Module 1 | Session 4 Treatment planning and restoring the single posterior dental implant Please note: It is encouraged that the presentation at hand.

Module 1 | Session 4 Treatment planning and restoring the single posterior dental 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. My name is and I’m delighted to be your speaker today Welcome to session four of the first of four modules of our Esthetic Alliance Program This is the 4th and last session for this module. 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.

Module 1: Course objectives
Treatment planning and restoring the single posterior dental implant 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: Session overview
Dental implants – the standard of care Indications and contraindications for dental implants Cement vs. screw-retained restorations Options for replacing a missing tooth Diagnosis and treatment planning Clinical examples How to find patients and gain treatment acceptance Time: 3 hours Session 2 Review of restorative options Surgical templates 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

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

Managing complications
Our goal for the lecture component of this session is to discuss managing restorative complications and implant maintenance.

Managing restorative complications
Surgical complications Restorative complications There are surgical complications and restorative complications, and the two are often inter-related. However, today we are only going to address complications of a restorative nature. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 6 6

Some possible restorative complications Inflammation Tissue prolapse Gingival hyperplasia and gingival recession Ceramic fractures Occlusal overload Poor implant position Some of the most possible restorative related complications are: Inflammation Tissue Prolapse Gingival Hyperplasia & Gingival Recession Porcelain Fractures Occlusal Overload Poor Implant Position 7 7

Some possible restorative complications Inflammation: Plaque retention Loose abutment Poor fitting margins Excess cement retention Let’ s address these one at a time. First of all, Inflammation. This can be associated with one of the following: Plaque retention Loose abutment Poor fitting margins Excess cement retention 8 8

Some possible restorative complications Inflammation: Plaque retention If the inflammation is due to plaque retention, it will be obvious. Oral hygiene instructions should be reinforced for this patient. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 9 9

Some possible restorative complications Inflammation: Loose abutment If it’s a loose abutment, this will also be very obvious. The patient will tell you that the crown is loose, and you will see and feel that the restoration is loose. If it is a screw retained restoration, life will be very easy. Simply remove the composite filling and tighten and torque the abutment screw. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 10 10

However, if it is a cement retained restoration, this may be a little more difficult. You will have to estimate where the screw access hole is, drill an opening and try to find the head of the screw. I might add that this problem occurred more with external connection implants, and is not so much of an issue with internal connection implants. Also, this problem can be avoided if the abutment screw is tightened to the recommended torque value in the first place. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 11 11

Some possible restorative complications Inflammation: Poor fitting margins Poor fitting margins will harbor bacteria and cause tissue inflammation. This will be easily detected with a radiograph. Unfortunately, the only correction for this problem is to remake the restoration, most likely, remaking both the abutment and the superstructure crown. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 12 12

Some possible restorative complications Inflammation: Excess cement retention Implant position 21 Implant position 21 Excess cement retention is the result of inaccessible cement margins. Care must be taken to design appropriate abutments and restorations when the tissue is very deep. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 13 13

Some possible restorative complications Tissue prolapse Soft tissue above the implant must be supported or tissue prolapse will occur. With routine one stage surgeries, the tissue is supported by the healing abutment while waiting for osseointegration to occur. During the restorative phase, for example, when the healing abutment is removed to take an impression, if the healing abutment is removed and left off for too long the tissue will collapse and begin to cover the implant. Care must be taken to always keep something in the implant to prevent this from occurring, that something could be the provisional, the healing abutment, the impression coping, or even something called a “soft tissue plug”. If the implant becomes excessively covered by the soft tissue, it may become necessary to use a tissue punch to expose the implant. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 14 14

Some possible restorative complications Gingival hyperplasia and gingival recession Implant Gingiva Bone Gingival hyperplasia occurs when the restoration is not properly contoured. This restoration constantly trapped debris under the ledge which was poorly designed with a ridge lap, and the result was gingival hyperplasia. 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. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 15 15

Some possible restorative complications Gingival hyperplasia and gingival recession Implant Gingiva Bone Development of an adequate emergence profile with a provisional restoration, prior to restoring the implant with the final restoration. 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. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 16 16

Some possible restorative complications Gingival hyperplasia and gingival recession Gingival recession may be troubling to the restorative dentist, and may require surgical intervention to correct. It may require remaking the prosthesis if the esthetics are not acceptable, or alternatively a bone graft or soft tissue graft in order to cover any exposed margins. Ultimately, the best treatment for recession is prevention: proper site preparation, proper placement of the implant, proper abutment selection and proper prosthesis design. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 17 17

