1. in partnership with Nobel Biocare Diagnosis and treatment planning for the replacement of missing teeth Module 1 | Session 4 Treatment planning and restoring the single posterior dental implant Disclaimer: 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. 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.

2. Treatment planning and restoring the single posterior dental implant 2 Gain proficiency in diagnosis and treatment planning Master the restorative steps for a posterior dental implant Transform restorative decision-making and execution into a simple and easy process Learn how to avoid or manage complications Learn how to gain patient acceptance for dental implant treatment Module 1: Course objectives Treatment planning and restoring the single posterior dental implant

3. 3 Dental implants – the standard of care Indications and contraindications for dental implants Cement vs. screw-retained restorations Options for placing a missing tooth Diagnosis and treatment planning Clinical examples How to find patients and gain treatment acceptance Session 1 Session 2 Review of restorative options Surgical guides Biomechanics and occlusion in implant dentistry Case presentation from participants Treatment plan and case work-up with faculty Introduction for surgical preparation Time: 3 hours Time: 3 hours Module 1: Session overview

4. Treatment planning and restoring the single posterior dental implant 4 Impression techniques Cement vs. screw-retained restorations Provisionalization NobelProcera Restorative workshop and hands-on Patient treatment status Basic patient communication concepts Session 3 Session 4 Avoiding or managing complications Dental implant maintenance Final case presentations Time: 3 hours Time: 3 hours Module 1: Session overview

5. in partnership with Nobel Biocare Diagnosis and treatment planning for the replacement of missing teeth Managing complications

6. Treatment planning and restoring the single posterior dental implant Managing restorative complications 6 Surgical complications Restorative complications Clinical case courtesy of Dr. Baldwin Marchack

7. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Inflammation Tissue prolapse Gingival hyperplasia and gingival recession Ceramic fractures Occlusal overload Poor implant position 7

8. Treatment planning and restoring the single posterior dental implant 8 Managing restorative complications Some possible restorative complications Inflammation: Plaque retention –Loose abutment –Poor fitting margins –Excess cement retention

9. Treatment planning and restoring the single posterior dental implant Clinical case courtesy of Dr. Baldwin Marchack 9 Managing restorative complications Some possible restorative complications Inflammation: Plaque retention

10. Treatment planning and restoring the single posterior dental implant 10 Clinical case courtesy of Dr. Baldwin Marchack Managing restorative complications Some possible restorative complications Inflammation: Loose abutment

11. Treatment planning and restoring the single posterior dental implant 11 Clinical case courtesy of Dr. Baldwin Marchack Managing restorative complications

12. Treatment planning and restoring the single posterior dental implant 12 Clinical case courtesy of Dr. Baldwin Marchack Managing restorative complications Some possible restorative complications Inflammation: Poor fitting margins

13. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Inflammation: Excess cement retention 13 Clinical case courtesy of Dr. Baldwin Marchack Implant position 21

14. Treatment planning and restoring the single posterior dental implant 14 Clinical case courtesy of Dr. Baldwin Marchack Managing restorative complications Some possible restorative complications Tissue prolapse

15. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Gingival hyperplasia and gingival recession 15 Clinical case courtesy of Dr. Baldwin Marchack Gingival hyperplasia occurs when the restoration is not properly contoured. In this example, due to the ridge lap design, the restoration constantly trapped debris under the ledge, and the result was gingival hyperplasia.

16. Treatment planning and restoring the single posterior dental implant 16 Managing restorative complications Some possible restorative complications Gingival hyperplasia and gingival recession Clinical case courtesy of Dr. Baldwin Marchack Solution: If the tissue had been first sculpted with a provisional, the final restoration would have taken a different shape and gingival hyperplasia would not have occurred.

17. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Gingival hyperplasia and gingival recession 17 Clinical case courtesy of Dr. Baldwin Marchack

18. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Ceramic fractures 18 Clinical case courtesy of Dr. Baldwin Marchack

19. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Ceramic fractures 19 Clinical case courtesy of Dr. Baldwin Marchack

20. Treatment planning and restoring the single posterior dental implant 20 Managing restorative complications Some possible restorative complications Ceramic fractures To avoid ceramic fractures a consistent material thickness of the coping and cusp support is needed  guaranteeing a consistent veneering material thickness No cusp supportCusp support

21. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload –Loose screws –Broken screws –Broken restorations –Broken abutments –Broken implants –Minor bone loss –Severe bone loss/Implant failure 21

22. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Loose screws 22 Clinical case courtesy of Dr. Baldwin Marchack

23. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken screws –More common with older design implants and restorations –Remember, even though it was torqued originally, it is broken now –Therefore the shank should be loose in the implant 23

24. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken screws Instructions 1.Use an explorer, curette, or probe and try to engage a rough spot and move in a counter-clockwise direction. 2.Use an ultrasonic scaler with a thin tip to tease it in a counterclockwise direction. 3.Use lots of water, sharp new round bur, light touch, make a dimple, 5mm deep, off-center. 4.Now use explorer or curette in a counterclockwise direction. 5.Nobel Biocare has a “screw removal kit.” This is essentially a bur that cuts in reverse. Try it manually first; if not, run handpiece in reverse, the bur will engage the screw and it will rotate out. 24

25. Treatment planning and restoring the single posterior dental implant Managing restorative complications Nobel Biocare screw removal kit 25

26. Treatment planning and restoring the single posterior dental implant 26 Managing restorative complications Nobel Biocare screw removal kit

27. Treatment planning and restoring the single posterior dental implant 27 Managing restorative complications Nobel Biocare screw removal kit

28. Treatment planning and restoring the single posterior dental implant 28 Managing restorative complications Nobel Biocare screw removal kit

29. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken restorations 29 Clinical case courtesy of Dr. Baldwin Marchack

30. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken restorations –Bruxism –Gross interferences 30

31. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken abutments 31 Photographs and clinical case courtesy of Dr. Baldwin Marchack

32. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken abutments 32 Photographs and clinical case courtesy of Dr. Baldwin Marchack

33. Treatment planning and restoring the single posterior dental implant 33 Managing restorative complications Some possible restorative complications Occlusal overload: Broken abutments → solution Photographs courtesy of Dr. Baldwin Marchack

34. Treatment planning and restoring the single posterior dental implant 34 Managing restorative complications Some possible restorative complications Occlusal overload: Broken abutments To avoid the breaking of an abutment it is important to consider the correct loading of the restoration when planning the treatment and position of the implant. Also consider correct articulation and occlusion. When placing the abutment on the implant in the patient’s mouth it is important: To make sure that the abutment is completely seated on the implant (take x- ray for check) The correct screw is used to fix the abutment onto the implant The appropriate torque value is applied when tightening the screw (see torque guide)

35. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken implants –Bruxism –Gross interferences –Unintentional cantilevers 35 Clinical case courtesy of Dr. Baldwin Marchack

36. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Broken implants –Bruxism –Gross interferences –Unintentional cantilevers Refer to oral surgeon for removal 36 Clinical case courtesy of Dr. Baldwin Marchack

37. Treatment planning and restoring the single posterior dental implant 37 Clinical case courtesy of Dr. Baldwin Marchack Managing restorative complications Some possible restorative complications Occlusal overload: Bone loss

38. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Occlusal overload: Severe bone loss/ Implant failure 38 Clinical case courtesy of Dr. Baldwin Marchack

39. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Poor implant position –Too far apical –Too far labial/buccal –Too far lingual –Too close to adjacent tooth –Too close to adjacent implant –Severe angulation 39

40. Treatment planning and restoring the single posterior dental implant Managing restorative complications Some possible restorative complications Poor implant position - too deep 40 Clinical case courtesy of Dr. Baldwin Marchack

