Presentation on theme: "Module 1 | Session 2 Treatment planning and restoring the single posterior implant Please note: It is encouraged that the presentation at hand is adapted."— Presentation transcript:
1Module 1 | Session 2 Treatment planning and restoring the single posterior implant Please note:It is encouraged that the presentation at hand is adapted and enhanced by clinical cases of the lecturer. Please feel free to adjust the slides according to your preferences.Welcome to session two of the first of four modules of our Esthetic Alliance ProgramMy name is and I’m delighted to be your speaker todayDisclaimer:Some products may not be regulatory cleared/released for sales in all markets.Please contact the local Nobel Biocare sales office for current product assortment and availability
2Module 1: Course objectives Treatment planning and restoring the single posterior dental implantGain proficiency in diagnosis and treatment planningMaster the restorative steps for a posterior dental implantTransform restorative decision-making and execution into a simple and easy processLearn how to avoid or manage complicationsLearn how to gain patient acceptance for dental implant treatmentNote for lecturer:If course participants want to have additional training, Nobel Biocare can provide individual support and trainings on specific topics (e.g. how to restore on certain abutment)
3Module 1: Session overview Dental implants – the standard of careIndications and contraindications for dental implantsCement vs. screw-retained restorationsOptions for replacing a missing toothDiagnosis and treatment planningClinical examplesHow to find patients and gain treatment acceptanceTime:3 hoursSession 2Review of restorative optionsSurgical templatesBiomechanics and occlusion in implant dentistryCase presentation from participantsTreatment plan and case work-up with facultyIntroduction for surgical preparationTime:3 hours
4Module 1: Session overview Impression techniquesCement vs. screw-retained restorationsProvisionalizationNobelProceraRestorative workshop and hands-onPatient treatment statusBasic patient communication conceptsTime:3 hoursSession 4Avoiding or managing complicationsDental implant maintenanceFinal case presentationsTime:3 hours
5Module 1 | Session 2 Agenda Review restorative optionsSurgical templatesBiomechanics and occlusion in implant dentistryOur goal for the lecture portion of today’s session is to cover 3 topics, namelyReview restorative optionsSurgical templatesBiomechanics and Occlusion in Implant dentistry5
6Restorative solutions for dental implants Implant supported solutions from single tooth to full arch restorationsSingleposterior implantSingleanterior implantMultiple implantsFull arch implantsIn the last session, we described how this program is dedicated to addressing Implant supported restorative solutions for partially edentulous and edentulous arches, and is divided into 4 modules, the Single Posterior Implant, Single Anterior Implant, Multiple Implants and Implants in the Edentulous Arch.
7Restorative solutions for dental implants Implant supported solutions from single tooth to full arch restorationsSingleposterior implantWe concentrated on Restoring the Single Posterior Dental Implant77
8Single missing toothRestorative options for a single posterior implant:We discussed treatment planning, case presentations and informed consent.We discussed the restorative options for a single posterior implant in detail.Today, what we are going to do for the first few minutes is to review these restorative options.Clinical cases courtesy of Dr. Baldwin Marchack, Pasadena, USA88
9Single missing tooth Single posterior implant We said that we had found the patient, performed the diagnosis and treatment plan, the surgeon had placed the implant, the implant has integrated and the case was ready to restore.Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany
10Single missing toothRestorative options for a single posterior implant:Pre-fabricated abutment, cement-retained crownIndividualized abutment, cement-retained crownScrew-retained crown (one piece)And once again, if you have a single posterior implant, your abutment choices are to have a pre-fabricated abutment(Snappy or Esthetic), with a cemented crown, a custom abutment with a cemented crown,or no separate abutment, just a screw retained restoration.
