Overall Grading Components Critical Assessment Paper 40 % Online Quizzes 10% Laboratory Simulation Project 20% Final Exam 30%

01 Implant Introduction
Thursday, June 01, 2017 7:06 AM
Overall Grading Components

1. Critical Assessment Paper 40 %
2. Online quizzes 10%
3. Laboratory Simulation Project 20%
Final Exam 30%
Implant Lectures Page 1

treatment planning
<--
systemic factors
tobacco
• failure rate is higher in smokers
• success of grafting procedures are even more compromised
diabetes
• similar success rates in non-diabetic as controlled diabetic patients
radiation therapy
• 5y success rates are 60-75% depending on the study
ASA
• ASA 3, 4 (?)
phase I tx. alternatives

control disease • each alternative has to be explained; advantages, cost
• periodontal • each tx. could be appropriate under certain conditions
• caries ○ patient desires
• TMD ○ medical condition
• especially important for diabetic patients ○ occlusal discrepancies
• preserve bone ○ biologic deficiencies (bone, soft tissue)
• RPD, CD
phase II ○ a pt. can wear an RPD until conditions are favorable for implant placement
re-evaluate for definitive phase • FPD
○ adjacent teeth must be prepared
clinic protocol ○ failure of one unit in most cases results in entire loss
• first complete prosthodontic consult, and give pt all ○ common issues w. FPD's…
alternative treatments ▪ caries (#1 @18% abutments) **
• then, complete implant eval. form ▪ pulpal health (11%)
▪ loss of retention (7%)
adjunctive procedures

• first complete prosthodontic consult, and give pt all ○ common issues w. FPD's…
alternative treatments ▪ caries (#1 @18% abutments) **
• then, complete implant eval. form ▪ pulpal health (11%)
▪ loss of retention (7%)
adjunctive procedures ▪ esthetics (6%)
prior to, or concurrently w. RCT ▪ perio health (4%)
• crown lengthening ▪ tooth fracture (3%)
• apical surgery ▪ prosthesis fracture (2%)
• core buildup, post/core ▪ esthetic veneer fracture (2%)
• implant-supported restoration
standard of care
• all options must be presented regardless of whether that
service would be provided at your office
• may require referral to a specialist to fulfill the std. of care
dental considerations for implants **[EXAM q's]... (2) residual edentulous space
• occlusal eval
• interarch space interarch distance min. 2mm in anterior
min. 4mm in posterior
• interdental space
• root proximity mesio-distal distance about 7mm
• 1.5mm x2 from adjacent tooth to implant on both sides
• 4mm implant
implant position --> so 7mm of space
• prosthodontically-driven, not surgically/periodontally driven **
size of the edentulous space in should be carefully matched for good esthetic results in the
• properly placed implants reduce cost and complications relation to the adjacent tooth anterior region
• avoid contacting adjacent teeth or vital structures
crown/implant ratio should be kept to 1:1 for sound biomechanics
bone width
a sound esthetic result is dependent on…
• minimum bone width for 4mm root form is 5mm in midfacial and lingual region • optimal bone & gingival contours
• because the round implant design results in more bone in all other dimensions • accurate 3D implant positioning
(width and height)
width of implant
interarch distance • 1mm of bone on each side, at the minimum; this dictates the size of the implant (wider
• minimum 3-4mm of space for a posterior crown or FPD doesn't necessarily mean better) **
• non-esthetic, only functional
length of implant
• it is recommended that maxillary implants be >10mm in length, because of the higher
interdental space -- 3-4mm
implant loss associated with shorter implants
• in the mandible, shorter implants can be used but splinting and increasing the number of
implant-tooth distance -- 1.5mm implants is recommended
implant-implant distance -- 3mm for having papilla

splinted posterior restorations
• crown/implant ratio
• high fail rate with angulated abutments
• <13mm = splint
• >13mm = individual
for FPD
<13mm -- one implant per tooth
>13mm -- two implants for 3-unit FPD
grinder, bruxer, group function may affect
papilla -- esthetic guidelines

• papilla was always complete (100%) when the distance from the
tooth contact to crest of bone <5mm **
• when distance 6mm, only 50% of papilla filled in
• when distance >7mm, only 25% of papilla filled in
**[EXAM q]
crown occlusal thickness = 2mm
abutment height = 4-5mm
cement-retained a little taller

screw-retained a little shorter
overdenture
interarch space = 14mm
• tooth >8mm
• denture base 2-3mm
• locator housing 3.17mm

Minimum bone width for 4 mm wide implant is 5 mm of bone in
the midfacial and midlingual region. This is because the round
implant design results in MORE bone in all other dimensions
(width and height).
What that means is you MUST have atleast 1mm of bone in the
buccal and lingual dimensions. What about mesial and distal?
• Implant to Implant: needs 3 mm of bone
• Implant to Tooth: needs 1.5 mm of bone
So the Mesial-Distal dimension depends on the type of

prosthesis that is next to the implant.

