‫مياهلل حرال نمحرالمسب‬

Dental Implants

Part II

By

Assoc. Prof. Lamia Dawood

Treatment Planning for the Implant Recipient
Clinical Evaluation:
1. Visual examination
2. Palpation
• Flabby excess tissue.
• Bony ridges.
• Sharp underlying osseous formations.
• Undercuts that would limit implant insertion.
• Radiographic Evaluation:
-The best initial image is the panoramic view.

Panoramic radiograph
 CBCT
CBCT
• Diagnostic Casts:
• Study the remaining teeth.

• Evaluate the residual bone.

• Analyze maxillomandibular relationships.

• Helpful for fixture placement.

• A diagnostic waxing.

• Proposed fixture sites checked for proper alignment, location, and relation to the
remaining teeth.

• The waxing helps determine the most esthetic placement of the teeth to be restored
and the potential for functional speech disturbances
Diagnostic Casts:
• Bone Sounding:

• Sharpened & sterilized Boly gauge

 Principles of Implant Location
• Anatomic Limitations:

-10 mm of vertical bone dimension and 6 mm of horizontal should be available for implant
placement.

-1mm of bone on both the lingual and facial surfaces of the implant.
• Anterior Part of the Maxilla:

-1 mm of bone should remain between the apex of the implant and the nasal vestibule.

-Slightly off midline, on either side of the incisive foramen.

• Posterior Part of the Maxilla:
-Less dense than that of the posterior part of the mandible.

-Increased time for integration of the implants

-Additional implants may be needed (one implant for every tooth).

-1 mm of bone between the floor of the sinus and the implant.

• Anterior Part of the Mandible:
-Placed through the entire cancellous bone so that the apex of the implant engages the cortex of
the inferior mandibular border.
• Premolar area:
-Implant does not impinge on the inferior dental nerve.

-Implant should be at least 5 mm anterior to the foramen.

• Posterior Part of the Mandible:
-2 mm away from the superior aspect of the inferior alveolar canal.
-Attachments of the mylohyoid.
Restorative consideration
• Implant placement:
-Implant placement must begin with a restorative dentistry consultation.
-At least 1 mm away from the adjacent natural tooth is essential.
-A minimum of 3 mm should be left between implants.
-Implants must not encroach on the embrasure spaces.
 - Long axis of implant should be positioned in the central fossa of the restoration.
-Implants must not angled so that screw access is through the facial surfaces of the
completed restoration.

Esthetics and access for

hygiene can be greatly
affected.
 -Superior or inferior positioning may affect crown contours and pocket depth .
-Accurate implant depth is critical to a successful result.
• Implant and Restoration Size:
- Size should be considered during treatment planning

- 4mm diameter for maxillary central.

- 3mm for mandibular incisors.

- 5-6mm for molars.

 -The minimum bone dimension for a small diameter
implant is 5 mm.
-At least 1 mm of bone should still remain laterally after the site has been prepared.
• Single Tooth Implant:
-To minimize screw loosening → place an implant with an antirotational feature
built into the system (a spline or a hexagon) is
essential.
• Soft Tissue Contours:
-Achieving a completely formed papilla between the implant restoration and the
adjacent teeth in the final outcome can be challenging.
-If the distance between the bone and the contact is short (<5 mm), a papilla is
usually present.
-If the distance is long >8 mm, a papilla would not normally be present without
additional soft tissue grafting
Surgical Guide
-A surgical guide template is extremely useful for anterior implants because slight variations in
angulation can significantly affect the appearance of the final restoration.

-Objectives for using a surgical guide:

1 Delineate the embrasures.

2 Locate the implant within the restoration contour.

3 Align implants with the long axis of the completed restoration.

4 Identify the level of the CEJ or tooth emergence from the soft tissue.
Wax model of a tooth to be replaced in the surgical guide
Surgical guide template
Stent used as guide for implant placement
Holes are drilled through
the resin into the
underlying cast and are
paralleled with a milling
machine or dental
surveyor.
Implant surgery

• Surgical access

• Implant placement

• Postoperative evaluation

• Implant uncover
• Surgical access

-Flapless technique
-Flap technique
• Implant Placement

Guide drill / 2mm twist drill / Pilot drill / 3mm twist drill / Countersink
• Smoothing the bone

• Marking the implant position with

Twist drill
Drilling Tapping the thread Opening the implant pack Attach the handle to
and seating the insertion the implant driver
tool
 Sub-crestal implant position Suturing
Placing the implant
• Postoperative Evaluation

• Significant factors for success

1 Precise placement

2A traumatic surgery

3- Unloaded healing

4- Passive restoration
• Implant Uncovering
In 2-stage surgery:
Incision
-6 months in the maxilla.

