Implant dentistry in aesthetic zone and videos about cad cam and custom abutments

3. Multidisciplinary approach

4. Pre surgery considerations
prosthetic overview

6. Supporting bone influence
(Garber DA, Belser UC. Compend Contin Educ Dent
1995;16(8):796, 798–802, 804.)

7. Periodontal overview

8. Site evaluation
 Graber classification (garber DA, rosenberg ES. Compend contineduc dent 1981;2(4):212–23.)
 Garber class i :
 Favorable horizontal and vertical levels of both soft tissue and bone
are present.
 Garber class ii:
 Sites with no vertical bone loss and slight horizontal bone deficiency
measuring about 1 to 2 mm narrower than normal.
 Garber class iii:
 For sites with no vertical bone loss and horizontal bone loss greater
than class II.
 Garber class iv:
 In sites with no vertical bone loss but significant horizontal loss.
 Garber class v:
 Sites with extensive apicocoronal bone loss present a significant
challengeto the surgeon

9. Timing of implant placement
following tooth removal
 Hammerele et al:
 type 1:immidiate after extraction
 type 2:4-8 weeks later(soft tissue healed)
 type 3:12-16 weeks later(bone formation in clinic and
radiographic evaluation)
 type 4:more than 16 weeks
Hammerele et al Int J Oral Maxillofac Impl. 2004; 19(supp):43-61

10. Alveolar bone resorption
after tooth extraction
 Following tooth removal, a variable amount of ridge
collapse takes place in either buccal-lingual or
apicocoronal dimensions
 An average of 40% to 60% original height and width is
expected to be lost after tooth extraction with the
greatest loss happening within the first 2 years
 Thin buccal ,more resorption had to result in a vertical
reduction .Wider lingual bone, less resorption

11. Socket bone wall in relation to
immediate implant placement
 It has been suggested that immediate placement of
implants into extraction sockets may preserve the bony
architecture
 Denissen & kalk 1991; denissen et
al. 1993; sclar 1999
 Implants placed immediately into extraction sockets will
not prevent the occurrence of ridge alterations
 Botticelli et al. 2004a, 2004b;
covani et al. 2004; araujo & lindhe
2005 ferrus et al. 2009; sanz et al.
2009

12. Implant size selection
 Commonly depends on
 Dimension of the edentulous crest
 Proximity of the adjacent roots
 Maintain at least 3mm of inter implant distance to
decrease the chance of crestal bone loss
 Ideal diameter usually are 3.75-4 mm
Boudrias P et al. J Dent Que 2003;40:301-302

13. Multidisciplinary approach

14. Tischler guideline
(Tischler M.NY State Dent J 2004;70(3):22–6.)
1. Employ a conservative flap
design;
2. Evaluate the existing bone
and soft tissue;
3. Time the placement
correctly;
4. Visualize the three-
dimensional position of the
implant;
5. Consider healing time before
implant loading;
6. Consider the determinants of
emergence profile
7. Select a proper abutment
and final restoration design.

15. Buccolingual position
 Ideal position of implant depends on:
1. desired crown location
2. design of the implant
3. design of the abutment

16. Implant positioning
 The centerline of the
implant must often be
located at or near the
center of the tooth it
replaces
 The implant must be
positioned in such a
way that the buccal
aspect of the implant
platform just touches
an imaginary line that
touches the incisal
edges of the adjacent
teeth

17. Implant placement
An implant placed too far
buccally
An implant placed too far to the
palataly

18. Implant positioning
 Spray et al ( Spray JR, Black CG, Morris HF, et
al. An Periodontol 2000;5(1):119–28.)
 As the bone thickness in buccal area
approached 1.8 to 2 mm, bone loss
decreased significantly and some
evidence of bone gain was seen
 Buser et al (Buser D, Martin W,
Belser UC. Int J Oral Maxillofac Implants
2004; 19(Suppl):43–61.)
 in patients presenting with a thin
gingival biotype some palatoversion
is desirable
 Graber et al (Garber DA, Belser UC.
Compend Contin Educ Dent 1995;16(8):796, 798–
802, 804.)
 Occlusal considerations occasionally
necessitate labioversion, particularly
in cases involving excessive vertical
overlap.