Notice that in this case, the final crown product or bridge
will have very short clinical crowns. They will be unesthetic
restorations that will ONLY provide function to chew with,
not good esthetics. The patient will not mind this because
this area of the mouth is NOT an esthetic area!
EXAM
Space between implant and adjacent tooth 1.5 mm
Space between two implants 3.0 mm
Minimum interdental space for posterior crown or 3-4 mm
FPD prosthesis to have enough room

• papilla was always complete (100%) when the distance
from the tooth contact to crest of bone <5mm **

02 Single implant retained restorations

legally you have to present all alternatives to the patient
bridge lasts 6-13 years

properly done implants can last much longer
"success" different from "survival"

• success means esthetics and function
• survival means it's still there
overdentures are nowadays the standard of care
prosthetic treatment planning

• treatment planning for the placement and restoration of dental implants involves the consideration of many variables, includi ng…
○ systemic host factors
○ local host factors
○ design of the prosthesis
local host factors prosthetic design principles

single tooth implants
• successfully used since late 1980's to replace single teeth, both in the
anterior and posterior
• implant loss has been reported to be < 5% **[EXAM q]
• failures, about 50% pre-prosthetic and 50% post-prosthetic
• complications include screw loosening, fistulas at the implant-abutment
level, esthetic problems, post-operative neurosensory disturbances
highest reason for complications = abutment screw loosening **

• because screw loosening was such a problem, they started using cement
• Literature today, what is the #1 reason for implant failures? = excess cement **
• so now we've created another problem
• you don't need as much cement for implants as you do for real teeth; practitioners
forget this, and use excess cement
work up for single tooth implant care

1. diagnosis -- assessing hard and soft tissues and their relations
○ clinical evaluation
○ study models
○ implant template
○ imaging evaluation
2. treatment plan -- designing and sequencing surgical and
restorative aspects of the treatment
○ restorative design
○ surgical design
3. therapy
○ execution of the clinical procedures

diagnosis
clinical evaluation
• functional and esthetic outcome of the single tooth implant therapy
depends on the proper clinical analysis of these four elements….
a. edentulous tissues
b. residual edentulous space
c. adjacent dentition
d. opposing dentition
(1) edentulous tissues

• achieving ideal soft tissue form and implant position is dependent on
residual tissue contours
• interdental papilla height & buccal plate should be carefully analyzed
for deficiencies, which might affect functional and esthetic outcomes
• attached tissue amount is important in establishing periodontal health
around the implant crown
buccal plate deficiency in single tooth site

• following ext, particularly if traumatic, the labial plate resorbs
• resorption creates a site that dictates a palatal placement and ridge-
lapped restoration **
ridge lapped restorations

• hygiene more difficult
• esthetics compromised in patients with a high smile line, who display lots
of gingiva
• esthetics is compromised because such patients lack interdental papilla
horizontal deficiencies
• bone augmentation
• grafting serves to restore bone and soft tissue contours to enhance the
final esthetic result by idealizing implant position

(2) residual edentulous space
**[EXAM q]
interarch distance min. 2mm in anterior
min. 4mm in posterior
mesio-distal distance about 7mm
• 1.5mm x2 from adjacent tooth to
implant on both sides
• 4mm implant
--> so 7mm of space
size of the edentulous space in should be carefully matched for good
relation to the adjacent tooth esthetic results in the anterior region
crown/implant ratio should be kept to 1:1 for sound
biomechanics
a sound esthetic result is dependent on…