-3 months in the anterior part of the mandible.

-4 months in the posterior part of the mandible.

Minimally invasive uncover

Components of implant Restoration

restoration Composite resin

Gutta percha
Screw- retained implant restorations
consists of 3 components. Retaining screw
Abutment screw
(a) Implant fixture
(b) Abutment
Abutment
(c) Restoration

-The abutment screw secures the abutment Implant fixture

to the fixture
-The prosthetic retention screw secures the
prosthesis to the abutment.
 Prosthetic Crown
Look and feel of real tooth.
Easily replaced.

Implant Abutment
Secures the crown to the Dental Implant.
Can be straight or angled depending on
implant location

Dental Implant
Should promote bone in-growth. Structure and geometry
differences are the selling point for most companies.
 Implant Restorations
• Clinical Implant Components

1. Implant Body (Implant fixture screw or cylinder)

-It is the component placed within the bone during first-stage surgery.

-All contemporary dental implants have an internally threaded portion that can accept
second-stage screw placements.

-These implants also may incorporate an antirotational feature within the design of the
fixture body (internal or external).
2. Healing Screw (Sealing screw, Cover screw, First-stage cover screw)
-Seals the occlusal surface of the implant during osseointegration, if a two-stage procedure is
used.

-At second-stage surgery, it is removed and replaced by subsequent components.

-The screw is made slightly larger than the diameter of the implant, which facilitates abutment
placement by ensuring that bone does not grow over the edge of the implant.
3. Healing abutment (Interim Abutment, Temporary gingival
cuff, Healing collar, Implant healing cap, Gingival former)
-A cover, attached to the implant, that is used to maintain the opening
through the tissue until the restoration is completed.
-Placed immediately onto the implant if a one-stage protocol is used.
-Interim abutments are dome-shaped screws placed after second-stage
surgery and before insertion of the prosthesis.
-They range in length from 2 to 10 mm and project through the soft
tissue into the oral cavity.
4. Abutments (Transmucosal abutment, Tissue extension, Permucosal
extension)
-Component of the implant system that screw directly into implant to support or retains a
prosthesis or implant superstructure.

-An intermediate component placed between the implant and metal

framework/restoration, providing support Abutmen
t screw
and retention for a fixed/removable restoration. (green)

(red)
• Abutments take many forms:
-Their walls are usually smooth, polished, and straight-sided titanium or titanium alloy.
-Their length ranges from 1 - 10 mm. In non esthetic areas, 1 - 2 mm of titanium should be
allowed to penetrate the soft tissue to maximize the patient ability to clean the prosthesis.
• In esthetic areas, an abutment can be
selected to allow the porcelain to be
carried subgingivally for optimum
esthetics.
Types of abutments:
Standard:
Length can be selected to make the margin subgingival or
supragingival.

Fixed:
This abutment is much like a conventional post and core restoration.
It is screwed into the implants, has a prepared finish line, and
receives a cemented restoration.
Angled (fixed):
This type is used when implant angles must be corrected for esthetic
or biomechanical reasons.
Tapered:

This type can be used to make the transition to restoration more gradual in
larger teethto provide more physiologic contours.

Nonsegmented, or direct:
This type is used in areas of limited interarch distance or in areas where an
esthetic outcome is important.
The restoration can be built directly on the implant, so that there is no
intervening abutment. This direct restoration technique has been called the
UCLA abutment.
• In implant systems that incorporate an antirotational feature:
the abutment must have two components that move For a single
tooth, the
independently of each other: One engages the antirotational hex must be
feature, and the other secures the abutment within the fixture. “engaged”
Classification of implant abutments
A. According to prosthesis attachment:
(The method by which the prosthesis or superstructure is retained to
the abutment)

Abutment for attachment

Abutment for screw retention Abutment for cement retention

1. Screw retained implant:
• Advantages:
-Low profile of retention.
-Less momentum of force.
-No risk of cement in the sulcus.
-Easily retrievable.

• Disadvantages:
-Loosening of the screws.
-Difficult to obtain passivity.
-Difficult to obtain esthetics.
-Greater chances of porcelain fracture.
-Access in posterior region is difficult and risk of aspiration.
2. Cement retained implant:

• Advantages:

-Better passivity.
-Easier to obtain esthetics.

