Disclaimer This presentation is reprinted by Cigna with the permission of its author, Dr. Thomas Taylor. The health information in this presentation is.

Disclaimer This presentation is reprinted by Cigna with the permission of its author, Dr. Thomas Taylor. The health information in this presentation is provided by Cigna solely for informational purposes as a public service to promote health. It does not constitute medical advice and is not intended to be a substitute for your professional judgment. Neither Cigna, nor the author of the materials, nor the author's institution assume any responsibility for any circumstances arising out of the use, misuse, interpretation or application of any information supplied in this presentation or on this website.

Dental Implants: Past and Present
Thomas D.Taylor, D.D.S., M.S.D. UConn School of Dental Medicine Effective December, 2011 – December, 2016 Welcome to the Cigna Dental Implant course. This course is approximately 2 hours long and has a test at the end. Once you pass the test, you’ll be given instructions on how to receive your certificate of completion. This course is worth 2 continuing education credits. Special thanks to Dr. Thomas Taylor at the University of Connecticut Health Center for his contributions to this course. Cigna Dental wishes to thank the following for their contributions to this continuing education program: Thomas D.Taylor, D.D.S., M.S.D., UConn School of Dental Medicine Jenna Marcinczyk, UConn School of Dental Medicine Clay Hedlund, D.D.S., Cigna Dental

During this program, you’ll gain an understanding of:
Objectives During this program, you’ll gain an understanding of: Tooth loss and its consequences The evolution of today’s dental implant The importance of osseointegration and the factors that influence it The steps involved in the dental implant process Some of the many applications of dental implant therapy Just read the slide starting with “during this program…

Then and Now: A Brief History of the Evolution of the Dental Implant
Tooth Loss can result from a variety of factors including: Disease Periodontal disease Dental caries Trauma Failure to develop Tooth loss can occur for a variety of reasons. The most common reasons for tooth loss include periodontal disease, dental caries, trauma, failure to develop, and adverse consequences of restorative dentistry.

“Statistics show that 69% of adults ages 35 to 44 have lost at least one permanent tooth to an accident, gum disease, a failed root canal or tooth decay. Furthermore, by age 74, 26% of adults have lost all of their permanent teeth.”- American Association of Oral and Maxillofacial Surgeons According to the American Association of Oral and Maxillofacial Surgeons, 69% of adults ages 35 to 44 have lost at least one permanent tooth to an accident, gum disease, a failed root canal or tooth decay. Furthermore, by age 74, 26% of adults have lost all of their permanent teeth. Tooth loss is clearly a significant and prevalent problem facing many Americans today.

Consequences of tooth loss Nutritional Psychosocial Esthetic Physiological Consequences of tooth loss may include nutritional consequences due to a reduction in the efficiency of mastication, psychosocial consequences due to potential difficulties with pronunciation and speech, esthetic consequences due to the presence of spaces, and physiological consequences revolving around preservation of the alveolar ridges and vertical dimension.

Physiological consequences of tooth loss A healthy tooth root transfers biting forces to supporting bone and maintains its strength and integrity. When a tooth is lost, there are no longer any forces being transferred. The bone may then begin to atrophy. Adjacent teeth can begin to migrate causing additional gaps and an unsightly appearance. The alveolar jaw bone houses and supports the teeth. Normally the tooth root transfers biting forces to the alveolar bone and maintains its strength and integrity. Therefore, when a tooth is lost, the alveolar ridge may begin to atrophy. Adjacent teeth may also begin to migrate and cause additional gaps and an unsightly appearance.

Physiological Consequences of tooth loss Changes in Intraoral Structure While alveolar bone resorption is cumulative, its extent and pattern is variable. The left image shows some residual alveolar ridge, while the right image shows very little residual alveolar ridge. The lack of predictability in the degree of bone resorption makes it difficult to determine how efficient the denture bearing foundation will be for a given patient. Very little remaining alveolar ridge Some remaining alveolar ridge

Traditional Solutions for Tooth loss include: Fixed partial dentures Removable complete or partial dentures The primary treatment options for tooth loss have traditionally been fixed partial dentures or removable complete and partial dentures. While these continue to be valuable treatment options, implants are being considered more and more often and many times implants are the best treatment option.

Fixed partial dentures can lead to Negative effects on adjacent healthy teeth Recurrent caries Periodontal disease Fixed partial dentures require the preparation of adjacent teeth that may or may not require restorations. There may also be additional costs to replace the fixed partial denture several times over the patients lifetime due to recurrent caries or other failure. Other complications that may occur with conventional fixed partial dentures include periodontal disease, endodontic treatment, the impact of multiple missing teeth on the length of a fixed partial denture, and finally, difficulties in repairing a damaged prosthesis.