• optimal bone & gingival contours
• accurate 3D implant positioning

(3) adjacent dentition
prognosis of very important for avoiding potential implant failure
adjacent teeth inflicted from adjacent pathology
soft tissue should be reviewed to identify any deficits that might
contours and have direct impacts on the esthetic outcome
levels
position of the rotated, tilted, out of curve, extruded, intruded
adjacent teeth along with position of proximal contacts, can cause
functional and esthetic problems if not addressed
properly
wear facets analyze to understand occlusal pattern
restorations and on adjacent teeth, would assist in designing the optimal
materials implant restoration
canine guidance probably the best for anterior implants **

balanced occlusion for posterior **
smile line
• existence and maintenance of harmonious gingival levels provide better
esthetic outcomes
• rotation of #10 --> decreases papilla height and causes a less than ideal
contact position **
(4) opposing dentition

• plane of occlusion plays an important role on the loads exerted on
the implant restoration
• occlusal scheme should be carefully evaluated for planning the
centric and laterotrusive contacts
• type of restoration -- fixed would transmit more forces than a >
removable restoration **
• prognosis of a compromised tooth might be negatively impacted
when opposed by rigid implant restoration **
diagnosis
study casts
• edentulous site along with the adjacent structures can be analyzed in
detail on the casts
• diagnostic prototype in the missing tooth site would help visualize the
proposed restoration
• location and alignment of the proposed implant can be studied through
the diagnostic work up
• sometimes, a more difficult and financially-challenging case may be
done in stages to 'simplify'
○ eg. start with an RPD, then do implants
imaging
• radiographic exam can be done with PA's & PAN's
○ however, further information can be obtained via tomograms
• eg.
○ ideal alignment seems to be possible in the facial view; however,
proposed implant alignment would end up perforating the buccal
plate in the sagittal view
○ therefore, implant axis needs to be redirected within bone which
would cause screw access hole to be buccally positioned

prosthetic design principles
• 1mm of bone on each side, at the minimum; this dictates the size of the
implant (wider doesn't necessarily mean better) **
• fabricating the implant template initiates the restoratively-driven implant
therapy
○ this process would identify restorative concerns and possible
restorative/surgical solutions
○ implant restorations should have similar emergence profile as
natural teeth for establishing and maintaining esthetic soft tissue
architecture
○ this can be achieved by proper 3D placement of the implant
wider may not be better

• use largest diameter that… **
○ leaves 1mm each at buccal & lingual crests
○ allows for coronal anatomy
• an implant having a greater diameter would generally produce smaller
stresses than one with a smaller diameter, because stresses induced are
inversely proportional to the area transferring the load **
length of implants **
• it is recommended that maxillary implants be >10mm in length, because
of the higher implant loss associated with shorter implants
• in the mandible, shorter implants can be used but splinting and
increasing the number of implants is recommended

splinted posterior restorations
• crown/implant ratio
• high fail rate with angulated abutments
• <13mm = splint
• >13mm = individual
for FPD
<13mm -- one implant per tooth
>13mm -- two implants for 3-unit FPD
grinder, bruxer, group function may affect
occlusion
• while there is no clinical data documenting the effect of occlusion
upon implant success, clinicians have felt that occlusion can affect
implant success
• Lang & Razzoog: occlusal interference may ultimately be the prime
factor in the lifetime survival rate of dental implants
• Strib, Witkowski, Einsele: indicate the importance of harmonic
occlusion and articulation should not be underrated
• clinicians have frequently recommended that a balanced occlusion
be used with implant overdentures, particularly when the opposing
arch is edentulous ***
ideal implant biomechanics

• occlusal forces // vertical axis
• major forces distributed periapically, only some forces
@crest-screw

greater force in posterior region
lateral interferences
• lateral occlusal forces concentrate on crest of ridge
• increased strain & torque on abutment screw
cantilevers
• significantly increase forces at crest
• significantly increase forces on abutment screw

• papilla was always complete when the distance from
contact bone to crest of bone <5mm **

examples of poorly placed implants
distally placed implant

• causes mesial lever arm when chewing
lack of sufficient space b/w tooth and implant

• lack papillae
platform
• keep the implant platform 3mm apical to CEJ of adjacent teeth **

interims
interim RPD
• shouldn't exert pressure on the site
implant supported provisional

• provisional is the prototype of the final restoration
• purpose = form the most ideal gingival contours for the definitive
crown, and to test & evaluate the restorative plan
they look different, they are color coded differently, but the technique is similar

abutment selection
• the final restoration can be either screw or cement retained
• various abutments can be used to facilitate the connection between
the implant & final crown
• the UCLA abutment is the most versatile, since it can be used for both
screw and cement retained
• screw retained restorations are used when retrievability of the
restoration is desired and minimum inciso-cervical or occluso-cervical
height is available

hex lock abutment
if you have the right angulation and need minimal correction
features and benefits **

