

WS Universal

Post

WS Abutment

4.8mm 4.5mm4.8mm

4.5mm 4.5mm4.5mm

0.8mm 0.8mm0.8mm

0.8mm 0.8mm0.8mm

1.5mm 1.5mm1.5mm

1.5mm 1.5mm1.5mm

2.5mm 2.5mm2.5mm

2.5mm 2.5mm2.5mm

3.5mm 3.5mm3.5mm

3.5mm 3.5mm3.5mm

Available Ø Available Ø

Screw retained WS options Cement retained WS options

Available Ø Available Ø

7. HEALING PHASE

8. ABUTMENT TRY IN KIT

The Healing protocol relies on:

(1) Final placement torque of the implants or primarily stability measured with the torque wrench;

(2) Type of bone when a minimum of 20 N.cm of torque is reached.

More time is required when low values of torque are achieved, while a faster protocol can be used if

torques are over 20N.cm. Also immediate loading procedures can be applied as described at the table XX

in 6.4.2.

To help choosing healing abutments and prosthetic components, NEODENT has developed a CM

Prosthetic Try in Kit with the main possible combinations of width, transmucosal height, angulation and

interoclusal height. It is a cassette composed with titanium pieces similar to abutments.

Healing phaseSituation

Primarily stability > 20N.cmPrimarily stability ≤ 20N.cm

Good bone quality (Type I and II)

and adequate bone quantity

At least 17 weeks

(close to 4 months)At least 9 weeks (2 months)

At least 18 weeks (4 months) At least 26 weeks (6 months)Cancellous bone quality

(Type III and IV)

55

56

Every component has individual dimensions replicating important references for diagnosis of the spaces.

Once this stage is reached, the definite post or abutment needs to be chosen for the final

restoration. This step can be performed in the healed mucosa (submucosa healing, conventional protocol)

or during surgeries for protocols as one phase/transmucosal healing or immediate loading.

To help in the selection of the components, Neodent offers two aids, the CM height measurer and

the CM Prosthetic Try in Kit. All items are manufactured in titanium and come in a cassette that can be

sterilized and visualized in the X-rays.

The following characteristics must be considered:

a. Single or multiple restoration;

b. Screw-retained or cemented restoration;

c. Interocclusal space, height and width;

d. Gingival height (transmucosal height);

e. Biological width (distance from the component to the bone crest);

f. If there is necessity of the implant angulation correction for the

abutment or if there is parallelism between adjacent components.

The main references are:

A) Diameter;

B) Occlusal height of the prosthetic component;

C) Height Mesuarement;

D) Angle (in Neodent it can be straight, 17° and 30°).

9. PROSTHODONTICS GENERAL GUIDELINES

A

BD

C

C

A

B

Straight Selection Abutment Angled Selection Abutment

57

CM Height Measurer allows the gingival height to be determined.

Example of a negative situation where the

component is collapsing against the bone

crest

Example of the right situation where the

component is respecting the biological

width of the peri-implant soft tissue.

Subcrestal implant positioning results in a certain amount of bone over the implant coronal area

that could collide against components which go adapted over the implants.

The Try in Kit helps in checking if all biological spaces are free, either with direct view during a

surgery or through an x ray periapical exam in healed sites.

58

9.1 Temporary Abutment options

Pro Peek CM can be used in processes of one or two-stages,conventional or immediate loading and

single tooth or multiple. It is indicated as a temporary abutment for establishing tooth emergence profile

before the final abutment selection. Pro Peek can be used as cemented or screwed restoration as the

screw can be accessed through the temporary crown as presented in the Figure below.

Pro Peek CM can be used as screwed or cemented restorations.

59

The Neodent kits come in a cassette for organization and sterilization of the instruments. The

cassette is made of a shock-proof thermoplastic polymer, which is suitable for frequent sterilization in the

autoclave.

The Neodent kits should be sterilized the day before or on the day of the procedure. The

recommended is to follow the parameters for autoclave sterilization established by the norm BS EN ISO

17665-1: “Sterilization of health care products. Moist heat. Requirements for the development, validation

and routine control of a sterilization process for medical devices”.

Do not sterilize in dry heat , since the cassette will be damaged.

Validity for sterilization: 7 to 15 days, if stored in a clean dry environment, away from sunlight.

The Neodent kits and instruments should be cleaned thoroughly after each procedure. Do not

leave the instruments in a humid environment for long periods, since they may oxidize.

Step 1- Separate and disassemble the instruments (if this is the indication)

Step 2- Emerge completely in an enzymatic detergent solution (10%-15%)

Step 3- Wash cycle in an ultrasonic washer for 10 minutes

Step 4- Flush in distilled water to completely remove any residues, with the aid of brushes.

Step 5- Dry thoroughly with paper towels and/or compressed air

Step 6- Inspect the instruments to certify that the cleaning process has been effective

Step 7- Select the adequate packaging for the sterilization phase.

Important: do not leave or store the instruments if they are not completely dry, so as to avoid

oxidation. Do not use desincrustation solutions (non-enzymatic), since they may darken and oxidize the

instruments.

The use of enzymatic detergent solutions over 10%, and the inadequate removal of the solution

during the cleaning procedure may also favor oxidation.

10. NEODENT KITS

10.1 Sterilization

10.2 Cleaning and care of instruments

(1) Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O et al Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132.

