templates and loading of implants/ orthodontics courses

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IMPLANT DENTISTRYIMPLANT DENTISTRY

PRE-SURGICAL PROSTHESES

TEMPLATES

PRE-MAXILLA IMPLANT CONSIDERATIONS

LOADING OF IMPLANTS

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.comwww.indiandentalacademy.com

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These are provisional restorations that are made These are provisional restorations that are made and inserted prior to first surgical procedure. and inserted prior to first surgical procedure. These are also called as treatment prostheses.These are also called as treatment prostheses.

These may be used to improve the soft tissue These may be used to improve the soft tissue used for support and stability before restorative used for support and stability before restorative procedures. A tissue conditioning treatment is procedures. A tissue conditioning treatment is often indicated. often indicated.

The existing denture can also be used as a The existing denture can also be used as a treatment prostheses.treatment prostheses.

Pre-Surgical Prostheses:Pre-Surgical Prostheses:


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The treatment denture satisfyies the esthetic The treatment denture satisfyies the esthetic considerations that may be indicated before considerations that may be indicated before surgery, tooth shape, size, position, color, surgery, tooth shape, size, position, color, gingival color and contour.gingival color and contour.

A fixed restoration design must allow access A fixed restoration design must allow access for proper hygiene procedures around the for proper hygiene procedures around the teeth and implants. a high or low lip line teeth and implants. a high or low lip line position may influence the gingival contour of position may influence the gingival contour of the restoration. A treatment prosthesis may the restoration. A treatment prosthesis may determine if an implant-supported removable determine if an implant-supported removable prosthesis rather than a fixed restoration is prosthesis rather than a fixed restoration is required to satisfy patient's goals and desires.required to satisfy patient's goals and desires.www.indiandentalacademy.comwww.indiandentalacademy.com

www.indiandentalacademy.comwww.indiandentalacademy.com 44

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The maxillary vermillion border is usually altered by the

loss of the maxillary anterior teeth. Once bone is also lost

the natural support of the entire lip is often deficient and

depends on the labial flange of the prosthesis. A fixed partial denture may require an anterior cantilever away from the soft tissue in a horizontal and vertical dimension to provide this support. A treatment prosthesis can provide the information required to determine if a fixed prosthesis will compromise esthetics, support, or hygiene in this region.


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Long-term edentulous- patients who have worn the same denture may require a treatment denture to restore vertical dimension and ridge relationship before implant surgery. The OVD may gradually collapse, especially in the completely edentulous patient, as a result of continued bone loss and prosthesis occlusal wear. Temporomandibular joint and myofacial dysfunction may be the further sequence of this condition. A treatment prosthesis to reestablish proper OVD and/or an asymptomatic joint helps determine the patient's specific needs regarding the dysfunction.


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As the OVD decreases, the jaw rotates As the OVD decreases, the jaw rotates forward and closes in a more prognathic forward and closes in a more prognathic pseudo-Class III relationship. Subperiosteal pseudo-Class III relationship. Subperiosteal implants, require the design of the prosthetic implants, require the design of the prosthetic superstructure concomitant with the implant superstructure concomitant with the implant substructure. Hence a treatment prosthesis is substructure. Hence a treatment prosthesis is indicated to establish the proper OVD and indicated to establish the proper OVD and tooth position before the fabrication and tooth position before the fabrication and placement of the implant and attached placement of the implant and attached superstructure bar.superstructure bar.


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The greater the OVD, the more Class II the The greater the OVD, the more Class II the mandible becomes in relationship to the mandible becomes in relationship to the maxilla. This influences the position or maxilla. This influences the position or angulations of the implant. In addition, the angulations of the implant. In addition, the location of an over denture bar may be equally location of an over denture bar may be equally influenced by variations of the vertical influenced by variations of the vertical dimension of occlusion. the treatment dimension of occlusion. the treatment prosthesis may be used to establish prosthetic prosthesis may be used to establish prosthetic position of teeth.position of teeth.

A treatment prostheses for a completely A treatment prostheses for a completely edentulous patient before a fixed or a edentulous patient before a fixed or a removable implant prosthesis is most often a removable implant prosthesis is most often a complete denturecomplete denture


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. This denture is fabricated with acrylic teeth so . This denture is fabricated with acrylic teeth so the teeth may be reshaped easily, or acrylic is the teeth may be reshaped easily, or acrylic is added to change the OVD or lip support. A added to change the OVD or lip support. A partially edentulous patient most often has a partially edentulous patient most often has a fixed treatment prosthesis. an additional benefit fixed treatment prosthesis. an additional benefit i of treatment prostheses is that patient i of treatment prostheses is that patient management may be established, including management may be established, including financial and compliance considerations. financial and compliance considerations.

A treatment prosthesis most always is used on A treatment prosthesis most always is used on the implants before the fabrication of the final the implants before the fabrication of the final restoration. Acrylic restorations that gradually restoration. Acrylic restorations that gradually load bone for progressive loading may be load bone for progressive loading may be considered treatment prostheses.considered treatment prostheses.


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Improve hard and soft tissues Improve hard and soft tissues Evaluate the bone volume necessary for grafting Evaluate the bone volume necessary for grafting

procedures procedures Evaluate esthetics and hygiene considerations Evaluate esthetics and hygiene considerations Reestablish proper OVD Reestablish proper OVD Establishment of Co at the CR positionEstablishment of Co at the CR position Determine placement of the superstructure bar Determine placement of the superstructure bar Evaluate the patient's psychological health and Evaluate the patient's psychological health and

attitude attitude Determine conditions for patient managementDetermine conditions for patient management

Treatment prosthesis and its Goals:Treatment prosthesis and its Goals:


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Implant dentistry is a complex treatment modality and Implant dentistry is a complex treatment modality and involves many specialists. And careful treatment planning. involves many specialists. And careful treatment planning. The use of templates outlines the planned restoration in The use of templates outlines the planned restoration in relation to the anatomic situation enables the clinician to relation to the anatomic situation enables the clinician to plan and communicate the patient's treatment needs to plan and communicate the patient's treatment needs to everyone involved in the process. Using the same everyone involved in the process. Using the same template, which is a duplicate of the provisional template, which is a duplicate of the provisional restoration, throughout the whole process of the diagnosis restoration, throughout the whole process of the diagnosis reduces transfer errors during the augmentation and reduces transfer errors during the augmentation and implant placement procedures to a minimum and allows a implant placement procedures to a minimum and allows a predictable step-by-step approach to implant dentistry.predictable step-by-step approach to implant dentistry.

Templates:Templates:


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1.1. Diagnostic/Radiographic templateDiagnostic/Radiographic template

2.2. Surgical template.Surgical template.

3.3. CombinationCombination

4.4. CADCAM Stereotactic surgical templateCADCAM Stereotactic surgical template

Types:Types:


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The purpose of diagnostic radiographic templates is to The purpose of diagnostic radiographic templates is to incorporate the patient's proposed treatment plan into the incorporate the patient's proposed treatment plan into the radiographic examination. This requires a treatment plan radiographic examination. This requires a treatment plan developed prior to the imaging procedure. ideally, developed prior to the imaging procedure. ideally, mounted diagnostic casts, a diagnostic wax-up, mounted diagnostic casts, a diagnostic wax-up, agreement between the clinicians on the number and agreement between the clinicians on the number and location of proposed dental implants, and prior location of proposed dental implants, and prior authorization of the proposed treatment by the patient authorization of the proposed treatment by the patient makes the diagnostic template a very useful tool and makes the diagnostic template a very useful tool and many times the determining factor in the final treatment many times the determining factor in the final treatment plan of the patient. plan of the patient.

Diagnostic Templates:Diagnostic Templates:


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The pre-prosthetic imaging procedure enables evaluation of the proposed implant site at the ideal position and orientation identified by radiographic markers incorporated into the template.

An accurate preview of the supporting bone related to the proposed implant sites avoids complications that occurs due to the lack of available bone leading to errors in positioning as minimal as 2mm or in angulations of merely 10` degrees can render implant fixture unusable.


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The radiographic template is fabricated acrylic resin The radiographic template is fabricated acrylic resin which normally is radiolucent, therefore this which normally is radiolucent, therefore this template requires a radio-opaque marker on them, template requires a radio-opaque marker on them, making the template or a part of the template visible making the template or a part of the template visible during radiographic imaging.during radiographic imaging.

These radio-opaque markers are:These radio-opaque markers are:1.1. Gutta-perchaGutta-percha2.2. Metal spheresMetal spheres3.3. Barium sulphateBarium sulphate4.4. Stainless steel tubesStainless steel tubes5.5. Color chalk powderColor chalk powder6.6. Lead foilLead foil7.7. Composite materialComposite material8.8. Radio opaque teethRadio opaque teeth


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To evaluate the relationship between anatomic structures To evaluate the relationship between anatomic structures and the stent, investigators have reported radiographic and the stent, investigators have reported radiographic pre-surgical evaluations with gutta-percha, metal pre-surgical evaluations with gutta-percha, metal spheres, the baseline with color chalk powder, and spheres, the baseline with color chalk powder, and barium sulfate as radiopaque materials. Gutta-percha has barium sulfate as radiopaque materials. Gutta-percha has an advantage because of its thermoplasticity. The an advantage because of its thermoplasticity. The advantages of metal spheres are its round shape, easy advantages of metal spheres are its round shape, easy fabrication procedure, and ease of measurement of image fabrication procedure, and ease of measurement of image magnification. Color chalk powder and barium sulfate magnification. Color chalk powder and barium sulfate materials are useful for observing the outline of the pre-materials are useful for observing the outline of the pre-designed superstructure because of their radiopacity. designed superstructure because of their radiopacity. Three-dimensional imaging with computed tomography Three-dimensional imaging with computed tomography (CT) or tomography is extremely helpful to evaluate the (CT) or tomography is extremely helpful to evaluate the pre-designed surgical plan. Several types of radiopaque pre-designed surgical plan. Several types of radiopaque materials have been used to examine their difference in materials have been used to examine their difference in appearance on radiographic images.appearance on radiographic images.


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Requirements Requirements

1.1. StableStable2.2. RigidRigid3.3. Radio-opaque markersRadio-opaque markers4.4. Enable optimum visualizationEnable optimum visualization5.5. Ease of fabricationEase of fabrication6.6. Should allow conversion to a surgical Should allow conversion to a surgical

templatetemplate7.7. Transparent.Transparent.


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Use of Barium SulphateUse of Barium Sulphate

Christoph R J. Baden, John C. Kois, described Christoph R J. Baden, John C. Kois, described A controlled step-by-step approach for the use A controlled step-by-step approach for the use of templates for placement of dental implants. of templates for placement of dental implants. The provisional restoration, the blueprint for The provisional restoration, the blueprint for the final restoration, is duplicated, and a the final restoration, is duplicated, and a radiographic template is fabricated. This radiographic template is fabricated. This illustrates the outline of the planned restoration illustrates the outline of the planned restoration in relation to the hard tissues (J Prosthet Dent in relation to the hard tissues (J Prosthet Dent 1996;76-451-4.).1996;76-451-4.).


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Plan and adjust the outline of the prostheses as Plan and adjust the outline of the prostheses as needed.needed.

When both patient and dentist are satisfied, When both patient and dentist are satisfied, make the impressions and casts both without make the impressions and casts both without and with the provisional restoration in place.and with the provisional restoration in place.

Make an Omnivac shell over the cast with the Make an Omnivac shell over the cast with the provisional restoration (made in step 2) in provisional restoration (made in step 2) in place.place.


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Paint a suitable tinfoil substitute on the Paint a suitable tinfoil substitute on the pretreatment cast, seal onto the pretreatment cast pretreatment cast, seal onto the pretreatment cast made in step 2 and use sticky wax to seal the made in step 2 and use sticky wax to seal the Omnivac shell onto the pretreatment cast.Omnivac shell onto the pretreatment cast.

Make a mix of radiopaque resin by mixing one Make a mix of radiopaque resin by mixing one part barium sulfite with two parts acrylic resin part barium sulfite with two parts acrylic resin powder . Mix the powder thoroughly then add powder . Mix the powder thoroughly then add the acrylic resin monomer to make the mixture the acrylic resin monomer to make the mixture fluid (Barium sulfate is a nontoxic, white, fluid (Barium sulfate is a nontoxic, white, tasteless, odorless powder used in intestinal tasteless, odorless powder used in intestinal radiography.)radiography.)


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Make a small opening in the shell and fill the Make a small opening in the shell and fill the shell with the mix of fluid radiopaque resin. shell with the mix of fluid radiopaque resin. Inject the resin with a 12 cc Monoject disposable Inject the resin with a 12 cc Monoject disposable syringe. (When the resin polymerizes, it provides syringe. (When the resin polymerizes, it provides a radiopaque duplicate of the provisional a radiopaque duplicate of the provisional restoration.)restoration.)

Separate the radiopaque provisional restoration Separate the radiopaque provisional restoration from the shell and the cast.from the shell and the cast.

Cut and trim the opaqued provisional restoration Cut and trim the opaqued provisional restoration to preserve only the block of teeth.to preserve only the block of teeth.

Separate the resin teeth, trim them to open the Separate the resin teeth, trim them to open the gingival embrasures, and do contouring necessary gingival embrasures, and do contouring necessary to make them look like individual teethto make them look like individual teeth


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Position the tooth on the pretreatment cast (made in step Position the tooth on the pretreatment cast (made in step 2), and use a small amount of sticky wax to hold them in 2), and use a small amount of sticky wax to hold them in place. (Because the ridge laps of the opaqued resin tooth place. (Because the ridge laps of the opaqued resin tooth were made in direct contact with the cast, except for a thin were made in direct contact with the cast, except for a thin coating of separation medium, it is easy to replace them coating of separation medium, it is easy to replace them accurately on the cast. accurately on the cast.

Box the opaqued resin teeth positioned on the cast with Box the opaqued resin teeth positioned on the cast with beading wax and include several of the stone teeth both beading wax and include several of the stone teeth both anterior and posterior to the edentulous portion of the anterior and posterior to the edentulous portion of the ridge. ridge.

Paint tinfoil substitute separating medium on the adjacent Paint tinfoil substitute separating medium on the adjacent stone teeth and the cast that will be contacted with the stone teeth and the cast that will be contacted with the Orthodontic resin which will be applied next.Orthodontic resin which will be applied next.

Apply Orthodontic resin by the salt and pepper method to Apply Orthodontic resin by the salt and pepper method to create an acrylic resin overlay over the adjacent teeth and create an acrylic resin overlay over the adjacent teeth and to hold the opaqued resin teeth in position.to hold the opaqued resin teeth in position.


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After the resin polymerizes, remove the After the resin polymerizes, remove the assembly from the cast, then finish and polish it.assembly from the cast, then finish and polish it.

Fit the restoration to the patients mouth and Fit the restoration to the patients mouth and have a CT scan to show the relationship of the have a CT scan to show the relationship of the anatomic topography to the planned restoration. anatomic topography to the planned restoration.

Using the same template, which is a duplicate of Using the same template, which is a duplicate of the provisional restoration, thought the whole the provisional restoration, thought the whole process of the diagnosis reduces transfer errors process of the diagnosis reduces transfer errors during the augmentation and implant placement during the augmentation and implant placement procedures to a minimum and allows a procedures to a minimum and allows a predictable step-by-step approach to implant predictable step-by-step approach to implant dentistry.dentistry.


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Template with Barium Sulfate & Template with Barium Sulfate & Stainless TubesStainless Tubes

Fumitaka Takeshita; Tsutomu Tokoshima; Tsuneo Suetsugu, Fumitaka Takeshita; Tsutomu Tokoshima; Tsuneo Suetsugu, described a stent for pre-surgical evaluation of implant described a stent for pre-surgical evaluation of implant placement using with barium sulfate and stainless steel placement using with barium sulfate and stainless steel tubes for the accurate radiographic evaluation of the tubes for the accurate radiographic evaluation of the relationships of the pre-designed superstructure, the relationships of the pre-designed superstructure, the scheduled implant placement, and the anatomic structure. scheduled implant placement, and the anatomic structure. The barium sulfate in the stent depicts the outline of the The barium sulfate in the stent depicts the outline of the pre-designed superstructure, and the stainless steel tubes pre-designed superstructure, and the stainless steel tubes indicate the intended location and inclination of the indicate the intended location and inclination of the implants on the computed tomographic scans. In addition, implants on the computed tomographic scans. In addition, this stent can be used as a surgical stent to guide the pilot this stent can be used as a surgical stent to guide the pilot drill to the desired site. (J Prosthet Dent 1997;77:36–8.)drill to the desired site. (J Prosthet Dent 1997;77:36–8.)www.indiandentalacademy.comwww.indiandentalacademy.com

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Procedure:Procedure: Form wax sprues at the Form wax sprues at the

distal most teeth bilaterally distal most teeth bilaterally of the approved trial wax of the approved trial wax denture and make a silicone denture and make a silicone impression. The stent is impression. The stent is made of clear made of clear autopolymerized methyl autopolymerized methyl methacrylate resin pour methacrylate resin pour material.material.

After the clear stent is After the clear stent is recovered from the recovered from the impression, remove all the impression, remove all the teeth. Reposition the clear teeth. Reposition the clear stent base in the impression. stent base in the impression.


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Mix powder that consists of a 4:1 ratio of resin polymer Mix powder that consists of a 4:1 ratio of resin polymer and barium sulfate with monomer. Pour the mixture into and barium sulfate with monomer. Pour the mixture into the tooth forms of the impression. (The degree of the tooth forms of the impression. (The degree of radiopacity of various mixture ratios.radiopacity of various mixture ratios.