DENTURES The traditional maxillary denture is held in place by air pressure, like a suction cup. While the maxillary denture is typically easier to MANAGE, the MANDIBULAR DENTURE RARELY EXHIBITS RETENTION AND IS SUSCEPTIBLE TO DISLODGEMENT AND INSTABILITY.

Natural teeth have significantly more support than dentures. The quantitative and qualitative loss of support dramatically reduces the efficiency of dentures relative to natural teeth. At best 17% as efficient as real teeth!

Surgical Attempts to improve the denture bearing foundation have included: Vestibuloplasty Osteotomy Implantology In order to improve the denture bearing foundation, various surgical procedures have been attempted. These have included soft tissue surgery (vestibuloplasty), hard tissue surgery (osteotomy) and implant surgery (implantology)

In the 1970’s a popular technique to enhance the denture bearing foundation was the vestibuloplasty. This was a soft tissue surgery that involved a skin graft taken from the hip and placed on the periosteum with a temporary denture. After approximately 10 days of healing the skin graft would help provide a denture foundation. Soft tissue surgery- vestibuloplasty

1 month post surgery 6 months post surgery 1 year post surgery Another type of surgery that was performed in order to improve the denture bearing foundation was a hard tissue surgery known as an osteotomy, in this case, a vizor osteotomy. In this technique the mandible was sectioned horizontally and the coronal segment elevated to allow for a a bone graft from the iliac crest to be placed between the two layers in a sandwich like manner. The horizontal osteotomy was typically done anteriorly between the mental foramina. These images taken at 1 month, 6 months and 1 year intervals post-operatively demonstrate that the surgeries were often unsuccessful due to postoperative bone resorption. Hard tissue surgery- osteotomy

Osteotomy treatment often failed, leaving the patient worse off than before. These images demonstrate the dramatic bone resorption that occurred OVER A PERIOD OF one year following surgery, and, the patient was also left with a numb lower lip. Immediately after osteotomy One year after osteotomy

Dental Implants Until 1982 limited to anecdote and empiricism Premature clinical use and poor documentation Lack of clinical trials Lack of longitudinal results Evidence shows that throughout history, man has tried to replace missing teeth with various materials, including carved ivory, wood and bone. In the late 1800’s experiments using different materials and designs of appliances to replace missing teeth were reported in the dental literature. It was not until 1982 that the use of dental implants was considered a scientific discipline rather than an art form. Early implant progress suffered from limited anecdotal evidence, premature clinical use, and a lack of clinical trials. The modern era of dental implantology is approximately 30 years old. Today we have solid scientific evidence that supports the use of these devices with predictable long term results. Archeological evidence of dental implants using whale bone or ivory From Central America 1909 radiograph of iridium basket implant used to replace one tooth

Traditional dental implants can be divided into several main types, and they can be described according to their shape and how they are attached to the jaw. ENDOSSEOUS IMPLANT (within the bone) SUBPERIOSTEAL IMPLANT (on top of the bone) TRANSOSTEAL IMPLANT (through the bone) Traditional dental implants can be subdivided into SEVERAL main types. The implant type most often used today is the endosseous OR CYLINDRICAL implant, placed directly into the jaw bone. Subperiosteal implants are placed on top of the jawbone, and transosteal implants are placed completely through the jawbone and mucosa. Subperiosteal and transosteal implants are used far less frequently than endosseous implants.

Blade Implant ENDOSSEOUS IMPLANT “within the bone” blade-shaped implants During the 1970’s an endosseous implant known as the blade implant became the most widely used design in dental implants. Using a handpiece, a small slot was made in the alveolar bone and the blade implant was tapped into place. Some cases were successful, however, many cases resulted in failure. The blade was anchored to bone via a surrounding sheath of pseudo periodontal ligament that was really a poorly differentiated layer of scar tissue. Over time, epithelial migration would occur in response to the body’s attempt to reject the implant, allowing bacteria to enter. The result was a chronic infection that ultimately required removal of the blade implant. Epithelial down growth over time with blade implants

This histological section demonstrates the presence of scar tissue that would develop between the alveolar bone and blade implant. BLADE IMPLANT FAILURE Scar tissue Alveolar bone Dental implant

SUBPERIOSTEAL IMPLANTS -“on top of the bone” These implants consist of a metal framework that rests on top of the jawbone but underneath the gum tissue. Subperiosteal implants were first introduced in the 1940’s and worked well for many years. This type of implant consists of a non-osseointegrated mesh-like framework that rests on the surface of the mandible or maxilla but underneath the mucosa. Posts protrude through the mucosa to support a prosthesis.