19. Mesiodistal position
 evaluating mesiodistal space available for:
 select a proper implant size
 good esthetic out come
 preservation of interdental bone and papilla
 a minimum distance of 1.5 to 2 mm should be
maintained between implants and neighboring teeth.
(Esposito M, Ekestubbe A, Grondahl K. Clin Oral
Implants Res 1993;4(3):151–7.)
 in multiple implants, a space of 3 to 4 mm at the
implant abutment level should be maintained between
implants.(Tarnow DP, Cho SC, Wallace SS. J Periodontol
2000;71(4):546–9.)

20. Mesiodistal position
 Graber et al (Garber DA. J Am Dent Assoc 1995;126(3):319–25. )
 In the case of a maxillary central incisor site, it may be
desirable to place the implant slightly to the distal to
mimic the natural asymmetry of the gingival contour
often seen in these teeth.

21. Apicocoronal position or
countersink
 need to mask the metal of implant
 depends on implant diameter
 The wider the implant, the less distance is needed to
form a gradual emergence profile ( Jansen CE, Weisgold A.
Compend Contin Educ Dent 1995;16(8):748–52).
 esthetic VS biology (Cochran DL, Hermann JS, Schenk RK, et al.
J Periodontol 1997;68(2):186–98.)

22. Apicocoronal position or
countersink
Not deep enough Too deep

23.  In a patient without gingival recession,
cemento-enamel junction (CEJ) location of
adjacent teeth is a point of reference to
determine the apicocoronal position of the
implant platform and In patients with gingival
recession, the mid-buccal gingival margin can be
used as a reference in lieu of the CEJ
 The sink depth of the implant shoulder should
be 1 to 2 mm for a one-stage implant or 2 to 3
mm for a two-stage implant apically to the
imaginary line connecting mid-buccal of CEJs of
the adjacent teeth without gingival recession
Hermann JS, Buser D, Schenk RK, et al. Clin Oral Implants Res 2000;11(1):1–11.

24. Implant angulations
 Ideally, implants should be placed so that the abutment resembles the
preparation of a natural tooth; implant angulation should mimic the
angulation of adjacent teeth
 poor angulation can:
 alter screw access hole
 poor esthetic result
 difficult home care
 some undesirable cantilevers
Sullivan DY, Sherwood RL. J Esthet Dent 1993;5(3):118–24.

25. Multidisciplinary approach

26. Emergence profile
importance
 Proper emergence profile can
obtained with 3 different
methods
1. proper implant positioning
and using healing abutment
or special gingival
former)khoury K,happe
A.Quintessence Int 2000;31:483-
499.)
2. using ovate pontic or an
acrylic resin restoration (jemt
T.int j periodontics restorative
dent 1999;19:20-29.)
3. cervical contouring
method(using custom healing
abutments). (bichacho
N,Landsberg CJ.pract periodontics
aesthet dent 1994;6:35-41.)

27. Healing abutments
 Healing abutments were good for
implants in no esthetic zones, but
lacked appropriate esthetics for
implants in esthetic zones (Chee
WW: Periodontol 27:139, 2000)
 Advantages
 Healing abutments are usually
chosen preoperatively by the
implant surgical clinicians
 These designs greatly simplify
implant level
 Pre design emergence profile
developing

28. Provisional restoration
 improved tissue contours related to
emergence profile (Higginbottom F,
Belser U, Jones JD, et al:. Int J Oral
Maxillofac Implants 19:62, 2004 (suppl))
 development of an interdental or
interimplant papillae (Small PN,
Tarnow DP: Int J Oral Maxillofac Implants
15:527, 2000)
 potential avoidance of a third surgical
procedure
( Byrne D, Houston F, Cleary R, et al: J
Prosthet Dent 80:184, 1998)
 customization during the healing
process to form an esthetically
contoured prosthesis
(Biggs WF. J Prosthet Dent 1996;75:231-3

