article discussion

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Presented by: Dr.Abbasi Begum MDepartment of prosthodontics

Narayana dental college & hospital

IMPLANTS

The Future of Prosthodontics

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Immediate loading and customized restoration of a single implant in the maxillary esthetic zone:

A clinical report

Laurens den Hartog et al

J Prosthet Dent 2009;vol:102:211-215

JOURNAL DISCUSSION

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What is an Implant???A prosthetic device or alloplastic material

implanted into the oral tissue beneath the mucosal or/and periosteal layer and/ or in the bone to provide retention and support for the fixed and removable prosthesis.

GPT-8

INTRODUCTION

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Single/multiple missing tooth/Teeth

What are the treatment options available ???????

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?

Single/multiple missing tooth/Teeth1. Removable Partial

Denture (R.P.D.)

2.Fixed Partial Denture (F.P.D.)

3. Implant Prosthesis 29

Removable Partial Denture (R.P.D.)DISADVANTAGES :-

1. do not maintain bone- compromise the

esthetic result

2. bulk – need for cross arch stabilization

3. food debris , plaque accumulation

4. movement-speech-function

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Fixed partial denture (F.P.D.)

DISADVANTAGES :-1. caries and endodontic failure of abutment teeth is the most common failure

2. increased plaque retention of pontic increases caries and periodontal disease risk 3. damage to healthy teeth

4. fracture ( porcelain , tooth )

5. esthetics ( anterior region )6. Uncemented restorations 27

Fixed partial denture (F.P.D.)…

• It is contra indicated in

1.Poor abutment teeth support

2. inadequate hard and soft tissue in esthetic regions

3. patient desire

4. young patients with large pulp horns 26

Implants for single/multiple tooth replacement

ADVANTAGES :-1.Adjacent teeth do not require splinted restoration- - less risk of caries

- Less risk of porcelain fracture- Less risk of uncemented

restoration- Less fracture of tooth

2. Psychological need of patient 25

3. Improved hygiene conditions- less decay risk- less pontic overhang

4. Decreased cold and contact sensitivity5. Improved esthetics6. Maintains bone height7. Decreases adjacent tooth loss 24

•The replacement of a single missing anterior tooth with an implant-supported crown is a demanding therapy

DELAYED LOADING

•LOADING

IMMEDIATE LOADING

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•The application of an implant supported crown for the restoration of a missing single tooth in the anteriordentition is challenging

•In the esthetic zone, both the appearance ofthe implant crown and the soft tissue contribute to a successful treatment outcome and should consequently be in harmony with the surrounding dentition.

•Attention has been focused on immediate or early loading protocols in which a provisional restoration is placed soon after implant placement.

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Immediate or early loading have reported

•favorable treatmentoutcomes in terms of implant survival,marginal bone resorption, soft tissue level, and the incidence of complicationsof treatment in which implantswere inserted in healed sites, as well as treatment in which implants wereplaced in fresh extraction sockets 21

Advantages• a shorter overall treatment time

• avoidance of a second-stage surgery• elimination of the need for a

removableprosthesis during the healing

phase.• Good primary implant stability is a prerequisite, as is the development of a protected occlusion to create a nonoccluding provisional crown 20

Purposeto demonstrate an immediate implantloading protocol for restorationof a missing central incisor.

After the provisional restoration phase, an individually fabricated impression post was used and, subsequently, a definitive screw-retained 1 piece all-ceramic crown was placed.

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CLINICAL REPORT

CLINICAL PRESENTATION

The patient was healthy, did not smoke, and intraoral examination revealed a healthy, well maintained dentition.

Clinically, adequate bone volume was present at the future implant site.

In all dimensions, sufficient space was available for animplant crown with an anatomical design.

Radiographically, no pathology of the bone and adjacent teethwas noted.

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•Preoperatively, diagnostic castswere made with a diagnostic arrangementrepresenting the future implant crown in an ideal position.

•Transparent acrylic resin template(Vertex Castapress; Vertex-Dental BV,Zeist, the Netherlands) was fabricated,and a guide channel was preparedin the template to aid in proper implantplacement.

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Care was taken with the surgical guide so that the guide channel would direct the implant sufficiently toward the palate to accommodate a screw-retained restoration.

Antibiotic prophylaxis (amoxicillin 500 mg, 3 times daily for 7 days used a 0.2% chlorhexidine mouthwash

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Following the administering of local anesthesia (Ultracaine D-S Forte; Aventis Pharma DeutschlandGmbH, Frankfurt am Main, Germany), a slightly palatal crest incision was made with extensions through the buccal and palatal sulcus of the adjacent teeth.

Mucoperiosteal flap was elevated to expose only the ridge crest.