Metal framework lies on top of the mandible Subperiosteal Implants Posts remain above the gum tissue as anchors for a prosthesis The subperiosteal framework is positioned beneath the mucosa and covers a large portion of the jawbone as it wraps around buccally and lingually. It typically contains a number of posts penetrating the mucosa to support an overdenture.

Down growth of epithelium and exposure of the implant Complications that occurred with subperiosteal implants included infection, exposure of the implant to the oral cavity due to epithelial down growth and damage to the underlying bone. Sometimes the subperiosteal implant would submerge into the bone making it extremely difficult to remove. Note the abcess distal to the patient’s right side abutment post. Subperiosteal Implant Failure

TRANSOSTEAL IMPLANTS “through the bone” These implants are either a metal pin or a U-shaped frame that passes through the jawbone and the gum tissue, into the mouth. Transmandibular implants represent another type of dental implant that have been used in the practice of dentistry. The transmandibular implant was originally designed to provide individuals with a severely resorbed mandible with a stable implant supported overdenture. These implants were either a metal pin or U-shaped frame that passed through the jawbone and mucosa, into the mouth. STAPLE OR TRANSMANDIBULAR IMPLANTS (TMI) IMPLANTS

Placement of the implant involved the insertion of two metal rods extra orally directly through the mandible to provide support for an overdenture. This approach was suitable only for the mandible. Although some reports showed good results over periods of up to 10 years, this treatment was also subject to gradual failure and involved extensive surgery. It is not recommended in current practice. Radiographic and intraoral views of a transmandibular staple implant

THE MODERN ERA OF DENTAL IMPLANTOLOGY BEGAN IN 1982 AT A CONFERENCE IN TORONTO Now that we’ve reviewed implantology from a historical perspective, lets move into the current science of implantology.

Per Ingvar Brånemark, MD, PhD Professor of Orthopedics University of Gothenburg In the late 1960’s, Branemark, a Swedish professor of orthopedics at the University of Gothenburg, established that direct contact exists between bone and dental titanium implants and that this contact results in the clinical stability of implants during loading. As a result of this mode of anchorage, Branemark coined the term “osseointegration” in 1967.

Branemark conducted research on dental implants for 17 years before publicly presenting his findings at the Toronto Conference. Studies on the placement of titanium implants in dogs revealed a strong bond between bone and implant. The left image shows a sectioned jaw from a dog with a titanium implant firmly bonded to bone. The image on the right shows a 1965 radiograph of ONE OF THE first titanium implants placed in a human. Despite the mechanically unfavorable crown to implant ratio seen in this image, the implant remained secure due to the strong union that was formed between bone and the titanium implant. Titanium dental implant in the jaw of a dog Radiograph of one of the first human titanium implants placed in 1965

OSSEOINTEGRATION Direct contact, at the light microscopic level, between the implant surface and vital bone in a functionally loaded implant. Also called “functional ankylosis” (Schroeder). Direct contact at the light microscopic level Alveolar bone Older implants developed a fibrous attachment that was thought could achieve the same functions as the periodontal ligament, including effective attachment, shock absorption, and sensory properties. Instead of this ideal scenario, older types of dental implants were anchored to bone by a surrounding sheath of pseudo periodontal ligament which was nothing more than a poorly differentiated layer of scar tissue. In most cases it resulted in initially good success rates but was soon followed by gradual widening and loosening of the implant, leading to eventual failure. Osseointegration differs from the prior layer of scar tissue because newer dental implants result in direct contact at the light microscopic level between the implant surface and vital bone in a functionally loaded implant. This is also known as functional ankylosis. The ability of titanium to osseointegrate is what ultimately revolutionized implantology. Implant

Titanium is a highly corrosion resistant, lightweight metal and when exposed to oxygen, its’ surface develops a natural oxide coating. This layer of titanium oxide determines the biological response that allows bone cells to attach. Unlike other metal alloys, titanium establishes good bone-to-implant contact. The image on the left demonstrates the direct integration of bone and titanium making this treatment very stable. Titanium Highly corrosion resistant Lightweight metal Conducive to osseointegration

Osseointegration begins when the titanium implant is initially placed and a blood clot forms between bone and the implant. Surgical trauma at the bone surface causes cell necrosis and initiates an inflammatory response. This is followed by the formation of a fibrin mesh attachment to the implant which is rapidly replaced by living cells, hopefully with osteogenic capability. This graph illustrates that when the implant is screwed into the prepared site it is stabilized by the cut edges of the boney crypt, and this is termed primary stability. As resorption begins to remodel the damaged bone, this primary stability decreases. Then, as healing begins, secondary stability (osseointegration) increases over time until complete healing has occurred and the initial primary stability is completely replaced with the secondary stability of osseointegration.