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Cure the finished stent at Cure the finished stent at 40° C for 20 minutes in 40° C for 20 minutes in the processor, then the processor, then recover and polish. recover and polish.

Make the access holes to Make the access holes to guide the first surgical guide the first surgical drill according to drill according to information obtained information obtained from the final cast and the from the final cast and the provisional restoration. provisional restoration.

stainless steel tube sprues stainless steel tube sprues to a uniform height, place to a uniform height, place into the access hole, and into the access hole, and retain with wax retain with wax


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Obtain a panoramic tomograph and a CT scan with the Obtain a panoramic tomograph and a CT scan with the stent in place.stent in place.

After the radiographs are obtained, remove the tube After the radiographs are obtained, remove the tube sprues.sprues.

Sterilize the stent so it (the access holes) can be used to Sterilize the stent so it (the access holes) can be used to guide the surgical drill to the desired site for implant guide the surgical drill to the desired site for implant placement.placement.


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The barium sulfate in the stent depicts the outline of the predesigned The barium sulfate in the stent depicts the outline of the predesigned superstructures, and the stainless tubes represent the location and superstructures, and the stainless tubes represent the location and inclination of the intended implant placement. The powder barium inclination of the intended implant placement. The powder barium sulfate and resin polymer mixture exhibit good radiopacity without sulfate and resin polymer mixture exhibit good radiopacity without radiologic artifact and the panoramic radiographs revealed the radiologic artifact and the panoramic radiographs revealed the markers and the inclination.markers and the inclination.

The most important advantage is found in its use with a CT scan. The The most important advantage is found in its use with a CT scan. The radiopaque markers located on the reconstructed image of the CT scan radiopaque markers located on the reconstructed image of the CT scan can be clearly observed. The clear image of the stainless steel tube can be clearly observed. The clear image of the stainless steel tube demonstrates the predesigned inclination of implant placement, demonstrates the predesigned inclination of implant placement, whereas the image of the barium sulfate shows the position of the whereas the image of the barium sulfate shows the position of the anterior teeth on CT scans. The location and inclination of anterior teeth on CT scans. The location and inclination of predesigned implant placement in the stent can then be corrected as predesigned implant placement in the stent can then be corrected as necessary before surgery according to the radiographic information. necessary before surgery according to the radiographic information. Other advantages of using this procedure with barium sulfate and Other advantages of using this procedure with barium sulfate and stainless steel tubes are its ease of use, economy (inexpensive), and stainless steel tubes are its ease of use, economy (inexpensive), and simple design of the materials. simple design of the materials.


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Template with Lead FoilTemplate with Lead Foil

Javier Urquiola; R. W. Toothaker, described the Javier Urquiola; R. W. Toothaker, described the fabrication of a radiographic template using fabrication of a radiographic template using lead foils.lead foils.

There are several advantages to using lead foil; There are several advantages to using lead foil; the material is readily available, inexpensive, the material is readily available, inexpensive, and easy to manipulate. Because the lead foil and easy to manipulate. Because the lead foil is found in standard periapical radiograph film is found in standard periapical radiograph film packets, the cost is less than other packets, the cost is less than other commercially available materials.commercially available materials.


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PROCEDUREPROCEDURE 11 Fabricate a template.Fabricate a template. 22 Select prosthetically favorable implant sites.Select prosthetically favorable implant sites. 33 Cut the lead foil into strips.Cut the lead foil into strips. 44 Adhere the foil to the template with cyanoacrylate.Adhere the foil to the template with cyanoacrylate. 55 Cover the lead strips with a thin layer of clear, Cover the lead strips with a thin layer of clear,

autopolymerizing acrylic resin autopolymerizing acrylic resin www.indiandentalacademy.comwww.indiandentalacademy.com

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The major disadvantage of using Lead foil as a The major disadvantage of using Lead foil as a marker because its density produces beam marker because its density produces beam hardening artifact and distorts the diagnostic hardening artifact and distorts the diagnostic value of the CT films. The authors found that if value of the CT films. The authors found that if lead foil strips are placed on the buccal aspect of lead foil strips are placed on the buccal aspect of the template and at a significant distance from the the template and at a significant distance from the area being analyzed, the center of the ridge, the area being analyzed, the center of the ridge, the beam hardening artifact produced by the lead foil beam hardening artifact produced by the lead foil at the buccal periphery of the template fails to at the buccal periphery of the template fails to reach the ridge and cause distortion in this area reach the ridge and cause distortion in this area


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Surgical template.Surgical template.

The surgical template dictates to the surgeon the The surgical template dictates to the surgeon the implant body placement that offers the best implant body placement that offers the best combination ofcombination of

(1) support for the repetitive forces of Occlusion, (1) support for the repetitive forces of Occlusion, (2) Esthetics, and (2) Esthetics, and (3) Hygiene requirements.(3) Hygiene requirements.


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The purpose of the surgical template is to The purpose of the surgical template is to provide information regarding implant fixture provide information regarding implant fixture sites and desired angulations. The surgeon can sites and desired angulations. The surgeon can assess the information in relation to anatomic assess the information in relation to anatomic limitations, along with the radiological data limitations, along with the radiological data especially that of the reformatted multiplaner CT especially that of the reformatted multiplaner CT scans. This provides optimal implant placement. scans. This provides optimal implant placement. The surgeon and the prosthodontist must plan The surgeon and the prosthodontist must plan the type of surgical template that will be used to the type of surgical template that will be used to aid in placement of the fixture. aid in placement of the fixture.


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Ideally, fixtures are placed parallel to each Ideally, fixtures are placed parallel to each other, parallel to the labial face of the anterior other, parallel to the labial face of the anterior teeth, and in an area slightly lingual to the teeth, and in an area slightly lingual to the cingulum of the anterior teeth in the cingulum of the anterior teeth in the parasymphyaseal region. They are placed parasymphyaseal region. They are placed parallel to the long axis of the posterior teeth parallel to the long axis of the posterior teeth and in the central fossae region of the and in the central fossae region of the mandibular posterior teeth and the palatal cusp mandibular posterior teeth and the palatal cusp region of the maxillary posterior teeth. The region of the maxillary posterior teeth. The maxillary anterior fixtures are placed parallel to maxillary anterior fixtures are placed parallel to each other as much as possible, in the cingulum each other as much as possible, in the cingulum area of the artificial teeth and should not area of the artificial teeth and should not interfere with the occlusion.interfere with the occlusion.www.indiandentalacademy.comwww.indiandentalacademy.com

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'With the completely edentulous jaw, after the 'With the completely edentulous jaw, after the transitional complete denture has been transitional complete denture has been constructed, whether maxillary or mandibular, it constructed, whether maxillary or mandibular, it is beneficial to duplicate this denture for use as a is beneficial to duplicate this denture for use as a surgical template so the surgeon can observe surgical template so the surgeon can observe where the anticipated tooth placement and where the anticipated tooth placement and angulation would be during placement of the angulation would be during placement of the fixtures during first-stage surgery. The template. fixtures during first-stage surgery. The template. as well as the mounted set of diagnostic casts, are as well as the mounted set of diagnostic casts, are then sent to the surgeon prior to implant fixture then sent to the surgeon prior to implant fixture placement so the topography of the mouth can be placement so the topography of the mouth can be envisioned.envisioned.


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Mandibular surgical templates, or guides, are valuable aids in the optimal placement of endosseal fixtures. They aid the surgeon to avoid restorative complications, such as lingual tipping of posterior fixtures, that will interfere with tongue movement after the prosthesis is inserted, avoid labial angulation of anterior fixtures that will compromise esthetics, and limit severely lingually inclined anterior fixtures that will interfere with tongue movements.


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Requirements:Requirements:Several methods of fabrication for the surgical template are Several methods of fabrication for the surgical template are

available. The requirements are more relevant than the available. The requirements are more relevant than the options of fabrication.options of fabrication.

The template should be stable and rigid when in correct The template should be stable and rigid when in correct position. If the arch treated has remaining teeth, the position. If the arch treated has remaining teeth, the template should fit over and/or around enough teeth to template should fit over and/or around enough teeth to stabilize it in position.stabilize it in position.

When no remaining teeth are present, the template should When no remaining teeth are present, the template should extend onto unreflected soft tissue regions (i.e., the palate extend onto unreflected soft tissue regions (i.e., the palate and tuberosities in the maxilla or the retromolar pads in the and tuberosities in the maxilla or the retromolar pads in the mandible). In this way, the template may be used after the mandible). In this way, the template may be used after the soft tissues have been reflected from the implant site.soft tissues have been reflected from the implant site.www.indiandentalacademy.comwww.indiandentalacademy.com

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The ideal angulation for implant insertion should be The ideal angulation for implant insertion should be determined on the diagnostic wax-up, and the template determined on the diagnostic wax-up, and the template should relate this position during surgery. This requires should relate this position during surgery. This requires at least two reference points for each implant. For that at least two reference points for each implant. For that purpose, the surgical guide must be elevated above the purpose, the surgical guide must be elevated above the edentulous bone. The distance between two points edentulous bone. The distance between two points located respectively on the occlusal surface (central fossa located respectively on the occlusal surface (central fossa or incisal edge) of the planned abutment crown and the or incisal edge) of the planned abutment crown and the crest of the ridge represents about 8 mm. As a result, crest of the ridge represents about 8 mm. As a result, these two points of reference can be joined by a line that these two points of reference can be joined by a line that represents the path of ideal implant insertion. The ideal represents the path of ideal implant insertion. The ideal angulation is perpendicular to the occlusal plane and angulation is perpendicular to the occlusal plane and parallel to the most anterior abutment (natural or parallel to the most anterior abutment (natural or implant) joined to the implant.implant) joined to the implant.


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Other ideal requirements of the surgical template include Other ideal requirements of the surgical template include size, surgical asepsis, transparency, and the ability to size, surgical asepsis, transparency, and the ability to revise the template as indicated, The template should not revise the template as indicated, The template should not be bulky and difficult to insert or obscure surrounding be bulky and difficult to insert or obscure surrounding surgical landmarks. The surgical template must not surgical landmarks. The surgical template must not contaminate a surgical field during bone grafts or contaminate a surgical field during bone grafts or implant placement. It should be transparent. In this way, implant placement. It should be transparent. In this way, the bony ridge and drills can be observed more easily the bony ridge and drills can be observed more easily when the template is in place. The surgical template when the template is in place. The surgical template should relate the ideal facial contour. should relate the ideal facial contour.

Many edentulous ridges have lost facial bone, and the Many edentulous ridges have lost facial bone, and the template can determine the amount of augmentation template can determine the amount of augmentation required for implant placement or support of the lips and required for implant placement or support of the lips and face. The surgical template may be used in conjunction face. The surgical template may be used in conjunction with a bone graft, and later the same template may be with a bone graft, and later the same template may be used for insertion of implants and again for implant used for insertion of implants and again for implant uncovery. A sturdy template permits resterilization. and uncovery. A sturdy template permits resterilization. and use for several procedures.use for several procedures.www.indiandentalacademy.comwww.indiandentalacademy.com

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Mandibular Completely Edentulous Mandibular Completely Edentulous TemplatesTemplates

1.1. A complete mandibular surgical template A complete mandibular surgical template that has a cutout in the parasymphyaseal that has a cutout in the parasymphyaseal region corresponding to the cingulum areas region corresponding to the cingulum areas

2.2. A complete mandibular surgical template in A complete mandibular surgical template in which the facial aspects have been removed which the facial aspects have been removed in the parasymphyaseal region. This template in the parasymphyaseal region. This template provides improved visibility.provides improved visibility.


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Mandibular Partially Edentulous Mandibular Partially Edentulous TemplatesTemplates

1.1. A surgical template with a groove cutout in the A surgical template with a groove cutout in the region of the central fossae of the posterior teeth.region of the central fossae of the posterior teeth.

2.2. A surgical template with a buccal or facial cut-out A surgical template with a buccal or facial cut-out with maintenance of the lingual aspect of the with maintenance of the lingual aspect of the posterior or anterior teeth to prevent lingual posterior or anterior teeth to prevent lingual inclination of the fixtures. This type of template is inclination of the fixtures. This type of template is preferred since it provides better access for the preferred since it provides better access for the surgeon and better visibility during surgery.surgeon and better visibility during surgery.


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Maxillary Completely Edentulous Maxillary Completely Edentulous TemplateTemplate

A maxillary surgical stent A maxillary surgical stent should have sufficient should have sufficient tuberosity extension to avoid tuberosity extension to avoid anterior displacement during anterior displacement during surgery.surgery.

The maxillary surgical The maxillary surgical template is prepared with a template is prepared with a large palatal vent to large palatal vent to accommodate the palataly accommodate the palataly raised flap.raised flap.

It possesses sufficient It possesses sufficient tuberosity extension for tuberosity extension for stability and prevent stability and prevent displacement.displacement.


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Dual purpose TemplatesDual purpose Templates

The use guides for radiographic evaluation and The use guides for radiographic evaluation and surgical placement of dental implants can surgical placement of dental implants can improve the final outcome of treatment for improve the final outcome of treatment for patients receiving implants. if a template is patients receiving implants. if a template is fabricated for radiographic evaluation of fabricated for radiographic evaluation of implant placement and also serves as a implant placement and also serves as a surgical guide for placement of the implant surgical guide for placement of the implant they are known as dual purpose template.they are known as dual purpose template.


4545

Michael Gardner & Igor J Pesun’s Michael Gardner & Igor J Pesun’s Dual Template Dual Template

They described the fabrication of a template for They described the fabrication of a template for radiographic evaluation and surgical placement of radiographic evaluation and surgical placement of implants, to aid in the determination of the ideal implants, to aid in the determination of the ideal site for the implant, guides with markers were used. site for the implant, guides with markers were used. they used a template during a CT scan, that they used a template during a CT scan, that contains no metal therefore useful to eliminate the contains no metal therefore useful to eliminate the possibility of scatter. Gutta-percha was the malarial possibility of scatter. Gutta-percha was the malarial of choice, because it is radiopaque and can be of choice, because it is radiopaque and can be formed to a desired shape. the goal of any implant formed to a desired shape. the goal of any implant location and trajectory template is to guide the location and trajectory template is to guide the surgeon in the ideal placement of the implantssurgeon in the ideal placement of the implantswww.indiandentalacademy.comwww.indiandentalacademy.com

4646

Technique:Technique:

Make duplicate casts of the arch to be evaluated for Make duplicate casts of the arch to be evaluated for implant restoration and mount one set of casts on an implant restoration and mount one set of casts on an articulator in the centric relation position.articulator in the centric relation position.


4747

If any alteration of the vertical dimension of occlusion is If any alteration of the vertical dimension of occlusion is planned, determine the altered vertical dimension of planned, determine the altered vertical dimension of occlusion and set the articulator, Complete a diagnostic occlusion and set the articulator, Complete a diagnostic wax-up of the final restoration.wax-up of the final restoration.


4848

Duplicate the diagnostic Duplicate the diagnostic wax-up in dental stone.wax-up in dental stone.

Block out undercuts on Block out undercuts on the unaltered diagnostic the unaltered diagnostic and with a material dud and with a material dud is not heat-sensitiveis not heat-sensitive


4949

Make vacuformed templates over the blocked out Make vacuformed templates over the blocked out diagnostic cast and the duplicate cast of the diagnostic diagnostic cast and the duplicate cast of the diagnostic wax-up with a clear plastic sheet.wax-up with a clear plastic sheet.


5050

Trim the templates to 5 mm below the gingival margin Trim the templates to 5 mm below the gingival margin of the teeth or to the height of contour of the soft tissue, of the teeth or to the height of contour of the soft tissue, whichever is less.whichever is less.

Return the template to the unaltered diagnostic Cast and Return the template to the unaltered diagnostic Cast and place the template of the diagnostic wax-up over the place the template of the diagnostic wax-up over the cast. Trim the edges of the two templates to make them cast. Trim the edges of the two templates to make them coincident. coincident. www.indiandentalacademy.comwww.indiandentalacademy.com

5151

Remove the diagnostic wax template and fill it Remove the diagnostic wax template and fill it with clear orthodontic resin, Place the filled with clear orthodontic resin, Place the filled template over the template of the unaltered template over the template of the unaltered diagnostic cast and hold in place with finger diagnostic cast and hold in place with finger pressure until the initial set of the resinpressure until the initial set of the resin

Trim off excess material that may have flowed Trim off excess material that may have flowed between the templates.between the templates.

Place an elastic band around the cast and Place an elastic band around the cast and templates to aid in holding the templates in templates to aid in holding the templates in place. (Completion of the polymerization place. (Completion of the polymerization process may be done with pressure.)process may be done with pressure.)


5252

Trim and smooth the Trim and smooth the edges of the guide.edges of the guide.

Prepare holes in the Prepare holes in the guide at the desired guide at the desired implant locations. implant locations. Use a No- a round Use a No- a round bur to prepare a pilot bur to prepare a pilot hole, and enlarge the hole, and enlarge the width to 3 mm in width to 3 mm in diameter, Fill the diameter, Fill the prepared holes with prepared holes with gutta-percha.gutta-percha.


5353

Trial fit the template in the patients mouth Trial fit the template in the patients mouth before the radiographic appointment to ensure before the radiographic appointment to ensure that it is comfortable and stable. Adjust the that it is comfortable and stable. Adjust the flange or the tissue surface as necessary to flange or the tissue surface as necessary to allow the guide to sent with ease.allow the guide to sent with ease.


