Professional Documents
Culture Documents
Treatment Planning of Implants
Treatment Planning of Implants
- Dr .saleh said this lecture is very important and most of his Q will be on it , and we are responsible to study
from the reference .
-this script includes : the record , summary of the reference.
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Medical status
Dental status
Psychological and financial factors ; you have to prepare the patient
4psychologically for implant surgery because some patients are afraid of surgery, so dont
push them for implant. Also Implant is a very expensive procedure worldwide and the cost
may be an obstacle for many patients who are suitable for implants, for example a patient
who has three teeth missing and he is suitable for two or three implants (two implants
and three implants can do the job) , but because he has limited budget for the implants
you will go for two, always give the least number for implants that gives enough retention
and resistance for the final prosthesis.
5-
Marketing of implant from the companies, Choose the implant which has a
system documented in the literature; choose the implant with a good clinical profile and
good history, dont be tempted with any offer, sometimes the cheapest implant is the
best and sometimes it is the worst.
Planning for implant in anterior area is much more challenging, it's more critical in
esthetic.
Not every patient is appropriate for implants.
Psychological and financial factors are very important for case selection and evaluation,
implants need a patient who can afford it and understand the procedure, you have to
prepare the patient for implants from A to Z , tell him everything about the procedure
then leave him to decide .
keep in your mind that the implant is not a root or a tooth, or even tooth analogous, it's
a device for replacement of missing teeth, so the biomechanical concepts for teeth are
not applicable for implants they are completely different, teeth have PDL and move in
bone but implant is ankyolsed, it has very limited movement ( 3 to 5 microns).
Phases of treatment:
1-
Treatment planning.
History.
Examination
X-rays (CBCT with or without radiographic guide).
2- After you know the number of teeth missing, the diameter and the high of
each implant, the system ..) move to the surgical phase, there are different
surgical procedures ( flaps , computer added, different stages surgery ) .
3- The restorable phase, after the healing of implant, take impression then
abutment selection and finally the restoration.
4- Maintenance phase, the most neglected phase even it is the most important,
whatever you do the procedure will have complications over time, patients
who are on follow up protocols have lower complications (its easier to treat the
complication at the beginning).
In any case of implants you have to follow these phases in sequence, failure to
fulfill any of them will lead to fail.
Implant surgery is a straight forward procedure if you plan your case in a proper
way.
Available space
A. Mesiodistal
The mesiodistal space required essentially depends on the type of tooth being
replaced (molar or premolar), and the number of teeth being replaced.
- The size of the prosthetic tooth must be considered when placing implants; the implant
must be placed sufficiently away from the adjacent tooth to allow the restorative
dentist to develop appropriate contours. If an implant placed for a premolar restoration
is placed too close to the adjacent tooth, compromised contours and unnecessary loss
of hard and soft tissue adjacent to the implant result.
In general The implant should be 1-1.5 away from the adjacent teeth, if the
adjacent tooth has a flat surface proximally leave 1.5 mm either from the contact
point or from the root surface; it doesnt make a difference, but if the adjacent tooth
has a bulbous surface proximally its better to leave 1 mm as minimum from the
contact point(NOT root surface) or you modify the tooth by enameloplasty to
improve the contact area , because If you leave 1-1.5 mm from the root surface ,
your implant might be under the contact point and the final restoration will not fit.
-For example, Missing upper six if your implant is 5 mm in diameter and you leave
1.5 mm distally and 1.5 mm mesially then 8 mm space is needed ;
( 5mm +1.5mm+1.5mm).
- Lets take the space for two 4mm implants ; I need 14mm :
1.5+1.5=3 3+3=6 6+4+4=14mm
Mesially+
Distally
inter-implant
space
diameter of the
two implants
For anterior area ; the implant should be 1.5-2 mm from adjacent teeth to avoid
encroachment on interdental bone and to avoid its resorption which causes loss of
the papilla and poor esthetic.
ended up with 1.5 mm resorption of bone that will cause loss of the inter
implant bone flat bone + papilla will fall down to the bone level black
triangle will be formed poor esthetic especially in the anterior area.
2- To maintain good oral hygiene .