Some possible restorative complications Ceramic fractures Ceramic fractures in the implant restoration are not impossible. If the restoration is a screw retained restoration, it could be easily retrieved and sent to the dental lab technician for repair. However, if it is a cemented restoration, it will most likely be destroyed during removal. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 18 18

Some possible restorative complications Ceramic fractures Porcelain fused to metal can fracture just as well as porcelain fused to zirconia. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 19 19

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 support Cusp support

Some possible restorative complications Occlusal overload Loose screws Broken screws Broken restorations Broken abutments Broken implants Minor bone loss Severe bone loss/Implant failure If the biggest cause of peri-implant disease is retained excess cement, the biggest cause of implant failure is occlusal overload. The complications caused by implant overload range from loose screws, to broken screws, to broken restorations, or broken abutments, to broken implants, to minor bone loss, to severe bone loss, and implant failure. 21 21

Some possible restorative complications Occlusal overload: Loose screws We previously discussed the issue of loose screws and how to access the screw whether it is screw retained or cement retained. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 22 22

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 Broken screws are a different story. The broken screw must be carefully removed and replaced. Broken screws were more common with older design implants and restorations. Keep in mind, that even though the screw was originally tightened, now it is broken, and therefore the shank should be loose in the implant. 23 23

Some possible restorative complications Occlusal overload: Broken screws Instructions Use an explorer, curette, or probe and try to engage a rough spot and move in a counter-clockwise direction. Use an ultrasonic scaler with a thin tip to tease it in a counterclockwise direction. Use lots of water, sharp new round bur, light touch, make a dimple, 5mm deep, off-center. Now use explorer or curette in a counterclockwise direction. Nobel Biocare has an “Abutment Screw Retrieval 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. Attempting to remove a broken screw shank requires a definite plan or sequence. Do not pick up a hand piece and start drilling into the top of the shank. First, just use an explorer or a sharp curette and try to engage a rough spot on the broken surface and rotate it out with a counterclockwise motion. Try to engage a spot that is off center so you can rotate. If it does not come out easily, use an ultrasonic scaler with a fine tip in the same manner. If you are unable to engage a spot; create a spot with a sharp, new round bur such as a #1 or #1/2 round, about .5mm deep, and repeat steps one and two above. The next alternative is to use a “screw removal kit”, which can be purchased from Nobel Biocare. 24 24

Nobel Biocare Abutment Screw Retrieval Kit Nobel Biocare makes a screw removal kit. The screw removal kit includes the following tooling and comes packaged in a clear box as pictured above. The Nobel Biocare screw removal kit contains two round burs for making a hole. The other two components are removal instruments. 25 25

Nobel Biocare Abutment Screw Retrieval Kit Nobel Biocare makes a screw removal kit. The screw removal kit includes the following tooling and comes packaged in a clear box as pictured above. The Nobel Biocare screw removal kit contains two round burs for making a hole. The other two components are removal instruments. 26 26

Some possible restorative complications Occlusal overload: Broken restorations Another repercussion of occlusal overload is broken restorations, and we addressed the materials and design aspect of this complication earlier. While we must see whether the restorations are properly constructed, what’s more important is to see what caused the damage. Was the first occlusal contact too heavy, was it “high”? Were there balancing or working interferences? Is the patient a bruxer? Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 27 27

Some possible restorative complications Occlusal overload: Broken restorations Bruxism Gross interferences Bruxism and gross interferences are the major causes of implant overload. If this is a single implant, most likely we should be able to transfer lateral loads to adjacent natural teeth, and avoid lateral contacts on the implant. We covered this topic during session two, when we discussed biomechanics. 28 28

Some possible restorative complications Occlusal overload: Broken abutments Properly designed abutments should not break even under severe heavy loading. For example, metal abutments made of titanium or gold, for internal or external connection implants, should be so strong that something else in the system should give and not the abutment itself; i.e, the screw, the restoration, maybe even the implant itself, but probably not the abutment. The only broken abutments we have seen were Abutments that should not have been used in the first place, and these were ceramic abutments for internal connection implants where the engaging part of the abutment was also milled out of ceramic. For example, this generic zirconia abutment shown in the picture was milled for this implant by an independent milling service. Photographs and clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 29 29

Some possible restorative complications Occlusal overload: Broken abutments The engaging feature was a very small diameter insert milled from the same piece of zirconia. The abutment failed within one week of insertion. The broken piece had to be carefully removed from the implant. Photographs and clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 30 30