5454

Radiographic analysisRadiographic analysis Select the cross-sectional images Select the cross-sectional images

that contain the gutta percha that contain the gutta percha cylinders, therefore correspond cylinders, therefore correspond to the most desirable locations to the most desirable locations for the implants.for the implants.

Compare angulation of the gutta-Compare angulation of the gutta-percha cylinder with the percha cylinder with the available bone and the position available bone and the position of the vital structures to of the vital structures to determine the best angulation for determine the best angulation for the implant. (The need for the implant. (The need for angled abutments or pre implant angled abutments or pre implant augmentation surgery can be augmentation surgery can be determined.)determined.)

33 Transfer this information Transfer this information to the surgeon by modifying the to the surgeon by modifying the guide for surgery. (The vertical guide for surgery. (The vertical height of the guide in reduced, height of the guide in reduced, and the gutta percha is removed and the gutta percha is removed The guide can now be used to The guide can now be used to place the implant in the desired place the implant in the desired location.)location.)


5555

Marcus A. R. Lima Verde, Steven M. Marcus A. R. Lima Verde, Steven M. Morgano’ s Dual purpose Stent Morgano’ s Dual purpose Stent

A stent is any device used with a surgical A stent is any device used with a surgical procedure and is commonly fabricated to procedure and is commonly fabricated to direct the positioning of implants. In addition, direct the positioning of implants. In addition, a perceptively designed stent can serve as an a perceptively designed stent can serve as an adjunct during radiological diagnostic adjunct during radiological diagnostic procedures. The dual-purpose stent combined procedures. The dual-purpose stent combined with computed tomography (CT) can reveal with computed tomography (CT) can reveal the available bone and the location of vital the available bone and the location of vital structures at an implant site. This same stent structures at an implant site. This same stent functions as a guide to the surgeon placing the functions as a guide to the surgeon placing the implants.implants. www.indiandentalacademy.comwww.indiandentalacademy.com

5656

A stent was designed that is a modification of A stent was designed that is a modification of one originally introduced by Stella and one originally introduced by Stella and Tharanon7 to locate the inferior alveolar canal Tharanon7 to locate the inferior alveolar canal in the posterior edentulous mandible. This in the posterior edentulous mandible. This stent precisely relates the CT cross-sectional stent precisely relates the CT cross-sectional images in the maxillae or mandible to the images in the maxillae or mandible to the anticipated location and angulation of the anticipated location and angulation of the implants. The stent then acts as a surgical implants. The stent then acts as a surgical template to ensure accurate placement and template to ensure accurate placement and favorable angulation of the fixtures.favorable angulation of the fixtures.


5757

Fabrication:Fabrication: For Partially For Partially

edentulousedentulous

patientpatient

Make diagnostic casts of the dental arches from Make diagnostic casts of the dental arches from irreversible hydrocolloid impressions. Complete a irreversible hydrocolloid impressions. Complete a diagnostic waxing of the proposed implant-supported diagnostic waxing of the proposed implant-supported FPD or set acrylic resin artificial teeth as an alternative FPD or set acrylic resin artificial teeth as an alternative to replace the missing teeth.to replace the missing teeth.


5858

Make an irreversible hydrocolloid impression of the cast Make an irreversible hydrocolloid impression of the cast with the waxed FPD, and duplicate the cast in dental with the waxed FPD, and duplicate the cast in dental stone.stone.

Make a vacuum-formed plastic template of the duplicate Make a vacuum-formed plastic template of the duplicate cast.cast.

Seat the plastic template on the original diagnostic cast Seat the plastic template on the original diagnostic cast (wax removed), and pour clear, chemically activated (wax removed), and pour clear, chemically activated acrylic resin in the template.acrylic resin in the template.www.indiandentalacademy.comwww.indiandentalacademy.com

5959

Place the cast with the acrylic resin in a pressure pot Place the cast with the acrylic resin in a pressure pot with 110° F water at 25 psi for 20 minutes.with 110° F water at 25 psi for 20 minutes.

77 Remove gross excess and place gutta-percha rods Remove gross excess and place gutta-percha rods on the stent along the central occlusal line of posterior on the stent along the central occlusal line of posterior teeth or on the crest of the cingula of anterior teeth. teeth or on the crest of the cingula of anterior teeth.


6060

Place 2 mm gutta-percha Place 2 mm gutta-percha spheres at the desired spheres at the desired location of each implant location of each implant fixture.fixture.

Add acrylic resin with a Add acrylic resin with a brush to cover the gutta-brush to cover the gutta-percha spheres and the rods percha spheres and the rods at the central occlusal line at the central occlusal line

Place a gutta-percha rod on Place a gutta-percha rod on the ridge crest Apply the ridge crest Apply autopolymerizing clear autopolymerizing clear acrylic resin with a brush to acrylic resin with a brush to the tissue surface of the the tissue surface of the stent and gutta-percha to stent and gutta-percha to attach the rod to the stent, attach the rod to the stent, and reposition it on the cast.and reposition it on the cast.www.indiandentalacademy.comwww.indiandentalacademy.com

6161

Adapt weather stripping or beading wax to the facial and Adapt weather stripping or beading wax to the facial and lingual surfaces of the stent and several contiguous lingual surfaces of the stent and several contiguous teeth.teeth.

1313 Add additional clear acrylic resin to form an Add additional clear acrylic resin to form an occlusal index and ensure positive seating of the stent occlusal index and ensure positive seating of the stent intraorally.intraorally. www.indiandentalacademy.comwww.indiandentalacademy.com

6262

Finish and polish the Finish and polish the stentstent

Refer the patient to Refer the patient to the radiologist for the radiologist for the DentaScan CT the DentaScan CT scan with the scan with the diagnostic stent and diagnostic stent and a comprehensive a comprehensive prescription that prescription that includes drawings of includes drawings of the areas that must the areas that must be included in the be included in the CT scan.CT scan.


6363

FABRICATION FOR THE TOTALLY EDENTULOUS FABRICATION FOR THE TOTALLY EDENTULOUS PATIENTPATIENT

11 Duplicate a satisfactory complete denture in clear Duplicate a satisfactory complete denture in clear acrylic resin by using any standard technique. The acrylic resin by using any standard technique. The duplicated denture must have a physiologic vertical duplicated denture must have a physiologic vertical dimension of occlusion, stable centric occlusion dimension of occlusion, stable centric occlusion coincidental with centric relation, and favorable tooth coincidental with centric relation, and favorable tooth position. The patient's existing denture often has one or position. The patient's existing denture often has one or more major deficiencies and should be remade to more major deficiencies and should be remade to fabricate a reliable stent. Duplicating an unsuitable fabricate a reliable stent. Duplicating an unsuitable complete denture provides unreliable diagnostic complete denture provides unreliable diagnostic information with the DentaScan CT scan procedure.information with the DentaScan CT scan procedure.

22 Attach the gutta percha rods and spheres similar to Attach the gutta percha rods and spheres similar to the description for the partially edentulous patient.the description for the partially edentulous patient.


6464

ANALYSIS OF THE CT SCANANALYSIS OF THE CT SCAN Select the cross-sectional images Select the cross-sectional images

that correspond to the most that correspond to the most desirable locations of the desirable locations of the implants, namely the images that implants, namely the images that include the gutta-percha spheres. include the gutta-percha spheres. Because the cuts with the Because the cuts with the DentaScan CT scan are either 1 DentaScan CT scan are either 1 or 1.5 mm apart, each 2 mm or 1.5 mm apart, each 2 mm sphere is always visible in at sphere is always visible in at least one of the cross-sectional least one of the cross-sectional images.images.

a – Gutta-percha spherea – Gutta-percha sphere b – Gutta-percha rods at the ridgeb – Gutta-percha rods at the ridge c – Gutta-percha rod at the central occlusal c – Gutta-percha rod at the central occlusal

line.line. www.indiandentalacademy.comwww.indiandentalacademy.com

6565

Connect the two dots for each location that represents the Connect the two dots for each location that represents the gutta-percha rods at the central occlusal line and the ridge gutta-percha rods at the central occlusal line and the ridge crest. This line represents the most favorable angulation crest. This line represents the most favorable angulation of the implant fixture for prosthodontics.of the implant fixture for prosthodontics.

Compare this angulation with the available bone and Compare this angulation with the available bone and position of vital structures and determine the best position of vital structures and determine the best angulation for the surgical positioning of the implant angulation for the surgical positioning of the implant fixtures.fixtures. www.indiandentalacademy.comwww.indiandentalacademy.com

6666

Transfer this Transfer this information to the stent information to the stent by preparing guide by preparing guide channels to orient the channels to orient the surgeon's pilot drill, surgeon's pilot drill, converting the converting the diagnostic stent to a diagnostic stent to a surgical stent. surgical stent.

A – occlusal surfaceA – occlusal surface B – guide channels B – guide channels

prepared from facial prepared from facial surface guide surgeons surface guide surgeons pilot drill.pilot drill.


6767

Template for positioning and Template for positioning and angulation of intraosseous implantsangulation of intraosseous implants

The position angulation of the submerged implant need to The position angulation of the submerged implant need to be planned before the time of surgical implant placement be planned before the time of surgical implant placement for proper occlusal alignment with the opposing dentition for proper occlusal alignment with the opposing dentition prosthesis.prosthesis.

The surgeon uses different criteria for implant placement The surgeon uses different criteria for implant placement than that used by the prosthodontist. The surgeon must than that used by the prosthodontist. The surgeon must place the implant in a region where the quantity place the implant in a region where the quantity quality quality of bone is adequate to provide functional support.2 The of bone is adequate to provide functional support.2 The prosthodontist should not rely on the surgeon's skills alone prosthodontist should not rely on the surgeon's skills alone to provide appropriate implant placement, but should to provide appropriate implant placement, but should provide the surgeon with a templateprovide the surgeon with a template for the correct for the correct placement of the intraosseous implant.placement of the intraosseous implant.www.indiandentalacademy.comwww.indiandentalacademy.com

6868

David R. Burns, Donald G. Crabtree, and Dewey H. Bell describe a technique for fabrication of a surgical guide that gives the surgeon the appropriate location and angulation of the submerged implant.

In conjunction with the surgeon, the prosthodontist initially should evaluate the patient for potential implant treatment including an adequate history, oral examination, radiographic examination, and mounted diagnostic casts, and should carefully palpate the regions of potential implant placement for bone undercuts and thickness and morphology.


6969

In addition, it may be desirable to "sound" the bone In addition, it may be desirable to "sound" the bone through the soft tissue from the buccal and lingual through the soft tissue from the buccal and lingual aspect of the alveolar ridge. This can be done by locally aspect of the alveolar ridge. This can be done by locally anesthetizing the region and then inserting, anesthetizing the region and then inserting, perpendicular to the tissue surface, a 25 gauge needle perpendicular to the tissue surface, a 25 gauge needle (reamer with stopper) through the soft tissue until it hits (reamer with stopper) through the soft tissue until it hits the underlying bone. The distance of insertion into the the underlying bone. The distance of insertion into the soft tissue is measured on the buccal and lingual aspect soft tissue is measured on the buccal and lingual aspect of the alveolar ridge at varying vestibular depths. From of the alveolar ridge at varying vestibular depths. From this information, regions of potentially adequate bone, this information, regions of potentially adequate bone, implant size, number, and location can be tentatively implant size, number, and location can be tentatively determined. The surgeon and prosthodontist should determined. The surgeon and prosthodontist should carefully review and discuss their findings and develop carefully review and discuss their findings and develop a understanding regarding implant location and a understanding regarding implant location and angulation.angulation. www.indiandentalacademy.comwww.indiandentalacademy.com

7070

Diagnostic casts are Diagnostic casts are mounted in an articulator mounted in an articulator using a centric relation using a centric relation record (Fig. 1). The record (Fig. 1). The distance from the distance from the edentulous ridge to the edentulous ridge to the opposing occlusal surface opposing occlusal surface measured to make certain measured to make certain that adequate space is that adequate space is available for fabrication of available for fabrication of the prosthesis above the the prosthesis above the implant the vertical implant the vertical dimension of occlusion. dimension of occlusion.


7171

Artificial teeth of a size Artificial teeth of a size similar to the opposing or similar to the opposing or adjacent dentition selected. adjacent dentition selected. They are arranged in the They are arranged in the edentulous space the cast edentulous space the cast over the ridge, as over the ridge, as determined by the clinical determined by the clinical examination, to provide an examination, to provide an appropriate occlusal appropriate occlusal relationship with the relationship with the opposing arch. The artificial opposing arch. The artificial teeth, held in position with teeth, held in position with a small amount of utility a small amount of utility wax directly under each wax directly under each tooth tooth www.indiandentalacademy.comwww.indiandentalacademy.com

7272

An outline is drawn with a pencil on the cast around An outline is drawn with a pencil on the cast around each artificial teeth.each artificial teeth.


7373

). The cast with the artificial ). The cast with the artificial teeth is removed from the teeth is removed from the articulator and placed on a articulator and placed on a surveyor. The analyzing rod is surveyor. The analyzing rod is aligned with the long axis of aligned with the long axis of the artificial teeth.the artificial teeth.

After the surveyor is properly After the surveyor is properly aligned, the artificial teeth are aligned, the artificial teeth are removed from the cast. The removed from the cast. The center of the outline around the center of the outline around the artificial teeth that will artificial teeth that will represent location for implant represent location for implant placement is then marked, and placement is then marked, and the analyzing rod is removed the analyzing rod is removed from the surveyor mandrel.from the surveyor mandrel.


7474

A 10 mm length of 0.045 inch round tubing is prepared. A 10 mm length of 0.045 inch round tubing is prepared. The outer surface of the tubing is serrated with a The outer surface of the tubing is serrated with a separating disk to providing multiple serrations along the separating disk to providing multiple serrations along the entire tube length. This procedure provides mechanical entire tube length. This procedure provides mechanical retention for tube within acrylic resin on processing of retention for tube within acrylic resin on processing of the template and holds the tube in place during the template and holds the tube in place during investment and processing. Care must be taken not to cut investment and processing. Care must be taken not to cut through inner surface of the tube. through inner surface of the tube. www.indiandentalacademy.comwww.indiandentalacademy.com

7575

The open ends of the tub lumen are closed with a The open ends of the tub lumen are closed with a temporary plug material as much material as possible temporary plug material as much material as possible should be forced into lumen. All excess material is should be forced into lumen. All excess material is removed from around lumen. The tubing is placed and removed from around lumen. The tubing is placed and tightened into surveyor mandrel. The tube should be tightened into surveyor mandrel. The tube should be supported wit the mandrel with the metal sheath supported wit the mandrel with the metal sheath provided with surveyor to support the carbon marker provided with surveyor to support the carbon marker www.indiandentalacademy.comwww.indiandentalacademy.com

7676

The tubing is then centered over The tubing is then centered over the outline of one of artificial teeth the outline of one of artificial teeth representing the location for representing the location for implant placement. At this implant placement. At this angulation, the round tubing is m angulation, the round tubing is m to lightly contact the cast and is to lightly contact the cast and is luted into place wit small amount luted into place wit small amount of sticky wax.of sticky wax.

It is then carefully released from It is then carefully released from the surveyor. Additional the surveyor. Additional identically Paired pieces of tubing identically Paired pieces of tubing are luted into position in the same are luted into position in the same fashion as determined by the fashion as determined by the number of submerged Jams number of submerged Jams planned in the treatment. One planned in the treatment. One length of tubing for each length of tubing for each anticipated location anticipated location www.indiandentalacademy.comwww.indiandentalacademy.com

7777

After all of the round tubing After all of the round tubing is positioned on the is positioned on the edentulous ridge, the acrylic edentulous ridge, the acrylic resin portion of the surgical resin portion of the surgical template is outlined on the template is outlined on the cast, incorporating the tubes cast, incorporating the tubes and covering all denture-and covering all denture-bearing surfaces, similar to a bearing surfaces, similar to a record base .record base .

This template is built up This template is built up with three thickness of with three thickness of baseplate wax baseplate wax


7878

The cast is carefully invested and the template is The cast is carefully invested and the template is processed in the conventional mannerprocessed in the conventional manner with clear with clear heat-processed acrylic resinheat-processed acrylic resin. The surgical template . The surgical template is carefully recovered from the cast after processing is carefully recovered from the cast after processing to avoid damage or alteration to the tubes. Acrylic to avoid damage or alteration to the tubes. Acrylic resin flash around the tubes is removed with an resin flash around the tubes is removed with an acrylic resin bur and the temporary plug within the acrylic resin bur and the temporary plug within the tube lumen is pushed out with an anesthetic needle. tube lumen is pushed out with an anesthetic needle. Acrylic resin surgical template is smoothed and Acrylic resin surgical template is smoothed and polished ultrasonically cleaned, and sterilized by polished ultrasonically cleaned, and sterilized by using cold sterilization using cold sterilization www.indiandentalacademy.comwww.indiandentalacademy.com

7979

Each length of tubing on the template is measured with Each length of tubing on the template is measured with a Boley gauge on shortened to an accurate 5 mm a Boley gauge on shortened to an accurate 5 mm length. For the panoramic and other non occlusal length. For the panoramic and other non occlusal views, the 5 mm length of tubing is used as a standard views, the 5 mm length of tubing is used as a standard reference length to dimensionally correct any reference length to dimensionally correct any measurements taken from the radiograph in measurements taken from the radiograph in determining the availabilitydetermining the availability of bone. of bone. www.indiandentalacademy.comwww.indiandentalacademy.com

8080

The surgeon and prosthodontist study these The surgeon and prosthodontist study these radiographs in conjunction with the mounted radiographs in conjunction with the mounted diagnostic casts and findings from the clinical diagnostic casts and findings from the clinical evaluation to deter mine implant size, position, evaluation to deter mine implant size, position, and potential complications that may arise from and potential complications that may arise from the selected site. The tubing, as seen in the the selected site. The tubing, as seen in the radiograph, can help identify the location and radiograph, can help identify the location and angulation of the implant within the underlying angulation of the implant within the underlying bone and aid in providing a more predictable bone and aid in providing a more predictable outcome for the entire treatment. If problems outcome for the entire treatment. If problems are anticipated with the surgical site, are anticipated with the surgical site, reevaluation of the implant location on the reevaluation of the implant location on the diagnostic cast and redesign and fabrication of a diagnostic cast and redesign and fabrication of a new-template must be done before surgery.new-template must be done before surgery.