Tooth root replacement Bone forms a bond with the dental implant The discovery of osseointegration revolutionized the use of dental implants and allowed implantology to evolve to what it is today, enabling the replacement of the entire missing tooth. Osseointegration is a physiological state that undergoes maturation over the life of the implant. This allows the implant body to function like a natural tooth root. Biting forces enable the surrounding bone to continually remodel and therefore helps to preserve bone. Unlike previous forms of dental implants, root replacement implants are resistant to infection and allow for long term success rates. The implant functions like a natural tooth and is biocompatible The implant fuses to bone – should be permanent The implant is resistant to infection (periodontal disease) Implants are usually shaped like a screw or cylinder and are made either of metal, metal covered with ceramic, or ceramic material.

What factors influence implant Osseointegration?
Implant design Host site Surgical technique The union of bone and implant surface that occurs during osseointegration can be measured histologically as the proportion of the total implant surface that is in direct contact with bone. The degree of contact that occurs can vary based on the material used as well as implant design, host site and surgical technique.

Implant Design Implant length
Research shows that various lengths of implants can be used ranging from 6 to 15 mm. It’s good practice to use the longest implant that can be safely placed. Implant diameter The diameter of most implants falls within the range of 3.25 to 6 mm. Larger diameter implants may be used in posterior areas of the mouth and where there is poor bone quality. While there are many different manufacturers with unique features that characterize their dental implant design, the basic components of each type are consistent. In addition to the implant body, implant components include abutments and various types of screws. Overall implant design is a major factor in determining stability and success. Features such as the shape, length and diameter are all important considerations when selecting the implant body. In order to determine implant length, it’s important to assess bone availability. The range varies from 6 to 15 mm, however it is generally good practice to use the longest implant that can be safely placed. The diameter of the implant used is based on the buccolingual ridge dimension as well as mesiodistal dimensions. This can result in implant diameters ranging from 3.25 to 6 mm. At least 1 mm of bone should remain buccally and lingually after placement of the implant. Mesio-distally, there should be approximately 3mm between adjacent implants and 1.5 mm between an implant and an adjacent tooth. Implants with smaller diameters can be used in small spaces, while larger diameter implants, that provide greater bone to implant contact, are commonly used in the posterior part of the mouth and where there is poor bone quality.

Implant Design Abutments are divided into two types
ABUTMENT: The component that connects the final prosthesis to the implant Another important component of implant design is the abutment. A dental abutment is either a pre-fabricated or custom-made component that connects the final prosthesis to the implant. A prefabricated abutment is usually made by the implant manufacturer from titanium, gold or ceramics. This type of abutment is simple to use because it requires minimal chair side and laboratory time, has a predictable precision fit, and exhibits good retention. Customized abutments may be fabricated by a dental lab using computer-aided design computer-aided manufacture or CAD/CAM technology. The selection and use of an abutment is based on several different factors such as implant orientation, depth of soft tissue from the implant body to the gingival cuff, aesthetic demands, interocclusal space and the dentist’s preference for a cement or screw retained prosthesis. Abutments are divided into two types Prefabricated abutments These are made by the manufacturer of the implant and can be modified by the restorative dentist as needed. Custom abutments These are fabricated by a dental lab using CAD/CAM technology similar to that used for crowns and are made for a specific patient.

Implant Design Screw Abutment Porcelain Fused to Metal Crown
This illustration demonstrates an abutment secured to the implant body with a screw. Screws may also be used to attach the final crown to the abutment, however this example illustrates a crown that will be cemented onto the abutment.

The Host Site Who is a good candidate?
Almost anyone can have dental implant surgery Areas of concern that affect wound healing: Tobacco use Uncontrolled diabetes Radiation therapy Ability to take care of the implants Overall health sufficient to undergo minor elective surgery Overall the patient must: Have a comprehensive evaluation Be in good health Have healthy oral tissues Have adequate bone structure Demonstrate a willingness to practice home care Maintain regular dental visits A review of the literature indicates patients with a variety of systemic conditions may be successfully treated with dental implants. However, implant placement is not recommended in young patients prior to completion of growth because the implant may result in infraocclusion. It’s widely accepted that FEMALE patients should be at least 18 years of age AND MALES 21 years of age BEFORE IMPLANTS ARE CONSIDERED. There is no upper age limit to implant placement as long as the patient is fit and able to undergo the necessary surgery. When the patient presents with general medical conditions, for example uncontrolled diabetes, it’s necessary to first work with their physician to ensure their diabetes is well controlled prior to placing dental implants. The patient must also be healthy enough to undergo minor surgery, and should possess the dexterity to maintain the implants with proper home care. From an overall standpoint , the patient’s comprehensive evaluation should reveal the patient to be in good health, have adequate bone structure, and demonstrate a willingness to maintain regular dental visits.