11Single missing tooth Screw-retained restoration Single posterior implantYou see, if you have a single posterior implant, you really only have two choices.You can have a screw retained restoration or you can have a cement retained restoration.Cement-retained restorationPhotographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany
12Single missing tooth Pre-fabricated abutment Cement-retained restorationIndividualized (CAD/CAM) abutmentNow if you choose to make a cement retained restoration, once again, you have two choices.You can cement on a pre-fabricated abutment or you can cement on a custom abutmentPhotographs courtesy of Dr. Baldwin Marchack, Pasadena, USAPhotographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany
13Guidelines for abutment selection Issues to be considered:Implant-abutment connectionDistance from the implant platform to bone crestInterocclusal distanceDepth of peri-implant soft tissuesBiotype of the tissueEmergence profileShape and contour of the tissueScrew-retained/cement-retainedI wish it could be so easy that with every case you just take a pre-fabricated abutment, insert it in the implant, make a crown and cement it. Life would be very easy. But there are many things that need to be considered.Issues to be considered:Read list
14Guidelines for abutment selection For exampleIf you have an Ideal gingival height – 1 to 3mm,Ideal interarch dimension – say 5 to 10mmAnd flat shape to the tissueGo right ahead and use a pre-fabricated abutment. In fact this would be an ideal situation for a Snappy abutmentIdeal gingival height – 1 to 3mm, flat shape Ideal interarch dimension – 5 to 10mm
15Too deep, not flat – use another solution. Guidelines for abutment selectionFor exampleIf you have an Ideal gingival height – 1 to 3mm,Ideal interarch dimension – say 5 to 10mmAnd flat shape to the tissueGo right ahead and use a pre-fabricated abutment. In fact this would be an ideal situation for a Snappy abutmentToo deep, not flat – use another solution.
16Guidelines for abutment selection A case study:“Resistance to dislodgement of zirconia copings cemented onto titanium abutments of different heights.”Abbo B, Razzoog M, Vivas J, Sierraalta M. J Prosthet Dent 2008; 99: 25-29Purpose:Authors measured the force it takes to dislodge a cemented crown onabutments of various heightsResults:The taller the abutment height the greater the force required to dislodge a cemented crown.Study recommends that abutments should be no less than 4mm in height when using a cemented crown.Abutment height: 6.5mm 5.5mm Average dislodgement force: N NOne other study I would like to share with you before we move on is this article by Razzoog and others. In this article the authors measured the force it takes to dislodge a crown cemented on abutments of various heights. They determined that the shortest height of an abutment should be no less than 4mm. Other wise the crown will fall off too easily regardless of what kind of cement you use
17Guidelines for abutment selection 2-3mm gingival height5mm interarch dimensionNow remember that we developed a decision tree in the last session. In that decision tree we looked at 5 mm as the minimum interarch dimension for a cemented crown. Why? Well, if you have a single posterior implant, the first thing that needs to be evaluated is the interarch dimension. We know that if an abutment is too short and we cement a crown on it, the crown will keep falling off.The minimum abutment height as we saw earlier is 4mm. We also saw that the cement margin should be no deeper than 1mm below the crest of the tissue otherwise we may leave cement behind, and run the risk of peri-implantitis. That means we need 3 mm above the tissue for the rest of the abutment. We also know that we need 2mm of clearance above the abutment to make room for a crown. Therefore the minimum interarch dimension needed for a cemented crown is 3 + 2, =5 mm.
19Guidelines for abutment selection Limited interarch dimensionHere is a case that illustrates that point. The interarch dimension is only 3 mm, there is no room for a cemented crownPhotographs courtesy of Dr. Baldwin Marchack, Pasadena, USA
20Guidelines for abutment selection Use a screw-retained crown:Limited interarch dimensionPatient is a bruxerRetrievability is desiredCement-free solution wantedScrew-retained crown:NobelProcera screw-retained crownGoldAdapt abutmentYou should consider using a screw-retained, non-segmented restoration when :Limited interarch dimensionPatient is a bruxerRetrievability is desiredScrew-retained, non-segmented restoration could be made from:NobelProcera custom abutmentGoldAdapt abutment / UCLA abutment
21Guidelines for abutment selection Here is the NobelProcera Zirconia Angulated Screw Channel abutment, designed with anatomic support for the porcelain and with the porcelain veneered directly on to the abutment.Photographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany
22Guidelines for abutment selection And here it is, the completed, fully retrievable screw retained final restoration, with a composite filling to close the screw access holeClinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany
24Guidelines for abutment selection Ideal gingival height (1–3mm)Ideal interarch dimension (5-10mm)Flat tissue architectureLets look at a case that illustrates this.We have Ideal gingival height (2–3mm)Ideal interarch dimension (6mm)Flat tissue architectureClinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany
25Snappy™ Abutment Ideal gingival height (1–3mm) Ideal interarch dimension (5-10mm)Flat tissue architectureThis is a perfect indication for a Snappy AbutmentClinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany
28Pre-fabricated Esthetic Abutment Esthetic Abutment (Titanium)Pre-fabricated, customizable Titanium abutment:Comprehensive selection of different margin designs and angulations minimize chair-side adjustmentsScalloped margin designed to profile natural soft tissue contoursOptional temporary coping available for temporizationIndications:Single- and multiple-unit implant restorationsCement-retainedEsthetic Abutments for use in the posterior teeth come in titanium, in various collar heights, and 15% angled in titaniumDepending on location, tissue biotype, etc we may elect to use one of these many choices.
