Module 1 | Session 2 Treatment planning and

Diagnosis and treatment planning for the replacement of missing teeth

Module 1 | Session 2

Treatment planning and restoring the single posterior implant

Please note:

It is encouraged that the presentation at hand is adapted and enhanced by clinical cases of the lecturer. Please feel free to adjust the slides according to your preferences.

Disclaimer :

Some products may not be regulatory cleared/released for sales in all markets.

Please contact the local Nobel Biocare sales office for current product assortment and availability in partnership with Nobel Biocare

Module 1: Course objectives

Treatment planning and restoring the single posterior dental implant

• Gain proficiency in diagnosis and treatment planning

• Master the restorative steps for a posterior dental implant

• Transform restorative decision-making and execution into a simple and easy process

• Learn how to avoid or manage complications

• Learn how to gain patient acceptance for dental implant treatment


2

Module 1: Session overview

Session 1

•

Dental implants

– the standard of care

•

Indications and contraindications for dental implants

•

Cement vs. screw-retained restorations

•

Options for replacing a missing tooth

•

Diagnosis and treatment planning

•

Clinical examples

•

How to find patients and gain treatment acceptance

Session 2

• Review of restorative options

• Surgical templates

• Biomechanics and occlusion in implant dentistry

• Case presentation from participants

• Treatment plan and case work-up with faculty

• Introduction for surgical preparation

Time:

3 hours

Time:

3 hours


3

Module 1: Session overview

Session 3

•

Impression techniques

•

Cement vs. screw-retained restorations

•

Provisionalization

•

NobelProcera

•

Restorative workshop and hands-on

•

Patient treatment status

•

Basic patient communication concepts

• Avoiding or managing complications

• Dental implant maintenance

• Final case presentations

Session 4

Time:

3 hours

Time:

3 hours


4


Module 1 | Session 2

Agenda

•

Review restorative options

•

Surgical templates

•

Biomechanics and occlusion in implant dentistry

in partnership with Nobel Biocare

Restorative solutions for dental implants

Implant supported solutions from single tooth to full arch restorations

Single posterior implant

Single anterior implant

Multiple implants

Full arch implants


6

Restorative solutions for dental implants

Implant supported solutions from single tooth to full arch restorations



7

Single missing tooth

Restorative options for a single posterior implant:

Clinical cases courtesy of Dr. Baldwin Marchack, Pasadena, USA


8




Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany in partnership with Nobel Biocare


Restorative options for a single posterior implant:

• Pre-fabricated abutment, cement-retained crown

• Individualized abutment, cement-retained crown

• Screw-retained crown (one piece)


10


Screw-retained restoration


Photographs courtesy of MDT Claus-Peter Schulz, Baden-Baden, Germany

Cement-retained restoration


11


Pre-fabricated abutment

Cement-retained restoration

Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA


Individualized (CAD/CAM) abutment


12

Guidelines for abutment selection

Issues to be considered:

• Implant-abutment connection

• Distance from the implant platform to bone crest

• Interocclusal distance

• Depth of peri-implant soft tissues

• Biotype of the tissue

• Emergence profile

• Shape and contour of the tissue

• Screw-retained/cement-retained


13


Ideal gingival height – 1 to 3mm, flat shape

Ideal interarch dimension – 5 to 10mm


14


Too deep, not flat – use another solution .


15


A case study:

“Resistance to dislodgement of zirconia copings cemented onto titanium abutments of different heights.”

Abbo B, Razzoog M, Vivas J, Sierraalta M. J Prosthet Dent 2008; 99: 25-29

Purpose:

Authors measured the force it takes to dislodge a cemented crown on abutments of various heights

Results:

• The taller the abutment height the greater the force required to dislodge a cemented crown.

• Study recommends that abutments should be no less than 4mm in height when using a cemented crown.

Abutment height:

Average dislodgement force:

6.5mm

198.09N

5.5mm

124.89N


16


2-3mm gingival height

5mm interarch dimension


17

Posterior abutment decision tree – single implant crown

Interarch distance

> 5mm

Single posterior implant restoration

Interarch distance

< 5mm

Posterior Abutment Decision Tree

© Copyright 2010 Baldwin Marchack, DDS.

Used by permission.

Screw-retained crown

Individualized one-piece restoration

NobelProcera

Screw-retained crown (Ti or Zr)


18


Limited interarch dimension

Photographs courtesy of Dr. Baldwin Marchack, Pasadena, USA


19


Use a screw-retained crown:

1.

Limited interarch dimension

2.

Patient is a bruxer

3.

Retrievability is desired

4.

Cement-free solution wanted

Screw-retained crown:

1.

NobelProcera screw-retained crown

2.