8181

When the presurgical evaluation is completed, the portion of When the presurgical evaluation is completed, the portion of tubing extending out of the polished surface of the template is tubing extending out of the polished surface of the template is removed with a separating disk. The remaining tubing, removed with a separating disk. The remaining tubing, embedded into the acrylic resin. should be approximately 3 mm embedded into the acrylic resin. should be approximately 3 mm in length as measured in length as measured withwith a Boley gauge around the template. a Boley gauge around the template. Metal Hash around the tubing lumen should be removed with Metal Hash around the tubing lumen should be removed with an explorer and smoothed with a rubber wheel. The entire an explorer and smoothed with a rubber wheel. The entire surgical template is then smoothed and polished and again surgical template is then smoothed and polished and again ultrasonically cleaned and sterilized by using cold sterilization.ultrasonically cleaned and sterilized by using cold sterilization.


8282

The surgical template is transferred to the surgeon. After The surgical template is transferred to the surgeon. After anesthesia, the template is positioned iniraorally and held anesthesia, the template is positioned iniraorally and held firmly onto the tissue. The lubes are used as a guide for firmly onto the tissue. The lubes are used as a guide for drilling a channel hole through the mucosa and into the drilling a channel hole through the mucosa and into the bone. The round-tube lumen diameter is select ed to bone. The round-tube lumen diameter is select ed to provide a close tolerance fit provide a close tolerance fit


8383

The hole should be The hole should be made approximately 4 made approximately 4 mm into the bone.mm into the bone.

On drilling, the bur is On drilling, the bur is lowered into the tube, lowered into the tube, which guides it into which guides it into the bone while the the bone while the surgical template is surgical template is held in place over the held in place over the tissue. The hole is tissue. The hole is then used as a guide then used as a guide for the location and for the location and angulation of the angulation of the guide pins.guide pins.


8484

Bilaminar dual-purpose stentBilaminar dual-purpose stent Murat C.cehreli, Yavuz Asian, and Sairne Sahin, Murat C.cehreli, Yavuz Asian, and Sairne Sahin,

describe a procedure for fabricating a bilaminar describe a procedure for fabricating a bilaminar dual-purpose stent. This stent is specifically dual-purpose stent. This stent is specifically designed for the use of surgical drills in bone with designed for the use of surgical drills in bone with low density. The outer lamina, which is prepared low density. The outer lamina, which is prepared as a shell, is used for radiographic purposes and for as a shell, is used for radiographic purposes and for verifying the alignment of implants with the guide verifying the alignment of implants with the guide pins in accordance with the predetermined pins in accordance with the predetermined superstructure. The inner lamina is designed to superstructure. The inner lamina is designed to accept 2 removable surgical stents bilaterally with accept 2 removable surgical stents bilaterally with 2 guide channels in diameter.2 guide channels in diameter.www.indiandentalacademy.comwww.indiandentalacademy.com

8585

There are 2 issues that should be taken into consideration There are 2 issues that should be taken into consideration while converting the stent, while converting the stent,

First, because errors in converting the stent may lead to First, because errors in converting the stent may lead to misalignment of the implants, the angle of the misalignment of the implants, the angle of the radiopaque markers should provide ease in reorienting radiopaque markers should provide ease in reorienting the surveying table if guide channel preparation has to be the surveying table if guide channel preparation has to be performed in a different angle. In addition, the performed in a different angle. In addition, the radiopaque marker should provide accurate transfer of radiopaque marker should provide accurate transfer of the 2-dimensional information to the 3-dimensional sent the 2-dimensional information to the 3-dimensional sent throughout the entire procedure.throughout the entire procedure.

Second, there are no prefabricated guide channels Second, there are no prefabricated guide channels offered by dental implant systems that would either be offered by dental implant systems that would either be "intcrplaced" to form an assembly or as single tubes "intcrplaced" to form an assembly or as single tubes whose dimensions would match the diameter of used whose dimensions would match the diameter of used surgical drills. The lack of this feature usually results in surgical drills. The lack of this feature usually results in a prepared single guide channel that allows only I a prepared single guide channel that allows only I surgical drill to pass throughsurgical drill to pass through


8686

Make the impressions of both arches using irreversible Make the impressions of both arches using irreversible hydrocolloid impression material and pour the casts in ty e III hydrocolloid impression material and pour the casts in ty e III dental stone. Using a face-bow transfer , and a centric relation dental stone. Using a face-bow transfer , and a centric relation record, mount the casts on a semiadjustable articulator.record, mount the casts on a semiadjustable articulator.

To fabricate the inner lamina, vacuum form a 2.0 x 125-mm clear To fabricate the inner lamina, vacuum form a 2.0 x 125-mm clear transparent foil on the upper cast. Gcntlv dislodge the foil, trim transparent foil on the upper cast. Gcntlv dislodge the foil, trim the borders to cover the edentulous ridges and the palate and a the borders to cover the edentulous ridges and the palate and a third of the incisal portions of the remaining anterior teeth,third of the incisal portions of the remaining anterior teeth,

To fabricate the outer lamina, prepare a diagnostic setup using To fabricate the outer lamina, prepare a diagnostic setup using denture teeth and modeling wax. Make an irrcvcrs1bIe denture teeth and modeling wax. Make an irrcvcrs1bIe hydrocolloid impression over the clear vacuum -formed foil and hydrocolloid impression over the clear vacuum -formed foil and the setup. Then, pour the cast in type III dental stone and vacuum the setup. Then, pour the cast in type III dental stone and vacuum form another foil over the obtained cast.form another foil over the obtained cast.

After removing the new foil, trim the borders of the shell portion After removing the new foil, trim the borders of the shell portion according to the cervical margins of the setup and shape other according to the cervical margins of the setup and shape other borders to approximately fit the inner lamina. borders to approximately fit the inner lamina.


8787

As an assembly, place both foils on the surveying table As an assembly, place both foils on the surveying table with the cast. Determine the ideal location and possible with the cast. Determine the ideal location and possible angle of implant axis. Drill pin holes through both angle of implant axis. Drill pin holes through both plates and secure pins (I mm in diameter) for plates and secure pins (I mm in diameter) for radiographic evaluation with a small amount of clear radiographic evaluation with a small amount of clear autopolymcrlzcd acrylic resin .autopolymcrlzcd acrylic resin .


8888

At this stage, the positioning of the pins should coincide At this stage, the positioning of the pins should coincide the anticipated central axis of the implants. Then, adjust the anticipated central axis of the implants. Then, adjust the stern in the mouth and make a bite registration using the stern in the mouth and make a bite registration using additional cure bite registration paste to immobilize the additional cure bite registration paste to immobilize the stent while obtaining the CT scan.stent while obtaining the CT scan.


8989

Perform measurements regarding dimensions of the available bone and the angulation of implants on the CT image.

Image of radiopaque marker that can only be viewed in I section of scan images provides accurate evaluation of predetermined axis of implant placement and area representing bone structure at central section of implant. Surveying table can simply be reoriented by using angle of pins if any change in angle of implant insertion is indicated.www.indiandentalacademy.comwww.indiandentalacademy.com

9090

Separate the outer portion-with the pins still in place-Separate the outer portion-with the pins still in place-from the inner lamina. Remove the plate covering the from the inner lamina. Remove the plate covering the edentulous ridges from the lamina with a carbide bur edentulous ridges from the lamina with a carbide bur and cut 4 stainless burs, leaving approximately I cm of and cut 4 stainless burs, leaving approximately I cm of their ends. Then, secure the bur ends (that are planned their ends. Then, secure the bur ends (that are planned for use in guiding the insertion of the removable for use in guiding the insertion of the removable surgical acrylic resin stents to the palatal sides of the surgical acrylic resin stents to the palatal sides of the inner lamina) bilaterally using clear autopolymerizing inner lamina) bilaterally using clear autopolymerizing acrylic resin on the surveying table.acrylic resin on the surveying table.www.indiandentalacademy.comwww.indiandentalacademy.com

9191

Make an irreversible hydrocolloid impression Make an irreversible hydrocolloid impression over the cast. Pour the cast and bilaterally over the cast. Pour the cast and bilaterally fabricate 2 acrylic stents covering only the fabricate 2 acrylic stents covering only the residual ridges. Trim the excess material and residual ridges. Trim the excess material and adjust the stents so as to pass through the adjust the stents so as to pass through the guiding probes.guiding probes.


9292

Fabricate a custom flap Fabricate a custom flap retractor using 1mm, retractor using 1mm, stainless steel stainless steel orthodontic wire. The orthodontic wire. The retractor should pass retractor should pass over the posterior over the posterior border of the stent, border of the stent, while extending to the while extending to the anterior (and parallel) anterior (and parallel) and the buccal sulcus and the buccal sulcus on both sides.on both sides.

Secure the custom flap Secure the custom flap retractor in place with retractor in place with clear autopolymerized clear autopolymerized acrylic resinacrylic resin


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Remove the palatal portion of Remove the palatal portion of the outer lamina with a carbide the outer lamina with a carbide bur and mount the assembly bur and mount the assembly on the surveying table. After on the surveying table. After determining the necessary tilt determining the necessary tilt of the surveying table through of the surveying table through radiopaque markers, separate radiopaque markers, separate the outer lamina and insert the the outer lamina and insert the fabricated removable acrylic fabricated removable acrylic resin stents. By using the first resin stents. By using the first 2 surgical drills, perform guide 2 surgical drills, perform guide channel preparation for 2 channel preparation for 2 stents in each segmentstents in each segment


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To verify the angulation of implants through the shell with To verify the angulation of implants through the shell with surgical guide pins, remove the radiopaque markers from surgical guide pins, remove the radiopaque markers from the outer lamina and drill holes on the occlusal aspect of the outer lamina and drill holes on the occlusal aspect of the shell approximately 4 mm in diameterthe shell approximately 4 mm in diameterwww.indiandentalacademy.comwww.indiandentalacademy.com

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Bilaminar stent is ready for use after sterilizationBilaminar stent is ready for use after sterilization


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The technique has 2 disadvantages. First, the custom flap retractor The technique has 2 disadvantages. First, the custom flap retractor was designed initially to improve the visualization by activating it was designed initially to improve the visualization by activating it buccally. However, a design with loops would probably be more buccally. However, a design with loops would probably be more efficient. efficient.

Second, the laboratory procedures to fabricate such stents arc Second, the laboratory procedures to fabricate such stents arc rather complicated and time-consuming. rather complicated and time-consuming.

Unfortunately, precise mechanisms for accurate placement of Unfortunately, precise mechanisms for accurate placement of implants are not provided by implant systems, which has led to the implants are not provided by implant systems, which has led to the compromised placement of a large number of implants, whereas compromised placement of a large number of implants, whereas conventional surgical stents include no safety measures to conventional surgical stents include no safety measures to eliminate the potential risk of contaminating the implant socket by eliminate the potential risk of contaminating the implant socket by misusing the surgical drills through acrylic resin guide channels. misusing the surgical drills through acrylic resin guide channels. However, the complex procedure described herein emphasizes the However, the complex procedure described herein emphasizes the significance of the existence of a prefabricated guide channel that significance of the existence of a prefabricated guide channel that would surely simplify the whole procedure. In that case, an acrylic would surely simplify the whole procedure. In that case, an acrylic resin stcnt that includes the form of the prosthesis and resin stcnt that includes the form of the prosthesis and prefabricated metal guide channels only as such be sufficient for prefabricated metal guide channels only as such be sufficient for CT evaluation.CT evaluation.


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Accurate three-dimensional models of the patients anatomy Accurate three-dimensional models of the patients anatomy can be produced by a number of CADCAM and can be produced by a number of CADCAM and prototyping procedures.' CADCAM surgical steriotactic prototyping procedures.' CADCAM surgical steriotactic templates can be produced from CT examinations have templates can be produced from CT examinations have used interactive CT that to devolop a three dimensional used interactive CT that to devolop a three dimensional treatment plan for the patient of the position and treatment plan for the patient of the position and orientation of dental implants. To incorporate the three orientation of dental implants. To incorporate the three dimensional treatment plan of implantdimensional treatment plan of implant

position and orientations into the model, the internalposition and orientations into the model, the internalarchetecture of the patient's anatomy must also be produced.archetecture of the patient's anatomy must also be produced.a model of the patient's alveolar anatomy incorporateda model of the patient's alveolar anatomy incorporatedwith the osteotomy positions and orientations can then bewith the osteotomy positions and orientations can then beprodeced.prodeced.

CADCAM Stereotactic surgical CADCAM Stereotactic surgical templatetemplate


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A Stereotactic surgical template is derived fromA Stereotactic surgical template is derived from

the model by aligning guide cylinders at the implant sites,the model by aligning guide cylinders at the implant sites,

which must accommodate a pilot drill, and producing awhich must accommodate a pilot drill, and producing a

vaccuform using surgical template material of the model vaccuform using surgical template material of the model and guide cylinders. This results in a plastic surgical and guide cylinders. This results in a plastic surgical template that fits and confirms to patient's bony anatomy template that fits and confirms to patient's bony anatomy and supports the position and orientation of the guide and supports the position and orientation of the guide cylinders, which precisely reproduces the position and cylinders, which precisely reproduces the position and orientation of the proposed implants. The surgical guide orientation of the proposed implants. The surgical guide is stabilized by confirmation of the vacuform. to the is stabilized by confirmation of the vacuform. to the patient's bony anatomy. the Stereotactic surgical template patient's bony anatomy. the Stereotactic surgical template is used to establish pilot holes / osteotomies to a depth of is used to establish pilot holes / osteotomies to a depth of approximately 10 mm for the position and orientation of approximately 10 mm for the position and orientation of the implants. the implants.


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PRE-MAXILLA IMPLANT PRE-MAXILLA IMPLANT CONSIDERATIONSCONSIDERATIONS


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INTRODUCTIONINTRODUCTION Several factors affect the condition of the pre maxilla Several factors affect the condition of the pre maxilla

and may result in a decrease in implant survival and/or and may result in a decrease in implant survival and/or an increase in prosthetic complications. an increase in prosthetic complications.

The maxillary anteriorridge is often inadequate in The maxillary anteriorridge is often inadequate in available bone for endosteal implants. The facial available bone for endosteal implants. The facial cortical plate may be resorbed from periodontal disease cortical plate may be resorbed from periodontal disease or is often fractured during the extraction of teeth. In or is often fractured during the extraction of teeth. In addition, it resorbs during initial bone remodeling after addition, it resorbs during initial bone remodeling after tooth loss, and the anterior ridge loses 25% of its tooth loss, and the anterior ridge loses 25% of its Width within the first year after tooth loss and 40% to Width within the first year after tooth loss and 40% to 60% over 3 years, mostly at the expense of the labial 60% over 3 years, mostly at the expense of the labial plate. As a result, it migrates to a more palatal position.plate. As a result, it migrates to a more palatal position.


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In the majority of patients, the bone is less In the majority of patients, the bone is less dense in the anterior maxilla than in the dense in the anterior maxilla than in the anterior mandible. In the mandible, a dense anterior mandible. In the mandible, a dense cortical layer increases trabecular bone cortical layer increases trabecular bone strength and permits implants to engage a strength and permits implants to engage a denser bone quality. The maxilla presents thin denser bone quality. The maxilla presents thin porous bone on the labial aspect, very thin porous bone on the labial aspect, very thin porous to-dense compacta in the nasal region, porous to-dense compacta in the nasal region, and a thick cortical bone on the palatal aspect. and a thick cortical bone on the palatal aspect. The trabecular bone may be coarse or fine and The trabecular bone may be coarse or fine and is often less dense in nature than the anterior is often less dense in nature than the anterior regions of the mandible.regions of the mandible.


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In the premaxilla, esthetics and phonetics dictate that the In the premaxilla, esthetics and phonetics dictate that the replacement teeth be placed at or near their original replacement teeth be placed at or near their original position, which is often cantilevered off the residual position, which is often cantilevered off the residual ridge,which is more palatal superior. ridge,which is more palatal superior.

The crown height is a force magnifier and is an The crown height is a force magnifier and is an important consideration in the anterior maxilla, where important consideration in the anterior maxilla, where the natural crown height is already greater than any other the natural crown height is already greater than any other region even under ideal conditions. arc of closure is region even under ideal conditions. arc of closure is anterior to residual ridge; as a consequence, the moment anterior to residual ridge; as a consequence, the moment force is greatest against the maxillary anterior crowns force is greatest against the maxillary anterior crowns supported by implants and directed against the thinner supported by implants and directed against the thinner facial bone. All mandibular excursions place lateral facial bone. All mandibular excursions place lateral forces on the maxillary anterior teeth, with resulting forces on the maxillary anterior teeth, with resulting increased stress on the crestal bone, especially on the increased stress on the crestal bone, especially on the labial of the implant.labial of the implant.