Some possible restorative complications Occlusal overload: Broken abutments → solution Abutment Retrieval Tool A new titanium abutment was fabricated, and a PFM superstructure crown was made which hopefully will now serve the patient successfully. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 31 31

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)

Some possible restorative complications Occlusal overload: Broken implants Bruxism Gross interferences Unintentional cantilevers Implant fixtures are not unbreakable! In times past, narrow bodied implants with thin walls frequently broke under occlusal overload. Today, with better designs and wider diameters they are more difficult to break. If your implant breaks due to overload, contact your surgeon to have it removed. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 33 33

Some possible restorative complications Occlusal overload: Broken implants Bruxism Gross interferences Unintentional cantilevers Refer to oral surgeon for removal (implant retrieval tool) Broken implants may have contaminated surfaces, may harbor bacteria, so it is best to remove them. If grafted afterward, the site could be ready for the placement of new implants. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 34 34

Some possible restorative complications Occlusal overload: Bone loss Some examples of early bone loss at the crest of the bone. The occlusion should be examined closely if this type of bone loss is detected at follow-up visits. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 35 35

Some possible restorative complications Occlusal overload: Severe bone loss/ Implant failure Heavy bruxing, and gross lateral interferences are the major cause of bone loss as severe as this. The occlusion must be checked closely, especially in the most posterior region where more torque can be applied to the second molars. In the event of severe bone loss, such as these examples, the implants are hopeless, and should be removed and replaced. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 36 36

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 Poorly placed implants present the most challenging task for the implant team; the surgeon and the restorative dentist. When you realize the implant is poorly placed its already too late! 37 37

Some possible restorative complications Poor implant position - too deep Implants that are placed too far apically are challenging to restore, the proximal contacts don’t match up, and often is an esthetic problem as well. Because of the way bone resorbs after extraction, and if no grafting is done, maxillary posterior implants are often placed too far lingually. On the other hand, as the mandibular ridge resorbs, it usually flattens out and mandibular posterior implants are often placed too far bucally. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 38 38

Some possible restorative complications Poor implant position – e.g. too closely positioned/ too buccal positioned Example 1 Example 2 This radiograph shows a case with several examples of poor judgment. Too many implants. Implants too close to the adjacent natural teeth, and implants too close to each other. I really believe, however, that with an emphasis on diagnosis and treatment planning these types of errors should not occur today. Solution: Depending on the positioning of the implant, an NobelProcera Angulated Screw Channel Abutment might allow correction for the restorative solution. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 39 39

Free choice of the screw access hole positioning NobelProcera Angulated Screw Channel Abutment The Angulated Screw Channel Abutment solves many challenges: Confidently use esthetic zirconia abutments in the molar region, due to the new metal adapter. Easy access to restoration with the option to position screw access hole mesially Optimum occlusal function (position of screw access hole for optimal occlusal function) Cement-free: Intelligently designed mechanically retained adapter Work easily with the pick-up function and securely hold the screw using the Omnigrip Screwdriver Manage challenging cases with the free choice of the screw access hole position Easy removal and replacement of the mechanically retained metal adapter during the porcelain veneering process Safe design: NobelProcera CAD Software dynamically ensures the required material thickness is always met Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany Photographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany 40 40

Some possible restorative complications Poor implant position – too closely positioned Here is another example of poor planning. Three implants to replace two molars may have been too many. The result is that the middle implant is too close to the anterior one, making impression taking a difficult, because the impression copings intersect with each other. Ultimately, to get an accurate impression, the middle impression coping was first cut in such a way to allow access for the most anterior impression coping. It was then screwed to place with an abutment screw. Next, the other two impression copings were inserted with regular impression pins. The three impression copings were luted together with GC pattern resin. Once set, the abutment screw was removed from the middle impression coping. A cotton applicator stick was inserted into the screw access hole, and only then was making the impression possible. When the impression material was set, the stick was removed to gain access to the screw. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 41 41

Some possible restorative complications Poor implant position – too closely positioned This final case, again, shows poor judgment in placing too many implants too close to each other. The final restoration was made utilizing only three implants. In retrospect, it could even have been treated by putting two implants to sleep and restoring only two. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 42 42

~1.5mm on each side of implant, 2mm is better for soft tissue
Treatment planning What is the minimum space needed between teeth for a single-tooth implant? ø 3.5mm ø 4.3mm ø 5.0mm 1.5-2mm 1.5-2mm ~1.5mm on each side of implant, 2mm is better for soft tissue So 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. 1.5-2mm Ø 4.3mm Illustrations refer to Nobel Biocare implants with Conical Connection 1 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):