41. Treatment planning and restoring the single posterior dental implant 41 Clinical case courtesy of Dr. Baldwin Marchack Managing restorative complications Some possible restorative complications Poor implant position – e.g. too closely positioned/ too buccal positioned Example 1Example 2

42. Treatment planning and restoring the single posterior dental implant 42 Managing restorative complications Some possible restorative complications Poor implant position – too closely positioned Clinical case courtesy of Dr. Baldwin Marchack

43. Treatment planning and restoring the single posterior dental implant 43 Managing restorative complications Some possible restorative complications Poor implant position – too closely positioned Clinical case courtesy of Dr. Baldwin Marchack

44. Treatment planning and restoring the single posterior dental implant Treatment planning 44 What is the minimum space needed between teeth for a single-tooth implant? ø 3.5mmø 4.3mmø 5.0mm NPRPWP ~1.5mm on each side of implant, 2mm is better for soft tissue Illustrations refer to Nobel Biocare’s tri-channel connection

45. Treatment planning and restoring the single posterior dental implant 45 Treatment planning

46. Treatment planning and restoring the single posterior dental implant 46 Treatment planning

47. in partnership with Nobel Biocare Diagnosis and treatment planning for the replacement of missing teeth Implant maintenance

48. Treatment planning and restoring the single posterior dental implant 48 Treatment planning and restoring the single posterior dental implant Implant maintenance

49. Treatment planning and restoring the single posterior dental implant 49 Treatment planning and restoring the single posterior dental implant Implant maintenance

50. Treatment planning and restoring the single posterior dental implant 50 Treatment planning and restoring the single posterior dental implant Implant maintenance Clinical case courtesy of Dr. Baldwin Marchack

51. Treatment planning and restoring the single posterior dental implant 51 Treatment planning and restoring the single posterior dental implant Implant maintenance

52. Treatment planning and restoring the single posterior dental implant 52 Treatment planning and restoring the single posterior dental implant Implant maintenance Implant scalers Only use specific implant scalers/ probes or plastic instruments  no piezo instruments!

53. Treatment planning and restoring the single posterior dental implant 53 Clinical case courtesy of Dr. Baldwin Marchack Treatment planning and restoring the single posterior dental implant Implant maintenance

54. Treatment planning and restoring the single posterior dental implant 54 Clinical case courtesy of Dr. Baldwin Marchack Treatment planning and restoring the single posterior dental implant Implant maintenance

55. Treatment planning and restoring the single posterior dental implant 55 Clinical case courtesy of Dr. Baldwin Marchack Treatment planning and restoring the single posterior dental implant Implant maintenance

56. Treatment planning and restoring the single posterior dental implant 56 Treatment planning and restoring the single posterior dental implant Clinical case courtesy of Dr. Baldwin Marchack

57. Treatment planning and restoring the single posterior dental implant 57 Treatment planning and restoring the single posterior dental implant Implant maintenance Use plastic scalers if touching titanium Avoid using metal scalers Avoid using the prophy jet Avoid using sonic or ultrasonic scalers Use soft rubber prophy cup, fine prophy paste Use periodontal probe prudently (consider using plastic probe) Always check for mobility Always check for plaque, calculus, and bleeding Reinforce oral hygiene instructions Routinely take x-rays of the implants Routinely check occlusion

58. Treatment planning and restoring the single posterior dental implant 58 Treatment planning and restoring the single posterior dental implant Clinical case courtesy of Dr. Baldwin Marchack Motivate dental hygienists to watch out for potential implant candidates

59. Treatment planning and restoring the single posterior dental implant 59 Gain proficiency in diagnosis and treatment planning Master the restorative steps for a posterior dental implant Transform restorative decision-making and execution into a simple and easy process Learn how to avoid or manage complications Learn how to gain patient acceptance for dental implant treatment Module 1: Course objectives Treatment planning and restoring the single posterior dental implant

60. THANK YOU! 60 Disclaimer: 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. © Nobel Biocare Services AG, 2012. All rights reserved.