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Treatment planningTreatment planning


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From a biomechanical perspective, the implant-From a biomechanical perspective, the implant-restored anterior maxilla is often the weakest restored anterior maxilla is often the weakest section compared with other regions of the section compared with other regions of the mouth. mouth.

Compromising conditions in this anatomic Compromising conditions in this anatomic region and their resultant consequences include region and their resultant consequences include

(1) The need for narrower implants (results in (1) The need for narrower implants (results in increased stress concentrations in both the increased stress concentrations in both the implant and contiguous interfacial tissues, implant and contiguous interfacial tissues, particularly at the crestal region); particularly at the crestal region);

(2) The use of facial cantilevers (results in (2) The use of facial cantilevers (results in increased moment loads at the implant crest, increased moment loads at the implant crest, often leading to localized crestal remodeling and often leading to localized crestal remodeling and implant and/or abutment fracture); implant and/or abutment fracture); www.indiandentalacademy.comwww.indiandentalacademy.com

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(3) Oblique centric contacts (results in potentially (3) Oblique centric contacts (results in potentially harmful, off-axis load components);harmful, off-axis load components);

4) Lateral forces in excursion (i.e., results in 4) Lateral forces in excursion (i.e., results in dangerous moment loads applied to the implant); dangerous moment loads applied to the implant);

(5) Reduced bone density (results in compromised (5) Reduced bone density (results in compromised bone strength and loss of implant support); bone strength and loss of implant support);

(6) Absence of thick cortical plate at the crest or (6) Absence of thick cortical plate at the crest or apex (results in loss of high strength implant apex (results in loss of high strength implant support); and support); and

(7) The inability to place central and/or lateral (7) The inability to place central and/or lateral incisor irnplants.incisor irnplants.


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These compromising characteristics of the These compromising characteristics of the premaxilla mandate special consideration when premaxilla mandate special consideration when establishing the occlusal scheme. An implant establishing the occlusal scheme. An implant protective -occlusion suggests the negative protective -occlusion suggests the negative factors be reduced by eliminating posterior factors be reduced by eliminating posterior contacts in excursions, increasing the number of contacts in excursions, increasing the number of maxillary anterior implants, , increasing the maxillary anterior implants, , increasing the diameter of implants (often requires bone diameter of implants (often requires bone augmentation), and increasing the number of augmentation), and increasing the number of implants that disocclude the posterior teeth in implants that disocclude the posterior teeth in each lateral excursion, each lateral excursion,


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As a result, at least three implants are usually As a result, at least three implants are usually required to replace the six anterior teeth, and two required to replace the six anterior teeth, and two of these should be in the canine positions . of these should be in the canine positions .

Posterior cantilevers should not be placed on these Posterior cantilevers should not be placed on these three implants, especially when increased factors three implants, especially when increased factors of force are present. The three implants should be of force are present. The three implants should be splinted together and share any lateral forces splinted together and share any lateral forces during excursions. If posterior teeth are also being during excursions. If posterior teeth are also being replaced in the prostheses, additional implants are replaced in the prostheses, additional implants are required.required.

Eight to ten implants are often required to restore a Eight to ten implants are often required to restore a maxilla with a fixed prostheses, especially when maxilla with a fixed prostheses, especially when opposing a natural dentition/ fixed restoration.opposing a natural dentition/ fixed restoration.www.indiandentalacademy.comwww.indiandentalacademy.com

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An important parameter in treatment planning An important parameter in treatment planning is the adequate surface area of support for the is the adequate surface area of support for the load transmitted to the prosthesis. Previous load transmitted to the prosthesis. Previous studies have shown that the force distributed studies have shown that the force distributed over three abutments results in less localized over three abutments results in less localized stress to the crestal bone than two abutments.stress to the crestal bone than two abutments.

In oder to resist mandibular excursions, In oder to resist mandibular excursions, implants should be splinted and as a result, implants should be splinted and as a result, premaxillary implants should be placed in both premaxillary implants should be placed in both canine and a lateral or both canine and a canine and a lateral or both canine and a central for each anterior section of the arch."' central for each anterior section of the arch."'


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When the canine region cannot be used to place When the canine region cannot be used to place an implant, then four implants often are required an implant, then four implants often are required for the premaxillary section of the arch a first for the premaxillary section of the arch a first premolar and/or lateral implant may distribute the premolar and/or lateral implant may distribute the working lateral load, and/or the lateral and a working lateral load, and/or the lateral and a central implant can be used for the protrusive central implant can be used for the protrusive excursion. Hence a minimum of two implants is excursion. Hence a minimum of two implants is most often required for each direction of most often required for each direction of excursion in a completely edentulous premaxilla, excursion in a completely edentulous premaxilla, and three implants may be required when there and three implants may be required when there are additional forces (especially with bruxism). are additional forces (especially with bruxism). This means the edentulous anterior maxilla often This means the edentulous anterior maxilla often requires four implantsrequires four implantswww.indiandentalacademy.comwww.indiandentalacademy.com

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A, Splinted maxillary implants in canine and lateral A, Splinted maxillary implants in canine and lateral incisor regions allow lateral incisor implants to support incisor regions allow lateral incisor implants to support protrusive movement. Right lateral incisor and canine protrusive movement. Right lateral incisor and canine support the right excursive movement, and left lateral and support the right excursive movement, and left lateral and canine implants support the left excursion. Because more canine implants support the left excursion. Because more force is generated in a lateral excursion, implants in this force is generated in a lateral excursion, implants in this arrangement are more ideal. arrangement are more ideal. www.indiandentalacademy.comwww.indiandentalacademy.com

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B, Splinted maxillary implants in regions of the central B, Splinted maxillary implants in regions of the central incisors and canines also can disocclude lateral forces with incisors and canines also can disocclude lateral forces with two implants. Esthetics of central implant crowns are more two implants. Esthetics of central implant crowns are more difficult than crowns on lateral incisor implants. Lateral difficult than crowns on lateral incisor implants. Lateral excursions include the lateral incisor region more often excursions include the lateral incisor region more often than the central incisor. Therefore this implant pattern is than the central incisor. Therefore this implant pattern is less ideal. less ideal.


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C, Splinted maxillary implants placed in canine and first C, Splinted maxillary implants placed in canine and first premolar regions are acceptable, but occlusal excursions premolar regions are acceptable, but occlusal excursions are difficult to design and have greater force on implants. are difficult to design and have greater force on implants. Protrusive force on canines often require altered incisal Protrusive force on canines often require altered incisal edge positions for the mandible. Lateral excursions give edge positions for the mandible. Lateral excursions give greater force than other options because the premolars are greater force than other options because the premolars are in contact. Therefore this pattern is less ideal.in contact. Therefore this pattern is less ideal.www.indiandentalacademy.comwww.indiandentalacademy.com

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Treatment OptionsTreatment Options Fixed partial dentureFixed partial denture Removable partial denture.Removable partial denture. Acid-etched bridgeAcid-etched bridge Implant-supported prosthesisImplant-supported prosthesis Combination of implant and tooth retained Combination of implant and tooth retained

restorationrestoration Contraindications of FPD Contraindications of FPD 1.1. Poor abutment teeth supportPoor abutment teeth support2.2. Inadequate edentulous bone for proper pontic contour.Inadequate edentulous bone for proper pontic contour.3.3. Anterior diastemas that the patient wants to maintain.Anterior diastemas that the patient wants to maintain.


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Local Contra IndicationsLocal Contra Indications

Inadequate bone volumeInadequate bone volume1.1. Width – lessthan 5mmWidth – lessthan 5mm

2.2. Length – less than 6 mm for a 3.2 mm implantLength – less than 6 mm for a 3.2 mm implant

3.3. HeightHeight Inadequate interarch spaceInadequate interarch space Mobility of 2 – 4 adjacent teeth.Mobility of 2 – 4 adjacent teeth.


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Limitations Limitations

1.1. TimeTime2.2. Removable transitional applianceRemovable transitional appliance3.3. Potential damage to adjacent teeth caused by Potential damage to adjacent teeth caused by

angulation and proximityangulation and proximity4.4. Challenging estheticsChallenging esthetics5.5. Frequent need for bone augmentationsFrequent need for bone augmentations6.6. age (adolescents)age (adolescents)7.7. Risk of failuresRisk of failures8.8. ExpensiveExpensive


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Introduction Introduction The surgical and prosthetic protocols for a predictable The surgical and prosthetic protocols for a predictable

direct bone to implant interface with root form implants direct bone to implant interface with root form implants were developed and reported by Branemark.were developed and reported by Branemark.

To reduce early implant failure, attention must be brought To reduce early implant failure, attention must be brought to the strength of the bone to implant interface during to the strength of the bone to implant interface during early implant loading.early implant loading.

Once an initial direct bone-to-implant interface has been Once an initial direct bone-to-implant interface has been obtained and confirmed at the post-healing Stage If obtained and confirmed at the post-healing Stage If surgery, the implant is most at risk for failure or crestal surgery, the implant is most at risk for failure or crestal bone loss within the first year.2-" This occurs primarily bone loss within the first year.2-" This occurs primarily as a result of excessive stress and/or poor bone strength as a result of excessive stress and/or poor bone strength at the interface. at the interface. www.indiandentalacademy.comwww.indiandentalacademy.com

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If the treatment plan is satisfactory for adequate If the treatment plan is satisfactory for adequate support, the three most common causes of early support, the three most common causes of early prosthetic-related implant failure are non-passive prosthetic-related implant failure are non-passive superstructures, partially un-retained restorations, superstructures, partially un-retained restorations, and loading of the implant support system and loading of the implant support system beyond the strength of the bone-to-implant beyond the strength of the bone-to-implant interface. interface.

The concept of progressive or gradual bone The concept of progressive or gradual bone loading during prosthetic reconstruction to loading during prosthetic reconstruction to decrease crestal bone loss and early implant decrease crestal bone loss and early implant failure of endosteal implants in 1980 on the. basis failure of endosteal implants in 1980 on the. basis of empirical information." of empirical information." www.indiandentalacademy.comwww.indiandentalacademy.com

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Bone DensityBone Density Wolff's law states, "Every change in the form and Wolff's law states, "Every change in the form and

function of bone or of their function alone is function of bone or of their function alone is followed by certain definite changes in their followed by certain definite changes in their internal architecture, and equally definite internal architecture, and equally definite alteration in their external conformation, in alteration in their external conformation, in accordance with mathematical laws." This accordance with mathematical laws." This phenomenon occurs throughout the skeletal phenomenon occurs throughout the skeletal system as evidenced by a 15% decrease in the system as evidenced by a 15% decrease in the cortical plate and extensive trabecular loss to bone cortical plate and extensive trabecular loss to bone immobilized for 3 months. Cortical bone decrease immobilized for 3 months. Cortical bone decrease of 40% and trabecular bone decrease of 12% have of 40% and trabecular bone decrease of 12% have also been reported in response to disuse. also been reported in response to disuse. www.indiandentalacademy.comwww.indiandentalacademy.com

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Generalized loss of bone volume and density occurs Generalized loss of bone volume and density occurs in regions of tooth loss from a decrease in in regions of tooth loss from a decrease in microstrain to the bone. microstrain to the bone.

The density decrease in the jaws is related to The density decrease in the jaws is related to The length of time the region has been edentulous, The length of time the region has been edentulous, The original density of bone, muscle attachments, The original density of bone, muscle attachments, Bone flexure and torsion, Bone flexure and torsion, Parafunction before and after tooth loss, Parafunction before and after tooth loss, Hormonal influence, and Hormonal influence, and Systemic conditions Systemic conditions


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Bone responds to both hormonal and Bone responds to both hormonal and biomechanical regulation. Even in instances where biomechanical regulation. Even in instances where there is a large demand for calcium (the primary there is a large demand for calcium (the primary objective for hormonal regulation), functional objective for hormonal regulation), functional loading can compete and maintain bone mass.loading can compete and maintain bone mass.

Bone cells in conjunction with the extra-cellular Bone cells in conjunction with the extra-cellular matrix comprise the strain-sensitive population, matrix comprise the strain-sensitive population, and each plays a vital role in the mediation of the and each plays a vital role in the mediation of the interface.interface.

Numerous investigators have generated in vitro Numerous investigators have generated in vitro data to determine the direct relationships of elastic data to determine the direct relationships of elastic modulus, structural density, and ultimate strength modulus, structural density, and ultimate strength of bone. of bone.


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The trabecular bone strength in the jaws The trabecular bone strength in the jaws related to these conditions was reported by related to these conditions was reported by Qu et al. Qu et al.

The bone strength is directly related to The bone strength is directly related to density, with DI bone 10 times stronger than density, with DI bone 10 times stronger than D4 bone to stresses that cause microfracture. D4 bone to stresses that cause microfracture. Therefore increasing bone density around an Therefore increasing bone density around an implant increases the strength of bone, which implant increases the strength of bone, which in turn can help avoid crestal bone loss and/or in turn can help avoid crestal bone loss and/or implant failure. implant failure.


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Bone-to-Implant Interface Bone-to-Implant Interface The biomechanical environment plays an intricate role in The biomechanical environment plays an intricate role in

the quality and compositional outcome of the new the quality and compositional outcome of the new implant-to-bone interface. Functional loading of the implant-to-bone interface. Functional loading of the implant brings additional biomechanical influences, implant brings additional biomechanical influences, which greatly affects its maturation. which greatly affects its maturation.

The ideal bone for prosthetic support is lamellar bone. It The ideal bone for prosthetic support is lamellar bone. It is highly organized but takes approximately 1 year to is highly organized but takes approximately 1 year to completely mineralize after the trauma induced by completely mineralize after the trauma induced by implant placement. Woven bone is the fastest and first implant placement. Woven bone is the fastest and first type of bone to form around the implant interface; type of bone to form around the implant interface; however, it is only partly mineralized and demonstrates however, it is only partly mineralized and demonstrates an unorganized structure less able to withstand full-scale an unorganized structure less able to withstand full-scale stresses. stresses.


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At 16 weeks the surrounding bone is only 70% At 16 weeks the surrounding bone is only 70% mineralized and still exhibits woven bone as a mineralized and still exhibits woven bone as a component.component.

The percentage of bone mineralization and the The percentage of bone mineralization and the type of supporting bone both influence whether a type of supporting bone both influence whether a load to the bone-to-implant interface is within its load to the bone-to-implant interface is within its physiologic limits.physiologic limits.

The greatest stress around a rigidly fixated occurs The greatest stress around a rigidly fixated occurs at the crest. A premature or excessive load may at the crest. A premature or excessive load may overstress the system and cause bone resorption overstress the system and cause bone resorption this region.', The stress applied to an implant may this region.', The stress applied to an implant may also lead to implant failure if it exceeds the also lead to implant failure if it exceeds the physiologic limits of the bone density present physiologic limits of the bone density present around the implant. around the implant. www.indiandentalacademy.comwww.indiandentalacademy.com

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As bone responds to physiologic forces, a gradual As bone responds to physiologic forces, a gradual increase in loads during prosthetic fabrications increase in loads during prosthetic fabrications stimulates an increase in density.stimulates an increase in density.

Thicker regions of lamellar cortical bone Thicker regions of lamellar cortical bone appeared around the loaded compared with appeared around the loaded compared with unloaded implants. The major bone increase in unloaded implants. The major bone increase in density and amount was observed in the crestal density and amount was observed in the crestal region around the loaded implants. region around the loaded implants.


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The macroscopic ranges in jaw bone density demonstrate The macroscopic ranges in jaw bone density demonstrate a physical difference in the amount of cortical and a physical difference in the amount of cortical and trabecular bone. As a result, the actual amount of bone in trabecular bone. As a result, the actual amount of bone in initial contact with the surface of the implant varies with initial contact with the surface of the implant varies with the bone density. the bone density.

In D4 bone approximately 25% of the implant may be in In D4 bone approximately 25% of the implant may be in contact with bone, contact with bone,

D3 bone has approximately~ 50% bone contact, D3 bone has approximately~ 50% bone contact, D2 bone about 70% bone interface, andD2 bone about 70% bone interface, and DI bone around 80%. DI bone around 80%. The greater bone contact improves the force distribution The greater bone contact improves the force distribution

and decreases the stress transmitted to any one region on and decreases the stress transmitted to any one region on the implant body. Hence similar loads applied to different the implant body. Hence similar loads applied to different bone densities may result in totally different adaptive or bone densities may result in totally different adaptive or failure responses. failure responses. www.indiandentalacademy.comwww.indiandentalacademy.com

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The implementation of progressive loading is The implementation of progressive loading is more critical for lesser bone densities because more critical for lesser bone densities because they are several times weaker than those with they are several times weaker than those with significant cortical bone. significant cortical bone.

Para-function, cantilevers, and other stress Para-function, cantilevers, and other stress magnifiers can increase the forces applied to the magnifiers can increase the forces applied to the prosthesis as well as their shear components and prosthesis as well as their shear components and cause bone micro-fracture or micro-strains in the cause bone micro-fracture or micro-strains in the pathologic zone around the implant.pathologic zone around the implant.

Progressive bone loading aims at increasing the Progressive bone loading aims at increasing the density of bone, decreasing the risk of implant-density of bone, decreasing the risk of implant-bone failure, and decreasing crestal bone loss.bone failure, and decreasing crestal bone loss.