GoldAdapt abutment


20




21


Clinical case courtesy of Dr. Sebastian Horvath, Jestetten, Germany


22


Interarch distance

> 5mm


Cement-retained crown


Interarch distance

< 5mm



Used by permission.


Flat tissue

< 3mm

ID 5 –10mm


Snappy Abutment


NobelProcera



23


• Ideal gingival height (1 –3mm)

• Ideal interarch dimension (5-10mm)

• Flat tissue architecture



24

Snappy

™

Abutment

• Ideal gingival height (1 –3mm)

• Ideal interarch dimension (5-10mm)

• Flat tissue architecture



25

Snappy

™

Abutment



26


Interarch distance

> 5mm


Interarch distance

< 5mm



Used by permission.



Flat tissue

< 3mm

ID 5 –10mm

Scalloped

< 4mm

ID 5 –10mm


Snappy Abutment


Esthetic Abutment (Ti)

Procera Esthetic Abutment (Zr)


NobelProcera



27

Pre-fabricated Esthetic Abutment

Esthetic Abutment (Titanium) Pre-fabricated, customizable Titanium abutment:

• Comprehensive selection of different margin designs and angulations minimize chair-side adjustments

• Scalloped margin designed to profile natural soft tissue contours

• Optional temporary coping available for temporization

Indications:

• Single- and multiple-unit implant restorations

•

Cement-retained


28

Esthetic Abutment

Clinical case courtesy of Dr. Christopher Marchack, Pasadena, USA


29

Esthetic Abutment

• Milled titanium

• Can be adjusted by the lab

• Corrects minor angulation problems

• Fixture level impression

• Easy to cement



30


Interarch distance

> 5mm



Interarch distance

< 5mm


Depending on clinical situation and preference, the GoldAdapt Abutment can be a flexible solution for both cement- and screw-retained restorations and for various gingiva heights.



Used by permission.

Flat tissue

< 3mm

ID 5 –10mm

Scalloped

< 4mm

ID 5 –10mm

Scalloped or flat tissue

> 4mm

ID > 5 mm


Snappy Abutment



Procera Esthetic Abutment (Zr)

Individualized abutment

NobelProcera Abutment (Ti or

Zr)


NobelProcera



31


Individualized abutment

• Scalloped tissue architecture

• Thick soft tissue

• Angled implant placement

• Excessive interarch dimension

• Excessive interproximal dimension

Fabrication options:

1.

NobelProcera abutment in Titanium or Zirconia

2.

GoldAdapt abutment


32

NobelProcera

® abutment

• NobelProcera Angulated Screw Channel abutment

• Easy access due to tilted access hole




33

NobelProcera

® abutment




34

Posterior implant restoration



35


Interarch distance

> 5mm




Interarch distance

< 5mm


Depending on clinical situation and preference, the GoldAdapt Abutment can be a flexible solution for both cement- and screw-retained restorations and for various gingiva heights.



Used by permission.

Flat tissue

< 3mm

ID 5 –10mm

Scalloped

< 4mm

ID 5 –10mm

Scalloped or flat tissue

> 4mm

ID > 5 mm


Snappy Abutment



Procera Esthetic Abutment

(Zr)

Individualized abutment

NobelProcera Abutment (Ti or Zr)


NobelProcera

Screw-retained crown (Ti or

Zr)


36


Diagnosis and prosthetic treatment planning

Four important tools

1.

Diagnostic models

2.

Radiographs

3.

(CB)CT scans

4.

NobelClinician Software in partnership with Nobel Biocare

Diagnostic Models

Evaluate:

• Centric relation position

• Edentulous ridge relationship to adjacent teeth, opposing ridge, opposing dentition

• Inclination, rotation, extrusion, alignment of the remaining dentition

• Soft tissue, gingival heights, and other esthetic parameters

• Interarch space

Determine:

• Options for occlusal schemes

• Ideal number and location of implants

• Direction of forces to which future implants would be subjected


38

Radiographs

Evaluate:

• Amount of bone available (2D only)

• Angulation of adjacent teeth

• Location of anatomical structures

• Sinus, mandibular canal, mental foramen

Please bear in mind that radiographs are not completely accurate

Clinical case courtesy of Dr. Richard Sullivan, Pasadena, USA


39

(CB)CT scans

Since radiographs are not completely accurate, a (CB)CT scan can improve the diagnosis



40

NobelClinician

®

Software

Visualize the patient’s (CB)CT data together with the intra-oral situation and the diagnostic setup thanks to

NobelClinician’s SmartFusion™ technology



41

Surgical templates

• Models, radiographs and (CB)CT scans are essential in fabricating surgical templates for various types of surgery:

– Flapless

– Mini flap

– Flap

• All options are covered with the NobelClinician Software and NobelGuide


42

Surgical templates

Benefits of surgical templates:

• More precise placement of implants

• Preservation of anatomic structures

• Shorter treatment times, surgery times

• Less invasive, flapless surgery and therefore less chance of swelling

• Less post-operative strain on dentist and patient

Manikandan R et al. Implant surgical guides: From the past to the present. J Pharm Bioallied Sci 2013;5(Suppl 1):S98-S102


43

One integrated treatment workflow, countless benefits

NobelConnect

®

Clinical diagnostics & treatment acceptance

Capturing both the current

& desired situation

Treatment planning & patient communication

Production of surgical template

Implant placement Design of final restoration

Production of prosthesis

1. Clinical diagnostics and treatment acceptance

2. Capturing both the current and desired situation

3. Treatment planning and patient communication

Production of surgical template

4. Implant placement either freehand or using pilot drill template or fully guided template

5. Prosthetic design

Production of prosthesis

6. Restoration placement


Restoration placement

44

Treatment planning

What is the minimum space needed between teeth for a single-tooth implant?

ø 3.5mm

ø 4.3mm

ø 5.0mm

~1.5mm on each side of implant,

2mm is better for soft tissue

Illustrations refer to Nobel Biocare implants with Conical Connection

1 Gastaldo JF et al. Effect of the Vertical and Horizontal Distances Between Adjacent Implants and Between a Tooth and an Implant on the

Incidence of Interproximal Papilla. J Periodontol 2004;75(9):1242-1246


45

Occlusion and biomechanics

Forces acting during a condition of malocclusion

• The picture shows which force occurs during a situation of malocclusion

• The resulting force is perpendicular to the plane of contact

• If the resulting force is too strong for the crown, the restoration may break or may result in crestal bone loss

• The principles are the same for both natural teeth and implants

→ how can breakage and crestal bone loss be avoided?

Illustrations obtained through internet research: http://www.scielo.br/img/revistas/bdj/v16n1/a08fig01.gif


46


Uneven loading

• Overloading may occur because of incorrect placement of the implant and critical restoration geometries

• This can result in uneven force distribution on the implant's surface

• Dental implants should ideally be placed so that the biting forces are directed straight downward onto the dental implant


47


F Bite a1

F Nx1

F N1

F Bite a2

F Nx2

F N2

• The steeper the line of contact, the stronger the resulting force

• The force necessary to equalize the vertical bite force is higher, when the line of contact is steeper

• In the dental environment, the occlusion should be shallow or flat in order to reduce the lateral forces impacting on the occlusion

→ it is recommended to create shallow or flat occlusion lines to reduce the overload risk


48


Possible consequences of overload

• Crestal bone loss

• Dislodged restorations

• Screw loosening

• Screw fracturing

• Restoration or ceramic fracture

• Peri-implantitis

• Implant failure

* This list makes not claim to be complete.

Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA


49


Possible consequences of overload

Clinical case courtesy of Dr. Baldwin Marchack, Pasadena, USA


50


Summary

• Keep cusp inclines flat or shallow to minimize lateral forces

• No premature contacts

• Light occlusal contacts

• Avoid supra-occlusal axial and lateral loading

• Keep contacts in the same line as the long axis of the implant, i.e., as close to the center as possible

• Avoid cantilevers, whether mesial, distal, buccal, or lingual

Chia-Chun Yuan J, Sukotjo C. Occlusion for implant-supported fixed dental prostheses in partially edentulous patients: a literature review and current concepts. J Periodontal Implant Sci 2013;43:51-57

Rani G, Gambhir A. Occlusion In Implants - A Review. Indian J Dental Sci 2012;3(4):95-98


51

Your next steps for session 3


• Refer your patient to your surgical specialist for implant treatment

• Ensure a complete patient documentation for later case presentation

•

You may invite your dental laboratory technician to participate in session 3 of the Esthetic Alliance Program


52

Thank you!

Disclaimer :

Some products may not be regulatory cleared/released for sales in all markets.

Please contact the local Nobel Biocare sales office for current product assortment and availability

© Nobel Biocare Services AG. All rights reserved.


53

Module 1 | Session 2 Treatment planning and

Treatment planning and restoring the single posterior implant

Agenda

Review restorative options

Surgical templates

Biomechanics and occlusion in implant dentistry

Single posterior implant

Diagnosis and prosthetic treatment planning

Thank you!

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Module 1 | Session 2 Treatment planning and

Treatment planning and restoring the single posterior implant

Agenda

Review restorative options

Surgical templates

Biomechanics and occlusion in implant dentistry

Single posterior implant

Diagnosis and prosthetic treatment planning

Thank you!

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