Surgical Technique Surgical Experience Operating conditions
Drilling technique Healing and loading times Delayed loading – 6-8 weeks post surgery Early loading – 4-6 weeks post surgery Immediate loading – day of surgery-one week post surgery Avoid loading the implant during the 2-4 week period post-surgery (transition period between primary and secondary stability) The surgical experience and skills of the operator have an impact on implant success rates. Therefore those who place implants must receive sufficient training. Operating conditions can also have an impact on success rates due to the negative effect that contamination has on osseointegration. And finally, drilling technique is also a crucial component during the dental implant procedure. The critical temperature and time parameters for bone tissue necrosis are approximately 47 degrees Celsius for one minute. As a result, surgical technique requires intermittent action, controlled operating pressures and copious amounts of irrigation. Healing periods and loading times are classified into three categories: delayed loading, early loading and immediate loading. The delayed loading approach involves loading the implant approximately 6 to 8 weeks after placement. The early loading approach usually involves loading during the 4 to 6 week timeframe after placement. Immediate loading is a less commonly used approach that involves the immediate loading of the implant on the day of placement or within the first week. Early and immediate loading approaches require good quality bone and favorable circumstances. Loading of the implant should be avoided during the 2-4 week post surgery timeframe since there a decrease in stability during the transition from primary to secondary stability as noted earlier in this presentation.

What are the risks and benefits?
Dental implants can replace teeth without involving adjacent natural teeth Dental implants help prevent bone resorption Dental implants eliminate the problem of ill-fitting dentures and subsequent irritation Clinically proven success rate of over 90% Implants look natural and healthy RISKS Bleeding Infection Failure to osseointegrate (very rare) There are many benefits associated with dental implants. Dental implants replace teeth without involving adjacent natural teeth, they minimize or prevent bone resorption associated with tooth loss, and they eliminate problems associated with traditional prostheses. Implants look natural and healthy and have a long term success rate of over 90%. The Risks associated with dental implants, as with any surgery, include infection, bleeding and potential failure to osseointegrate. Failure to osseointegrate is rare.

Who Should Place Implants?
Implant treatment may be provided in several ways: Implants can be placed by a team of dental professionals. This might include an oral surgeon or a periodontist who performs the surgical procedures, and a prosthodontist or a general dentist who fabricates the prosthesis over the implant. Prosthodontists now receive training in the placement of implants during their residency. A dentist who has had extensive dental implant and associated training and limits his or her practice to implants may perform both the surgery and fabricate the prosthesis over the implant A general dentist possessing the required knowledge, skills, and training may include implant procedures in his or her practice and perform all the procedures. A team approach to treatment is generally preferred for more complex implant cases. The most common approach to restoring patients with implants is the team approach. Either an oral surgeon or a periodontist will likely perform the surgical placement of the implant body and a restorative dentist will place the crown or other prosthesis over the implant. Less common is the individual provider possessing both the skills and the desire to perform the entire range of procedures necessary to complete an implant case. The team approach to treatment is generally preferred for the more complex implant cases.

Types of Prostheses over Implants
Partially Edentulous Cases Restored with single crown or fixed partial denture restorations Cemented or Screw retained design Porcelain fused to metal Completely Edentulous Cases Restored with fixed or removable restorations Fixed Porcelain fused to metal bridge design Hybrid design Removable Similar design to traditional dentures except containing attachments to supporting implants Implant patients are either partially edentulous or completely edentulous. Partially edentulous individuals may be treated with single crown restorations or fixed partial denture restorations. These restorations are generally porcelain fused to metal restorations. Completely edentulous individuals may be treated with either fixed or removable prostheses. The fixed prostheses used in completely edentulous cases can be of the porcelain fused to metal fixed partial denture design or of the hybrid design. The hybrid design refers to a fixed prosthesis made with removable materials, in other words, denture teeth and acrylic resin. The supporting implant structure may be visible with the hybrid design. And finally, a removable prosthesis may be utilized in completely edentulous cases that is similar in design to traditional dentures, except with the use of attachments.

What is the dental implant process?
There are generally four steps involved in the dental implant process that take several months to complete Careful planning Surgical placement of the implant body Followed by 6-8 weeks of healing and osseointegration Attachment of the abutment (if used) Placement of the final restoration The dental implant process typically includes four main steps. These steps include careful planning, surgical placement of the implant body, attachment of the abutment and finally, placement of the restoration.