29Esthetic AbutmentIn this case with thick fibrous tissue biotype, there is no chance of metal show through, but by taking an implant level impression the lab has an opportunity to adjust the height and adjust the level of the margin to .5 to 1 mm below the crest of the tissueClinical case courtesy of Dr. Christopher Marchack, Pasadena, USA
30Esthetic Abutment Milled titanium Can be adjusted by the lab Corrects minor angulation problemsFixture level impressionEasy to cementHere are some advantages to the esthetic abutmentMilled for proven accuracy of fit Can be prepped by the lab Corrects minor angulation problems Fixture level impression Easy to cementClinical case courtesy of Dr. Christopher Marchack, Pasadena, USA3030
32Guidelines for abutment selection Individualized abutmentScalloped tissue architectureThick soft tissueAngled implant placementExcessive interarch dimensionExcessive interproximal dimensionFabrication options:NobelProcera abutment in Titanium or ZirconiaGoldAdapt abutmentTo summarize, we would utilize a custom abutment when we have:Scalloped tissue architectureDeep tissueAngled implant placementExcessive Interarch dimensionExcessive interproximal dimensionScrew access on buccal, working cuspAnd we have a choice of fabrication:NobelProcera custom abutment, titanium or zirconiaGoldAdapt abutmentUCLA abutment
33NobelProcera® abutment NobelProcera Angulated Screw Channel abutmentEasy access due to tilted access holeThis slide shows the NobelProcera angulated screw channel abutmentClinical case courtesy of Dr. Sebastian Horvath, Jestetten, GermanyPhotographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany
34NobelProcera® abutment And here we have the completed laboratory procedures with a NobelProcera custom abutmentAnd a NobelProcera Zirconia crownClinical case courtesy of Dr. Sebastian Horvath, Jestetten, GermanyPhotographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany
35Posterior implant restoration And the final photographsClinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany
37Diagnosis and prosthetic treatment planning Four important toolsDiagnostic modelsRadiographs(CB)CT scansNobelClinician SoftwareNow let’s discuss diagnostic and prosthetic treatment planningAnd, four important tools we need to utilize:37
38Diagnostic Models Evaluate: Centric relation position Edentulous ridge relationship to adjacent teeth, opposing ridge, opposing dentitionInclination, rotation, extrusion, alignment of the remaining dentitionSoft tissue, gingival heights, and other esthetic parametersInterarch spaceDetermine:Options for occlusal schemesIdeal number and location of implantsDirection of forces to which future implants would be subjectedDiagnostic models allow us to evaluate:Centric relation positionEdentulous ridge relationship to adjacent teeth, opposing ridge, opposing dentitionInclination, rotation, extrusion, alignment of the remaining dentitionSoft tissue, gingival heights, and other esthetic parametersInterarch spaceThey allow us to determine:Options for occlusal schemesIdeal number and location of implantsDirection of forces to which future implants would be subjected3838
39Radiographs Evaluate: Amount of bone available (2D only) Angulation of adjacent teethLocation of anatomical structuresSinus, mandibular canal, mental foramenPlease bear in mind that radiographs are not completely accurateRadiographs allow us to evaluateAmount of bone availableAngulation of adjacent teethLocation of anatomical structures such as the sinus, mandibular canal, mental foramenHowever radiographs are limited, they are a 2-dimensional view only, and therefore not 100% accurateClinical case courtesy of Dr. Richard Sullivan, Pasadena, USA39
40(CB)CT scansSince radiographs are not completely accurate, a (CB)CT scan can improve the diagnosis(CB)CT scans on the other hand are 100% accurate, but incur additional costsClinical case courtesy of Dr. Christopher Marchack, Pasadena, USA40
41NobelClinician® Software Visualize the patient’s (CB)CT data together with theintra-oral situation and the diagnostic setup thanks toNobelClinician’s SmartFusion™ technologySmartFusion technology allows the full automatic matching of (CB)CT data with surface scan of the dental castIntra-oral situation of patient during (CB)CT scan and shown by dental cast – must be the sameYou can also scan the dental cast with the wax-up to allow for esthetic treatment planning.Use this opportunity to demonstrate the NobelClinician Software to the participants.For more information, please contact your local Nobel Biocare sales representativeClinical case courtesy of Dr. Christopher Marchack, Pasadena, USA
42Surgical templatesModels, radiographs and (CB)CT scans are essential in fabricating surgical templates for various types of surgery:FlaplessMini flapFlapAll options are covered with the NobelClinician Software and NobelGuideModels, radiographs and CT scans are essential in fabricating surgical guides.Basically there are two types of surgical guides, guides for flapless surgery, often referred to as guided surgery, and guides for conventional open-flap surgery.42