• pre-defined offset margin
○ margin mimics profile of soft tissue
○ lower on buccal aspect by 1.5mm
• available in various cuff heights
• saves time
○ little or no preparation needed
• enhances esthetics
○ minimizes potential for metal being exposed due to tissue
remodelling
○ shape enables natural emergence profile

hex lock short abutment system
• designed for limited occlusal space in the POSTERIOR

custom abutments
advantages
• eliminates angulation problems
• eliminates screw access opening
• develops proper emergence profiles
• improves esthetics - control of metal & porcelain thicknesses
patient-specific abutments
• the retrofitted model is laser scanned to generate a 3D image
• virtual teeth are designed to simulate the final restoration
• PSA abutments are designed by clinically-based software
• custom parameters are applied as requested on the optional prescription

corrects mal-alignments and improves emergence profile

Zimmer CAD-designed abutment
advantage
• internal connection is completely recorded + Zimmer
abutment screw is included

impression technique
open tray impression

• drill a hole on your custom tray, attach this on your implant
in the mouth
• take an impression
• before you remove it from the mouth, unscrew it so it's not
attached to the implant
• it's more accurate, especially in multiple implants **
closed tray
• less accurate, but faster (it's basically the same
technique for regular crowns)
• don't have to unscrew before removing the tray
closed tray impression

• coping, doesn't has a screw that sticks out; the whole thing is in the
impression
• you have to block out areas of the coping with wax
• the implants do not stick out through the tray

• the tray has holes in it, so the implants can stick out through it
• impression coping is directly attached to your tray
open tray technique -- impression coping is always with impression material,

∴ more accurate **

check occlusion with shim stock, check that it indeed bites
Don't just focus on the implant site.

Do use a surgical guide, but don't totally rely on it.
Do offer implants as an option for replacing missing teeth,
but don't replace all missing teeth with implants.
Do beware high smile lines and high expectations.
3-unit FPD (traditional)

• still a predictable option with >95% success rate 1-5y

03 Implant Course Hands-On

contacts on the implant
• centric -- want light centric contacts
• lateral -- want no lateral contacts

steps
1. remove healing cap
2. seat appropriate transfer (open or closed)
3. seal screw access opening (wax, cotton)
4. place indirect transfer impression coping
(fixture mount)

04 Digital implants
information for treatment planning

• past medical and dental histories
• patient education
• prosthesis design
• site evaluation…
○ bone volume
○ bone quality
○ anatomic limitation
radiographic
• PA, panoramic, cephalogram
• CT, CBCT
panoramic
advantages disadvantages
• identification of landmarks • distortions
• evaluation of gross anatomy of the jaws and related • errors in patient position
pathologic findings • does not demonstrate bone quality
• initial assessment of vertical bone height • misleading quantities and not 3D
• convenience and easy available in most dental offices

CBCT
advantages ***
• negligible magnification
• relatively high-contrast image
• views from various orientations
• 3D bone models
• interactive tx planning
• cross-referencing
watch out for…

• thin buccal plate
• submandibular nerve
• mandibular lingual concavity (molar area)
ALARA principle = as low as reasonably available

• CBCT 36µSV, versus natural yearly exposure 2400µSV

fully edentulous patient partially edentulous patient
traditional way new way traditional way new way
• impression • digital denture fabrication • impression • digital impression and
• wax rims (Avadent) • facebow & wax-up
• facebow & • try-in articulating
articulating • wax-up
• teeth set-up • X-ray taking
• X-ray taking
**[EXAM q]
crown occlusal thickness = 2mm
abutment height = 4-5mm
cement-retained a little taller

screw-retained a little shorter

the greatest system has accuracy to… 25 microns

overdenture
interarch space = 14mm
• tooth >8mm
• denture base 2-3mm
• locator housing 3.17mm
Digital Smile Design

• all digital, for replacing anterior teeth
• take an intraoral photo, they analyze the dimensions etc.
limitations
• scan quality (powder vs. powderless, scan method)
• scanner size
• initial fee
• seeing is believing
limitations for digital dentures

• time management
• still uses the same concept for CD's
○ border molding
○ bite registration
○ vertical dimension
○ centric relation
limitations of traditional implant surgical guides