Step 1: Careful Planning
The initial planning steps are crucial for obtaining predictable results. Prior to surgery, the patient should receive a thorough evaluation, radiographs, and DIAGNOSTIC CASTS. It’s important for the doctor to have complete and accurate information while planning treatment. Radiographs provide the surgeon with important information regarding the characteristics of the maxillary or mandibular bone. This information aids in selecting the size of the implant and its ultimate placement. Cone beam ct imaging is a relatively new technology and is commonly used in implant treatment because it offers precise information to aid in surgical implant placement. Diagnostic casts are another important component of treatment planning. Diagnostic casts are important throughout the process, from assisting the surgeon with implant placement all the way through fabrication of the final prosthesis. And finally, other general tests may also be performed during the treatment planning stage. These tests may include checks for blood characteristics, heart and lung function, and general health status, depending upon the patients presenting condition. Careful assessment of the patients oral and overall health Address any patient questions and concerns Radiographs Diagnostic casts Other tests

Step 2: Surgical Placement of Implant
The second step of the implant process is the surgical placement of the implant body into the alveolar ridge. Implant site preparation is accomplished by using drills of increasing diameter that gradually widen the site concentrically. The goal of this technique is to create a site as atraumatically as possible into which a slightly wider-sized implant will be threaded. This allows for stable placement of the implant in the bone (primary stability) which is necessary for successful osseointegration. The implant will USUALLY BE SUBMERGED under the MUCOSA for a healing PERIOD OF 6-8 WEEKS. (In the maxilla and posterior part of the mandible, complete healing usually takes longer.) Some implants are not buried below the mucosa; they are left uncovered during the healing period. With these implants, a second surgery is not required, however, a healing period of 6-8 WEEKS is still necessary.

The day after surgery, the patient should expect some swelling and discoloration. Medication can be used to lessen any discomfort. Within 4 to 5 days, the initial swelling will be gone and the surgical area will be less tender. If the patient was EDENTULOUS and has an existing denture, it can be relined with a soft material, allowing the patient TO USE THE DENTURES during healing. Patients can typically return to work or comfortably resume normal activities by this time. Approximately 10 to 14 days post surgery, any remaining sutures can be removed. Successful osseointegration depends on the implant not being disturbed during the first 4 to 6 weeks after surgery. A soft diet must be maintained during this period. Implants that are unstable at placement are more likely to fail and therefore Step 2 is a critical step in the dental implant process. The dentures of an edentulous patient can be lined with a soft material and placed back in patient’s mouth after implants are placed. Single Implant placement

Healing cap Once the implant body is in place, a protective healing cap is fitted to the head of the implant to protect it during the healing process.

Step 3: Attachment of Abutment
In the case of implants that are left submerged below the mucosa during healing, the second stage of surgical treatment to uncover the implants is completed 6-8 WEEKS after the implants were placed. This second stage of surgery would not be necessary if the implant body was left uncovered during healing. This brings us to Step 3 in the process, when abutments are attached to the implant body. Abutments are either pre-fabricated or custom-made components that connect the final prosthesis to the implant. Restorations may be connected to the abutment either by screw retention or cementation. At this time, the implants are also examined to be certain of their firmness and osseointegration.

Step 3: Attachment of Abutment
In this illustration, a second stage surgery was required to uncover the submerged implants. After placement of the abutments, the gum tissue was replaced around the abutments and sutured. If available, the patient’s existing dentures, with a soft lining, MAY be placed over the abutments to help the gum tissue heal and to lessen discomfort. Again, during this step in the process, the dentist should determine that osseointegration has been achieved, and that the abutments are firmly and accurately attached to the implants. Radiographs should be taken at this time to help confirm this. The patient should then be instructed in how to keep the abutments clean.

Step 4: Placement of Restoration
Crown Restoration Once the abutment has been attached to the implant body, impressions may be taken for fabrication of the crown or other restoration. In this case, with patient and doctor approval, the final crown was placed over the abutment, and retained either with a screw or dental cement.

Step 4: Placement of Restoration
The end result is excellent demonstrating a natural appearance, appropriate function, and a restoration that should last for many years. During the first year after case completion, regular follow up appointments should be scheduled to confirm continued fit and function. These follow up visits should be scheduled at the ONE WEEK and 6-month intervals during the first year. Dental radiographs ARE USUALLY taken AT ONE YEAR to examine the implant-bone relationship and rule out any disease. After the first year, follow-up examinations are usually necessary only once a year AND RADIOGRAPHS are usually TAKEN EVERY 3-5 YEARS. Aftercare

Other Applications: Fixed Partial Denture
In addition to single tooth restorations, dental implants may also be used to replace multiple missing teeth. This individual lost the four mandibular incisors as a result of periodontal disease. The use of two implants allows for the placement of an implant supported fixed partial denture. Similar to the single tooth restoration, two implants were placed and allowed to heal.

After sufficient time passed, and osseointegration had occurred, the abutments were placed. In this case, because abutments were used to connect the prosthesis to the implants, the prosthesis is termed an abutment supported fixed partial denture. In those cases where the prosthesis is connected directly to the implant bodies, in other words abutments are not used, the prosthesis would be termed an implant supported fixed partial denture.