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PROGRESSIVE LOADING PROGRESSIVE LOADING PROTOCOLPROTOCOL

Time intervalTime interval DietDiet Occlusal materialOcclusal material Occlusal contactsOcclusal contacts ProsthesesProstheses DesignDesign


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Time IntervalTime Interval The two surgical appointments used for initial implant The two surgical appointments used for initial implant

placement and Stage II un-covery are separated by 4 to 8 placement and Stage II un-covery are separated by 4 to 8 months depending on the bone density at the initial months depending on the bone density at the initial surgery. surgery.

Five prosthodontic steps are suggested for the Five prosthodontic steps are suggested for the reconstruction of a partially or completely edentulous reconstruction of a partially or completely edentulous patient, with endosteal implants supporting a cemented patient, with endosteal implants supporting a cemented prosthesis. Each of the five major prosthodontic prosthesis. Each of the five major prosthodontic appointments are also separated by a period of time appointments are also separated by a period of time related to the bone density observed at the initial time of related to the bone density observed at the initial time of surgery. In addition, an attempt is made to gradually surgery. In addition, an attempt is made to gradually increase the load to the implant at each prosthetic step.increase the load to the implant at each prosthetic step.www.indiandentalacademy.comwww.indiandentalacademy.com

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The macroscopic coarse trabecular bone heals The macroscopic coarse trabecular bone heals approximately 50% faster than dense cortical bone. approximately 50% faster than dense cortical bone.

DI bone has the greatest strength and greater bone DI bone has the greatest strength and greater bone contact, so even though it heals in a slower fashion, contact, so even though it heals in a slower fashion, the bone-implant contact at the interface is high the bone-implant contact at the interface is high and of lamellar type. Therefore the healing time and of lamellar type. Therefore the healing time between the initial and second stage surgeries is between the initial and second stage surgeries is kept similar for D1 and D2 bone. kept similar for D1 and D2 bone.

A longer time is suggested for the initial healing A longer time is suggested for the initial healing phase of D3 and D4 bone (6 and 8 months, phase of D3 and D4 bone (6 and 8 months, respectively) because of the lesser bone contact and respectively) because of the lesser bone contact and decreased amount of cortical bone. This allows decreased amount of cortical bone. This allows additional time for the maturation of the interface additional time for the maturation of the interface and the development of some lamellar bone. and the development of some lamellar bone. www.indiandentalacademy.comwww.indiandentalacademy.com

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The D4 implant-to-bone interface typically found in The D4 implant-to-bone interface typically found in posterior regions of the maxilla exhibits minimum initial posterior regions of the maxilla exhibits minimum initial bone contact, with little to no cortical bone at the crest or bone contact, with little to no cortical bone at the crest or apex. An implant surgery may initially trigger an increase apex. An implant surgery may initially trigger an increase in the amount of bone in the region. For example, bone in the amount of bone in the region. For example, bone has been shown to grow in contact of a submerged has been shown to grow in contact of a submerged titanium screw inserted into an open marrow chamber of titanium screw inserted into an open marrow chamber of the femur. The initial increase of bone cell activity is the femur. The initial increase of bone cell activity is most likely a result of the surgical trauma and the most likely a result of the surgical trauma and the regional acceleratory phenomenon (RAP)." The regional acceleratory phenomenon (RAP)." The combined observations of the macroscopic amount of combined observations of the macroscopic amount of bone in contact with a non-loaded implant and the bone in contact with a non-loaded implant and the microscopic type of bone at the Stage II surgery of the microscopic type of bone at the Stage II surgery of the implant demonstrates a wide difference in DI to D4 bone implant demonstrates a wide difference in DI to D4 bone densities. However, to improve the bone density and densities. However, to improve the bone density and strength long term, the implant must be loaded.strength long term, the implant must be loaded.


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DI bone benefits from the greatest amount of lamellar DI bone benefits from the greatest amount of lamellar bone contact at the beginning of the restoration process. bone contact at the beginning of the restoration process. As a result, gradual loading of the implant interface As a result, gradual loading of the implant interface through spacing of the prosthodontic. appointment is through spacing of the prosthodontic. appointment is least important, and the restorative appointments can be least important, and the restorative appointments can be separated by as little as a week. separated by as little as a week.

D2 bone is ideal in its ability to respond to physiologic D2 bone is ideal in its ability to respond to physiologic loads. The five prosthetic appointment during which the loads. The five prosthetic appointment during which the implant body is sequentially loaded are separated by implant body is sequentially loaded are separated by approximately 2 or more weeks. As a result, the initial 4 approximately 2 or more weeks. As a result, the initial 4 months of healing after surgery and 2 months for months of healing after surgery and 2 months for prosthesis fabrication make the overall treatment time prosthesis fabrication make the overall treatment time approximately 6 months. approximately 6 months.


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The, prosthodontic appointments for D3 bone The, prosthodontic appointments for D3 bone are separated by at least 3 weeks, and overall are separated by at least 3 weeks, and overall treatment takes almost 10 months to complete, treatment takes almost 10 months to complete, including the 6 months' Stage I healing. including the 6 months' Stage I healing. During this time, the bone contact percentage During this time, the bone contact percentage can increase, and the fine woven bone can increase, and the fine woven bone trabeculae can mature into coarser lamellar trabeculae can mature into coarser lamellar trabeculae, with an increase in mineral content. trabeculae, with an increase in mineral content. The progressive loading process is more The progressive loading process is more critical for D3 bone than for D2 or D1 because critical for D3 bone than for D2 or D1 because of its weakness and lesser initial bone contact. of its weakness and lesser initial bone contact.


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In D4 bone, the progressive bone loading In D4 bone, the progressive bone loading protocol is most critical. The scheduling of protocol is most critical. The scheduling of restorative appointments err on the side of safety, restorative appointments err on the side of safety, separated by at least 4 weeks. As a consequence, separated by at least 4 weeks. As a consequence, the overall treatment time for D4 bone is twice the overall treatment time for D4 bone is twice that of DI Dr D2 bone and at least 12 months that of DI Dr D2 bone and at least 12 months (including 8 months' Stage I healing). This allows (including 8 months' Stage I healing). This allows sufficient time for mature lamellar, mineralized sufficient time for mature lamellar, mineralized bone to develop at the interface, and increases the bone to develop at the interface, and increases the amount of trabeculae in direct contact and within amount of trabeculae in direct contact and within the network region of the implant. the network region of the implant.

When multiple implants are used, the weakest When multiple implants are used, the weakest bone area determines the gradual load protocol.bone area determines the gradual load protocol.www.indiandentalacademy.comwww.indiandentalacademy.com

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DietDiet The diet of the patient is controlled to prevent The diet of the patient is controlled to prevent

overloading during the early phases of the overloading during the early phases of the restorative phase. During the initial healing restorative phase. During the initial healing phase, the patient is instructed to avoid chewing phase, the patient is instructed to avoid chewing in the area. Once uncovered, the implant in the area. Once uncovered, the implant connected to a high abutment is at greater risk of connected to a high abutment is at greater risk of loading during mastication. The patient is limited loading during mastication. The patient is limited to a soft diet such as pasta and fish, from the to a soft diet such as pasta and fish, from the initial transitional prosthesis delivery until the initial transitional prosthesis delivery until the initial delivery of the final prosthesis. The initial delivery of the final prosthesis. The masticatory force for this type of food is masticatory force for this type of food is approximately 10 pounds/in approximately 10 pounds/in 22 of force. of force. www.indiandentalacademy.comwww.indiandentalacademy.com

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This not only minimizes the masticatory force This not only minimizes the masticatory force on the implants on the implants but also decreases the risk of also decreases the risk of temporary restoration fracture or partially temporary restoration fracture or partially uncemented resrotation. Either of these uncemented resrotation. Either of these consequences can overload an implant and consequences can overload an implant and cause unwanted complications. The diet cause unwanted complications. The diet should not be overlooked during the should not be overlooked during the restorative procedure, since most clinicians restorative procedure, since most clinicians have observed the fracture of acrylic have observed the fracture of acrylic prostheses with harder foods and certainly see prostheses with harder foods and certainly see more uncemented restoration when the type of more uncemented restoration when the type of diet is ignored during the transitional diet is ignored during the transitional prosthesis stages.prosthesis stages.


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After the initial delivery of the final prosthesis, After the initial delivery of the final prosthesis, the patient may include meat in the diet, which the patient may include meat in the diet, which requires approximately 21 pounds/in requires approximately 21 pounds/in 22 bite force. bite force. The final restoration can bear the greater force The final restoration can bear the greater force without risk of fracture or uncementation. After without risk of fracture or uncementation. After the final evaluation appointment, the patient may the final evaluation appointment, the patient may include include raw vegetables into the diet. It takes 27 vegetables into the diet. It takes 27 pounds/inpounds/in22 of force to chew a raw carrot. A of force to chew a raw carrot. A normal diet is permitted only after the final normal diet is permitted only after the final prosthesis function, occlusion, and proper prosthesis function, occlusion, and proper cementation are evaluated.cementation are evaluated.


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Occlusal Material Occlusal Material The occlusal material may be varied to gradually The occlusal material may be varied to gradually

load the bone-to-implant interface. During initial load the bone-to-implant interface. During initial steps there is no occlusal material over the steps there is no occlusal material over the implant. During subsequent appointments, acrylic implant. During subsequent appointments, acrylic is used as the occlusal material, with the benefit is used as the occlusal material, with the benefit of a lower impact force than metal or porcelain. of a lower impact force than metal or porcelain. Either metal or porcelain can be used for the Either metal or porcelain can be used for the occlusal aspect of the final prosthesis. If occlusal aspect of the final prosthesis. If parafunction or cantilever length cause concern, parafunction or cantilever length cause concern, the softer diet and acrylic restoration phase may the softer diet and acrylic restoration phase may be extended several months.be extended several months.


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OcclusionOcclusion The occlusal contacts are gradually intensified during The occlusal contacts are gradually intensified during

prosthesis fabrication. prosthesis fabrication. There are no occlusal contacts during initial healing . The There are no occlusal contacts during initial healing . The

first transitional prosthesis is left out of occlusion in first transitional prosthesis is left out of occlusion in partially edentulous patients. partially edentulous patients.

The occlusal contacts are then similar to those of the final The occlusal contacts are then similar to those of the final restoration for areas supported by implants. However, there restoration for areas supported by implants. However, there are no occlusal contacts on any cantilevers. are no occlusal contacts on any cantilevers.

The occlusal contacts of the final restoration follow the The occlusal contacts of the final restoration follow the implant protective occlusal (IPO) concepts. The occlusal implant protective occlusal (IPO) concepts. The occlusal contacts are very important to address, because parafunction contacts are very important to address, because parafunction is common and generates greater stresses in magnitude and is common and generates greater stresses in magnitude and duration than eating food.duration than eating food.www.indiandentalacademy.comwww.indiandentalacademy.com

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Prosthesis DesignProsthesis Design During initial healing, an attempt is made to avoid any load During initial healing, an attempt is made to avoid any load

on the implants, including soft tissue loads, The first on the implants, including soft tissue loads, The first transitional acrylic restoration in partially edentulous transitional acrylic restoration in partially edentulous patients has no occlusal contact and no cantilevers. Its patients has no occlusal contact and no cantilevers. Its purpose is to splint the implants together, to reduce stress by purpose is to splint the implants together, to reduce stress by the biomechanical advantage, and to have implants sustain the biomechanical advantage, and to have implants sustain masticatory forces solely from chewing. The second acrylic masticatory forces solely from chewing. The second acrylic transitional restoration has occlusal contacts above implants transitional restoration has occlusal contacts above implants with occlusal tables similar to the final restoration but no with occlusal tables similar to the final restoration but no cantilevers in nonesthetic regions. The final restoration has cantilevers in nonesthetic regions. The final restoration has the final occlusal table and cantilevers and has occlusal the final occlusal table and cantilevers and has occlusal contacts following IPO guidelines contacts following IPO guidelines


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Progressive Loading Phases Progressive Loading Phases

1. Initial abutment selection and preliminary 1. Initial abutment selection and preliminary impression impression

2. Final impression and transitional prosthesis 1 2. Final impression and transitional prosthesis 1 3. Metal superstructure try-in and transitional 3. Metal superstructure try-in and transitional

prosthesis 11 prosthesis 11 4. Initial insertion of final prosthesis 4. Initial insertion of final prosthesis 5. Final delivery and evaluation5. Final delivery and evaluation


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Progressive Loading for Cement Progressive Loading for Cement Retained ProsthesesRetained Prostheses

First AppointmentFirst Appointment


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Initial Abutment Selection andInitial Abutment Selection andPreliminary ImpressionsPreliminary Impressions

This first prosthetic appointment is to assess the This first prosthetic appointment is to assess the implant and soft tissues and make sure all the implant and soft tissues and make sure all the prosthetic components and details of the next long prosthetic components and details of the next long prosthetic appointment are addressed beforehand. prosthetic appointment are addressed beforehand.

this appointment may occur during either the suture this appointment may occur during either the suture removal appointment after Stage 11 surgery or removal appointment after Stage 11 surgery or during the uncovery procedure. In the team during the uncovery procedure. In the team approach, the suture removal is scheduled with the approach, the suture removal is scheduled with the doctor placing the healing permucosal extension, doctor placing the healing permucosal extension, and the tissue may be reassessed before referral for and the tissue may be reassessed before referral for the prosthodontic procedures. the prosthodontic procedures. www.indiandentalacademy.comwww.indiandentalacademy.com

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A sulcus depth greater than 5 mm requires A sulcus depth greater than 5 mm requires correction. The patient is referred to the restoring correction. The patient is referred to the restoring dentist once the proper soft tissue contour and dentist once the proper soft tissue contour and health has been achieved.health has been achieved.

The Stage 11 permucosal extensions are removed The Stage 11 permucosal extensions are removed by the restoring dentist, and straight abutments for by the restoring dentist, and straight abutments for cement retention or indirect impression transfers cement retention or indirect impression transfers are. The abutment for cement retention is placed are. The abutment for cement retention is placed with finger pressure and no torque wrench with finger pressure and no torque wrench because of the immature interface and also because of the immature interface and also because the abutment will be removed at the end because the abutment will be removed at the end of this appointment. of this appointment.


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Once straight abutments for cement are placed in Once straight abutments for cement are placed in the implants, they are evaluated as to parallelism to the implants, they are evaluated as to parallelism to each other and the natural teeth. If abutments each other and the natural teeth. If abutments diverge more than 30 degrees the preliminary diverge more than 30 degrees the preliminary impression will be very difficult to remove from the impression will be very difficult to remove from the mouth. When abutments are angled more 30 mouth. When abutments are angled more 30 degrees, a two-piece angled abutment and fixation degrees, a two-piece angled abutment and fixation screw are inserted for the preliminary impression. screw are inserted for the preliminary impression. The angled two-piece abutment system permits a The angled two-piece abutment system permits a conventional Impression to be removed from conventional Impression to be removed from nonparallel abutment . An alternate technique is to nonparallel abutment . An alternate technique is to use a direct impression transfer coping for the use a direct impression transfer coping for the implant body and a long fixation screw. The long implant body and a long fixation screw. The long fixation screw, however, must exit the occlusal of fixation screw, however, must exit the occlusal of the impression tray. the impression tray. www.indiandentalacademy.comwww.indiandentalacademy.com

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Once the impression material is set The screw is Once the impression material is set The screw is unthreaded, and the impression may be removed from the unthreaded, and the impression may be removed from the mouth '. with the direct impression coping in the mouth '. with the direct impression coping in the impression. The occlusal plane is also corrected to the impression. The occlusal plane is also corrected to the proper curves of Wilson and Spee at this appointment.proper curves of Wilson and Spee at this appointment.

The abutments for cement are removed, implant body The abutments for cement are removed, implant body analogs are attached, and the abutments are inserted into analogs are attached, and the abutments are inserted into the corresponding position within the impression. The low-the corresponding position within the impression. The low-profile permucosal healing caps are reinserted into the profile permucosal healing caps are reinserted into the implant bodies. An occlusal bite registration is made in implant bodies. An occlusal bite registration is made in centric relation occlusion. The patient is sent with centric relation occlusion. The patient is sent with instructions not to chew in the region and to gently clean instructions not to chew in the region and to gently clean the permucosal extensions with chlorhexidine the permucosal extensions with chlorhexidine


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Laboratory Phase - ILaboratory Phase - I

The laboratory technician pours the impression The laboratory technician pours the impression and attaches analogs with dental stone. The and attaches analogs with dental stone. The model are separated and mounted to the opposing model are separated and mounted to the opposing arch with the bite registration.arch with the bite registration.

The implant abutments are prepared for height, The implant abutments are prepared for height, parallelism, and position within the prosthesis parallelism, and position within the prosthesis contours. contours.


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A one-piece abutment for cement retention is used A one-piece abutment for cement retention is used for multiple implant restorations to decrease the for multiple implant restorations to decrease the decrease the use of abutment fixation screw decrease the use of abutment fixation screw loosening long term.loosening long term.

Two transitional acrylic prostheses may then be Two transitional acrylic prostheses may then be fabricated. Ideally, for partially edentulous fabricated. Ideally, for partially edentulous patients, the first transitional restoration is patients, the first transitional restoration is completely out of occlusion its primary purpose is completely out of occlusion its primary purpose is to rigidly splint the implants together. If a to rigidly splint the implants together. If a cantilever is present, no occlusal contact on the cantilever is present, no occlusal contact on the cantilevered portion should exist.cantilevered portion should exist.