• no information about the varying mucosal thickness,
topography of underlying bone, or vital anatomic structures
• dimensional accuracy and inability to visualize anatomic
structures in parasagittal sections
• doesn't allow fabrication of a surgical template that remains
stable during surgery, despite interference with reflected
tissue

stereolithography
• developed by 3D system of Valencia, CA
• widely used rapid prototyping technology
• builds plastic parts a layer at a time, by tracing a laser
beam on the surface of a vat of liquid polymer
• the self-adhesive property of the material causes the
layers to bond to each other and form the 3D object
3 types of surgical stents **

• tooth supported
• bone supported
• mucosa supported
accuracy of surgical guides vs. non-guided surgery

• angle most significant difference; angle sucks when not guided, vs.
very good when guided **
• shoulder, apex were better with guided but not as huge difference
• depth the same

closed tray impression
• coping, doesn't has a screw that sticks out; the whole thing is in the impression
• you have to block out areas of the coping with wax
• the implants do not stick out through the tray

• the tray has holes in it, so the implants can stick out through it
• impression coping is directly attached to your tray
open tray technique -- impression coping is always with impression material, ∴ more
accurate **
impression
traditional method new method
• fabricate individual trays • directly scan the healing abutment/
• adjust trays impression abutment
• unscrew healing abutment
• screw impression coping
• take impression
• unscrew impression coping
limitations
• no soft tissue data
• emergence profile
• healing abutment worn out

implant prosthesis fabrication
• UCLA custom abutment
• bar-type wax-up
• CAD/CAM abutments
CAD/CAM abutments
• Atlantis (Dentsply) -- abutment, Isis bar, Isis bridge, Isis hybrid
• limitations to CAD/CAM prostheses…
○ still need to work with technician
○ color matching
○ surface staining doesn't exist

5 steps
1. diagnostics, CBCT w/o template, 1st intraoral surface scan
2. computer based implant planning, 3D print surgical guide
3. guided implant surgery, 2nd intraoral surface scan
4. technical fabrication, implant supported reconstruction
5. prosthetic rehabilitation

05 Implant maintenance
Thursday, July 13, 2017 7:04 AM
tooth vs. implant (periodontally)

tooth implant
• cementum, bone, periodontium • osseointegration
• connective tissue = perpendicular fibres, attached • connective tissue = parallel, not attached
• biologic width = 2.04-2.91mm • biologic width = 3.08mm
• attachment level = 1-3mm in health • attachment level = 1-5mm in health
• bleeding on probing = more reliable • bleeding on probing = less reliable
stages of peri-implant disease

1. ailing mucositis (like gingivitis, just inflammation no bone loss)
2. failing peri-implantitis (bone loss)
3. failed clinically mobile implant
5 risk factors for peri-implant disease

• hx. of periodontitis
• smoking or other tobacco use
• poor plaque control
• diabetes mellitus
• residual prosthetic cement
implant maintenance
• primary etiologic factor in peri-implantitis = microbial plaque (like normal)
• Gram(-) anaerobic bacteria
• pathogenic complex bacteria contribute to failing implant sites
peri-implant mucositis
• inflammatory reaction
• no bone loss yet, reversible
• bleeds with gentle probing
peri-implantitis
• inflammatory reaction in hard & soft tissues
• bone loss
• vertical bone loss or bony wall defects
• anaerobic pathogens colonize in deep sulcus
• may or may not exhibit bleeding
• exudate on palpation

cumulative interceptive supportive therapy (CIST)
4-step protocol proposed as a management strategy for implant diseases...
1. mechanical debridement -- In case of implants with evident plaque or calculus deposits adjacent
to only slightly inflamed peri-implant tissues (Bleeding on probing is positive).
2. antiseptic treatment -- It is performed in situation where in addition to plaque and BOP, probing
depth in increased up to 4-5 mm. Chlorhexidine digluconate either the form of daily rinse of
0.1%, 0.12% or 0.2 or as a gel applied to the site of desired action.
3. antibiotic treatment -- When probing depth value of the peri-implant sulcus or pocket increase
to 6 mm or more. Beside the protocol A and B, an antibiotic directed at the elimination of gram
negative anaerobic bacteria is administrated.
4. regenerative or resective therapy -- Only if infection is controlled successfully by A,B and C as
evidenced by an absence of suppuration and reduced edema. It aimed to restore the bony
support of the implant by means of regenerative techniques.