A wider diameter implant should be selected for molar teeth ; we use regular
implants for the upper central incisors + premolars , narrower implants for the
upper laterals + lower anterior teeth + some cases in premolars (when it is small)
, wider implants in molars .
So the guidelines that should be used when selecting implant size and
evaluating mesiodistal space for implant placement:
o The implant should be at least 1.5 mm away from the adjacent teeth
o The implant should be at least 3 mm away from an adjacent implant
o A wider diameter implant should be selected for molar teeth.
D. Buccolingual
At least 6 mm of bone (not with soft tissue)
buccolingually is required for placement of a 4mm
diameter implant and at least 7 mm for a wider
diameter 5 mm implant. So the space is minimum 2
mm wider than the implant buccolingually .
- Implants in the picture illustrating inadequate buccolingual positioning. This can be avoided by use of an
appropriately fabricated surgical guide
- Correct angulation is always achieved if the surgeon is diligent and makes use of a surgical
guide to place implants in the correct position. Placing implants in off angle positions (like
the pictures below )always complicates the process for the restorative dentist who now has
to use a host of restorative components to achieve an acceptable end result .
C. Occlusogingival
- This parameter needs to be considered in two
dimensions:
1. Adequate space for restoration ; Sufficient space must
exist to allow the restorative dentist to fabricate
restorations which are harmonious aesthetically with the
adjacent teeth. On examination the space between the
residual ridge and the opposing occlusal plane should be
evaluated . Often, when teeth are missing for prolonged
periods of time, opposing teeth overerupt and
compromise the restorative space ,But If this is minimal
then enameloplasty or minimal restorative therapy may
be required to create space.
Ideally 7-10 mm of space is
required from the head ofthe
fixture to the opposing occlusion
- Multiple missing teeth it is not necessary to make an implant for each missing
tooth ; you can do 2 implants for 3 missing teeth , but in general the number of
implants almost is equal or less than the number of missing teeth .
The number of implants is dependent on :
1- bone quantity and quality. Often(not always) in the maxilla where less
dense bone is found, surgeons favor placing three implants one for
each tooth and 2 implants in the mandible for 3 missing teeth. (but as we
- If anterior or posterior implants were to fail the prosthesis design they would
include an anterior or posterior cantilever. Cantilever type prostheses have been
associated with higher rates of failure in traditional prosthodontics. These types
of prosthesis failed due to mechanical complications of the abutment teeth. Also
Distal cantilevers have been reported to be unfavourable from a biomechanical point
of view and have increased the number of complications for implant supported
prostheses.
Occlusal considerations :
-Masticatory forces developed by a patient restored with implant supported
Type of prosthesis :
A- Splinted or non-splinted :
-when multiple implants are placed in posterior quadrants they may be splinted.
- Stress distribution can be manipulated by splinting. The retention of the prosthesis
is also improved with a greater number of splinted abutments. Splinting also has
biomechanical advantages in that it will also reduce the incidence of screw loosening
and unretained restorations.
B - Screw retained or cemented
- Many advantages of prosthesis retrievability can be afforded by screw retention.
Retrievability facilitates individual implant evaluation, soft tissue inspection and any
necessary prosthesis modifications. Additionally, future treatment considerations can be
made more easily and less expensively. But Many practitioners favor cemented type
restorations because this provides a more aesthetic result, as screw access holes can be
avoided.
When implants are aligned to allow screw retention, unless the soft tissue
depth is more than 3mm, the final restorations are almost always restored
directly to the implant.
Screw retained abutments are only used when the implants are placed
deeply or soft tissue depth is excessive( in deep implants its better to make the
final restoration at abutment level).Disadvantages of this that there will be a
display of metal on the restoration and there will be less room for transitional
contours.
For screw retained pre angled abutments the implant must be planned to be
placed deeper to accommodate the thickness of the abutment , However
loading implants at an angle can be problematic to the screw joint between the
restoration and the abutment.
The cement margin should not be placed more than 1 mm sub mucosal to
facilitate cement removal. When cement retention is desired there must be
sufficient inter occlusal space.
Summary:
Finally done :D
To live a creative life we must lose our fear of being wrong
Done by :
Rasha Al-Shboul & Rawan Shatnawi