An implant (NobelReplaceTapered RP, 16 mm; NobelBiocare AB, Goteborg, Sweden) was placed, guided by the surgical template

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1. The shoulder of the implant was placed at a depth of 3 mm apical to the buccal and cervical aspect of the prospective clinical crown to provide soft tissue to develop an adequate emergence profile.

2. Good primary implant stability of >45 Ncm was obtained, determined with a measurement device for implant site preparation (Osseocare;Nobel Biocare AB).

3. Next, an open tray impression was made at the implant

level using a custom acrylic resin impression tray and a polyether impression material (Impregum Penta; 3MESPE,St. Paul, Minn).Finally, a healing abutment (NobelReplace; Nobel Biocare AB) was placed, and the wound was closed with sutures

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•In the dental laboratory, a screwretainedprovisional restoration was fabricated, consisting of an engaging temporary abutment against which composite resin was modeled

•The abutment was removed and the provisionalcrown was placed and subsequently torqued to 32 Ncm

•Special care was taken to prevent any centric and eccentric occlusion contacts with the antagonist teeth.

•Furthermore, the provisional restoration was contoured so that the periimplant soft tissue was optimally supported

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The interproximal papillae were given enough space to regenerate.

Patients instructions;• A soft diet, to avoid exerting force on the provisional restoration,

• Continue chlorhexidine Rinses for 7 days. •

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•For pain control, 600-mgibuprofen (Brufen Bruis 600; AbottBV, Hoofddorp, the Netherlands) wasprescribed, to be taken 3 times daily

•the sutures were removed after 2 weeksFollow up once in a month 3 months-implant mobility, oral hygiene, and occlusion were evaluated

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important objective was the creationof an ideal emergence profileby removing the provisional crown.

View of periimplant soft tissue after provisional restorationphase. Note established emergence profile

Three months later (6 months following implant placement), an implant-level impression was made using an impression post

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the provisional crown was assembledwith an implant analogue embedded in type IV dentalstone .An addition silicone impression of the cervical portion of the crown was made . Next, the latter was substituted for an impressionpost and bis-acrylic composite resin was added to the post.

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Customized impression post.

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post (Fig. 5), it was insertedinto the implant and an open tray impressionwas made with a polyetherimpression material

In the dental laboratory, a soft tissue cast was prepared. First, a waxing of the definitive crown was made on a temporary abutment

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The screw access hole was located sufficiently near the palate to create a screw-retained crown and to prepare an appropriate abutment.

Therefore, the waxing was cut back to the desired form and scanned for fabrication of an individual zirconia abutmentPorcelain was added directly to the abutment to create a screw-retained 1-piece definitive restoration

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Application of porcelain to individually fabricated Procera (Nobel BiocareAB) zirconia abutment to create 1-piece screw-retained definitive crown

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The restoration was placed and the abutment screw was torqued to 32 Ncm. Finally, the screw hole was filled with a cotton pellet and composite resin (Clearfil AP-X; Kuraray Medical, Inc, Okayama, Japan).The restoration has been in service for 18 months without complication

DISCUSSION•An immediate loading protocol finalized with the placement of a screw-retained all ceramic restoration.•A major prerequisite for immediate loading is a high degree of primary stability in terms of high insertion torque•An initial insertion torque of atleast 45 Ncm was reached.

A substantial maturation of the papillae occurred duringthe provisional phase.

remodeling potential of the soft tissues to establisha proper biological height after the surgical manipulation.

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Finally, a screw-retained definitive restoration was fabricated. Advantages :

•This type of restoration compared to a cement-retainedrestoration include retrievability •No risk of cement remnants, thereby eliminating the possibility of irritation of the periimplant tissues by such remnants.DRAWBACKS•the presence of a screw access opening decreases fracture resistance of the porcelain.

•Furthermore, screw-retained restorations necessitate precise implant positioning for a proper palatal position of the screw access hole that does notinterfere with esthetics.

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SUMMARY

This clinical report describes a treatment in which a lost anterior tooth was replaced with a dental implant that was immediately restored with a provisional crown. After the provisional phase, an impression was made with a customized impression post for an accurate reproduction of the established emergence profile.

Finally, a 1-piece screw-retained all ceramiccrown was placed.

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Clinical view of definitive implant crown 18 monthsafter implant placement.

Radiographic view 18 months after implant placement

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References Contemporary implant dentistry- Carl Misch

1. Chang M, Wennstrom JL, Odman P, AnderssonB. Implant supported single-toothreplacements compared to contralateral natural teeth. Crown and soft tissue dimensions. Clin Oral Implants Res 1999;10:185-94. 2. Belser UC, Schmid B, Higginbottom F,Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants 2004;19 Suppl:30-42.

3. Palmer RM, Palmer PJ, Smith BJ. A 5-year prospective study of Astra singletooth implants. Clin Oral Implants Res2000;11:179-82.

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