data collection
• clinical assessment… soft tissue, hard tissue, occlusion,
mobility, prosthetic integrity, plaque index
radiographs
• vertical BW's (less distortion)
• periapicals
• monitor crestal bone height & density
• proper angulation to clearly show threads
• implant-abutment-prosthesis connection = clear line
• narrow, radiolucent space = mobile implant abutment
• frequency of radiographs…
○ year 1… 3mo. intervals (baseline)
○ years 2-5… yearly (compare w. baseline)
○ years >5… every 2 years
○ reasonable to expect 0.5-1mm bone loss in first year,
then 0.1-0.2mm each year after placement for 5y
probing
• extremely controversial
• not routinely recommended
• increases susceptibility to disease in implant sulcus
• aggressive pressure may create false BOP
• force can penetrate through JE & CT to alveolar bone
• inability to align probe properly
• if needed…
○ plastic (flexible) probe
○ very light pressure
○ radiographic bone loss present
○ pathology present
○ readings may still be inaccurate
○ PD >5mm presents a risk factor for disease

implant scalers
• plastic resin
○ unfilled resin results in the last amount of surface alteration
• gold tipped
• graphite
• titanium
usage of implant scalers

• only when calculus is present
• plastic doesn't scratch or pit titanium
• avoid excessive manipulation
• titanium implants…
○ outer layer "titanium oxide"
○ damage --> corrosion --> surface roughness --> plaque retention --> compromised implant
plastic scalers are used on…

• standard abutments
• supporting implant bar substructures
• implant supported splinted restorations
which one is best for sharpening implant scalers?

• dual grit
• India
• Arkansas
• ceramic is best
diamond sharpening cards

• 3 grit levels available
• convenient credit card size
• a good fit in pouches and cassettes
ultrasonic implant scaler

• ultrasonic implant scaler MUST be used with protective sheath
air polishing - primary indications

• biofilm management
• supra- and sub-gingival use
• perio maintenance, implant maintenance
• biofilm removed around orthodontic brackets
• stain removal
• prior to placement of sealants
literature review of air polishing

• powders
• effectiveness and efficiency of use
• effects on soft tissue, enamel, cementum, dentin
• effects on restorative materials, sealants, orthodontics, implants
• health concerns and safety
• use a fine, non-abrasive prophy paste, toothpaste, or tin oxide

using rubber cup or bristle brush

home care for implants
• manual or electric brush
• end-tuft brush, Proxybrush, floss
• rubber tip stimulator
• irrigation devices
• chemotherapeutic agents
• non-abrasive products
• neutral sodium fluoride products (never use acidic fluoride
around implants) **[EXAM q]
toothbrushes
• soft, multi-tufted, nylon, various handle angles, end-tufted,
rotary, oscillating or sonic, flattened, rubber cup
• modified Bass technique
• proximal areas stress
• wide or narrow embrasures beneath prosthesis
• goal = increase blood flow, enhance tone of gingiva

chemotherapeutics
• phenolic compounds -- Listerine, Crest ProHealth (2x/day)
• chlorhexidine gluconate 0.12% -- Peridex, PerioGard (1x/day)
○ reduces 90% aerosol bacteria for 5h
○ 30sec rinse
• CloSYS toothpaste & rinse
○ cloralstan -- main ingredient
○ alcohol, sulfate, triclosan, gluten free
use of chemotherapeutics
• as oral irrigator
• applied w. interdental aid to limit staining, with saturated Superfloss, etc.
• dip plastic probe in chlorhexidine in between measurements (prevents transferring bacteria)
• aids in fibroblast reattachment
maintenance interval
• assess homecare
• general rule -- monitor peri-implant status, conditions of implant-supported prostheses,
and plaque control
○ 1 implant -- see restoring DDS 2x/year
○ 2 implants -- + see surgeon 1x/year
○ 4 implants -- see both alternating 3months
• keys to success…
○ always individualize oral hygiene care
○ reinforce patient's role as a team effort
re-evaluation and referral

• return to implant surgeon or periodontist if…
○ fractured prostheses, bone loss, etc.

implant maintenance code (D6080)
• summary…
○ visual exam
○ radiographic exam
○ periodontal exam
○ evaluate mobility
○ symptomatic/asymptomatic
○ reinforce oral hygiene
○ adjust care frequency as necessary
○ refer to surgeon or graduate periodontics