43Surgical templates Benefits of surgical templates: More precise placement of implantsPreservation of anatomic structuresShorter treatment times, surgery timesLess invasive, flapless surgery and therefore less chance of swellingLess post-operative strain on dentist and patientRead the bullets:Note: The list in this slide refers to the use of surgical templates with flapless surgery. The list does not rule out any advantages of free-hand surgery.Note to lecturer: Please feel free to adapt the slide according to your preferences.Manikandan R et al. Implant surgical guides: From the past to the present. J Pharm Bioallied Sci 2013;5(Suppl 1):S98-S10243
44One integrated treatment workflow, countless benefits NobelConnect®Clinical diagnostics & treatment acceptanceCapturing both the current & desired situationTreatment planning & patient communicationProduction of surgical templateImplant placementDesign of final restorationProduction of prosthesisRestoration placementClinical diagnostics and treatment acceptanceCapturing both the current and desired situationTreatment planning and patient communicationProduction of surgical templateImplant placement either freehand or using pilot drill template or fully guided templateProsthetic designProduction of prosthesisRestoration placementIncreasing treatment efficiencySave valuable time by linking several steps to form one integrated treatment workflow.From clinical diagnostics to implant placement, NobelConnect* seamlessly links the tools the clinician needs:NobelClinician supports efficient treatment planning by linking with the NobelProcera 2G System, allowing the capture of digitized prosthetic information for the current and desired situations, eliminating the need for a radiographic guide.NobelClinician Viewer or Communicator facilitates collaboration with all treatment partners and the iPad® app allows the clinician to present patient-specific treatment options in a way that is visual and easy to understand for increased patient acceptance.OsseoCare Pro records and documents final implant values or any surgical information the clinician needs. Information can be retrieved in NobelClinician automatically.Switch to guided surgery at any point during the planning process with no need for an additional patient visit.
45~1.5mm on each side of implant, 2mm is better for soft tissue Treatment planningWhat is the minimum space needed between teeth for a single-tooth implant?ø 3.5mmø 4.3mmø 5.0mm1.5-2mm1.5-2mm~1.5mm on each side of implant, 2mm is better for soft tissueSo if we look at the platform diameters of the three implants we will be concerned with, for a narrow platform, 3-1/2-millimeter diameter, if you allowed a minimum of 1.5 millimeters on each side, you’re looking for 6-1/2 millimeters of space. And accordingly, more for the regular platform and more for the wide platform.Speaker note:And when you’re on the wide platform, you can give them what your thoughts are on what space is too big for one wide platform implant.For example, if you think 12 millimeters is about the limit of what you would put in, one 5-millimeter or even 6-millimeter diameter implant, if you had room for it and you got the implant right in the middle, what is the effect of having a cantilever of 3 millimeters on each side or 4 millimeters on each side? But if the space gets to be 13-plus millimeters, should they be looking at two implants instead of one?That’s a good discussion point in treatment planning.1.5-2mmØ 4.3mmIllustrations refer to Nobel Biocare implants with Conical Connection1 Gastaldo JF et al. Effect of the Vertical and Horizontal Distances Between Adjacent Implants and Between a Tooth and an Implant on the Incidence of Interproximal Papilla. J Periodontol 2004;75(9):
46Occlusion and biomechanics Forces acting during a condition of malocclusionThe picture shows which force occurs during a situation of malocclusionThe resulting force is perpendicular to the plane of contactIf the resulting force is too strong for the crown, the restoration may break or may result in crestal bone lossThe principles are the same for both natural teeth and implants→ how can breakage and crestal bone loss be avoided?A failure of a dental implant is a rare condition that could happen if the structural integrity of the implant has deteriorated due to:Illustrations obtained through internet research:46
47Occlusion and biomechanics Uneven loadingOverloading may occur because of incorrect placement of the implant and critical restoration geometriesThis can result in uneven force distribution on the implant's surfaceDental implants should ideally be placed so that the biting forces are directed straight downward onto the dental implantNow remember that we developed a decision tree in the last session. In that decision tree we looked at 5 mm as the minimum interarch dimension for a cemented crown. Why? Well, if you have a single posterior implant, the first thing that needs to be evaluated is the interarch dimension. We know that if an abutment is too short and we cement a crown on it, the crown will keep falling off.The minimum abutment height as we saw earlier is 4mm. We also saw that the cement margin should be no deeper than 1mm below the crest of the tissue otherwise we may leave cement behind, and run the risk of peri-implantitis. That means we need 3 mm above the tissue for the rest of the abutment. We also know that we need 2mm of clearance above the abutment to make room for a crown. Therefore the minimum interarch dimension needed for a cemented crown is 3 + 2, =5 mm.