29. Immediate Implant Restoration
and Loading protocol
 Immediate restoration and loading can be used when the
implant is of adequate length (≥ 8 mm)and diameter (≥ 4 mm)
and the implant achieves “good” primary stability.
 The restoration should be taken out of any functional occlusal
contacts both in centric occlusion and during excursive
mandibular movements.
 The restoration should not be removed during the healing
period of approximately 6 weeks.
 The patient should be instructed in how to function during the
healing period and how to perform adequate oral hygiene.
 Screw-retained provisional restorations are recommended.
 Patients with parafunctional occlusal habits should be fitted
with a habit appliance.
 Immediate restoration and loading can be used when the bone
volume at the site is close to ideal
Grutter.INT JORAL MAXILLOFAC IMPLANTS 2009;24(SUPPL):169–179

30. Papilla consideration
 Existence of a predictable papilla
length usually can be predictable
in
 4.5mm inter implant distance
 5mm inter natural teeth distance
 5.5 mm inter tooth implant
distance
 (salama H,salama M ,graber D.pract periodont aesthet dent
1998;10(9):1131-1141.)

31. Emergence profile play a
role in papillary formation
Proximal restoration
contours &contact play a role in papillary
formation

32. Multidisciplinary approach

33. General rules
 Color
 Texture
 Gingival contour
 Restoration contour

34. Impression technique
 interim restoration as an
abutment for the definitive
impression.
 custom impression coping for
the replication of the healed
tissue around the implant
 Bain and Weisgold inserted
autopolymerizing acrylic
resin directly into the sulcus
during impression making
 Chee and Donovan advise
performing gingivoplasty
procedures to re contour the
tissues before making
provisional restorations

35. Abutment material
Abutment material influence
 titanium alloy (asperini, et al:
Clin Oral ImplantsRes 9:357, 1998)
 high noble
 ceramics
 zirconia abutments (Piconi C,
Maccauro G Biomaterials 20:1,
1999)
 biocompatibility
 toughness (Kucey BKS, Fraser
DC: J Can Dent Assoc 66:445,
2000)
 esthetic demands (Yildirim M,
Fischer H, Marx R, et al: J
Prosthet Dent 90:325, 2003)

36. Ceramic abutments vs metal
abutments biocompatibility (Abrahamsson et
al: J Clin Periodontol 25:721, 1998)
 color change in surrounding
tissue? 2mm vs 3 mm soft tissue
thickness (Jung RE, et al: Int J
Periodont Restor Dent 27:251, 2007)
 future gingiva resection (Jung RE,
et al: Int J Periodont Restor Dent
28:357, 2008)
 survival rate
 metal>=zirconia> alumina in 3-5
years follow up (Glauser et al: Int
J Prosthodont 17:285, 2004)
 metal>>zirconia>>alumina more
than 5 years follow up (Glauser R:
Osseointegration Res 4:41, 2004)

37. Abutment fabrication
Prefabricated
Custom
Porcelain application

38. CAD/CAM custom abutments
 superior
material
homogeneity
 material
properties
 custom
design
 ease of
fabrication

39. Multidisciplinary approach

40. soft tissue
 Small and Tarnow
reported that the
majority of recession
occurred within the
first 3 months. (Small
PN, Tarnow DP. Int J Oral Maxillofac
Implants 2000;15:527–532.)
 Deangelo et al showed
that peri-implant soft
tissue seemed to be
stable at about 4
weeks after
mucoperiosteal flap
surgery. (DeAngelo SJ, J
Periodontol 2007;78:1878–1886).

41.  Lai et al reported that the esthetic outcome of soft
tissue around a single-tooth implant had improved
significantly after 6 months compared with baseline
according to PES assessment. (Lai HC, Zhang ZY, Wang F,
Zhuang LF, Liu X, Pu YP. Clin Oral Implants Res 2008;19:560–
564.)

42. Question ?