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•Healing Abutment stage.•Preliminary impression procedure. •Soft diet.•No occlusal material.•Nil occlusal contacts. www.indiandentalacademy.comwww.indiandentalacademy.com

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Second AppointmentSecond Appointment


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Final Impression and Transitional Final Impression and Transitional Prosthesis IProsthesis I

The, patient returns after 1 to 4 weeks, The, patient returns after 1 to 4 weeks, depending on bone density. The permucosal depending on bone density. The permucosal extensions are removed from the implant extensions are removed from the implant bodies. A one-piece straight abutment is used bodies. A one-piece straight abutment is used for multiple abutment restorations when for multiple abutment restorations when possible. An anaerobic setting sealer is used possible. An anaerobic setting sealer is used on the abutment screw, and the abutment is on the abutment screw, and the abutment is hand, threaded into position with hand, threaded into position with approximately 10 N-cm force. approximately 10 N-cm force.


152152

The complete seating of the abutment is verified The complete seating of the abutment is verified with a radiograph. For a single tooth or angled with a radiograph. For a single tooth or angled implant,-a two-piece abutment is inserted using a implant,-a two-piece abutment is inserted using a counter torque system and torque wrench to counter torque system and torque wrench to preload the abutment screw at a 20 to 35 N-cm preload the abutment screw at a 20 to 35 N-cm force, depending on screw material and design. force, depending on screw material and design.

One piece abutments do not need preload, as long One piece abutments do not need preload, as long as the preparation has one or two flat sides on the as the preparation has one or two flat sides on the abutments to prevent unthreading or rotation abutments to prevent unthreading or rotation within the prosthesis.within the prosthesis.

Final abutment preparation is performed at this Final abutment preparation is performed at this appointment. appointment.


153153

The amount of retention is evaluated on the The amount of retention is evaluated on the abutments. When a subgingival margin is abutments. When a subgingival margin is indicated, retraction cord may be placed in the indicated, retraction cord may be placed in the sulcus. The transitional prosthesis may also be sulcus. The transitional prosthesis may also be relined to create an emergence profile below the relined to create an emergence profile below the tissue, if necessary. Another alternative is to tissue, if necessary. Another alternative is to remove the abutment, place it into an implant remove the abutment, place it into an implant analog, and prepare it out of the mouth. The analog, and prepare it out of the mouth. The abutment and analog may be coated with water-abutment and analog may be coated with water-soluble lubricant and reinserted into the transitional soluble lubricant and reinserted into the transitional restoration.restoration.


154154

The margins of the restoration may be extended to the The margins of the restoration may be extended to the abutment margin and develop the emergence profile of the abutment margin and develop the emergence profile of the final crown. An impression may then be made of the final crown. An impression may then be made of the abutment, and a separate die may be poured in dental stone. abutment, and a separate die may be poured in dental stone. The abutment post is reinserted into the implant body and The abutment post is reinserted into the implant body and tightened to 10 N-cm tightened to 10 N-cm 66. A final impression is obtained. The . A final impression is obtained. The centric occlusal registration is recorded. An face-bow record centric occlusal registration is recorded. An face-bow record is made, along with protrusive and check bites when is made, along with protrusive and check bites when required. The first transitional prosthesis is luted with a required. The first transitional prosthesis is luted with a noneugenol zinc oxide cement, and there is a total absence noneugenol zinc oxide cement, and there is a total absence of occlusal contacts. Petroleum jelly may be added to the of occlusal contacts. Petroleum jelly may be added to the cement when the restoration is very retentive, to facilitate cement when the restoration is very retentive, to facilitate the transitional prosthesis retrieval at the next appointment.the transitional prosthesis retrieval at the next appointment.


155155

The patient is notified that If too much force is The patient is notified that If too much force is placed on the implant too early, the implant may placed on the implant too early, the implant may become loose or bone may be lost around the become loose or bone may be lost around the implant. Either will cause additional time and implant. Either will cause additional time and expense to treat. Therefore the patient is told to expense to treat. Therefore the patient is told to avoid this region of the mouth while eating. The avoid this region of the mouth while eating. The diet should consist of soft food like pastas or fish. diet should consist of soft food like pastas or fish. No sticky foods or gum should ever be chewed, No sticky foods or gum should ever be chewed, and aggressive chewing or oral habits that may and aggressive chewing or oral habits that may cause the temporary to loosen or break should be cause the temporary to loosen or break should be avoided. The implants now belong to the patient, avoided. The implants now belong to the patient, and he or she is responsible for them, just as for the and he or she is responsible for them, just as for the other teeth in the mouth.other teeth in the mouth.www.indiandentalacademy.comwww.indiandentalacademy.com

156156

Laboratory Phase IILaboratory Phase II The final impressions are poured with die stone. The final impressions are poured with die stone.

Models are mounted following prosthodontic Models are mounted following prosthodontic principles. Porcelain fracture is more common on principles. Porcelain fracture is more common on implants than teeth, and unsupported porcelain is implants than teeth, and unsupported porcelain is more common on small-diameter implant more common on small-diameter implant abutments. A full-contour wax-up and cut down of abutments. A full-contour wax-up and cut down of 2 mm in regions of porcelain is made for the 2 mm in regions of porcelain is made for the prostheses framework. A precious metal prostheses framework. A precious metal superstructure is fabricated. An occlusal acrylic superstructure is fabricated. An occlusal acrylic index is used to indicate the occlusal registration index is used to indicate the occlusal registration recorded for the implant-supported prostheses.recorded for the implant-supported prostheses.www.indiandentalacademy.comwww.indiandentalacademy.com

157157

•Transitional prosthesis I.•Final impression procedure.•Soft diet.•Acrylic occlusal material.•No occlusal contacts & cantilever.


158158

Third AppointmentThird Appointment


159159

Metal Try-inMetal Try-in The patient returns in 1 to 4 weeks (or more)

depending on the bone density. The first transitional restoration is removed and its retention evaluated to help select the proper luting agent for the final restoration. The superstructure is tried-in. Since the patient is not anesthetized and the mouth has only been open a few minutes the centric relation can be checked easier than at the previous appointment. If the patient bites into the laboratory occlusal acrylic index, the previous record was accurately registered.


160160

If incorrect, the occlusion is evaluated and corrected as indicated, and a closed mouth centric occlusal registration is recorded using a rigid addition silicone on top of the casting.

The second transitional prosthesis is delivered. The second transitional prosthesis is delivered. This may be a new transitional prosthesis or the This may be a new transitional prosthesis or the first transitional with a modified occlusal table first transitional with a modified occlusal table through the addition of acrylic on the occlusal through the addition of acrylic on the occlusal contact areas. Occlusion is evaluated using a contact areas. Occlusion is evaluated using a heavy bite force occlusal adjustment. Occlusal heavy bite force occlusal adjustment. Occlusal contacts are limited to those directly on implant contacts are limited to those directly on implant bodies. The diet remains soft with pasta, fish, or bodies. The diet remains soft with pasta, fish, or softer food types.softer food types.


161161

Laboratory Phase IIILaboratory Phase III

The prosthesis is completed with an occlusal The prosthesis is completed with an occlusal scheme that follows IPO guidelines and with scheme that follows IPO guidelines and with occlusal contacts corresponding to the long occlusal contacts corresponding to the long axis of each implant body. The laboratory axis of each implant body. The laboratory evaluates the first model of the preliminary evaluates the first model of the preliminary impression. Angled implant bodies are noted, impression. Angled implant bodies are noted, so the occlusal contacts may be modified to be so the occlusal contacts may be modified to be in the long axis of the implant body, or in the long axis of the implant body, or reduced in intensity.reduced in intensity.


162162

•Transitional prosthesis II.•Metal tryin, modify provisional I.•Soft diet.•Acrylic occlusal material.•Contacts only on implant, no contacts on pontics and cantilevers.•Occlusal table same as final prosthesis.


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Fourth AppointmentFourth Appointment


164164

Initial Prosthesis DeliveryInitial Prosthesis Delivery The next appointment follows I to 4 weeks later The next appointment follows I to 4 weeks later

depending on the bone density. The transitional depending on the bone density. The transitional prosthesis is removed and its retention evaluated prosthesis is removed and its retention evaluated to help select the cement used in the final to help select the cement used in the final prosthesis. If satisfactory, similar cement is used prosthesis. If satisfactory, similar cement is used at the initial delivery of the final restoration. The at the initial delivery of the final restoration. The final restoration is inserted and carefully final restoration is inserted and carefully evaluated relative to occlusal contacts. After a evaluated relative to occlusal contacts. After a light bite force is used to equilibrate the occlusal light bite force is used to equilibrate the occlusal contacts, a heavy bite force occlusal adjustment is contacts, a heavy bite force occlusal adjustment is made, with no lateral contacts in excursions.made, with no lateral contacts in excursions.


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A radiograph is obtained and used as a baseline for A radiograph is obtained and used as a baseline for future radiographic evaluation for crestal bone loss future radiographic evaluation for crestal bone loss and implant health. If crestal bone loss is observed and implant health. If crestal bone loss is observed when compared with the Stage II uncovery when compared with the Stage II uncovery appointment, parafunction is suspected, and night appointment, parafunction is suspected, and night guards are fabricated to control stresses.guards are fabricated to control stresses.

The bone has benefited from the additional time The bone has benefited from the additional time and is now more mineralized and exhibits and is now more mineralized and exhibits improved load-bearing capability than at the first improved load-bearing capability than at the first transitional prosthesis delivery. In addition, the transitional prosthesis delivery. In addition, the stronger final restoration (compared with stronger final restoration (compared with transitional) can sustain greater masticatory loads. transitional) can sustain greater masticatory loads. Therefore the diet of the patient may now include Therefore the diet of the patient may now include slightly harder foods, such as meat.slightly harder foods, such as meat.


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•Final prostheses.Occlusion adjusted.•Harder diet.•Metal or porcelain occlusal material.•Occlusion follows IPO guidelines.•Narrow occlusal table. www.indiandentalacademy.comwww.indiandentalacademy.com

167167

Fifth AppointmentFifth Appointment


168168

Final Delivery and EvaluationFinal Delivery and Evaluation

The patient returns in approximately 4 weeks. The patient returns in approximately 4 weeks. The restoration is retrieved and evaluated as to The restoration is retrieved and evaluated as to retention. If adequate, a similar cement strength retention. If adequate, a similar cement strength is used for the final delivery. The soft tissues and is used for the final delivery. The soft tissues and home care are evaluated, a final occlusal home care are evaluated, a final occlusal equilibration is performed, and the restoration is equilibration is performed, and the restoration is cemented. The diet of the patient may now cemented. The diet of the patient may now include raw vegetables and harder foods. The include raw vegetables and harder foods. The patient is scheduled for a maintenance patient is scheduled for a maintenance appointment in 3 to 4 months appointment in 3 to 4 months


169169

Progressive loading in Completely Progressive loading in Completely Edentulous Patient ProtocolEdentulous Patient Protocol

FIRST APPOINTMENTFIRST APPOINTMENT


170170

Initial Abutment Selection and Initial Abutment Selection and Preliminary ImpressionPreliminary Impression

During surgical phases, a treatment prosthesis is During surgical phases, a treatment prosthesis is fabricated. It restores the patient to the proper occlusal fabricated. It restores the patient to the proper occlusal vertical dimension (OVD) and determines the correct vertical dimension (OVD) and determines the correct tooth position for the final prosthesis. At Stage 11 tooth position for the final prosthesis. At Stage 11 uncovery, the surgical template fabricated from the uncovery, the surgical template fabricated from the treatment prosthesis is used to assess the position of the treatment prosthesis is used to assess the position of the implant bodies with regard to angulation and soft tissue implant bodies with regard to angulation and soft tissue support. It may be used as a guide to augment the soft support. It may be used as a guide to augment the soft tissue thickness as dictated by esthetics. During the tissue thickness as dictated by esthetics. During the preliminary impression and initial abutment selection preliminary impression and initial abutment selection appointment, an initial record of the OVD and jaw appointment, an initial record of the OVD and jaw relationships is also obtained, if the laboratory is to relationships is also obtained, if the laboratory is to fabricate the transitional prostheses, fabricate the transitional prostheses, www.indiandentalacademy.comwww.indiandentalacademy.com

171171

A clear template (0.008 inch) is fabricated over a A clear template (0.008 inch) is fabricated over a study model made from the treatment prosthesis. study model made from the treatment prosthesis. All the following steps can be performed at Stage All the following steps can be performed at Stage II uncovery (if all soft and hard tissue criteria are II uncovery (if all soft and hard tissue criteria are satisfactory) or at suture removal. The clear satisfactory) or at suture removal. The clear template (.008 inch) is placed in position over the template (.008 inch) is placed in position over the denture, and both are inserted together into the denture, and both are inserted together into the mouth. A centric relation registration is obtained, mouth. A centric relation registration is obtained, and the denture is then removed from the and the denture is then removed from the template. The straight abutments for cement template. The straight abutments for cement retention, are inserted into the implant bodies. The retention, are inserted into the implant bodies. The template and bite registration are positioned over template and bite registration are positioned over the straight abutments for cement and serve as a the straight abutments for cement and serve as a custom impression tray. custom impression tray.


172172

Putty impression material may first be placed in the palate Putty impression material may first be placed in the palate region of the clear template for maxillary restorations and region of the clear template for maxillary restorations and accounts for the thickness of the palate portion of the accounts for the thickness of the palate portion of the complete denture. The length of the abutments is complete denture. The length of the abutments is evaluated. Minor corrections may be performed evaluated. Minor corrections may be performed intraorally. Once properly seated the clear prosthetic intraorally. Once properly seated the clear prosthetic template is evaluated for lip position, esthetics, and template is evaluated for lip position, esthetics, and vertical centric occlusion. The clear prosthetic ~template vertical centric occlusion. The clear prosthetic ~template is then filled with an addition silicone and reinserted. The is then filled with an addition silicone and reinserted. The patient closes into the previous occlusal recording (Plates patient closes into the previous occlusal recording (Plates 123 and 124). The template impression and bite 123 and 124). The template impression and bite registration are removed and serve as a preliminary registration are removed and serve as a preliminary impression and initial OVD record to be mounted in the impression and initial OVD record to be mounted in the laboratory to the opposing arch impression.laboratory to the opposing arch impression.


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If a prosthetic template/custom tray was not If a prosthetic template/custom tray was not fabricated beforehand, a roll of addition silicone fabricated beforehand, a roll of addition silicone putty is placed onto the abutments for cement, putty is placed onto the abutments for cement, and the mandible is guided to centric relation and the mandible is guided to centric relation occlusion at the approximate vertical dimension. occlusion at the approximate vertical dimension. A preliminary impression is then made of the A preliminary impression is then made of the abutments for cement and of the opposing arch.abutments for cement and of the opposing arch.

The abutments for cement are removed, The abutments for cement are removed, attached to the implant body analogs, and seated attached to the implant body analogs, and seated into the impression. The Stage II permucosal into the impression. The Stage II permucosal extensions are reinserted into the implant extensions are reinserted into the implant bodies. bodies.


174174

The soft liner is relieved over the permucosal The soft liner is relieved over the permucosal extensions. The patient is instructed to limit extensions. The patient is instructed to limit mastication to very soft foods and remove the mastication to very soft foods and remove the denture at night to prevent nocturnal denture at night to prevent nocturnal parafunction. Parafunction during this time is a parafunction. Parafunction during this time is a major concern of overload for the completely major concern of overload for the completely edentulous patient, because the implants are edentulous patient, because the implants are independent and do not have the biomechanical independent and do not have the biomechanical advantage of splinting, since a fixed transitional advantage of splinting, since a fixed transitional prosthesis is not inserted. The patient returns in prosthesis is not inserted. The patient returns in I to 2 weeks for the next prosthetic appointment.I to 2 weeks for the next prosthetic appointment.


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Laboratory Phase ILaboratory Phase I Laboratory steps following the first prosthetic Laboratory steps following the first prosthetic

appointment include pouring the preliminary impression appointment include pouring the preliminary impression with the implant abutment and implant body analogs in with the implant abutment and implant body analogs in dental stone. The casts are mounted on an articulator dental stone. The casts are mounted on an articulator using the prosthetic template/custom tray and occlusal using the prosthetic template/custom tray and occlusal registration before it is separated from the cast. The registration before it is separated from the cast. The abutments may be adjusted in length, angulation, and abutments may be adjusted in length, angulation, and proper clearance for crown contours using the clear proper clearance for crown contours using the clear overlay template of the wax-up 'or denture as a guide. A overlay template of the wax-up 'or denture as a guide. A wax-up using denture teeth elaborates the proposed form wax-up using denture teeth elaborates the proposed form of the final prosthesis. A clear template is fabricated over of the final prosthesis. A clear template is fabricated over this waxup.this waxup.


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A transitional acrylic prosthesis is then fabricated on the A transitional acrylic prosthesis is then fabricated on the study cast using the clear prosthetic template that was used study cast using the clear prosthetic template that was used to evaluate the abutments. No posterior cantilever should be to evaluate the abutments. No posterior cantilever should be present on this first transitional restoration, unless required present on this first transitional restoration, unless required for esthetics. Pontics also should be left out of occlusion. for esthetics. Pontics also should be left out of occlusion. Ideally, only implants that can be loaded with axial forces Ideally, only implants that can be loaded with axial forces within 20 degrees should exhibit occlusal contacts at this within 20 degrees should exhibit occlusal contacts at this early loading stage. There are no posterior contacts during early loading stage. There are no posterior contacts during excursions if adequate anterior teeth or implants are present, excursions if adequate anterior teeth or implants are present, especially when the restoration opposes a fixed or natural especially when the restoration opposes a fixed or natural dentition. Posterior occlusal tables are very narrow and dentition. Posterior occlusal tables are very narrow and ideally correspond to the width of the abutment. The first ideally correspond to the width of the abutment. The first transitional restoration is designed to completely fill in the transitional restoration is designed to completely fill in the interproximal areas of the implants in the premaxilla. interproximal areas of the implants in the premaxilla.