Treatment planning It also demonstrates the need to know the average width of bicuspids and molars. The lab could be instructed to make the appropriate wax-up so that planning and designing surgical guides can be made easier. 44 44

One integrated treatment workflow, countless benefits
NobelConnect® Clinical diagnostics & treatment acceptance Capturing both the current & desired situation Treatment planning & patient communication Production of surgical template Implant placement Design of final restoration Production of prosthesis Restoration placement Clinical diagnostics and treatment acceptance Capturing both the current and desired situation Treatment planning and patient communication Production of surgical template Implant placement either freehand or using pilot drill template or fully guided template Prosthetic design Production of prosthesis Restoration placement Finally, treatment planning with the support of a treatment planning software such as the NobelClinician Software, with models, radiographs and (CB)CT scans can help to avoid complications before the surgery. Pilot drill guides or fully guided surgery can be used to avoid complications during surgery and ensure the planned implant position. Increasing treatment efficiency Save 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.

Implant maintenance Now let’s change topics, our goal for this section of the presentation is to discuss implant maintenance. 46

Treatment planning and restoring the single posterior dental implant
Implant maintenance There are three people who look inside the patient’s mouth: The dentist, the hygienist and the assistant. Each should play a part, and each should have a role in implant maintenance for the patient. 47 47

Implant maintenance While the hygienist plays the major role in maintenance, the assistant should reinforce hygiene procedures throughout the restorative phase, and the dentist should set the stage when the final restorations are placed about the importance of visits for examination and maintenance every three months. 48 48

Implant maintenance Patients should be aware that it would be detrimental to the health of the implants, and the peri-implant tissue, to allow plaque to accumulate on the implant restoration. As seen in this example. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 49 49

Implant maintenance Early in implant dentistry restorations were either gold or titanium and protruded out of the gingiva. Therefore, it was critical not to scratch the titanium components so a variety of plastic instruments were introduced for this purpose. 50 50

Implant maintenance Implant scalers Only use specific implant scalers/ probes or plastic instruments  no ultrasonic / piezo instruments! Today the instruments follow the design of conventional scalers for natural teeth and are made of a variety materials in addition to plastic. There is nothing wrong with continuing to have the hygienist scale implant restorations with plastic instruments. 51 51

Implant maintenance And certainly if plastic instruments were used on the above examples, they would avoid scratching the titanium abutments. Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA 52 52

Implant maintenance But, since it would be impossible for every hygienist to know what material was used on each and every case, it would probably be prudent to simply allow them to scale every implant restoration with plastic instruments so to avoid damage when there is titanium under the tissue! The above restorations could be scaled with conventional instruments. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 53 53

Implant maintenance Patients should be instructed to floss their single implant restorations as they would normal teeth. Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 54 54

And to use the interdental brush in the appropriate embrasures adjacent to the soft tissue, and not where the porcelain crown meets the pink porcelain. 55 55

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 This checklist will allow both the hygienist, and the dentist, to be as thorough as possible when conducting implant maintenance on the patient. 56 56

Motivate dental hygienists to watch out for potential implant candidates And finally, all hygienists should remember to offer implants to patients whenever they see edentulous spaces. Whenever they see a patient, such as the ones above, they should call the doctor, and ask the patient if they have ever thought of having implants? Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA 57 57

Your next steps Treatment planning and restoring the single posterior dental implant Find patients hiding in your files eligible for implant treatment Register for other modules of the Esthetic Alliance Program Module 2: Treatment planning and restoring the single anterior dental implant Module 3: Treatment planning and restoring multiple dental implants in a partially edentulous arch Module 4: Treatment planning and restoring dental implants in the edentulous mandible Note for lecturer: You may define the length of the case presentations in order to ensure time management during session 4. 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 Abutment Multi-unit Abutment Snappy Abutment And other Nobel Biocare solutions The educational series can be executed by you or your Nobel Biocare representative

THANK YOU! Thank you for your attention and for attending all four sessions of the first module of the Nobel Biocare Esthetic Alliance Program. 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. All rights reserved. 59 59

Module 1 | Session 4 Treatment planning and restoring the single posterior dental implant Please note: It is encouraged that the presentation at hand.

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Module 1 | Session 4 Treatment planning and restoring the single posterior dental implant Please note: It is encouraged that the presentation at hand.

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Presentation on theme: "Module 1 | Session 4 Treatment planning and restoring the single posterior dental implant Please note: It is encouraged that the presentation at hand."— Presentation transcript:

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