Dental cement was used to attach the fixed partial denture to the abutments, completing the final restoration. Again, an excellent and very predictable long term solution.

Other Applications: Implant Supported Overdenture
O-Ring or Stud Retained Overdenture And Bar-Clip Type Overdenture For completely edentulous cases there are typically two options: implant or abutment supported fixed dentures, or implant or abutment supported removable overdentures. Implant supported overdentures are typically the most cost-effective way to restore a patient when there are no remaining teeth in the arch. Fewer dental implants are necessary, because the removable superstructure is partially supported by the mucosa. If severe bone loss is present, the best option is a removable restoration because there may not be enough support for a fixed restoration. Implant supported overdentures can be fabricated in two main ways. The illustration on the right demonstrates the use of splinted implants. Splinted implants are joined by a connecting bar that is then used to attach the prosthesis. The connecting bar is secured to the implants with screws while the tissue side of the denture contains the clip that will attach to the connecting bar. This form of overdenture is referred to as a bar-clip type. The illustration on the left demonstrates the use of implants that are not connected by a bar but instead remain separate. With this technique, the abutments that attach to the implant bodies also serve as the male component of the attachment. The corresponding female component of the attachment is located on the tissue side of the denture. Several types of attachments can be used in this design however the most common is a ball shaped attachment. This form of overdenture is known as an O-Ring or STUD retained type.

Initial placement Non-splinted implants will support an overdenture This patient was treatment planned for the STUD retained type of overdenture. The images demonstrate two implants at initial surgical placement and again after a healing period, with the healing caps in place. After healing

Once the surgical sites healed and osseointegration occurred, the healing caps were removed in order to place the ball shaped attachments. Removal of the healing caps reveals the implant bodies Ball-shaped attachments (abutments)

This illustration demonstrates one of the ball-shaped attachments securely placed into the implant body.

After placement of the ball-shaped attachments , the overdenture was used to make an impression of the arch in order to properly fit the overdenture. Close inspection of the lower right image reveals the location of the attachments in the anterior ridge area of the impression material. An alternative approach that may be used is to attach the studs to the denture directly in the mouth as a pick up procedure. Impressions are taken to properly fit the overdenture

Stud recipient sites The overdenture was then modified to contain the STUD recipient sites on the tissue side of the denture. These recipient sites securely attach the overdenture to the ball shaped abutments.

The overdenture design provides a removable and natural-looking prosthesis that is significantly more stable than a traditional lower denture. It’s also easy to maintain because the patient can remove the overdenture for thorough cleaning.

Other Applications: Fixed Denture
This radiograph demonstrates a fully edentulous patient with significant resorption of the mandibular ridge, resulting in an ill fitting lower denture. She was treatment planned for an abutment supported fixed denture, also known as a hybrid prosthesis. This type of prosthesis is considered a hybrid prosthesis because even though it’s a fixed restoration, the teeth are set in removable denture acrylic.

Hybrid design The ability to use an implant or abutment supported fixed denture increases with the number of implants that can be placed. For this patient, six dental implants were placed in the mandible. After healing, the hybrid design prosthesis was secured onto the abutments. These types of restorations are extremely successful. With this design, the implants and mucosa can be easily cleaned because of the spaces between adjacent abutment posts. As can be seen in the illustration on the right, the hybrid prosthesis does not rest on the mucosa, but is entirely supported by the dental implants. The patient’s chewing efficiency has increased from roughly 17% with dentures back to virtually 100% with this prosthesis. Abutment posts Small spaces allow for cleaning the prosthesis and abutment posts

The result is a comfortable and natural looking dentition. The abutment posts are not visible when the patient smiles.

Other Applications: Fixed Prostheses
This patient presented with a failing maxillary fixed restoration due to recurrent caries. She also wore a removable partial denture that could no longer be maintained. Let’s see how this patient was restored with the use of dental implants. Radiograph and intraoral images of a patient with a failing maxillary fixed restoration and removable partial denture.

Surgically placed implants in the maxilla and mandible After treatment planning, eight implants were placed in the maxilla and four in the mandible.

4 anterior and 4 posterior implants were placed in the maxilla These images show the four anterior and four posterior implants that were placed in the maxilla that will support a fixed prosthesis. Additionally four implants were placed in the posterior mandible. 4 posterior implants were placed in the mandible

Impression copings Temporary bridge IMPRESSION COPINGS were then used to make a master impression. A temporary prosthesis was fabricated for the mandible for use during the healing process. Impression copings were used to make the master impression A temporary bridge was also used during the healing process

Here we see the final impression with implant replicas attached to the impression copings and the resultant maxillary master working cast. An implant level Impression was made of the maxillary arch. Implant replicas were then attached to the impression copings A stone cast was then made from the impression.