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Difficulty in speech is a common complication reported Difficulty in speech is a common complication reported when restoring a completely edentulous maxillary arch when restoring a completely edentulous maxillary arch with a fixed prosthesis. The patient must accommodate the with a fixed prosthesis. The patient must accommodate the absence of the palate on the prosthesis, and air often absence of the palate on the prosthesis, and air often escapes through the embrasures between the implants. The escapes through the embrasures between the implants. The more bulky temporary restoration can ease the transition more bulky temporary restoration can ease the transition from denture to fixed restoration and facilitate speech from denture to fixed restoration and facilitate speech accommodation. A second clear prosthetic template is also accommodation. A second clear prosthetic template is also fabricated from the wax-up of the final prosthesis, incase a fabricated from the wax-up of the final prosthesis, incase a different transitional restoration is required at the next different transitional restoration is required at the next clinical appointment. It can also be used to evaluate clinical appointment. It can also be used to evaluate abutment preparation intraorally.abutment preparation intraorally.

A modified base plate and wax-rim are fabricated over the A modified base plate and wax-rim are fabricated over the abutments. With a technique similar to that of complete abutments. With a technique similar to that of complete denture fabrication, the wax rim is used to record the denture fabrication, the wax rim is used to record the incisal edge position, OVD, midline, high lip line, and incisal edge position, OVD, midline, high lip line, and centric relation occlusion. A custom impression tray may centric relation occlusion. A custom impression tray may also be fabricated on this working model.also be fabricated on this working model.www.indiandentalacademy.comwww.indiandentalacademy.com

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SECOND APPOINTMENTSECOND APPOINTMENT


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Final Impression and Transitional Final Impression and Transitional Prosthesis IProsthesis I

The permucosal extensions are removed and The permucosal extensions are removed and the final abutments for cement inserted . the the final abutments for cement inserted . the clear template of the final prosthesis wax-up is clear template of the final prosthesis wax-up is placed in position, and the abutments are placed in position, and the abutments are evaluated for ideal placement and height (1 to evaluated for ideal placement and height (1 to 2 mm less than the occlusal plane depending 2 mm less than the occlusal plane depending on the occlusal material) and recontoured as on the occlusal material) and recontoured as required.required.


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The first transitional prosthesis is inserted. A most The first transitional prosthesis is inserted. A most important step for the provisional prosthesis is the important step for the provisional prosthesis is the evaluation of incisal edge position for esthetics and evaluation of incisal edge position for esthetics and phonetics. This position should be established before the phonetics. This position should be established before the superstructure is fabricated, to ensure ideal support of superstructure is fabricated, to ensure ideal support of porcelain and/or acrylic in the final restoration. This porcelain and/or acrylic in the final restoration. This position also greatly influences posterior occlusal position also greatly influences posterior occlusal relationships in any excursive position. The thickness of relationships in any excursive position. The thickness of the acrylic provisional prosthesis facial to the abutments the acrylic provisional prosthesis facial to the abutments for cement retention can be measured to ensure adequate for cement retention can be measured to ensure adequate space for metal and porcelain on the final restoration. An space for metal and porcelain on the final restoration. An impression and occlusal registration are made when the impression and occlusal registration are made when the transitional prosthesis has the correct incisal edge, vertical transitional prosthesis has the correct incisal edge, vertical dimension, and necessary prosthetic guidelines.dimension, and necessary prosthetic guidelines.


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If the transitional prosthesis is not ideal relative to If the transitional prosthesis is not ideal relative to incisal edge, OVD, esthetics, and midline, the incisal edge, OVD, esthetics, and midline, the modified base plate and wax rim are inserted and modified base plate and wax rim are inserted and used to establish these criteria similar to the used to establish these criteria similar to the methods for a maxillary complete denture. Centric methods for a maxillary complete denture. Centric relation occlusal records are then obtained on the, relation occlusal records are then obtained on the, base plate and wax rim at the appropriate OVD. base plate and wax rim at the appropriate OVD. These relationships and criteria will again be These relationships and criteria will again be evaluated on the metal framework at the next evaluated on the metal framework at the next prosthetic appointment.prosthetic appointment.

Anterior teeth shape and arrangement may be Anterior teeth shape and arrangement may be selected using a denture mold guide or using the selected using a denture mold guide or using the study cast of the treatment prosthesis, to assist in study cast of the treatment prosthesis, to assist in the personalization of the final esthetic result. the personalization of the final esthetic result. www.indiandentalacademy.comwww.indiandentalacademy.com

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A face-bow transfer is made of the maxillary arch to permit A face-bow transfer is made of the maxillary arch to permit correct mounting of the cast on the articulator. The correct mounting of the cast on the articulator. The transitional prosthesis is cemented with a zinc oxide-transitional prosthesis is cemented with a zinc oxide-noneugenol temporary "soft access" cement. Modifier or noneugenol temporary "soft access" cement. Modifier or petroleum jelly is often added to the soft access cement for petroleum jelly is often added to the soft access cement for multiple abutments to facilitate the retrieval of the multiple abutments to facilitate the retrieval of the transitional prosthesis without complication.transitional prosthesis without complication.

The occlusal contacts are carefully evaluated. In centric The occlusal contacts are carefully evaluated. In centric relation- occlusion the implants should ideally be, loaded relation- occlusion the implants should ideally be, loaded with only axial loads. When Possible, no offset loads or with only axial loads. When Possible, no offset loads or cantilevers should be present. In addition, the first cantilevers should be present. In addition, the first transitional prosthesis has no contact on long span pontics transitional prosthesis has no contact on long span pontics and narrow posterior occlusal tables. The occlusal scheme and narrow posterior occlusal tables. The occlusal scheme is similar to that of the final restoration.is similar to that of the final restoration.


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This is the first time the patient has worn a fixed This is the first time the patient has worn a fixed prosthesis since the denture. ne diet of the prosthesis since the denture. ne diet of the patient at this time is still very soft (e.g., pasta patient at this time is still very soft (e.g., pasta and fish). It is wise to explain to the patient the and fish). It is wise to explain to the patient the need to remain on this very soft diet. A force too need to remain on this very soft diet. A force too aggressive may cause implant overload or break aggressive may cause implant overload or break the cement seal of the provisional restoration, the cement seal of the provisional restoration, which will cause cantilever and moment loads which will cause cantilever and moment loads on the remaining implants. The patient is warned on the remaining implants. The patient is warned that any implant or bone loss from this point that any implant or bone loss from this point may require implant removal, bone graft, may require implant removal, bone graft, implant replacement, and long heating times.implant replacement, and long heating times.


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Laboratory Phase IILaboratory Phase II The master cast is mounted first on an articulator using a face-The master cast is mounted first on an articulator using a face-

bow and centric registration. It is then removed, and the cast of bow and centric registration. It is then removed, and the cast of the provisional restoration is mounted with the separate bite the provisional restoration is mounted with the separate bite registration recording, and/or the modified base plate and wax registration recording, and/or the modified base plate and wax rim is inserted on the master cast. An index is Made of the rim is inserted on the master cast. An index is Made of the incisal edge and facial tooth position of the temporary, or wax incisal edge and facial tooth position of the temporary, or wax rim, in the proper position. The master cast is replaced on the rim, in the proper position. The master cast is replaced on the articulator. A wax,up of the final restoration is made, then cut articulator. A wax,up of the final restoration is made, then cut back 2 min for porcelain thickness in the appropriate regions. back 2 min for porcelain thickness in the appropriate regions. The metal framework is then fabricated. White wax may be used The metal framework is then fabricated. White wax may be used for the shape and size of the six anterior teeth on the metal for the shape and size of the six anterior teeth on the metal superstructure. This will allow clinical evaluation of the incisal superstructure. This will allow clinical evaluation of the incisal edge, esthetics, and speech on the actual casting. Acrylic edge, esthetics, and speech on the actual casting. Acrylic occlusal indices are fabricated on the posterior regions at the occlusal indices are fabricated on the posterior regions at the recorded OVD to verify its accuracy at the metal try-in recorded OVD to verify its accuracy at the metal try-in appointment.appointment.


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THIRD APPOINTMENTTHIRD APPOINTMENT


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Metal Try-in and TransitionalMetal Try-in and TransitionalProsthesis IIProsthesis II

The transitional prosthesis retention is evaluated The transitional prosthesis retention is evaluated and then removed. If it is not loose, the same and then removed. If it is not loose, the same cement will be used at the conclusion of this cement will be used at the conclusion of this appointment. The metal framework is tried-in. appointment. The metal framework is tried-in. The casting should not be tapped into position if The casting should not be tapped into position if too tight. Instead, modification of the abutment too tight. Instead, modification of the abutment for cement retention can be made with a coarse for cement retention can be made with a coarse diamond. Once the casting fit is deemed diamond. Once the casting fit is deemed acceptable, the posterior occlusal acrylic indices acceptable, the posterior occlusal acrylic indices are used to check centric occlusion and OVD are used to check centric occlusion and OVD


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The patient is not anesthetized, has been wearing a The patient is not anesthetized, has been wearing a transitional prosthesis with no interferences, has only transitional prosthesis with no interferences, has only been opening the mouth for a short time, and has a very been opening the mouth for a short time, and has a very rigid, stable structure in place. As a result, an accurate rigid, stable structure in place. As a result, an accurate jaw relationship record can be evaluated and/or obtained. jaw relationship record can be evaluated and/or obtained. If any variance is noted in the original occlusal If any variance is noted in the original occlusal registrations, a new recording is indicated. The posterior registrations, a new recording is indicated. The posterior acrylic indices (and metal occlusal) are adjusted to the acrylic indices (and metal occlusal) are adjusted to the proper OVD. The white wax on the anterior teeth is proper OVD. The white wax on the anterior teeth is evaluated for lip position, phonetics, and esthetics. The evaluated for lip position, phonetics, and esthetics. The high lip line is determined and scored in the cervical high lip line is determined and scored in the cervical region of the wax. The final decision relative to FP-2 or region of the wax. The final decision relative to FP-2 or FP-3 restoration options may be made at this time.FP-3 restoration options may be made at this time.


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When fixed prostheses are opposing natural teeth When fixed prostheses are opposing natural teeth or fixed restorations, there are no posterior or fixed restorations, there are no posterior contacts during mandibular excursions in any contacts during mandibular excursions in any lateral or protrusive jaw position. Anterior lateral or protrusive jaw position. Anterior guidance is primarily responsible for the guidance is primarily responsible for the separation of the posterior teeth. Therefore once separation of the posterior teeth. Therefore once the vertical occlusal dimension and incisal edge the vertical occlusal dimension and incisal edge are determined, the protrusive and lateral are determined, the protrusive and lateral excursions of the mandible may be evaluated. The excursions of the mandible may be evaluated. The final crown contour (taken from a denture mold final crown contour (taken from a denture mold chart) and shade selection for the gingiva and/or chart) and shade selection for the gingiva and/or teeth are confirmed during this session.teeth are confirmed during this session.


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The first transitional restoration is then modified. Monomer The first transitional restoration is then modified. Monomer is added to the occlusal aspect, and petroleum jelly is placed is added to the occlusal aspect, and petroleum jelly is placed over the opposing teeth. Acrylic is added on the occluding over the opposing teeth. Acrylic is added on the occluding surfaces of the temporary restoration, and the patient surfaces of the temporary restoration, and the patient occludes into the material and moves in all excursions. The occludes into the material and moves in all excursions. The nonworking and working occlusal contacts are eliminated. nonworking and working occlusal contacts are eliminated. The pontic areas and angled abutments can be brought into The pontic areas and angled abutments can be brought into light centric occlusion. Heavier contacts are developed on light centric occlusion. Heavier contacts are developed on the implants in ideal position. There are no cantilevers to the the implants in ideal position. There are no cantilevers to the restoration unless needed for esthetics. The occlusal scheme restoration unless needed for esthetics. The occlusal scheme is similar to that of the final prosthesis. The restoration is is similar to that of the final prosthesis. The restoration is cemented with a soft access cement. If the transitional cemented with a soft access cement. If the transitional prosthesis was too difficult to remove at the beginning of prosthesis was too difficult to remove at the beginning of this appointment, a softer cement may be used and vice this appointment, a softer cement may be used and vice versa,versa,


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The patient continues with the softer diet of The patient continues with the softer diet of pasta and fish until the next appointment. Harder pasta and fish until the next appointment. Harder foods (such as meats or raw carrots) are still foods (such as meats or raw carrots) are still avoided. Patients exhibiting Parafunction may avoided. Patients exhibiting Parafunction may remain at this stage with an acrylic transitional remain at this stage with an acrylic transitional restoration for as long is 6 months. A laboratory restoration for as long is 6 months. A laboratory processed restoration is usually indicated for this processed restoration is usually indicated for this extended period. If the patient generates extended period. If the patient generates excessive forces, and the restoration has more excessive forces, and the restoration has more than two pontics, a composite fixed bridge with than two pontics, a composite fixed bridge with metal substructure may be indicated during the metal substructure may be indicated during the extended transition period.extended transition period.


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FOURTH APPOINTMENTFOURTH APPOINTMENT


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Initial DeliveryInitial Delivery

The fourth restorative appointment The fourth restorative appointment (approximately 2 to 4 weeks later) marks the (approximately 2 to 4 weeks later) marks the initial delivery of the final restoration. The final initial delivery of the final restoration. The final occlusion is adjusted as indicated. This is the occlusion is adjusted as indicated. This is the first time posterior cantilevers (if any) appear on first time posterior cantilevers (if any) appear on the restoration. The occlusion is designed to the restoration. The occlusion is designed to axially load the implants wherever possible. axially load the implants wherever possible.


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A panoramic radiograph and vertical bite-wings A panoramic radiograph and vertical bite-wings may be taken to establish the baseline values of may be taken to establish the baseline values of crestal bone for future comparison and compared crestal bone for future comparison and compared with the bone level at implant uncovery surgery.with the bone level at implant uncovery surgery.

A soft access cement is used in the restoration. A soft access cement is used in the restoration. Oral hygiene regimens are reinforced, Oral hygiene regimens are reinforced, demonstrated, and stressed. The diet of the demonstrated, and stressed. The diet of the patient still does not include hard foods, but most patient still does not include hard foods, but most foods can be enjoyed, and meat may be added to foods can be enjoyed, and meat may be added to the diet. No raw vegetables or hard crunchy foods the diet. No raw vegetables or hard crunchy foods are yet in the diet at this time.are yet in the diet at this time.


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FIFTH APPOINTMENTFIFTH APPOINTMENT


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Final DeliveryFinal Delivery

At the fifth prosthetic appointment At the fifth prosthetic appointment (approximately 4 weeks later), the final (approximately 4 weeks later), the final restorative result is evaluated. Difficult access restorative result is evaluated. Difficult access areas for hygiene are improved. The patient's soft areas for hygiene are improved. The patient's soft tissue health and hygiene regimen are scrutinized. tissue health and hygiene regimen are scrutinized. Periimplant probing is indicated to establish soft Periimplant probing is indicated to establish soft tissue baseline measurements at this appointment. tissue baseline measurements at this appointment. The occlusion is refined. No posterior contacts are The occlusion is refined. No posterior contacts are present during excursions when opposing natural present during excursions when opposing natural dentition or a fixed prosthesis. dentition or a fixed prosthesis.


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A soft access cement is preferred, but a partially A soft access cement is preferred, but a partially unretained restoration places considerable risk on the unretained restoration places considerable risk on the remaining cemented units. Therefore zinc oxide eugenol remaining cemented units. Therefore zinc oxide eugenol with EBA is often used if no cantilevers are present. Glass with EBA is often used if no cantilevers are present. Glass ionomer or resin cements are not used if prosthesis ionomer or resin cements are not used if prosthesis retrieval is contemplated 'in the future. A harder cement retrieval is contemplated 'in the future. A harder cement (e.g., zinc phosphate) may be used on the most distal and (e.g., zinc phosphate) may be used on the most distal and anterior abutments when cantilevers are present, because anterior abutments when cantilevers are present, because tensile forces are more likely on these positions.tensile forces are more likely on these positions.

The diet of the patient is normal at this time. Hen hard The diet of the patient is normal at this time. Hen hard foods such as raw vegetables may still be avoided bone foods such as raw vegetables may still be avoided bone patients. Parafunction dictates the use of a night guard for patients. Parafunction dictates the use of a night guard for bruxism or a soft occlusal appliance for clenching. The bruxism or a soft occlusal appliance for clenching. The patient is asked to return every 4 months during the first patient is asked to return every 4 months during the first year, so that bone changes and occlusal patterns may be year, so that bone changes and occlusal patterns may be evaluated. Maintenance hygiene appointments are often evaluated. Maintenance hygiene appointments are often scheduled every 4 to 6 months after the first year, when scheduled every 4 to 6 months after the first year, when ideal patient conditions are present.ideal patient conditions are present.


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templates and loading of implants/ orthodontics courses

Education

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implant surgery

denture bar

implant substructure

removable prosthesis

fixed partial denture

ovd decreases