48Occlusion and biomechanics FBitea1FN1FNx1The steeper the line of contact, the stronger the resulting forceThe force necessary to equalize the vertical bite force is higher, when the line of contact is steeperIn the dental environment, the occlusion should be shallow or flat in order to reduce the lateral forces impacting on the occlusion→ it is recommended to create shallow or flat occlusion lines to reduce the overload riskFBitea2FN2FNx2The angle of force to the implant body may be influenced by the cusp inclination. The natural dentition often has steep cuspal inclines. A greater cusp angles may incise food more easily and efficiently, yet the occlusal contact along an angled cusp results in an angled force to the crestal bone. The steeper the inclination of the occlusion the greater the lateral component of the resulting force. Which corresponds to a less favorable loading situation. The occlusal contact over an implant crown therefore should be ideally on a flat surface perpendicular to the implant body.48
49Occlusion and biomechanics Possible consequences of overloadCrestal bone lossDislodged restorationsScrew looseningScrew fracturingRestoration or ceramic fracturePeri-implantitisImplant failureWe refer to excessive lateral forces on implants as overload, and some of the consequences of overload are:Crestal bone loss, Crowns falling off, Screw loosening, Screw fracturing, Prosthesis or porcelain fracture,Peri-implantitis, and Implant failureHere are two examples of severe bone loss leading to implant failure* This list makes not claim to be complete.Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA4949
50Occlusion and biomechanics Possible consequences of overloadAnd after extensive bone loss such as this, there is no option except to trephine out the implant and start all overClinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA50
51Occlusion and biomechanics SummaryKeep cusp inclines flat or shallow to minimize lateral forcesNo premature contactsLight occlusal contactsAvoid supra-occlusal axial and lateral loadingKeep contacts in the same line as the long axis of the implant, i.e., as close to the center as possibleAvoid cantilevers, whether mesial, distal, buccal, or lingualOcclusion has been an important variable in the success or failure of most prosthodontic reconstructions. With natural teeth, a certain degree of flexibility permits compensation for any occlusal irregularities. Implant dentistry is not as forgiving. The status of the occlusion must be properly diagnosed, corrected or compensated for, and properly integrated into the design of the definitive restoration. The occlusion must be more rigorously evaluated with implant-supported prosthodontics adjacent to natural dentition. Occlusal overload can be the main factor for an already osseointegrated implant to lose osseointegration. Hence careful consideration of the various components of implant protective occlusion is mandatory for the successful functioning of the implant supported prosthesis.Chia-Chun Yuan J, Sukotjo C. Occlusion for implant-supported fixed dental prostheses in partially edentulous patients: a literature review and current concepts. J Periodontal Implant Sci 2013;43:51-57Rani G, Gambhir A. Occlusion In Implants - A Review. Indian J Dental Sci 2012;3(4):95-985151
52Your next steps for session 3 Treatment planning and restoring the single posterior dental implantRefer your patient to your surgical specialist for implant treatmentEnsure a complete patient documentation for later case presentationYou may invite your dental laboratory technician to participate in session 3 of the Esthetic Alliance ProgramNote for lecturer:Nobel Biocare offers to support participants along the Esthetic Alliance Program. E.g. additional individual training session, patient education material, training opportunities, preparation of case presentation etc.In case your restorative general practitioner, your dental staff or yourself need additional support on certain topics, we are glad to support you with small educational series on:Esthetic AbutmentMulti-unit AbutmentSnappy AbutmentAnd other Nobel Biocare solutionsThe educational series can be executed by you or your Nobel Biocare representative