The master working cast with the abutments in place was used to fabricate the final fixed prosthesis The maxillary master working cast with the abutments in place was used to fabricate the final FIXED prosthesis.

After the prostheses were fabricated on the master working casts, they were tried in the patients mouth. Once the fit, function and appearance were confirmed, the prostheses were ready for final placement in the mouth. The prostheses were fabricated on the master working casts and then placed in the patient’s mouth to confirm fit, function and appearance.

Final fixed prosthesis in the maxilla These intraoral images show both the maxillary and mandibular fixed prostheses cemented in place, demonstrating complete restoration of this patient’s dentition. The image on the right also demonstrates an excellent result that is esthetically pleasing with proper occlusal function. The result is a secure and natural looking dentition

Here we see an excellent final result THAT FULFILLS THE PATIENT’S NEEDS. It’s both ESTHETICALLY PLEASING AND functionally sound.

Other Applications: Ectodermal Dysplasia
The next series of images follow a case that’s a rare exception to the rule of thumb that males be at least 21 years of age prior to considering the use of dental implants. Dental implants can be an excellent solution to the problems that arise in children with congenital diseases such as ectodermal dysplasia. According to the National Foundation for Ectodermal Dysplasia, this genetic disorder affects approximately 7 out of every 10,000 babies born. While there are a variety of PRESENTATIONS associated with this disease, the teeth of individuals with ectodermal dysplasia may be missing, pointed, AND widely spaced. Dental treatment is almost always necessary.

The boy in the photo demonstrates the typical dental AND FACIAL effects that characterize ectodermal dysplasia.

These patients often suffer from microdontia and malocclusion. The alveolar ridge is often narrow where the teeth are missing, and those teeth that are present, are widely spaced and pointed.

The radiograph reveals the lack of developing teeth, and is an important tool in the proper treatment planning of such patients. BECAUSE THERE ARE NO TOOTH BUDS PRESENT IN THE MANDIBLE THERE WILL BE NO FURTHER VERTICAL OR CIRCUMFERENCIAL GROWTH ANTICIPATED, AND THEREFORE IMPLANTS CAN BE PLACED IN THESE AREAS AT AN EARLY AGE.

Four dental implants with connecting bars can be seen in the mandible post surgery.

The intraoral view shows four abutments attached to the implant bodies.

This view of the mouth shows the connecting bars in place over each pair of implant abutments, since the restoration selected for this patient was the bar-clip type overdenture. The connecting bars were secured to the implants with screws while the tissue side of the overdenture contains the clips that attach the prosthesis to the connecting bars.

This photograph reveals the two ATTACHMENTS, or clips, on the tissue side of the mandibular overdenture that allow the denture to be snapped on and off. Compared with a traditional mandibular denture, this prosthesis provides for significantly increased stability and retention. Bar-clip type overdenture

The maxillary and mandibular prostheses were fabricated to simulate the primary dentition as it would normally appear during the patients presenting age.

The final result is a very natural looking and secure dentition, that is close to being as efficient, as a child’s natural teeth.

Updated overdentures can be fabricated as the patient ages to provide an appearance that is appropriate to the older age.

Conclusion You have now completed a review of the following topics as stated at the beginning of the program: Tooth loss and its consequences The evolution of today’s dental implant The importance of osseointegration and the factors that influence it The steps involved in the dental implant process Some of the many applications of dental implant therapy Questions regarding the course material can be directed to: Dr. Thomas D. Taylor at Read the slide beginning with “You have now completed…”

Thank you for completing the Dental Implant Course.
In order to receive credit for completing this course you must complete a 10 question, multiple choice test and receive a passing score of 80% or higher. You will have an unlimited number of attempts to take the test. Please copy and paste or click on the link below which will redirect you to the test. Please note that it may take up to 10 seconds for the test to begin. We hope that you’ve enjoyed this continuing education program. When you click on the link below you’ll be redirected to a 10 question evaluation. You’ll need to score 80% or higher in order to receive instructions on how to obtain your certificate of completion. If you don’t pass on your first attempt, you’ll be able to retake the test without having to repeat the entire course. Thank you for your participation.

Disclaimer This presentation is reprinted by Cigna with the permission of its author, Dr. Thomas Taylor. The health information in this presentation is.

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Disclaimer This presentation is reprinted by Cigna with the permission of its author, Dr. Thomas Taylor. The health information in this presentation is.

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Presentation on theme: "Disclaimer This presentation is reprinted by Cigna with the permission of its author, Dr. Thomas Taylor. The health information in this presentation is."— Presentation transcript:

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