(2) Gaviria L, Salcido JP, Guda T, Ong JL. Current trends in dental implants. J Korean Assoc Oral Maxillofac Surg. 2014 Apr;40(2):50-60.;

(3) Gupta A, Dhanraj M, Sivagami G.Status of surface treatment in endosseous implant: a literary overview. Indian J Dent Res. 2010 Jul-Sep;21(3):433-8.

(4) Lambert PM, Morris HF, Ochi S.Positive effect of surgical experience with implants on second-stage implant survival.J Oral Maxillofac Surg. 1997 Dec;55(12 Suppl 5):12-8.

(5) Bernardes SR, da Gloria Chiarello de Mattos M, Hobkirk J, Ribeiro RF.Loss of preload in screwed implant joints as a function of time and tightening/untightening sequences.Int J Oral Maxillofac Implants. 2014 Jan--Feb;29(1):89-96.

(6) Coppedê AR et al. Fracture resistance of the implant-abutment connection in implants with internal hex and internal conical connections under oblique compressive loading: an in vitro study. Int J Prosthodont. 2009 May-Jun;22(3):283-6.

(7) Lazzara RJ & Porter SS. Platform switching: A new concept in implant dentistry for controlling abutment restorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:9-17.

(8) Martin C, Thomé G, Melo AC, Fontão FN. Peri-implant bone response following immediate implants pla-ced in the esthetic zone and with immediate provisionalization-a case series study. Oral Maxillofac Surg 2015 Jun;19(2):157-63.

(9) Barros RR, Novaes AB Jr, Muglia VA, Lezzi G, Piattelli A.Influence of interimplant distances and place-ment depth on peri-implant bone remodeling of adjacent and immediately loaded Morse cone connection implants: a histomorphometric study in dogs Clin Oral Implants Res. 2010;21(4):371-8.

(10) Castro DS, Araujo MA, Benfatti CA, Araujo Cdos R, Piattelli A, Perrotti V, et al. Comparative histological and histomorphometrical evaluation of marginal bone resorption around external hexagon and Morse cone implants: an experimental study in dogs. Implant Dent 2014;23(3):270-6.

(11) Novaes AB Jr, Barros RR, Muglia VA, Borges GJ.Influence of interimplant distances and placement depth on papilla formation and crestal resorption: a clinical and radiographic study in dogs. J Oral Implantol 2009;35(1):18-27.

(12) Siqueira RAC. Avaliação do índice de sucesso e comportamento dos tecidos periimplantares de implantes cone morse equicrestais ou subcrestais em arcos inferiores.[master’s dissertation on internet].[Curitiba(Brazil)]: ILAPEO; 2013. [cited 28 out 2015] 126p. Available from: http://www.ilapeo.com.br/Monogra-fias_e_Dissertacoes/Dissertacoes_turma2011/Rafael_Amorin_Cavalcanti_de_Siqueira.pdf.

(13) Sotto-Maior BS, Lima Cde A, Senna PM, Camargos Gde V, Del Bel Cury AA. Biomechanical evaluation of subcrestal dental implants with different bone anchorages. Braz Oral Res 2014;28.

(14) dos Anjos CM, Harari ND, Reis RSA, Vidigal Junior GM. Análise in vitro da infiltração bacteriana na interface de pilares protéticos e implantes cone-morse / In vitro analysis of bacterial leakage at the interface between Morse taper implant platform and prosthetic abutments. ImplantNews;8(2):239-243, 2011.

BIBLIOGRAPHIC REFERENCES

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(15) Sartoretto SC, Alves AT, Resende RF, Calasans-Maia J, Granjeiro JM, Calasans-Maia MD. Early os-seointegration driven by the surface chemistry and wettability of dental implants. J Appl Oral Sci. 2015 May--Jun;23(3):279-87.;

(16) Rupp F, Scheideler L, Eichler M, Geis-Gerstorfer J. Wetting behavior of dental implants. Int J Oral Maxil-lofac Implants. 2011 Nov-Dec; 26(6):1256-66.

(17) da Silveira BM. Análises tomográfica, microtomográfica e histológica entre enxertos em bloco autó-geno e xenógeno nas reconstruções ósseas de maxila. [master’s dissertation on internet].[Curitiba(Brazil)]: ILAPEO; 2013. [cited 15 jun 2014] 133p. Available from: http://www.ilapeo.com.br/biblioteca-detalhe/tomogra-phic-microtomographic-and-histological-analysis-between-grafts-in-autogenous-and-xenogeneic--C162410.html;

(18) Mendonça G, Mendonça BD, Oliveira SL, Araujo AC. Efeitos da diferenciação de células-tronco mesen-quimais humanas sobre superfícies de implantes hidrofílicas. ImplantNews 2013 Nov-Dez 10(6a):111-116.

(19) Glauser R, Portmann M, Ruhstaller P. Initial implant stability using different implant designs and surgi-cal techniques. Appl Osseointeg Res. 2001;2(1):6-8.

(20) da Cunha HA, Francischone CE, Filho HN, de Oliveira RC. A comparison between cutting torque and resonance frequency in the assessment of primary stability and final torque capacity of standard and TiUnite single-tooth implants under immediate loading. Int J Oral Maxillofac Implants. 2004 Jul-Aug;19(4):578-85.

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Documents

SURGICAL MANUAL - Rawex Dental · SURGICAL MANUAL. 2. CONTENTS 1.0 BASIC INFORMATION FOR SURGICAL PROCEDURES 5 2.0 THE NEODENT IMPLANT SYSTEM 5. ... 10.2 Cleaning and care of instruments