06 Implant complications
Thursday, July 13, 2017 7:05 AM

implant success criteria
• no evidence of pathosis, symptoms, discomfort
• no peri-implant radiolucency
• no mobility
• 1mm bone loss first year, 0.2mm yearly (5 years)
○ you should not see bone loss beyond the first thread
• the implant design does not preclude the placement of an
acceptable restoration
statistics of success
• success rate = 85% @5y, and 80% @10y
• smokers, uncontrolled diabetes etc., will have lower rates
platform switching
• abutment is narrower than the shoulder of the implant
• so you don't have a vertical component of the biologic width, you
have a horizontal one
• so you'd expect not to have bone loss up to the first thread, you'd
expect less
• it's possible platform switching implants cause less bone loss than
traditional
to ensure the maintenance of dental implant health, the

dental team must properly assess the health of…
• peri-implant tissues
• alveolar bone housing
• restorative implant consequences

microflora of peri-implant
• implant microflora (plaque) is similar to natural tooth
• implant soft & hard tissues also prone to breakdown (inflammatory lesions)
peri-implant tissues - disease

• when untreated, inflammatory lesions in the peri-implant tissue may
progress into… surrounding soft tissue -> supporting bone -> implant failure
peri-implant mucositis -- like gingivitis (gingival inflammation)

peri-implantitis -- like periodontitis (periodontal inflammation)
failed implant -- mobility (loss of osseointegration)
Peri-implantitis always ends with surgery, because you cannot clean that deep.
Whenever possible, you want a tissue-level implant because it leads to less

periodontal problems. **

evaluation of peri-implant tissues
establish baseline measurements…
• probing depth
• bleeding on probing, suppuration
• keratinized gingiva (attached gingiva)
• PA, BW, baseline at implant placement, then final
restoration delivery
• implant mobility

note the crestal bone level
• bone loss up to first thread is acceptable and normal, beyond
that is not
• this picture is "no bone loss"
peri-implant tissue follow-up

• healthy pt -- periodontal cleaning every 4-6mo
• periodontal pt -- periodontal cleaning every 3-4mo,
alternate w. periodontist
• PA, BW -- in 6mo and every 1-2y

objectives of maintenance therapy
• overall goal of therapy = establish a functional restoration &
acceptable esthetics
• any therapy should arrest further bone loss, and re-
establish a healthy peri-implant mucosa (non-surgical &
surgical therapies

(below)
[CIST protocol = cumulative interceptive-supportive therapy

CIST includes 4 steps…
a. mechanical debridement (CIST protocol A)
b. antiseptic therapy (CIST protocol A+B)
c. antibiotic therapy (CIST protocol A+B+C)
d. regenerative or resective therapy (CIST protocol A+B+C+D)

probi BOP/supp bone mobili tx refer
ng uration loss ty to
CIST <3mm +/- no no (A) mechanical hygien
protocol debridement - scaling and ist
A polishing q3-6mo
CIST protocol A
peri-implant tissue evaluation and monitoring
• when an implant has plaque/calculus accumulation with…
○ BOP but no suppuration, and
○ PD <4mm
--> then mechanical debridement may be sufficient
○ this can be done by implant specific instruments; conventional stainless
steel or ultrasonics should be avoided
• precautions…
○ instruments that will not scratch the implants
○ avoid acidic fluoride prophylactic agents
○ nonabrasive prophy pastes
○ screw-retained prosthesis unscrewed by the office responsible for
placing the prosthetics
probing BOP/sup bone mob tx refer to

puration loss ility
CIST 4-5mm +/- no no (A) mechanical hygienist
protocol debridement - scaling
B and polishing q3-6mo
+
(B) CHX rinse q12h for
3-4w
CIST >5mm BOP (+) no no (A) mechanical implant
protocol take X- suppurati debridement - scaling surgeon
B ray ** on and polishing q3-6mo
+
3-4w
CIST protocol B
• implant sites with BOP and PD of 4-5mm with or without suppuration,
should be treated with antiseptic therapy along with mechanical
debridement
• generally, chlorhexidine 0.2% used for 3-4weeks
probi BOP/sup bone mobili tx refer to

ng puration loss ty
CIST >5m BOP (+) yes no (A) mechanical implant
protocol m suppurati <2mm debridement - scaling and surgeon
C take on polishing q3-6mo
X-ray +
3-4w
+
(C) systemic/local
antibiotics
(no comment for CIST protocol C)
probi BOP/sup bone mobili tx refer to

ng puration loss ty
CIST >5m BOP (+) yes no (A) mechanical implant
protocol m suppurati >2mm debridement - scaling and surgeon
D take on polishing q3-6mo
X-ray +
3-4w
+
(C) systemic/local
antibiotics
+
(D) regenerative tx
CIST protocol D
• implant sites with BOP and PD >6mm with or without suppuration, and
there is radiographic bone loss, then tx. will include…
○ mechanical debridement