-Less porcelain fractures-due to occlusal surface integrity.

-Less fatigue.

-Manipulation in posterior region is easier with cement.

-looseness is less often compared to that of screw retained.

- Occlusal surfaces remain intact as there is no screw hole → better axial loading.
• Disadvantages:

-Difficult to retrieve unless soft cements are used.

-Abutments sometimes must be prepared intraorally.

-Gingival retraction may be needed.

-When permanent cements are used, evaluation and maintenance of implants is difficult.

-Increase in the momentum of force.

B. According to method of fabrication:
1. Prefabricated abutment
• 2. UCLA (castable abutment or custom abutment)
3. CAD/CAM generated abutment
5. Impression Posts (Impression Copings):
-They facilitate transfer of the intraoral location of the implant or abutment to a
similar position on the laboratory cast.

-They may screw into the implant or onto the abutment and are customarily
subdivided into fixture types or abutment or pick-up, types.
• Types of impression posts:

1. One piece (screws onto abutment) Abutment type

Is used if the abutment does not need to be changed on the laboratory cast.

2. One-piece (transfer) Fixture type

Is attached directly to the fixture if the abutment does need to be changed on

the cast (it should have a flat side if angle correction will be necessary).

3. Two-piece (pick-up) direct impression technique

Used to orient the anti-rotational feature or to make impressions of very

divergent implants.
Verify the impression
coping is fully seated
 Impession techniques for implant

Two impression techniques

Closed tray impression Open tray impression

 Closed Tray Impression (Transfer technique)

Remove the healing abutment

Place the impression coping

Syringe around the impression
coping to capture the flat sides
-Remove the impression

-Remove the impression post from implant

-Mount impression post onto the analog (same color)

-Reposition and snap back into the impression

• The transfer technique is more convenient and sometimes mandatory
when space is limited and screwdriver access would be limited.
 Open Tray Impression
Two-piece pickup (direct) technique

Implant & impression post Intraoral situation Analog & impression post
Impression procedure

-Remove closure screw or healing abutment

-Insert impression post and hand tighten screw with the screwdriver
 -Take impression with an open tray

-Use an elastomeric impression material

-When impression material is set,

unscrew and remove the impression

 Used for:
-Single or Multiple units
-A MUST in single non-parallel implants

Advantages: 30° per

implant
More Precise

Disadvantages:
-Vertical Height (pick up coping is long)
-Tray needs a hole in it for impression screw
(customized or standard)
Two piece Impression coping

Impression coping attached to the implant analog

 Impression with laboratory analog to make the master cast.

The impression posts attached to the implants

fixtures.

The master cast is that one used to fabricate the final

prosthesis.
6. Implant Analogs:

-They are made to represent exactly the top of the implant fixture or the abutment in the
laboratory cast.

They are classified as:

Fixture analogs.

Abutment analogs.
Attach Analog
Push Analog/Impression Coping Assembly into Impression
Twist and Lock Grooves into Impression
7. The gingival tissues:
-It can be reproduced by injecting an elastomer (eg., Permadyne) to represent soft tissues
around the laboratory analog before pouring.
-This will facilitate removal of the impression post from the stone cast and the placement of
subsequent abutments without breaking the stone and loosing the reference point of the soft
tissue.

-The gingival material should not cover any retention features of the analog.

- The impression material reproduces the patient's soft tissue contours adjacent to the implant.
8. Waxing Sleeves:
-They are attached to the abutment by the relating screw on the laboratory model.

-They become part of the prosthesis. In nonsegmented implant crowns, they are attached directly
to the implant body analog in the cast.

-UCLA abutments may be plastic patterns that are burned out and cast as part of the restoration
framework, precious metal that is incorporated in the framework when it is cast to the precious
alloy cylinder, or a combination of each.

-Use of a metal waxing sleeve ensures that two machined surfaces are always in contact. The cast
surface of the plastic waxing sleeve may be retooled before it is returned to the fixture.
 After the wax-up is
complete, remove
from model and
mark the gingival
margin with a black
marker.

Place screw into waxing sleeve and engage onto

the implant analog in the working model.

When the abutment is

placed back on the model,
the black line will indicate
the margin in relation to the
soft tissue. Adjust as
required, relieve undercuts
and finalize surface
smoothness
Adjust waxing sleeve using a low-speed handpiece
9. Prosthesis-Retaining Screws:
• Abutment retaining screw
Secures abutment to the fixture.

• Prosthetic retaining screw

Secures the prosthesis to abutment.