CIST protocol D
• implant sites with BOP and PD >6mm with or without suppuration, and
there is radiographic bone loss, then tx. will include…
○ mechanical debridement
○ chlorhexidine rinse
○ antibiotic therapy (7-10days); systemic or local
Once peri-implantitis is under control, then regenerative or resective therapy

can be instituted
• ie. once no BOP/suppuration, decreased PD
• the goal of regenerative therapy = new bone formation in the defect around
the implant
implant mobility
probin BOP/suppur bone mobilit tx refer to
g ation loss y
yes remove implant + implant
regenerative tx. surgeon
• mobility is a specific diagnostic test for loss of osseointegration and is

decisive in the decision to remove an implant

need for referral
• refer when… any time complexity requires when non-surgical
treatment is ineffective
• consider also referral to the prosthodontist (maybe they can
correct the local factors, eg. change angulation of the crown, etc.)

bleeding on probing
• BOP occurring following light pressure (0.25N) reveals
presence of inflammation
• through inflammation, collagen is destroyed and tissue
necrosis results
• this leads to pus formation, suppuration and the
development of a fistula
If light probing force is applied, the epithelial attachment of the

transmucosal tissue seal will be disrupted but will health within
5-7 days. **
The barrier epithelium around implants is 2-3mm. **
In peri-implantitis, probe will penetrate and reach the base of

the inflammatory lesion at the alveolar crest.

** google or re-listen or make sense of it

07 Implant Dentistry Education
Saturday, July 22, 2017 1:33 PM


Overall Grading Components Critical Assessment Paper 40 % Online Quizzes 10% Laboratory Simulation Project 20% Final Exam 30%

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Overall Grading Components Critical Assessment Paper 40 % Online Quizzes 10% Laboratory Simulation Project 20% Final Exam 30%

Uploaded by

Copyright:

Available Formats

01 Implant Introduction

Thursday, June 01, 2017 7:06 AM

Overall Grading Components

Implant Lectures Page 1

phase I tx. alternatives

Implant Lectures Page 3

Implant Lectures Page 4

papilla -- esthetic guidelines

cement-retained a little taller

Implant Lectures Page 5

So the Mesial-Distal dimension depends on the type of

Implant Lectures Page 10

Implant Lectures Page 11

Implant Lectures Page 12

Implant Lectures Page 15

bridge lasts 6-13 years

"success" different from "survival"

overdentures are nowadays the standard of care

prosthetic treatment planning

local host factors prosthetic design principles

Implant Lectures Page 16

highest reason for complications = abutment screw loosening **

work up for single tooth implant care

Implant Lectures Page 18

(1) edentulous tissues

buccal plate deficiency in single tooth site

ridge lapped restorations

Implant Lectures Page 19

a sound esthetic result is dependent on…

Implant Lectures Page 20

canine guidance probably the best for anterior implants **

(4) opposing dentition

Implant Lectures Page 21

wider may not be better

Implant Lectures Page 22

ideal implant biomechanics

Implant Lectures Page 23

papilla -- esthetic guidelines

Implant Lectures Page 24

distally placed implant

lack of sufficient space b/w tooth and implant

Implant Lectures Page 25

implant supported provisional

Implant Lectures Page 26

Implant Lectures Page 28

features and benefits **

Implant Lectures Page 29

Implant Lectures Page 30

Implant Lectures Page 31

Implant Lectures Page 32

Implant Lectures Page 34

open tray impression

closed tray impression

open tray impression

open tray technique -- impression coping is always with impression material,

Implant Lectures Page 36

Don't just focus on the implant site.

3-unit FPD (traditional)

Implant Lectures Page 38

Implant Lectures Page 41

Implant Lectures Page 44

Implant Lectures Page 49